Counter:

Fractures in osteoporosis

with special reference to their social & economic impact
Stephan M. Perren, Prof. Dr. med. D.Sc. (h.c.) [1]

Osteoporosis as a disease:

Fracture and treatment there of in osteoporosis

The osteoporotic bone does not only fracture more readily but its treatment is very demanding and often determines the prognosis quoad vitam: The choice is either life threatening prolonged bed rest or early return to normal life. Elderly people with fracture of porotic bone run a high risk of permanent disability due to today’s shortcoming in fracture treatment that should allow them to quit early and safely the bed to avoid mainly cardiovascular and respiratory complications.

Fractures in elderly osteoporotic patients do not only affect quality of life, they are life threatening.

The prognosis of fractures in porotic bone

General agreement is that in spite of up to date treatment of hip fractures in osteoporotic bone

• 20% of the patients with hip fractures in porotic bone died within one year.
• 1/3 of the patients remain bed or chair ridden
• 1/3 suffer functional limitations and require assistance
  

Only 1/3 of osteoporosis patients suffering from hip fractures return to full function

The goal of fracture treatment
is immediate return of mobility to avoid extended bed rest with its complications. This should be achieved by surgical stabilization, to alleviate pain and allow early safe weight bearing.

The problem
Stabilization of the fracture in porotic bone is difficult to achieve because the anchorage of implants in weak bone is deficient. While surgical stabilization even in healthy bone rarely allows for immediate full weight bearing the situation in fractures of osteoporotic bone is extremely difficult: Not only is the bone weak but because control of weight bearing is missing in elderly people, the stabilization must withstand peak load of uncontrolled weight bearing. The difficulties mentioned apply mainly to hip fractures and spine fractures, two very frequent incidences in osteoporosis beside wrist fractures. The direct costs of fractures in Osteoporotic bone in the USA are estimated to be 18 Billion $ a year and increasing, total economic impact is far greater..

Possible solutions:
Reduction of peak stress in uncontrolled loading can be achieved by a more appropriate basic construction and application of implants while improving anchorage at the interface of bone requires a large contact area and an especially tolerant design of the implant surface in contact with bone. This concerns the acute phase of fracture treatment that is before therapeutic improvement of bone quality can be achieved. In a second phase the thrust of medical activity will serve to improve bone strength to ensure long term success of the fracture treatment. Beside proper activity and nutrition the pharmaceutical armamentarium has recently seen a promising improvement avoiding fractures. Furthermore, physical exercise to improve coordination not only to prevent falling but to strengthen protecting muscles and coordinating their activity will help to minimize fracture risk.

[1] Stephan Perren trained as a trauma surgeon. With a wide spectrum of biological and technical interests, he took up clinically oriented biomechanical research. He built within 30 years as director of research and development of the International AO Foundation an interdisciplinary team of surgeons, biologists, physicists and engineers in the Davos AO centre devoted to the improvement of fracture treatment in trauma care. With his collaborators he contributed essentially to a new understanding of fracture healing that resulted in basically improved fracture treatment with global impact.

The data presented here is based on reports of national osteoporosis associations.