The guidelines, published by the Orthopaedic Branch of the Chinese Medical Association, provide an important basis for the treatment of osteoporotic fractures that can be used as a reference for orthopaedic surgeons. It is important for standardizing treatment and providing the level of diagnosis and treatment of related diseases. For this reason, it is also published here for the reference of patients who have had osteoporotic fractures.
Osteoporosis is a systemic bone disease characterized by reduced bone mass, destruction of bone microarchitecture, increased bone fragility, and susceptibility to fracture (World Health Organization, WHO, 1994). The National Institutes of Health (NIH, 2001) proposed that osteoporosis is a disease of the skeletal system characterized by decreased bone strength and increased risk of fracture, with bone strength including bone density and bone mass. Osteoporosis can be divided into primary osteoporosis and secondary osteoporosis.
Osteoporotic fractures (fragility fractures) are pathological fractures that can occur after osteoporosis due to decreased bone density and bone mass resulting in decreased bone strength and can occur with minor violence or even during daily activities, and are the most serious consequence of osteoporosis. Common fracture sites are the spine, hip, distal radius and proximal humerus.
The characteristics of osteoporotic fracture and the difficulties of treatment: ①After osteoporotic patients suffer from fracture and are bedridden, rapid bone loss will occur, which will aggravate osteoporosis; ②The fracture site has low bone mass, poor bone quality, mostly comminuted fracture, which is difficult to reset and not easy to achieve satisfactory results; ③The stability of internal fixation treatment is poor, the internal fixation and implants are easy to loosen and dislodge, and bone graft is easy to resorb; ④The fracture healing process is slow and (5) The risk of re-fracture in other parts of the body is significantly increased; (6) The fracture is usually seen in the elderly, often accompanied by diseases of other organs or systems, poor general condition, prone to complications during treatment, increasing the complexity and risk of treatment; (7) The rate of disability and death is high, seriously threatening the physical and mental health, quality of life and life expectancy of the elderly; therefore, the treatment of osteoporotic fractures is different from that of general fractures. Therefore, the treatment of osteoporotic fractures is different from that of general traumatic fractures, and it is necessary to pay attention to both the treatment of the fracture itself and the active treatment of osteoporosis.
Osteoporotic fractures are more common in women and more frequent in people over 60 years of age. They are mostly caused by minor trauma (defined as injury caused by a fall on a flat surface or at the height of the body’s center of gravity) or no obvious history of trauma, and can occur even during daily activities.
The clinical features are: general manifestations of fracture; specific manifestations of fracture; X-ray examination can determine the site, type, direction of displacement and degree of fracture, which is of great value for fracture diagnosis and treatment. x-ray films, in addition to the specific manifestations of fracture, also show signs of osteoporosis, such as reduced bone density, thinning of bone trabeculae, thinning of bone cortex and enlargement of bone marrow cavity, etc. CT can accurately show the degree of fracture comminution, and can CT can accurately show the extent of fracture comminution and can show intra-vertebral canal compression, 3D imaging can clearly show intra- or peri-articular fractures, and MRI is important for detecting occult fractures and distinguishing fresh and old fractures. Bone densitometry is feasible in patients with a proposed diagnosis of osteoporotic fracture. Dual-energy X-ray absorptiometry (DXA) is currently the internationally accepted method for bone density examination. With reference to the diagnostic criteria recommended by WHO, DXA measurement: BMD values less than 1 standard deviation below the peak bone mass of healthy adults of the same sex and race are considered normal (T value ≥ -1.0 SD); a decrease between 1 and 2.5 standard deviations is considered low bone mass (reduced bone mass, -2.5 D)
Displacement, fixation, functional exercise and anti-osteoporosis treatment are the basic principles of treatment of osteoporotic fractures, and the ideal treatment is an organic combination of the above four. The fracture should be repositioned without aggravating the local blood flow obstruction as much as possible, without hindering the limb movement as much as possible under the premise of firm fixation of the fracture, and with early functional exercise, so that the fracture healing and functional recovery can achieve a more ideal result. At the same time, anti-osteoporosis drugs are used reasonably to avoid aggravation of osteoporosis or the occurrence of re-fracture.
Because osteoporotic fractures are mostly seen in the elderly, the principle of simple, safe and effective methods of repair and fixation should be used to restore the quality of life before the injury as soon as possible, and methods with less trauma and less impact on joint function should be chosen as far as possible. For those who really need surgery, the following measures can be taken as appropriate, taking into full consideration the characteristics of osteoporotic fractures, such as poor bone quality and slow healing, which are different from general traumatic fractures: ① use special internal fixation devices, such as locking compression plates, screws with thick threads, expanded intramedullary nails, instruments with special coating materials, etc.; ② use devices with less stress masking to reduce further bone loss; ③ use special Internal fixation techniques, such as screw fixation through the bilateral bone cortex to increase the holding force; ④ the use of internal fixation reinforcement techniques, such as the use of bone cement, expander and biomaterial reinforcement around the screw; ⑤ the use of autologous or allogeneic bone graft and biomaterial (bone cement, calcium sulfate, etc.) filling can be considered for severe bone defects; ⑥ depending on the degree of fracture solidity, external fixation can be used as appropriate. External fixation should be reliable and of sufficient duration to minimize fixation of the joints adjacent to the fracture.
The rehabilitation of patients with osteoporotic fractures should follow the general rule of postoperative rehabilitation of fractures, but also take into account the characteristics of poor bone quality, poor internal fixation and slow fracture healing in this group of patients. Early active and passive muscle exercises, early movement of unfixed joints, and minimizing the time spent in bed are emphasized.
Osteoporotic fractures are commonly found in the spine and hip.
The spine is the most common site of osteoporotic fractures, of which about 85% have painful symptoms and the remaining 15% can be asymptomatic. Osteoporotic fractures of the thoracolumbar segment of the spine account for approximately 90% of all spine fractures. Osteoporotic fractures of the spine mainly include vertebral compression fractures and vertebral burst fractures, which are often mildly traumatized or have no obvious history of trauma and are easily missed or misdiagnosed as lumbar back strain.
The diagnosis mainly relies on the patient’s age, medical history and imaging examination, among which post-traumatic thoracic back pain, height reduction, scoliosis or kyphosis, X-ray plain film showing bone trabeculae thinning, bone cortical thinning, vertebral wedge shape change and biconcave deformation are the main basis for diagnosis. Bone densitometry, usually by DXA, can determine the degree of osteoporosis. CT scans can determine the type of fracture, the degree of vertebral destruction, and the compression in the spinal canal, and MRI examinations can determine whether the fracture is fresh and show the condition of nerve compression.
Vertebral burst fractures without neurological compression can be treated non-operatively with bed rest for 2-3 weeks followed by external fixation in a brace for 3 months. Vertebral burst fractures with nerve compression symptoms can be treated surgically with nerve decompression, fracture repositioning, internal fixation and fusion. Vertebral compression fractures should be treated either non-surgically or surgically depending on the specific situation. If the degree of vertebral compression is small (less than 1/3 height loss) and the pain is not severe, non-operative treatment can be adopted. For those with significant vertebral compression (height loss greater than 1/3), no damage to the posterior wall of the vertebral body, or a multi-segment fracture with significant pain and no significant effect by conservative treatment, minimally invasive surgical treatment can be considered. Percutaneous vertebroplasty and kyphoplasty are currently recommended minimally invasive surgical treatment measures to reduce pain, stabilize the spine, restore the physiological curvature of the spine, and achieve early movement. Percutaneous vertebroplasty and kyphoplasty should be performed under close X-ray surveillance, and the surgeon must have formal training and standardized surgical techniques to avoid major complications such as bone cement leakage. For multiple vertebral compression fractures, the treatment segment needs to be selected according to the specific clinical situation.
Osteoporotic fractures of the hip mainly include femoral neck fractures and intertrochanteric fractures, which are characterized by high rates of nonunion, femoral head necrosis, deformation and disability, slow recovery, and high morbidity and mortality.
Non-surgical or surgical treatment is possible depending on the patient’s specific situation. If the fracture is not significantly displaced or is an embedded fracture, or if the patient’s general condition is too poor to tolerate surgery, non-operative treatment can be used. Non-operative treatment includes bed rest, traction (bone traction or skin traction), brace immobilization, infection prevention, nutritional support, and other therapeutic measures. During the period of non-operative treatment, it is necessary to closely observe the changes in the condition, adjust the position of the limb and traction weight in time, and take comprehensive measures to prevent and treat complications such as respiratory and urinary system infections and bed sores. Surgical treatment includes external fixation frame, internal fixation, artificial joint replacement (artificial femoral head replacement, artificial total hip replacement), etc.
For femoral neck fractures, Garden I and II fractures are mostly fixed with percutaneous multiple hollow compression screws, while Garden III and IV fractures have a low healing rate and a high rate of femoral head necrosis, and the efficacy of internal fixation is inaccurate, so artificial femoral head replacement or artificial total hip replacement can be considered for older patients. As for whether to choose artificial femoral head replacement or artificial total hip replacement, it depends on the patient’s age, general condition, life expectancy and whether there is damage to the acetabulum. For elderly patients with poor general condition, short life expectancy and basically intact acetabulum, artificial femoral head replacement can be considered, which can shorten the operation time and reduce bleeding, and elderly patients have less postoperative activities and can basically meet the requirements of daily life, otherwise, artificial total hip replacement is feasible.
For intertrochanteric fracture, internal fixation can be performed by incision and reduction. Internal fixation includes intramedullary fixation and extramedullary fixation. Intramedullary fixation system includes Gamma nail, proximal femoral intramedullary nail (PFN), femoral reconstruction nail, etc. Extramedullary fixation system includes power hip screw (DHS), power condyle screw (DCS), locking compression plate (LCP), hip anatomical plate, etc. Intramedullary or extramedullary fixation can be chosen according to the patient’s specific situation and the operator’s experience. For patients with poor bone quality, intramedullary fixation is more in line with biomechanical requirements. If the patient has multiple injuries or is in poor general condition and cannot tolerate larger surgery, closed repositioning can be performed under local anesthesia with external fixation bracket fixation, and the patient can perform functional exercises early after fixation.
Artificial femoral head replacement or total hip arthroplasty is not recommended as the first choice of treatment for intertrochanteric fractures. For intertrochanteric fractures with old fractures or concomitant hip disease, artificial femoral head replacement or artificial total hip arthroplasty can be considered.
Along with surgical treatment of osteoporotic fractures, special emphasis is placed on the aggressive treatment of osteoporosis.
Basic osteo-nutritional supplements, calcium intake can slow bone loss and improve bone mineralization. When used for the treatment of osteoporosis, it should be used in combination with other medications. Vitamin D deficiency can lead to secondary hyperparathyroidism and increased bone resorption, which can cause or worsen osteoporosis. Adequate intake of vitamin D facilitates the absorption of calcium in the gastrointestinal tract, promotes bone formation, and enhances muscle strength and balance.
Osteoporotic fractures originate from osteoporosis, therefore the use of effective medication for osteoporosis is the necessary basis for the treatment of osteoporotic fractures. Anti-osteoporotic medication after fracture is recommended for.
1, the early stage of osteoporotic fracture, due to enhanced bone resorption, bed rest and braking and lead to further bone loss, so it is appropriate to use drugs to inhibit bone resorption. Calcitonin can increase bone density, improve bone quality, enhance bone biomechanical properties, and has a significant effect on reducing the incidence of osteoporotic fractures. Early application of calcitonin can both relieve pain and improve or prevent acute bone loss, and can be the first choice of treatment for patients with high-conversion osteoporosis with low back pain (especially when the vertebrae are acutely fractured). No adverse effects have been seen on the repair and reconstruction of osteoporotic fractures with conventional doses.
2, the rational use of calcium, calcium absorption is mainly in the intestinal tract, so calcium supplementation to oral effect.
3.Active vitamin D3 can not only promote bone formation and mineralization, increase bone mass and reduce the risk of re-fracture, but also help to enhance muscle strength, improve neuromuscular coordination and prevent the tendency to fall.
4, Bisphosphonates can improve bone density in the lumbar spine and hip, reduce the risk of fracture and mortality in patients after fracture. However, some studies have shown that bisphosphonates can affect the quality of bone scab reconstruction, so the early application of bisphosphonate preparations in osteoporotic fractures is currently debated.
5, SERMs have good efficacy in improving bone density and reducing the incidence of osteoporotic fractures, but some studies have shown that SERMs can increase the risk of venous thrombosis in the lower extremities of bedridden patients, so they should be used with caution in bedridden patients after fracture. It is contraindicated in patients with a history of venous embolism and a propensity for thrombosis (e.g., prolonged bed rest, sedentary).
Self-preventive measures include smoking cessation and alcohol restriction, moderate weight control, daily moderate muscle strength exercise, whole-body balance and coordination exercise, appropriate outdoor activities, increased sunlight, various measures to prevent falls, and preventive and correct medication use.