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Epidemiology Diagnosis Prevention and Management of Osteoporotic Fractures PowerPoint Presentation

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Slide 1-

Epidemiology, Diagnosis, Prevention and Management of Osteoporotic Fractures Hassan R. Mir, MD, MBA, FACS Associate Professor Created March 2004; Kenneth Egol, MD Revised February 2010; Revised May 2015
Slide 2-

Population is Aging Demographics WORLD USA
Slide 3-

Initial Evaluation Thorough H&P Focus on: PMH Meds PSH and Response DNR / DNI Functional Status Pre-Op Social History
Slide 4-

Co-Morbid Conditions Cardiac, Pulmonary Diabetes Wound Infection, Delayed Healing PVD Decubitus Ulcers Infection Risk Nutrition
Slide 5-

Initial Evaluation Physical Examination Skin/Soft Tissues Vascularity Labs, CXR, EKG Films – Bone Quality Consent – Competent? Goals of Care
Slide 6-

Treatment Goals Restore Pre-Injury Level of Function Social Assistance Post-op
Slide 7-

Non-Operative Care? Consider when: Moribund/Terminal Patient Refusal of Consent Futility of Surgery Patient Would Not Survive Procedure
Slide 8-

Medical Clearance Based on Stability Patient Optimized Testing Required? Perioperative Care Type of Anesthesia
Slide 9-

Fleisher LA, et al. 2014 ACC/AHA Perioperative Guideline Published with permission J Am Coll Cardiol. 2014;64(22):e77-e137
Slide 10-

Cardiac Testing 253 Patients 35 (15%) had Preop Cardiac Testing Stress Thallium or Echo Testing Due to New Dx (EKG, CHF) in 16 Patients
Slide 11-

Cardiac Testing Conclusions Preop Cardiac Testing In 48% Did Not Lead to New Medical Tx. In 52%, Recommendations were only made for Medical Management of Previously Known Cardiac Disease. No changes in Perioperative Orthopaedic or Medical Management Significant Delay to Surgery. (3.3 vs 1.9 days, p<0.001) Extrapolated to 250,000 US Annual Hip Fxs Preop Cardiac Testing of 15% Would Cost nearly $47,000,000 annually.
Slide 12-

ASA Classification
Slide 13-

ASA Score ASA Survival Class 1 – 8.5y Class 2 – 5.6y Class 3 – 3.5y Class 4 – 1.6y
Slide 14-

ASA Score ASA LOS 1 ASA : 2.053 Days ASA Cost 1 ASA : $9300
Slide 15-

Patients on Anticoagulation ASA/Plavix Ok to Operate with No Delay
Slide 16-

Patients on Anticoagulation Coumadin IV Vit K vs FFP Depends on Comorbidities and Response May need bridging with LMWH
Slide 17-

Patients on Anticoagulation Direct Thrombin Inhibitor Dabigatran Factor Xa Inhibitors Rivaroxaban Apixaban Difficult to Monitor/Reverse Currents Tests are Surrogates Only No Antidotes Highly Variable Strategies Currently Wait Out (48-72 Hrs) if not Emergent
Slide 18-

Cognitive Function Dementia Afflicts > 5 million Americans Most secondary to AD followed by Multi-Infarct Prevalence 60-65 years ~ 1/100 >90 years ~ 50/100 Ability to Consent, Rehab, Comply Fall Risk
Slide 19-

Clinical Ramifications of Cognitive Decline Higher Incidence of Delirium Higher Mortality and Morbidity Morrison: JAMA July 5, 2000 Copyright ©2000 American Medical Association. All rights reserved.
Slide 20-

Osteoporosis - Scope of the Problem 50% Caucasian Women will Fracture Most Serious Outcome - Hip Fracture 10-20% Excess Mortality at 1 year 25% Long Term NH Care Only 1/3 Regain Independence Psychological and Social Issues  Quality of Life
Slide 21-

Definitions Insufficiency Fracture Bone Fails with Normal WB Fragility Fracture Fall from a Standing Height or Less
Slide 22-

Diagnosis - DEXA BMD Relationship (SD) to Norms T-Score - Reference Standard Comparison to “young normal” adult same sex Z-Score Comparison to age matched adult same sex
Slide 23-

Orthopaedic Diagnosis - Osteoporosis Clinical Presentation Presence of Insufficiency or Fragility Fracture Bone Mineral Density (BMD) 2.5 SD Below the Young Adult Average Value (T)
Slide 24-

Further Diagnosis - Osteoporosis Labs Can Help R/O Secondary Causes CMP, Serum Thyrotropin, Protein Electrophoresis, PTH, Vitamin D, Urine Calcium, Cortisol Clinical Utility of Biochemical Markers still Not Proven
Slide 25-

FRAX Developed by WHO Incorporates Risk Factors + BMD Age, Sex, Ht, Wt, Family Hx, Previous Fx, Steroids, Smoking, EtOH, Secondary Causes, RA 10-yr Fracture Risk (%) Hip Other Major Fracture Online Tool Published with permission Osteoporosis International 2008 Vol 19 Issue 10 pp 1395-1408
Slide 26-

Pathophysiology - Osteoporosis Imbalance in Removal/Replacement of Ca Not an Organic Matrix or Mineralization Defect Loss of Trabecular Plates, Cortical Thinning Structural Weakening “Mechanical Problem”
Slide 27-

Surgical Issues - Osteoporosis Difficult Fracture Fixation Poor Screw Purchase Excessive Bowing (Distal Nail Penetration) Immobilization or Minimal WB Bone Loss Autogenous Bone Graft Not as Useful
Slide 28-

Surgical Timing Conflicting Results Regarding M/M being Increased or Unaffected by Delaying Surgery Early Surgery <48 Hrs Reduces Hospital Stay May also Reduce Complications and Mortality
Slide 29-

Surgical Timing 92 Patients Delay Greater than 4 days Increases the 6-month and 1-year Mortality Risks versus <48 Hours to Surgery
Slide 30-

Surgical Timing Different Story in Polytrauma Elderly Patient with 3 or More Comorbid Conditions have a Worse Survival Rate if Treated within 24 Hrs Need to Individualize Treatment Plan Pre-Existing Activity, Disease, Reserve, Injuries
Slide 31-

High Energy Trauma 6 x Greater Mortality for Elderly Polytrauma >65 yo Patient has 50% Mortality with ISS>20 24 - 44yo Patient has 50% Mortality with ISS>40
Slide 32-

Choice of Anesthesia Literature Search of Pubmed and Cochrane (1967-2010) 56 references, covering 18,715 patients with hip fracture
Slide 33-

Choice of Anesthesia Conclusions: Spinal Anesthesia Significantly Reduced Early Mortality, Fewer DVT, Less Acute Postop Confusion, Fewer MI, Fewer Pneumonia, Fewer Fatal PE, Less Postop Hypoxia. General Anesthesia Less Hypotension, Fewer CVA Data suggests that Regional Anesthesia is preferred, but the limited evidence does not permit definitive conclusion for mortality or other outcomes.
Slide 34-

Surgical Treatment Principles Plan for Possible Future Surgeries Incisions Implants Reduction Gentle Indirect Impaction - ↑ Stability
Slide 35-

Surgical Treatment Principles - Osteoporosis Fixation Length IM Nails, Long plates Augmentation Biologic Cements, Graft, Struts Angular Stability Locked screws with plates/nails Arthroplasty Shoulder, Elbow, Hip, Knee Allow WB if Possible
Slide 36-

Recognition - Osteoporosis Ortho Often the First to See Assure All at Risk Patients Have F/U Develop a System in Your Hospital Synthes Geriatric Program AOA Own the Bone
Slide 37-

Fractures Beget Fractures Risk of future fractures increases 1.5 - 9.5 fold following initial fracture History of fragility fracture is more predictive of future fracture than bone density
Slide 38-

Treatment - Osteoporosis Patients
Slide 39-

Treatment - Osteoporosis Address Risk Factors Avoid EtOH and Tob Ensure Nutrition Ca (1200mg) 600 mg po BID Vitamin D (>1500 IU) Other Nutrients Magnesium Silicon Vitamin K Boron
Slide 40-

Exercise and Rehab Improve Strength, Endurance, Posture Maintain Bone Density Prevent Falls 30 Minutes Moderate Intensity Daily Post Fracture Rehab May Reduce Future Fracture
Slide 41-

Fall Prevention Discuss with Family Medications Balance and Strength Training Correct Vision Walking Aids Fall Proofing the Home Poor Lighting Throw Rugs Pets
Slide 42-

Treatment - Osteoporosis Indication for Pharmacologic Intervention T-score < -2.5 without other Risk Factors T-score < -1.0 – 2.5 with other Risk Factors Fragility Fx FRAX Score Hip Fx 10-yr Risk >3% FRAX Score Other Major Fx 10-yr Risk >20%
Slide 43-

Pharmacological Therapy Anti-Resorptive Drugs Hormonal Replacement Therapy: Estrogen/Progestin Bisphosphonates: Alendronate, Ibandronate, Risendronate, Raloxifene, Zoledronic Acid Selective Estrogen Receptor Modulators: Raloxifene Calcitonin Bone Forming Drugs Teriparatide Recombinant Parathyroid Hormone
Slide 44-

Bisphosphonates Long T1/2 Side-Effects GI Jaw Osteonecrosis (Rare) Atypical Fractures Risk with Long term use Assess Both femurs Difficult to heal Must weigh risks of use against huge benefits of other Fx Prevention Hip, wrist, spine
Slide 45-

Conclusions Osteoporosis: Prevalence – Recognition is Key Need Effective Tx to  Fx Rate Nutrition Exercise Fall Prevention Medications Assure Follow Up Surgical Improvements Help
Slide 46-

Conclusions Careful Consideration of Pre-op, Intra-op, and Post-op Factors Unique to Geriatric Population Necessary to Obtain Goal of Long Term Functional Recovery