Wrist Fractures in Osteoporotic Patients (2008)

This issue of the Journal of Orthopaedic Trauma gives an overview of 2 comprehensive workshops held in Bologna, Italy, and Rome, Italy, organized by the Osteoporotic Fracture Campaign*, an initiative of the International Society for Fracture Repair, endorsed by the International Osteoporosis Foundation. The workshops investigated the challenges faced not only by orthopaedic surgeons but also by engineers, radiologists, scientists, and rheumatologists in attempting to find the optimal treatment solution for elderly osteoporotic patients with distal radial fractures. These fractures pose a tremendous challenge to the orthopaedic community as osteoporotic patients have a high rate of unsatisfactory results due to the frequent inability of both conservative and surgical treatment to maintain fracture reduction for the time required for complete bone callus formation. As a consequence, fracture malunion and inadequate functional results are common. Given that the level of activity in the elderly is much higher in 2008 than in the past, it is necessary to assist them in retaining their quality of life. Indeed, action must be taken to improve the current results. These fractures also offer a tremendous opportunity to diagnose the osteoporotic disease. This can be effectively treated with a variety of pharmaceuticals thus reducing the risk of secondary fractures. In a panel discussion, topics ranged from accurate assessment of bone mineral density and issues concerning conservative fracture treatment, the use of fixation augmentation techniques such as hydroxyapatite-coated implants and calcium phosphate cements, and the types of fixation methods which yield the best results. Another issue of great importance is the preoperative use of dual energy x-ray absorptiometry as a tool not only to diagnose the osteoporotic disease but also to help in the selection of the most appropriate surgical treatment. Fracture signs that help to determine whether conservative or surgical treatment is appropriate were also addressed. If a fracture needing reduction is stable after the volar cortices are engaged, it will remain stable. In this case, conservative treatment can be considered. However, when there is comminution and significant displacement, surgical treatment is recommended. This should also be implemented in all patients who had received conservative treatment and in whom fractures redisplaced. Although less invasive fixation methods are still the most commonly used (workshop audience poll 75%), it was suggested that fixed-angle plate fixation implanted through the volar approach will become more popular than the traditional fixation methods, such as percutaneous pinning, external fixation, and plate fixation implanted through the dorsal approach. Advantages of fixed-angle plate fixation include the possibility to adequately expose the fracture site thus obtaining a better reduction. Another important advantage is faster rehabilitation. External fixation also plays a great role in this patient population. Such fixation can be augmented by using screws coated with hydroxyapatite, Kirshner wires, and calcium phosphate cements. It has been reported that although the popularity of fixed-angle plates is dramatically increasing, there is no evidence that it is superior to external fixation. Regardless of the chosen fixation method, the interface between the implant and the bone is of great importance. Implant stability can be improved by using screws coated with calcium phosphates, which significantly reduce the incidence of postoperative complications including loosening, infection, and malunion. Improvement of fixation stability can also be obtained by injecting the host bone with calcium phosphate cements. However, whether this is cost effective remains to be seen and also needs to be investigated. As the number of surgical options continues, to increase, the surgeon's preference and expertise remains crucial. For a proper diagnosis of a distal radial fracture, standard anteroposterior and lateral radiographic views are sufficient. Additional views might help in evaluating associated injuries. Computed tomography scans are helpful in assessing the joint integrity. New sophisticated diagnostic tools will provide additional information about bone quality and geometry. It has been shown that the mechanical properties of the bone correlate with implant failure. The restoration of function and activities of daily living should be the ultimate goal for surgeons dealing with osteoporotic patients with distal radial fractures. Indeed, this requires a combined effort between orthopaedic surgeons, rheumatologists, implant manufacturers, and engineers. Workshops of the kind held in Bologna and Rome are proven to be the ideal environment to advance the level of knowledge in this field. ACKNOWLEDGMENTS *A collaboration between the International Society for Fracture Repair (ISFR) and the International Osteoporosis Foundation (IOF): Members of the Distal Forearm Workshop, Phase II (DFWII) include: Allen Goodship-UK Alan Johnstone-UK Amy Ladd-USA Amy Hoang-Kim-Italy Antonio Moroni-Italy Burkhardt Wippermann-Germany Charles Day-USA Carl Ekholm-Sweden Charles Melone-USA David Marsh-UK Emil Schemitsch-Canada Hannu Aro-Finland Harry Genant-USA Harry Van Lenthe-Switzerland Jesse Jupiter-USA Jörg Goldhahn-Switzerland Mark Kettler-Germany Mo Akmal-UK Nicola Fazzalari-Australia Nadine Vollevoet-Belgium Olof Johnell-Sweden Pietro Regazzoni-Switzerland Stefan Goemaere-Belgium Volker Kuhn-Germany We would also like to acknowledge: Thomas Einhorn-US, Peter Augat- Germany, Mathias Bostrom-US and Dorcas Beaton-Canada for their contribution to the supplement. Amy Hoang-Kim, BScH *Bologna, Italy Jörg Goldhahn, MD †Co-Guest Editor Zurich, Switzerland Antonio Moroni, MD ‡Guest Editor Bologna, Italy