Injury | International Journal of the Care of the Injured - Volume 47 - Supplement 2

The use of augmentation techniques in osteoporotic fracture fixation

Christian Kammerlander

a,b,

*, Carl Neuerburg

, Jorrit-Jan Verlaan

, Werner Schmoelz

, Theodore Miclau

Sune Larsson

Department of Trauma Surgery, Munich University Hospital LMU, Nußbaumstr. 20, 80336 Munich, Germany

Department of Trauma Surgery and Sportsmedicine, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria

Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands

Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, San Francisco, University of California, San Francisco, San Francisco, CA, United States

Department of Orthopedics, Uppsala University Hospital, Uppsala, Sweden

A B S T R A C T

There are an increasing number of fragility fractures, which present a surgical challenge given the reduced bone

quality of underlying osteoporosis. Particularly in aged patients, there is a need for early weight bearing and

mobilization to avoid further complications such as loss of function or autonomy. As an attempt to improve

fracture stability and ultimate healing, the use of biomaterials for augmentation of osseous voids and fracture

fixation is a promising treatment option. Augmentation techniques can be applied in various locations, and

fractures of the metaphyseal regions such as proximal humerus, femur, tibia and the distal radius remain the most

common areas for its use. The current review, based on the available mechanical and biological data, provides an

overview of the relevant treatment options and different composites used for augmentation of osteoporotic

fractures.

K E Y W O R D S

Fragility fractures

Augmentation

Cement

Biomaterials

Osteoporosis

Hip fracture

Distal radius fracture

Vertebral fracture

Proximal tibia fracture

Introduction

Fragility fractures are of increasing importance in orthopaedic

trauma surgery given the demographic changes of our aging

population. The National Osteoporosis Foundation estimates that

there are approximately 2 million osteoporosis-related fractures in

the U.S. each year, while additional studies suggest that the worldwide

burden is closer to 9 million [1,2]. Thus, a majority of fractures are

associated with osteoporosis, which result in 36% of the annual in-

patient care costs, or 860 million

€

, in Germany alone [1]. Over the next

few decades the incidence of osteoporotic fractures is expected to

increase [2]. In these fragility fractures, surgical treatment can be

challenging given the reduced bone quality that particularly affects

the frequently fractured metaphyseal regions such as the proximal

humerus, proximal femur, distal radius, spine, and proximal tibia.

Postoperative non-union, screw cut-out, and implant migration are

common complications adversely affecting patient outcomes. In the

elderly patient population susceptible to fragility fractures, full weight

bearing and early mobilization are of paramount importance in

order to avoid the significant peri- and post-operative complications

associated with frequently present comorbidities. The one-year

mortality of hip fractures for example is up to 30% [3].

While advances in implant design such as locked plates have

addressed some of the challenging issues, there is still need to promote

fracture biology, augment bone defects, and improve surgical fixation

in the osteoporotic patient. The aim of this review is to provide

an overview of a history of bone augmentation, clinical problems

associated with osteoporotic fractures, and potential solutions to these

challenges through the use of various augmentation techniques.

Mechanical and biological characteristics in osteoporotic fractures

Age-related resorption of calcium from bone results in thinning

of both trabecular and cortical bone and an associated increase in

bone diameter [2]. These anatomic changes have a direct effect on

mechanical properties. As the density of bone decreases, there is a

commensurate decrease in the yield stress, elastic modulus of cortical

bone, and compressive strength of cancellous bone [2]. Additional

cellular and physiologic changes in the bone contribute to an impaired

healing potential; there is a decrease in the number, responsiveness,

and activity of mesenchymal progenitor cells, and signaling molecules.

There also is a decrease in vascularity and impaired osteoblast function

that affect both endochondral and periosteal osteogenesis [3].

Corresponding author: Kammerlander Christian, Department of Trauma Surgery, Munich

University Hospital LMU, Nußbaumstr. 20, 80336 Munich, Germany. Tel.: 0049-89-4400-

53147; Fax: +49 89 4400 54437.

E-mail address:

christian.kammerlander@med.uni-muenchen.de

(C. Kammerlander).

Injury, Int. J. Care Injured 47S2 (2016) S36

–

S43

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