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preclude nailing. Using good surgical technique remains of critical
importance in treating patients with osteoporotic fractures, as
salvage after a surgical technical errors may be very difficult in this
scenario. Steps such as getting a good starting point and reamer path,
along with accurate fracture reduction, are key elements. Occasionally,
repair of an osteoporotic fracture is either not indicated or not possible.
In these cases, there remains a role for non-operative treatment or
treatment with arthroplasty, respectively. The benefits of arthroplasty
in the osteoporotic fracture patient are clear: the requisite for fracture
healing and protected weight bearing is obviated. Potential risks for
catastrophic failure (
e.g.
infection) and limited salvage options are
inherent.
A number of biomechanical studies have demonstrated that the
stability of modern nails and plates in osteoporotic fracture models are
comparable, although the characteristics of their respective
“
instabil-
ities
”
are different [15,16]. Clinically, intramedullary nails have been
shown to be effective for periarticular distal femur fractures in cohort
studies [17,18]. Recently, a large prospective, randomized trial has
shown that nails are at least as effective in treating distal femur
fractures compared with plates [19]. Qualitatively, nails typically
provide for abundant healing with symmetrical callus. Interestingly,
there has been a recent push to create more symmetrically balanced
constructs using plates in the form of dynamic plating [20], such that
the mechanical environment more closely matches that of intrame-
dullary nails.
Some surgeons have suggested further enhancement of fixation
by using traditional concepts of plates and nails by using them
together, such as overlapping them to stabilize an entire femur,
thereby prophylactically preventing future periprosthetic fractures.
Interprosthetic fractures have forced us to use creative solutions for
working with and around pre-existing implants. It does not seem
so far off where manufacturers design plates, nails, and even
arthroplasties that might link together for these reasons. Addition-
ally, changing the interface between the implants and the bone
has and will continue to be a field of interest for surgeons treating
osteoporotic fractures. Locally, bone cements and surface coat-
ings are being used to improve fixation. For example, fenestrated
screws are now approved by the U.S. Food & Drug Administration
to apply with injectable calcium phosphate to augment the screw
fixation.
Summary
It is clear that osteoporotic fractures create a number of
challenges that will increasingly affect the practices of orthopedic
surgeons. The current culture has arrived such that the energy
and resources for dealing with these issues is increasing seemingly
in proportion to the magnitude of the problem. Implants and
techniques will likely continue to evolve to address many of the
unique issues centered obtaining stable internal fixation in osteo-
porotic fractures.
Conflict of interest
Michael J. Gardner has received consulting fees from DePuy-
Synthes, Pacira and KCI; royalties from Lippincott Williams & Wilkins
and served as a speaker for KCI.
Cory Collinge has no conflict of interest.
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