Internal fixation of osteoporotic fractures

Fixation Failure in Osteoporotic Bone: A Review of Complications and Outcomes

Background

Osteoporotic bone poses significant challenges for fixation of fractures due to its compromised bone quality. This issue impacts patient outcomes and, necessitate proper understanding of the biomechanical limitations and the adequacy of current fixation devices.

Objective

This article aims to address the gaps in literature by examining both the biomechanical and biological factors that contribute to fixation failure in osteoporotic bone, and by analyzing the limitations of current management strategies, with the aim of identifying effective interventions for this vulnerable patient group.

What is Already Known

Literature acknowledges that osteoporotic bones have reduced bone density and compromised structural integrity, making fixation devices less effective. Fixation failure frequently occurs in these patients due to diminished bone strength and insufficient fixation support, which collectively hinder optimal stabilization and healing.

Gap in Literature

Despite recognition of the high failure rates associated with osteoporotic bone fixation, there is limited literature detailing a comprehensive approach that integrates biomechanical, biological, and technological advancements to improve fixation outcomes. This article reviews current diagnostic techniques and explores potential innovations in materials and regenerative strategies aimed at enhancing fixation success. Which also guide us about need for future research to focus on developing and validating multifaceted approaches that combine advanced fixation materials and bone regeneration technologies to mitigate failure risks and improve patient outcomes.

Conclusion

With increasing life expectancy, the incidence of osteoporosis and hence osteoporotic fractures steadily increasing there are multiple fractures which are responsible for this, however as orthopedic surgeon we are required to deal with these fractures in increasing numbers so we need to develop a comprehensive approach to prevention of these fractures' adequate treatment and also the prevention of refractures which are far too common.

A biomechanical study of locking spongious screws and failure rates are higher than expected in plate fixation

Locking plates have a rapidly growing process especially in the past decades and results are satisfactory especially in the osteoporotic bones compared to non-locking compression plates. There are many forms of failure in the fracture fixation of locking plates, and screw pull-out is one of the main failure reasons. In this study, we aim to investigate pull-out failure in locking plates using locking spongious screws. The pull-out force of an FDA approved locking plate system (LPS) and anonymous locking plate using the single lead head locking spongious screw (LPuLSS) was evaluated in vitro on the PCF-15 and PCF-10 osteoporotic sawbone models. A total of 28 individual plate-bone models were tested and pull-out force was evaluated on a distraction machine. The moment of separation of the screws from the bone blocks was noted. In the first study using PCF15 bone model, in Group 1, the pull-out force has an average of 606.82 N. In Group 2, the pull-out force has an average of 294.15 N. According to these results, Group 1 adhere to the bone model 206.29% more strongly than those in Group 2 (P = 0.025). In the second study using PCF 10, in Group 3, the average pull-out force was 166.50 N and in Group 4 the average was 42.83 N. According to these results, Group 3 adhere to the bone model 388.74% more strongly than those in Group 4 (P = 0.002). Locking plates are mostly used in osteoporotic bones and this study demonstrated that the single lead head locking spongious screws which is currently used worldwide have a serious technical problem which arouses with difference of the thread pitch distances on the body and on the head causes pull-out failure.

A novel model of locking plate and locking spongious screw: a biomechanical in vitro comparison study with classical locking plate

BACKGROUND

Locking plates are commonly used for the fixation of comminuted, periprosthetic and osteoporotic bone fractures. These plates are secured to the bone with screws, creating a stable connection with fixed angle between the plate and the screws. In this biomechanical in vitro study, our aim is to evaluate and compare the novel locking plate-locking spongious screw model with FDA approved classical locking plate.

METHODS

Sawbone PCF-15 osteoporotic bone model was utilized to simulate osteoporotic bone conditions. Two screws were used to attach both the classical locking plate and the novel locking plate-locking spongious screw model to these bone models. The attachment strength of the screws to the bone blocks was measured by pull-out tests.

RESULTS

Novel locking plate-locking spongious screw model exhibited an 84.38% stronger attachment to the osteoporotic bone model compared to the current locking plate model.

CONCLUSIONS

In conclusion, one of the important problems in the locking plates which is the high Pull-out risk of the locking spongious screws can been resolved with our proposed new model and has a chance of having a better purchase especially in osteoporotic bones.

Trichostatin A enhances the titanium rods osseointegration in osteoporotic rats by the inhibition of oxidative stress through activating the AKT/Nrf2 pathway

The use of titanium implants as fixed supports following fractures in patients with OP can often result in sterile loosening and poor osseointegration. Oxidative stress has been shown to play a particularly important role in this process. While TSA has been reported to facilitate in vivo osteogenesis, the underlying mechanisms remain to be clarified. It also remains unclear whether TSA can improve the osseointegration of titanium implants. This study investigated whether TSA could enhance the osseointegration of titanium rods by activating AKT/Nrf2 pathway signaling, thereby suppressing oxidative stress. MC3T3-E1 cells treated with CCCP to induce oxidative stress served as an in vitro model, while an OVX-induced OP rat model was employed for in vivo analysis of titanium rod implantation. In vitro, TSA treatment of CCCP-treated MC3T3-E1 cells resulted in the upregulation of osteogenic proteins together with increased AKT, total Nrf2, nuclear Nrf2, HO-1, and NQO1 expression, enhanced mitochondrial functionality, and decreased oxidative damage. Notably, the PI3K/AKT inhibitor LY294002 reversed these effects. In vivo, TSA effectively enhanced the microstructural characteristics of distal femur trabecular bone, increased BMSCs mineralization capacity, promoted bone formation, and improved the binding of titanium implants to the surrounding tissue. Finally, our results showed that TSA could reverse oxidative stress-induced cell damage while promoting bone healing and improving titanium rods' osseointegration through AKT/Nrf2 pathway activation.

A Degradable and Osteogenic Mg-Based MAO-MT-PLGA Drug/Ion Delivery System for Treating an Osteoporotic Fracture

Osteoporotic fractures are a very common bone disease that is difficult to completely cure. A large number of people worldwide suffer from pain caused by osteoporotic fractures every year, which can even cause disability and death. The compromised skeletal strength, lower density, trabecular microstructure, and bone-forming ability caused by osteoporotic fractures make them difficult to treat relative to normal fractures. An ideal scheme for osteoporotic fractures is to select internal fixation materials with matched mechanical and biological properties and carry anti-osteoporosis drugs on the plant to achieve bio-fixation and improve the condition of osteoporosis simultaneously. We designed a Mg-based MAO-MT-PLGA drug/ion delivery system (DDS) compatible with bone-like mechanical properties, degradation properties, and drug therapy. In this research, we evaluated the degradation behavior of Mg-based MAO-MT-PLGA DDS using immersion tests and electrochemical tests aided by SEM, EDS, XPS, XRD, and FT-IR. The DDS showed better corrosion resistance over Mg alloy and could release more Mg2+ due to the degradation of PLGA. According to cell viability and cell adhesion, the DDS showed better osteogenic characteristics over control group I (Mg alloy) and control group II (Mg-based MAO alloy), especially in the cells co-cultured with the leaching solution for 72 h, in which the DDS group increased to about 15% cell viability compared with group I (p < 0.05). The mRNA relative expressions, including ALP, collagen I, OCN, OPG, and Runx-2, as well as extracellular matrix calcium deposits of the DDS, are 1.5~2 times over control group I and control group II (p < 0.05), demonstrating a better ability to promote bone formation and inhibit bone resorption. After the DDS was implanted into the castrated rat model for one month, the trabeculae in the treatment group were significantly denser and stronger than those in the control group, with a difference of about 1.5 times in bone volume fraction, bone density, and the number of trabeculae, as well as the magnesium content in the bone tissue (p < 0.05). The above results demonstrated that the Mg-based MAO-MT-PLGA drug/ion delivery system is a potential treatment for osteoporotic fractures.

Expert consensus on the bone repair strategy for osteoporotic fractures in China

Osteoporotic fractures, also known as fragility fractures, are prevalent in the elderly and bring tremendous social burdens. Poor bone quality, weak repair capacity, instability, and high failure rate of internal fixation are main characteristics of osteoporotic fractures. Osteoporotic bone defects are common and need to be repaired by appropriate materials. Proximal humerus, distal radius, tibia plateau, calcaneus, and spine are common osteoporotic fractures with bone defect. Here, the consensus from the Osteoporosis Group of Chinese Orthopaedic Association concentrates on the epidemiology, characters, and management strategies of common osteoporotic fractures with bone defect to standardize clinical practice in bone repair of osteoporotic fractures.

Biomechanics of Osteoporotic Fracture Care: Advances in Locking Plate and Intramedullary Nail Technology

Osteoporotic fractures are extremely common and will continue to increase. Methods of internal fixation must address challenges presented by architectural changes of weakened bone. The goals of surgery are to provide mechanically stable internal fixation with minimal biologic insult that provides rapid rehabilitation and early mobilization. Novel techniques and technology that reinforce preservation of periosteal blood supply and utilization of biomechanically stable constructs diminish failure rates. Advents in locking plate technology, intramedullary nail designs, bone augmentation, and multiple implant constructs maximize strength while mitigating axial, torsional, and bending failure modes to provide optimal patient outcomes.

Bench-to-bedside strategies for osteoporotic fracture: From osteoimmunology to mechanosensation

Osteoporosis is characterized by a decrease in bone mass and strength, rendering people prone to osteoporotic fractures caused by low-energy forces. The primary treatment strategy for osteoporotic fractures is surgery; however, the compromised and comminuted bones in osteoporotic fracture sites are not conducive to optimum reduction and rigid fixation. In addition, these patients always exhibit accompanying aging-related disorders, including high inflammatory status, decreased mechanical loading and abnormal skeletal metabolism, which are disadvantages for fracture healing around sites that have undergone orthopedic procedures. Since the incidence of osteoporosis is expected to increase worldwide, orthopedic surgeons should pay more attention to comprehensive strategies for improving the poor prognosis of osteoporotic fractures. Herein, we highlight the molecular basis of osteoimmunology and bone mechanosensation in different healing phases of elderly osteoporotic fractures, guiding perioperative management to alleviate the unfavorable effects of insufficient mechanical loading, high inflammatory levels and pathogen infection. The well-informed pharmacologic and surgical intervention, including treatment with anti-inflammatory drugs and sufficient application of antibiotics, as well as bench-to-bedside strategies for bone augmentation and hardware selection, should be made according to a comprehensive understanding of bone biomechanical properties in addition to the remodeling status of osteoporotic bones, which is necessary for creating proper biological and mechanical environments for bone union and remodeling. Multidisciplinary collaboration will facilitate the improvement of overall osteoporotic care and reduction of secondary fracture incidence.

Locked Plating and Advanced Augmentation Techniques in Osteoporotic Fractures

"The incidence of osteoporotic fracture is increasing with the aging US population. Because osteoporosis leads to a decrease in bone mineral density with a decrease in both trabecular and cortical bones, osteoporotic fracture presents fixation challenges with standard plate and screw constructs. Locked plating has been developed to create a fixed-angle plate-screw construct that is more resistant to failure in osteoporotic bone. Endosteal replacement, additional plates, and cement augmentation have all been demonstrated to further supplement osteoporotic fracture fixation. Technologies on the horizon to treat osteoporotic fracture include SMV screws, hydroxyapatite-coated implants, and far cortical locking screws."

Clinical Management of Osteoporotic Fractures

PURPOSE OF REVIEW

This review examines recent literature regarding the clinical management of fragility fractures, provides insight into new practice patterns, and discusses controversies in current management.

RECENT FINDINGS

There are declining rates of osteoporosis management following initial fragility fracture. Management of osteoporotic fractures via a multidisciplinary team reduces secondary fracture incidence and improves overall osteoporotic care. Anabolic agents (abaloparatide and teriparatide) are effective adjuvants to fracture repair, and have shown positive results in cases of re-fracture in spite of medical management (i.e., bisphosphonates). For AO 31-A1 and A2 intertrochanteric hip fractures (non-reverse obliquity), no clinical advantage of intramedullary fixation over the sliding hip screw (SHS) has been proven; SHS is more cost-effective. As fragility fracture incidence continues to rise, orthopedic surgeons must play a more central role in the care of osteoporotic patients. Initiation of pharmacologic intervention is key to preventing subsequent fragility fractures, and may play a supportive role in initial fracture healing. While the media bombards patients with complications of medical therapy (atypical femur fractures, osteonecrosis of jaw, myocardial infarction), providers need to understand and communicate the low incidence of these complications compared with consequences of not initiating medical therapy.

Internal Fixation of Osteoporotic Bone

Osteoporosis is one of the costliest conditions managed by orthopaedic surgeons. This condition, which is characterized by decreased bone density and thinning of cortical bone, is strongly influenced by complex signaling in both the hormonal and mechanical environments. Osteoporosis cannot be cured; instead, it can only be managed to decrease patient morbidity. Current pharmacologic treatments are aimed at minimizing bone turnover and have substantial side effects. Therefore, much work remains to find safer and more effective agents to restore bone density. In addition to the high incidence of fracture in elderly patients, many of the traditional fixation constructs used for repair of these fractures are not suitable for use in osteoporotic bone. Increased use of fixed-angle locking plates, intramedullary devices, and bone substitutes has greatly improved outcomes in these patients.

Optimization of screw fixation in rat bone with extracorporeal shock waves

Screw fixation in osteoporotic patients is becoming an increasing problem in orthopaedic surgery as deterioration of cortical and cancellous bone hamper biomechanical stability and screw fixation. This might result in delayed weight-bearing or failure of instrumentation. We hypothesized that local peri-operative shock wave treatment can optimize osseointegration and subsequent screw fixation. In eight female Wistar rats, two cancellous and two cortical bone screws were implanted in both femora and tibiae. Immediately after implantation, 3.000 unfocused extracorporeal shock waves (energy flux density 0.3 mJ/mm² ) were applied to one side. The other side served as non-treated internal control. Evaluation of osseointegration was performed after 4 weeks with the use of microCT scanning, histology with fluorochrome labeling, and pull-out tests of the screws. Four weeks after extracorporeal shock wave treatment, treated legs exhibited increased bone formation and screw fixation around cortical screws as compared to the control legs. This was corroborated by an increased pull-out of the shock wave treated cortical screws. The cancellous bone screws appeared not to be sensitive for shock wave treatment. Formation of neocortices after shock wave therapy was observed in three of eight animals. Furthermore, de novo bone formation in the bone marrow was observed in some animals. The current study showed bone formation and improved screw fixation as a result of shock wave therapy. New bone was also formed at locations remote from the screws, hence, not contributing to screw fixation. Further, research is warranted to make shock wave therapy tailor-made for fracture fixation. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:76-84, 2018.

Osthole Enhances Osteogenesis in Osteoblasts by Elevating Transcription Factor Osterix via cAMP/CREB Signaling In Vitro and In Vivo

Anabolic anti-osteoporotic agents are desirable for treatment and prevention of osteoporosis and fragility fractures. Osthole is a coumarin derivative extracted from the medicinal herbs Cnidium monnieri (L.) Cusson and Angelica pubescens Maxim.f. Osthole has been reported with osteogenic and anti-osteoporotic properties, whereas the underlying mechanism of its benefit still remains unclear. The objective of the present study was to investigate the osteopromotive action of osthole on mouse osteoblastic MC3T3-E1 cells and on mouse femoral fracture repair, and to explore the interaction between osthole-induced osteopromotive effect and cyclic adenosine monophosphate (cAMP) elevating effect. Osthole treatment promoted osteogenesis in osteoblasts by enhancing alkaline phosphatase (ALP) activity and mineralization. Oral gavage of osthole enhanced fracture repair and increased bone strength. Mechanistic study showed osthole triggered the cAMP/CREB pathway through the elevation of the intracellular cAMP level and activation of the phosphorylation of the cAMP response element-binding protein (CREB). Blockage of cAMP/CREB downstream signals with protein kinase A (PKA) inhibitor KT5720 partially suppressed osthole-mediated osteogenesis by inhibiting the elevation of transcription factor, osterix. In conclusion, osthole shows osteopromotive effect on osteoblasts in vitro and in vivo. Osthole-mediated osteogenesis is related to activation of the cAMP/CREB signaling pathway and downstream osterix expression.

A Novel Computer-Aided Approach for Parametric Investigation of Custom Design of Fracture Fixation Plates

The present study proposes an integrated computer-aided approach combining femur surface modeling, fracture evidence recover plate creation, and plate modification in order to conduct a parametric investigation of the design of custom plate for a specific patient. The study allows for improving the design efficiency of specific plates on the patients' femur parameters and the fracture information. Furthermore, the present approach will lead to exploration of plate modification and optimization. The three-dimensional (3D) surface model of a detailed femur and the corresponding fixation plate were represented with high-level feature parameters, and the shape of the specific plate was recursively modified in order to obtain the optimal plate for a specific patient. The proposed approach was tested and verified on a case study, and it could be helpful for orthopedic surgeons to design and modify the plate in order to fit the specific femur anatomy and the fracture information.

Animal models for glucocorticoid-induced postmenopausal osteoporosis: An updated review

Glucocorticoid-induced postmenopausal osteoporosis is a severe osteoporosis, with high risk of major osteoporotic fractures. This severe osteoporosis urges more extensive and deeper basic study, in which suitable animal models are indispensable. However, no relevant review is available introducing this model systematically. Based on the recent studies on GI-PMOP, this brief review introduces the GI-PMOP animal model in terms of its establishment, evaluation of bone mass and discuss its molecular mechanism. Rat, rabbit and sheep with their respective merits were chosen. Both direct and indirect evaluation of bone mass help to understand the bone metabolism under different intervention. The crucial signaling pathways, miRNAs, osteogenic- or adipogenic- related factors and estrogen level may be the predominant contributors to the development of glucocorticoid-induced postmenopausal osteoporosis.

A reversal phase arrest uncoupling the bone formation and resorption contributes to the bone loss in glucocorticoid treated ovariectomised aged sheep

Large animals as sheep are often used as models for human osteoporosis. Our aim was therefore to determine how glucocorticoid treatment of ovariectomised sheep affects the cancellous bone, determining the cellular events within the bone remodelling process that contributes to their bone loss. Twenty female sheep were assigned for two groups; an untreated control group and an ovariectomised group treated with glucocorticoids (0.6 mg/kg/day, 5 times weekly) for 7 months. At 7 months the glucocorticoid-treated ovariectomised sheep showed a significant change in the bone microstructure revealed by a decreased trabecular bone volume and thickness compared to the control sheep. The treatment led to a temporary elevation of the bone resorption marker CTX (c-terminal collagen telopeptide), while the bone formation marker osteocalcin remained suppressed all 7 months. Histomorphometrically, the treated sheep had a complete absence of osteoid surfaces, and a 5-fold increase in the extent of eroded/reversal surfaces after 7 months. Most of these reversal surfaces were actually arrested reversal surfaces, defined as reversal surfaces without the presence of neighbouring osteoid surfaces or osteoclasts, which is classically observed next to active reversal surfaces. As in humans, these arrested reversal surfaces had compared to active reversal surfaces a reduced canopy coverage, a significantly decreased cell density, and a decreased immunoreactivity for the osteoblastic markers osterix, runx2 and smooth muscle actin in the mononuclear reversal cells colonising the surfaces. In conclusion, glucocorticoid treatment of ovariectomised sheep induced a significant bone loss, caused by an arrest of the reversal phase, resulting in an uncoupling of the bone formation and resorption during the reversal phase, as recently demonstrated in postmenopausal women with glucocorticoid-induced osteoporosis. This supports the relevance of the sheep model to the pathophysiology of glucocorticoid-induced osteoporosis in postmenopausal women, making it a relevant preclinical model for orthopaedic implant and biomaterial research.