Surgical strategies for high-energy fractures in patients with osteoporosis

The most obvious clinical pattern of osteoporosis is represented by the so-called low energy fractures. These are slight trauma bone lesions that would not occur in a subject with normal bone mineral density (BMD). The most frequently affected sites of this type of fracture are the last dorsal and lumbar vertebrae, the proximal femur, humerus, and the distal radius. These fractures are a challenge for the orthopedic surgeons because they occur on an altered bone, with decreased load resistance, reduced elasticity and decreased ability to absorb mechanical stresses. This physio-pathological pattern results in lower stability of the hardware, lower screws purchase, less resistance to bone-prosthesis interface, lower quality of the healing process. The problem becomes more complex when high-energy trauma occur in osteoporotic bone with fractures in nontypical locations such as distal femur, tibial plate, tibial malleolus, elbow or peri-phrostetic fractures after Total Knee or Hip Replacement. The surgical approach to these fractures aims to use devices that assure greater bone-implant stability and a great distribution of stresses by reducing the forces acting on the bone-implant interface. It is possible to use scaffolds such as bioactive cement and porous coating surfaces to increase the hardware purchase and homologous/autologous transplantation, post-operative pharmacological implementation and growth factors to stimulate potential repair of fractures. The use of locking plates allows converting the sliding forces, which the traditional plates generated, into compression forces to increase the stability of the system. There are also versatile hardware with dynamic angular stability screws that can be freely oriented in space unlike conventional plates where the direction of the screw is dictated by the placement of the plate. The philosophy of minimal invasive surgery is well represented by the use of intramedullary nails, which can stabilize the fracture from the inside of the bone marrow. This characteristic ensures a load distribution within the bone especially in meta-diaphysis areas, which are most affected by typical reduction of bone quality of osteoporosis. In the elderly, the total joint replacement is also indicated in cases of peri-articular fractures in which there is a high risk of bone fragments necrosis. Such fractures can be treated with a prosthetic implant to ensure immediate joint stability and thus allow an early recovery of the range of motion and the function of the affected limb. Treatment of peri-prosthetic fractures is another important chapter in surgery of traumatic fractures in osteoporosis as we find more and more frequent patients who have a prosthetic implant and who undergo a trauma that causes a peri-implant fracture. In this case, the evaluation of the implant's stability to the bone-prosthesis interface is crucial to decide whether to perform a synthesis with angular stability, nails and/or cerclage wires, or to perform a revision. In all cases, treatment of traumatic fractures in osteoporosis requires a multidimensional evaluation of the problem, as it is not only the type of fracture and site that can be considered, but also the bone quality by carefully evaluating the patient's functional and metabolic state and its comorbidity. It is a surgery that requires specific implants and devices that must be carried out by experienced hands.