Osteoporotic distal femur fractures in the elderly: peculiarities and treatment strategies

An Outline on the Advancements in Surgical Management of Osteoporosis-Associated Fractures

Osteoporosis significantly impairs bone density and increases fracture risk, representing a substantial global health challenge. The effectiveness of traditional treatments such as calcium supplementation and exercise in completely preventing fractures is limited. This review explores recent advancements in surgical techniques and treatment modalities to manage osteoporotic fractures better and improve patient outcomes. Osteoporotic fractures demand specialized surgical techniques due to compromised bone quality. Vertebroplasty and kyphoplasty are minimally invasive procedures that provide rapid pain relief and structural support using bone cement. While vertebroplasty is effective, it carries risks of cement leakage and new fractures. Kyphoplasty, with added balloon inflation, reduces leakage risk and improves vertebral height restoration but is costlier. Cement-augmented screws enhance fixation but can increase adjacent fracture risk and pose long-term complications. Surgical advancements encompass robotic-assisted surgery, offering precision and accelerated recovery, alongside biologic agents like bone morphogenetic proteins (BMPs), which enhance bone healing while reducing secondary interventions and eliminating donor site morbidity. Bone graft substitutes such as calcium phosphate cements enhance biomechanical compatibility, decrease morbidity, and reduce fracture loss and pain. Balloon kyphoplasty aids in height restoration and pain relief and diminishes the risk of subsequent vertebral fractures. Bioglass scaffolds promote bone regeneration by improving bone mineral density and lowering the incidence of new fractures. Optimal perioperative care, including patient selection, nutritional management, and early mobilization strategies, is crucial for mitigating risks in vulnerable populations. While current surgical interventions provide significant pain relief and functional benefits, ongoing research and multidisciplinary collaboration are crucial to prospectively refine these techniques and reduce the burden of osteoporosis. New technologies, such as tissue engineering and gene editing, hold potential for future treatment paradigms.

Geriatric distal femoral fractures: post-operative complications and nine-year mortality-a retrospective analysis of two tertiary trauma centres

PURPOSE

This study aimed to estimate the mortality at various post-operative intervals and explore influential variables for these outcomes in elderly patients with distal femur fractures (DFF).

METHODS

A retrospective observational study was conducted across two tertiary care institutions, between 2014 and 2020. The primary outcomes were mortality rates at 30-day, six month, and one year post-surgery. Secondary outcomes included 1-year readmission and reintervention rates along with their correlated complications.

RESULTS

A total of 37 DFF in 35 patients was analyzed; average age was 83.6 years (range, 65-98 years). The overall mortality rate at a maximum follow-up of 8.8 years was 74% (26/35 patients). The median survival time was 3.2 years and the survival probability at five years was 27% (95% confidence interval [CI], 13 to 43%). Mortality rates at 30 days, six months, and one year after surgery were 8.6% (3 patients), 23% (8 patients), and 34% (12 patients), respectively. Overall mortality rate was 64% (15/24 patients) for native distal femur fractures, and 92% (13/14 patients) for periprosthetic fractures (p = 0.109). Patients older than 85 years and male gender were identified as risk factors for mortality within the first year post-operatively.

CONCLUSION

Elderly fractures have a high mortality at eight years of follow-up. Mortality at one year was much higher than in other studies of the same nature. We did not find statistically significant differences when comparing native bone fractures with periprosthetic fractures. Factors that impact mortality were being a man, advanced age, elevated index comorbidity, and dementia. There is no relationship between the time to be taken to the surgical procedure and mortality results.

Cortical bone thickness on preoperative CT scans as predictor of bone quality in distal femur fractures: a retrospective study in Caucasians

AIM

Distal femur fractures (DFF) are rare, but associated with high complication rates and mortality, particularly in patients with osteoporosis. To improve preoperative assessment, we analyzed if cortical bone thickness on CT and AP radiographs is associated with clinical parameters of bone quality.

METHODS

Retrospective single-center study of adult patients presenting at a level-one trauma center, with a DFF between 2011 and 2020. Clinical parameters for bone quality, such as age, sex, body mass index (BMI), energy impact level of trauma, and known history of osteoporosis, were assessed. Mean cortical bone thickness (CBTavg) on AP radiograph was determined using a previously published method. Cortical thickness on CT scan was measured at 8 and 14 cm proximal to the articular surface of the lateral condyle.

RESULTS

71 patients (46 females) between 20 and 100 years were included in the study. Cortical thickness determined by CT correlated significantly with CBTavg measurements on AP radiograph (Spearman r = 0.62 to 0.80; p < 0.001). Cortical thickness was inversely correlated with age (Spearman r = - 0.341 to - 0.466; p < 0.001) and significantly associated with trauma impact level and history of osteoporosis (p =  < 0.001). The CT-based values showed a stronger correlation with the clinical parameters than those determined by AP X-ray.

CONCLUSION

Our results showed that cortical thickness of the distal femur correlates with clinical parameters of bone quality and is therefore an excellent tool for assessing what surgical care should be provided. Interestingly, our findings indicate that cortical thickness on CT is more strongly correlated with clinical data than AP radiograph measurements.

Distal Femur Replacement: An Option for Osteoporotic Fractures in the Elderly

Background A distal femur fracture (DFF) around the native or prosthetic knee is commonly seen in the osteoporotic elderly population. Surgical management is required to restore the function. Fracture fixation requires a period of restricted weight-bearing; however, distal femoral replacement (DFR) allows immediate weight-bearing and quicker recovery. Methods All patients who underwent distal femur replacement from 2020 to 2023 at our hospital were retrospectively reviewed. Data related to the patient's demographics, medical comorbidities, preinjury mobility status, perioperative management and length of stay were collected. Results Eleven patients with 13 distal femoral replacements were included. There were 10 periprosthetic and 3 native fractures around the distal femur. Two patients had bilateral periprosthetic fractures. The median age was 84 years (range 62-95) with all patients being females. Eight patients were living in their homes while three were care home residents. The median duration of surgery was 120 min. The mean blood loss was 350 ml. Patients were mobilised out of bed at a median of three days and were able to walk for 2 meters with a frame at a mean of 10 days (range 3-15) except for two patients whose mobility was limited to the chair. The mean length of hospital stay was 32 days (range 8-54). All patients were discharged back to their original destination except for one who was shifted to a care home instead of her own home. Conclusion In our opinion, distal femur replacement provided a more favourable outcome with respect to pain management, early rehabilitation with full weight-bearing immediately following the surgery and fewer complications. Furthermore, in our hands, the surgical time was short with limited blood loss.

Combined nail-plate constructs in the management of osteoporotic native distal femoral fractures: a systematic review of the available evidence

PURPOSE

Distal femoral fractures account for 4-6% of fragility fractures. These may be managed using a combined nail-plate construct (NPC). The use of NPCs is gaining traction. Whilst several theoretical advantages exist, there is little evidence reporting on binary or patient-reported outcomes. The aim of the current study was to perform a systematic review of the available literature pertaining to NPCs and their treatment of native distal femoral fractures, appraising the outcomes and focusing on the rationale for their increasing uptake in recent literature.

METHODS

A comprehensive search of MEDLINE, EMBASE, Clinical Key, PubMed and Cochrane library was performed from date of inception up to in August 9, 2022. All study languages were included initially. A further Google Scholar search review was performed to identify any other studies not identified in the database interrogation. Studies were eligible if they reported on the use of nail-plate constructs in managing distal femoral fractures. Any outcome metric was permitted. The study was conducted in accordance with PRISMA guidelines. Risk of bias was assessed using the Methodological Index for non-randomised Studies tool. Quantitative analysis was performed using a log odds ratio random effects model. The Knapp-Hartung adjustment was utilised if the total number of included studies was < 5. Study effect sizes and appropriate plots were constructed to illustrate the outcomes data.

RESULTS

A total of four studies were eligible for inclusion. Study data was extracted and summarised with their relevant outcomes presented. The literature review demonstrated that the use of NPCs led to significantly earlier full weight bearing (p < 0.001) and had reduced non-union rates over a single construct, without affecting infection rates (12.5% vs. 5.6%; p = 0.289) and significantly lower implant failure rates (10.5% vs. 0%; p = 0.011). A meta-analysis is performed of available studies and Forrest plots presented.

CONCLUSION

The use of NPC in the management of native osteoporotic DFFs is gaining traction but the available evidence is of low grade with significant heterogeneity in small cohorts of patients. We suggest that a large-scale, multicentre prospective study should be performed, with agreed functional and radiological outcome metrics, to provide a more robust evidence base.

Is the Citak classification of distal femur morphology age and gender dependent?

INTRODUCTION

The purpose of this study was to compare the distal femur morphology in different age and gender groups using the Citak classification.

MATERIALS AND METHODS

All patients who had standard knee anteroposterior radiographs between 2010 and 2020 were retrospectively reviewed using the electronic patient database. Patients were divided into three age groups as follows: young adults (Group I, younger than 50 years), middle-aged adults (Group II, ranging from age 51 to 73 years), and elderly (Group III, more than 74 years). From each age group, 80 patients were randomly selected with an equal number of gender (40 males/40 females). An age-stratified selection was applied to obtain the best sample that represents the selected age groups. Patients younger than 18 years of age, history of previous fracture or surgical procedure, those with fixation implants or prosthesis, and abnormalities of the lower limb, such as a congenital deformity, were excluded from the study. All measurements were performed by an experienced orthopedic surgeon familiar with the Citak classification. All measured variables were compared between age and gender groups.

RESULTS

There were 240 patients (120 male and 120 female) with a mean age of 59.6 ± 20.4 (range 18-95). The distal femur morphology index was similar (p:0.811), and the morphological types were equally distributed among age groups (p:0.819). Furthermore, there was no significant difference between genders on the measured variables (p > 0.05 for all variables). Citak classification types were similarly distributed between the genders (p:0.153). No correlation was found between age and the Citak index in either gender (p:0.967 and p:0.633, respectively).

CONCLUSIONS

Distal femoral morphology classified by the Citak index is not age and gender dependent. Type C, which has a wider diaphyseal diameter, and is supposed to be more common in elderly subjects, was equally distributed in all age groups.

LEVEL OF EVIDENCE

Level IV. Retrospective case series.

One-Year Mortality Rates Following Fragility Femoral Fractures in Patients Presenting to King Saud Medical City in Riyadh, Saudi Arabia: A Retrospective Study

Objective: The objective is to investigate one-year mortality rates following femur osteoporotic fractures, and to investigate factors that are associated with higher mortality rates.

Design: A retrospective study was conducted from 2010 to 2021 (11 years) of all patients who presented to King Saud Medical City, Saudi Arabia, and had a fragility fracture of the proximal or distal femur.

Patients: One hundred eight patients who sustained a proximal or distal femoral fracture, as a result of low-energy trauma, were included.

Results: The majority of our cohort (77.8%) had proximal femoral fractures, whereas only 22.2% had a distal femoral fracture. 55.6% were less than 75 years old, and 44.4% were 75 years or older. All patients had fallen from standing height. Hypertension and diabetes were the most common comorbidities among our cohort at 49.1% and 47.2%, respectively, but neither showed a statistically significant increase in the risk of mortality. When assessing the overall mortality, 21.3% of our patients had passed away. Although this finding was not statistically significant, mortality rates were found to be higher in patients with proximal femoral fractures compared to distal femoral fractures (25% vs. 8.3%, respectively, p=0.095). Patients with a normal bone mass density (BMD) had higher mortality rates as opposed to those with abnormal BMD (p=0.001).

Conclusions: Mortality rates are higher in proximal femoral fractures compared to distal femoral fractures. In addition, within our study cohort, patients with normal BMD had higher mortality rates. We recommend prospective studies that compare mortality rates between proximal and distal femoral fractures in patients with osteoporosis, as these studies would provide more accurate data. We also recommend having BMD measured in those patients to avoid further fractures in this patient population.

The geriatric distal femur fracture: nail, plate or both?

Surgical fixation of distal femur fractures in geriatric patients is an evolving topic. Unlike hip fractures, treatment strategies for distal femur fractures are ill-defined and lack substantive high-quality evidence. With an increasing incidence and an association with significant morbidity and mortality, it is essential to understand existing treatment options and their supporting evidence. Current fixation methods include the use of either retrograde intramedullary nails, or plate and screw constructs. Due to the variability in fracture patterns, the unique anatomy of the distal femur, and the presence or absence or pre-existing implants, decision-making as to which method to use can be challenging. Recent literature has sought to describe the advantages and disadvantages of each, however, there is currently no consensus on a standard of care, and little randomized evidence is available that directly compares intramedullary nails with plating. Future randomized studies comparing intramedullary nails with plating constructs are necessary in order to develop a standard of care based on injury characteristics.

Subtrocantheric nonunion following fracture of an arthrodesed hip: a case report

In recent years in the era of successful of total hip replacement, hip arthrodesis is rarely performed. The anatomy and biomechanics of an arthrodesed hip is altered, thus influencing the treatments strategies in case of fracture or nonunions. This case report describes the management and therapeutic solution for the treatment of subtrochanteric nonunion in a patient with hip arthrodesis. Satisfactory outcomes were finally obtained after a double surgical procedure.