Neue Osteoporose-Leitlinie DVO 2014 und ihre Bedeutung für den Unfallchirurgen

Autophagy as a target for glucocorticoid-induced osteoporosis therapy

Autophagy takes part in regulating the eukaryotic cells function and the progression of numerous diseases, but its clinical utility has not been fully developed yet. Recently, mounting evidences highlight an important correlation between autophagy and bone homeostasis, mediated by osteoclasts, osteocytes, bone marrow mesenchymal stem cells, and osteoblasts, and autophagy plays a vital role in the pathogenesis of glucocorticoid-induced osteoporosis (GIOP). The combinations of autophagy activators/inhibitors with anti-GIOP first-line drugs or some new autophagy-based manipulators, such as regulation of B cell lymphoma 2 family proteins and caspase-dependent clearance of autophagy-related gene proteins, are likely to be the promising approaches for GIOP clinical treatments. In view of the important role of autophagy in the pathogenesis of GIOP, here we review the potential mechanisms about the impacts of autophagy in GIOP and its association with GIOP therapy.

Screening for osteoporosis following non-vertebral fractures in patients aged 50 and older independently of gender or level of trauma energy-a Swiss trauma center approach

Screening in a standardized manner for osteoporosis in non-vertebral fracture patients aged 50 and older independently of both gender and level of trauma energy yielded the indication for osteoporotic therapy for every fourth male high-energy fracture patient.

PURPOSE

This study aimed to identify the rate of osteoporosis in patients of both genders after fracture independently of the underlying level of trauma energy.

METHODS

A random cohort of patients aged 50 or older with non-vertebral fractures participated in a standardized diagnostic protocol to evaluate the indication for treatment of osteoporosis (number needed to screen (NNS)). Univariate and multivariate analysis as well as correlation testing were performed to determine statistical relationships. Significance was set at p < 0.05.

RESULTS

Of 478 fracture patients with a mean age of 69.3 ± 11.8 years, 317 (66.3%) were female and 161 (33.7%) male. One hundred nineteen patients (24.9%) sustained high-energy fractures (HEFs) and 359 (75.1%) low-energy fractures (LEFs). Twenty-eight percent of males and 47% of females qualified as osteoporotic in densitometry (dual-energy X-ray absorptiometry (DXA)), resulting in a NNS of 2.1 for women and 3.6 for men. The indication for treatment of osteoporosis increased to an NNS of 1.5 for females and 2.4 for males if the fracture risk assessment tool (FRAX) was included in the diagnostics (DXA and FRAX). With regard to the energy of trauma, the NNS for treatment following DXA and FRAX was 1.5 for LEF and 2.9 for HEF. Subgroup analysis revealed that HEF males within the decennia 50+ and 80+ had an NNS of around 3, i.e., comparable to females and about twice as high as LEF patients.

CONCLUSIONS

These preliminary findings appear to confirm the pragmatic approach to screening in a standardized manner for osteoporosis in all non-vertebral fracture patients aged 50 and older-independently of both gender and level of trauma energy.

[Interdisciplinary management in geriatric trauma surgery : Results of a survey in Austria]

BACKGROUND

The treatment of geriatric patients in the field of trauma surgery is increasingly gaining importance. To provide optimized treatment to these mostly multimorbid patients, interdisciplinary treatment concepts between trauma surgeons and geriatricians have been designed and implemented successfully.

OBJECTIVES

The aim of this survey was to evaluate the current state of interdisciplinary management in the treatment of geriatric patients on trauma surgery wards throughout Austria.

MATERIAL AND METHODS

The directors of 64 Austrian trauma surgery wards were surveyed using an online-questionnaire regarding the current interdisciplinary treatment of geriatric patients.

RESULTS

A total of 39 (61 %) questionnaires were analyzed. Of the participating wards, 20 % distinguished between geriatric and non-geriatric patients. There were various criteria to classify the patients. The average percentage of patients older than 70 years was 43 %. Of the participating wards, 26 % had established a periodical cooperation between trauma surgeons and geriatricians and 8 % of the participants stated that there is no interdisciplinary cooperation. The establishment of an interdisciplinary treatment concept in the near future was planned in 28 %. The most commonly mentioned obstacle that prevented trauma surgery wards from establishing an interdisciplinary management model was the lack of personnel resources (59 %) - especially the lack of geriatricians (62 %).

CONCLUSION

The survey's results underline the geriatric trauma surgery's great importance especially regarding the high percentage of geriatric patients, as well as the fact that the significance of the interdisciplinary cooperation between trauma surgeons and geriatricians is not yet perceived by the majority of Austrian trauma surgery wards.

When is the stability of a fracture fixation limited by osteoporotic bone?

This article is concerned with the search for threshold values for bone quality beyond which the risk of fixation failure increased. For trochanteric fractures we recognized a BMD lower than 250mg/cm(3) as an additional risk for cut out. For medial femoral neck fractures since joint replacement surgery is available and produces excellent functional results, we see no indication for further differentiation or analysis of bone quality in relation to fracture fixation. In the area of osteoporotic vertebral body fractures, there are many experimental studies that try to identify BMD limits of screw fixation in the cancellous bone on the basis of QCT analysis. However, these values have not yet been introduced for application in clinical practice. In case of indication for surgical fixation, we favor minimally invasive, bisegmental, fourfold dorsal instrumentation with screw-augmentation for a T-value less than -2.0 SD (DXA analysis, total hip or total lumbar spine). For proximal humerus fractures, BMD value of 95mg/cm(3) could be seen as a threshold value below which the risk of failure rises markedly. In relation to osteoporotic distal radius fractures, based on our clinical experience and scientific analyses there are virtually no restrictions as far as bone quality is concerned on the application of palmar locking implants in the surgical management of distal radius fractures. Optimization of preoperative diagnostics might help to revise the treatment algorithm to take bone density into account, thus reducing the risk of failure and, at the same time, acquiring additional data for future reference.