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Medicina
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New Strategies in the Management of Geriatric Bone Fracture
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New Strategies in the Management of Geriatric Bone Fracture

A special issue of Medicina (ISSN 1648-9144). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: closed (31 December 2024) | Viewed by 4765

Special Issue Editor

Prof. Dr. Matthias Knobe

E-Mail Website
Guest Editor
1. Department of Orthopaedic Trauma, Westmuensterland Hospital, 48683 Ahaus, Germany
2. Medical Faculty, University of Zurich, Zurich, Switzerland
3. RWTH Aachen University Hospital, Aachen, Germany
Interests: anchorage strategies in geriatric hip fracture management; fragility fracture; fall prevention; ortho-geriatric co-management; geriatric trauma center; medical education; biomechanical investigations; microcirculation
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Special Issue Information

Dear Colleagues,

Geriatric trauma care is gaining more importance due to demographic changes. In addition to poor bone quality, which makes fracture fixation more difficult, comorbid conditions often lead to perioperative complications and hamper rehabilitation.

Surgical treatment in geriatric trauma care should be straightforward and less invasive, allow immediate weight-bearing, and should be associated with a low complication rate. The failed treatment of geriatric fragility fractures leads to remarkable disability and pain, and revision surgery is frequently accompanied by higher complication and reoperation rates than primary fixation. There is an urgent need to establish a profound strategy for the effective surgical management of these fragile patients. The answer to all problems is still lacking—all or partly in consequence of the complication rate induced by the surgeon themselves. Even though the fracture pattern indicates a specific treatment option to some extent, the patient characteristics play an important role in decision making. To improve construct stability, cement augmentation strategies should be evaluated critically. Adequate reduction and stable fixation are prerequisites for uneventful healing. A meticulous operative technique can prevent iatrogenic complications.

The purpose of this Special Issue is to discuss the evidence for the fixation/prosthetic treatment of osteoporotic fractures in the elderly considering innovations and developments in the future as well. The scope of this Special Issue is deliberately broad in order to encourage the coverage of a wide range of topics and perspectives related to the management of geriatric fractures. This includes not only clinical treatments but also biomechanical considerations regarding implant anchorage, patient experience, epidemiology, service delivery, complex co-management strategies in geriatric fracture care including fall prevention, and new interdisciplinary developments like the installation of a fracture liaison service or a geriatric fracture center.

Prof. Dr. Matthias Knobe
Guest Editor

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Keywords

  • osteoporosis
  • fracture fixation
  • implant anchorage
  • cement augmentation
  • co-management
  • fragility fracture
  • comorbidity
  • fall prevention
  • biomechanical investigation
  • geriatric fracture center

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Published Papers (5 papers)

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18 pages, 301 KiB  
Article
Does Baseline Hounsfield Unit Predict Patients’ Outcomes Following Surgical Management of Unstable Osteoporotic Thoracolumbar Fractures?
by Ahmed Qretam, Julien Ceuterick, Maher Ghandour, Ümit Mert, Christian Herren, Miguel Pishnamaz, Matthias Knobe, Frank Hildebrand, Rolf Sobottke and Mohamad Agha Mahmoud
Medicina 2025, 61(2), 227; https://doi.org/10.3390/medicina61020227 - 27 Jan 2025
Viewed by 509
Abstract
Background and Objectives: Osteoporotic fractures in the thoracic/lumbar spine pose significant challenges in surgical management, with high risks of complications. This study investigates the role of preoperative CT scans and Hounsfield Units (HUs) in predicting postoperative outcomes. Materials and Methods: A [...] Read more.
Background and Objectives: Osteoporotic fractures in the thoracic/lumbar spine pose significant challenges in surgical management, with high risks of complications. This study investigates the role of preoperative CT scans and Hounsfield Units (HUs) in predicting postoperative outcomes. Materials and Methods: A retrospective study was conducted from November 2015 to January 2018. Sixty-one patients over 60 years of age with unstable osteoporotic thoracolumbar spine fractures (OF: 3–4) were included. Preoperative CT scans were performed to measure HU values. Postoperative standing X-rays were taken at 3–12 months to assess signs of loosening, adjacent fractures, or screw dislodgement. HU was divided into quartiles: Q1 (<56.24), Q2 (56.24–72.63), Q3 (72.63–87.59), and Q4 (>87.59). Results: Out of the 61 patients, 14 (23%) exhibited signs of screw loosening, adjacent fractures, or screw dislodgement within 3 to 12 months postoperatively. The mean HU value measured was 65.21, with a range from 21.43 to 140.7. Notably, all patients with observed loosening or dislodgement had HU values below 68. HU significantly predicted mortality, with the second quartile showing a markedly increased risk (adjusted odds ratio [aOR] = 8.12; p = 0.044). However, HU quartiles were not significant predictors of other outcomes. Other factors (fracture level and ASA classification) also influenced clinical outcomes, particularly mortality. Conclusions: HU values from preoperative CT scans are crucial in predicting the risk of screw loosening, dislodgement, and adjacent fractures in osteoporotic spinal fractures. Integrating HU assessment into clinical practice can improve preoperative planning, allowing for more targeted surgical interventions and better clinical outcomes. Full article
(This article belongs to the Special Issue New Strategies in the Management of Geriatric Bone Fracture)
11 pages, 2266 KiB  
Article
Multiplanar Semicircular New-Generation Implant System Developed for Proximal Femur Periprosthetic Fractures: A Biomechanical Study
by Ahmet Burak Satılmış, Ahmet Ülker, Zafer Uzunay, Tolgahan Cengiz, Abdurrahim Temiz, Mustafa Yaşar, Tansel Mutlu and Uygar Daşar
Medicina 2025, 61(1), 110; https://doi.org/10.3390/medicina61010110 - 14 Jan 2025
Viewed by 537
Abstract
Background and Objectives: The study aimed to evaluate a newly designed semicircular implant for the fixation of Vancouver Type B1 periprosthetic femoral fractures (PFFs) in total hip arthroplasty (THA) patients. To determine its strength and clinical applicability, the new implant was compared [...] Read more.
Background and Objectives: The study aimed to evaluate a newly designed semicircular implant for the fixation of Vancouver Type B1 periprosthetic femoral fractures (PFFs) in total hip arthroplasty (THA) patients. To determine its strength and clinical applicability, the new implant was compared biomechanically with conventional fixation methods, such as lateral locking plate fixation and a plate combined with cerclage wires. Materials and Methods: Fifteen synthetic femur models were used in this biomechanical study. A Vancouver Type B1 periprosthetic fracture was simulated by osteotomy 5 mm distal to the femoral stem. The models were divided into three groups: Group I (lateral locking plate fixation), Group II (lateral locking plate with cerclage wires), and Group III (new semicircular implant system). All fixation methods were subjected to axial loading, lateral bending, and torsional force testing using an MTS biomechanical testing device. Failure load and displacement were measured to assess stability. Results: The semicircular implant (Group III) demonstrated a significantly higher failure load (778.8 ± 74.089 N) compared to the lateral plate (Group I: 467 ± 68.165 N) and plate with cerclage wires (Group II: 652.4 ± 65.474 N; p < 0.001). The new implant also exhibited superior stability under axial, lateral bending, and torsional forces. The failure load for Group III was more robust, with fractures occurring at the screw level rather than plate or screw detachment. Conclusions: Compared to traditional fixation methods, the newly designed semicircular implant demonstrated superior biomechanical performance in stabilizing Vancouver Type B1 periprosthetic femoral fractures. It withstood higher physiological loads, offered better structural stability, and could be an alternative to existing fixation systems in clinical practice. Further studies, including cadaveric and in vivo trials, are recommended to confirm these results and assess the long-term clinical outcomes. Full article
(This article belongs to the Special Issue New Strategies in the Management of Geriatric Bone Fracture)
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13 pages, 10350 KiB  
Article
Titanium Cable Cerclage Increases the Load to Failure in Plate Osteosynthesis for Distal Femoral Fractures
by Christopher Bliemel, Jakob Cornelius, Valerie Lehmann, Ludwig Oberkircher, Denis Visser, Bastian Pass, Steffen Ruchholtz and Martin Bäumlein
Medicina 2024, 60(9), 1524; https://doi.org/10.3390/medicina60091524 - 19 Sep 2024
Viewed by 1095
Abstract
Background and Objectives: The reduction of two-part oblique or spiral fractures of the distal femur using steel wire cerclage prior to plate osteosynthesis is a proven procedure. In addition to being useful in fracture reduction, wire cerclage was also shown to increase the [...] Read more.
Background and Objectives: The reduction of two-part oblique or spiral fractures of the distal femur using steel wire cerclage prior to plate osteosynthesis is a proven procedure. In addition to being useful in fracture reduction, wire cerclage was also shown to increase the stability of osteosynthesis. Nevertheless, metal corrosion and the allergenic potency of steel remain problematic disadvantages of this method. A biomechanical study was carried out to evaluate titanium cable cerclage as an alternative supplement for plate osteosynthesis of a distal femoral two-part fracture. Materials and Methods: An unstable AO/OTA 32-A2.3 fracture was created in eleven pairs of nonosteoporotic human cadaver femora. All the samples were treated with polyaxial angular stable plate osteosynthesis. One femur from each pair was randomly selected for an additional fracture fixation with multifilament titanium cable cerclage. Stepwise cyclic axial loading was applied in a load-to-failure mode using a servohydraulic testing machine. Results: All specimens (mean age: 80 years; range: 57–91 years) withstood a cycling force of at least 1800 N. With a mean load of 2982 N (95% CI: 2629–3335 N), the pressure forces resulting in osteosynthesis failure were significantly higher in specimens with an additional titanium cerclage (Group 1) than in samples that were solely treated with plate osteosynthesis (Group 2) at 2545 N (95% CI: 2257–2834 N) (p = 0.024). In both groups, cutting out the distal screws at the condyle region, resulting in shearing of the distal fragment proximal to the fracture line, was the most frequent cause of construct failure. Among the specimens assigned to Group 1, 36% exhibited a specific fracture pattern, namely, a fracture of the dorsal buttress above the cerclage. Analysis of axial stiffness (p = 0.286) and irreversible deformity of the specimens revealed no differences between the groups (p = 0.374). Conclusion: Titanium cable cerclage application, as a supplement to an angular stable plate, resulted in an increased load to failure. In terms of stability, the use of this adjunct for fracture fixation of supracondylar two-part oblique femoral fractures might, therefore, be an option, especially in patients who are sensitive to nickel. Full article
(This article belongs to the Special Issue New Strategies in the Management of Geriatric Bone Fracture)
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6 pages, 1825 KiB  
Case Report
Sandwiched Strut Allografts with Stem Retention to Treat Fragile Periprosthetic Femoral Fractures: A Case Report
by Hyoung Tae Kim, Hyun Jun Lee and Suenghwan Jo
Medicina 2025, 61(1), 166; https://doi.org/10.3390/medicina61010166 - 20 Jan 2025
Viewed by 687
Abstract
Managing periprosthetic femoral fractures is challenging, particularly in osteoporotic patients with fragile bones. Revision with a long stem is commonly considered but may fail to provide adequate fixation and stability in fragile bones. A novel approach using sandwiched strut allografts and controlled bone [...] Read more.
Managing periprosthetic femoral fractures is challenging, particularly in osteoporotic patients with fragile bones. Revision with a long stem is commonly considered but may fail to provide adequate fixation and stability in fragile bones. A novel approach using sandwiched strut allografts and controlled bone crushing with robust cable fixation can offer mechanical support and provide secondary stability to the loosened femoral stem and can be considered a treatment option for low-demand patients. A 73-year-old female with 23 years of hemodialysis experienced pain and instability in her right thigh following a slip. She had extremely low bone mineral density, and radiographs revealed a periprosthetic femoral fracture with a loosened femoral prosthesis, classified as Vancouver type B3. The patient underwent surgical fixation using a long anatomical plate augmented with dual strut allografts sandwiched anterior and posterior femur. Robust cable fixation was performed to partially crush the native cortical bone against the stem to enhance stability. Postoperative imaging at 18 months confirmed successful bone union and implant stability, and the patient regained preoperative functional capacity without pain. This case demonstrates that partially crushing native bone with dual strut allografts may provide stability to the loosened femoral stem and can be an effective alternative to long-stem revision surgery for patients with highly fragile bones. This approach may provide immediate mechanical stability and can be a potential treatment option for managing fragile periprosthetic femoral fractures. Full article
(This article belongs to the Special Issue New Strategies in the Management of Geriatric Bone Fracture)
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9 pages, 3908 KiB  
Case Report
Tibial Insufficiency Fracture with Characteristics of an Atypical Fracture: A Rare Case and Literature Review
by Ju-Yeong Kim and Se-Won Lee
Medicina 2024, 60(11), 1814; https://doi.org/10.3390/medicina60111814 - 4 Nov 2024
Cited by 1 | Viewed by 1564
Abstract
Background and Objectives: Osteoporosis is becoming more prevalent with the rise in the aging population, leading to the increased use of bisphosphonates for treatment. While these medications are effective in preventing osteoporotic fractures, long-term use has been associated with atypical insufficiency fractures, [...] Read more.
Background and Objectives: Osteoporosis is becoming more prevalent with the rise in the aging population, leading to the increased use of bisphosphonates for treatment. While these medications are effective in preventing osteoporotic fractures, long-term use has been associated with atypical insufficiency fractures, primarily in the femur. However, atypical fractures in other weight-bearing bones, such as the tibia, have rarely been reported. This study aims to present a case of an atypical insufficiency fracture of the tibia in an elderly female who has been on long-term bisphosphonate therapy and to review treatment outcomes within the context of the current literature. Patient concerns: A 76-year-old female presented with pain in the proximal right tibia, developing two months prior without trauma. She had been receiving long-term bisphosphonate therapy for osteoporosis, initially taking sodium risedronate orally for 4 years, followed by intravenous ibandronate for 10 years. Physical examination revealed localized tenderness, and radiographs showed cortical thickening and a horizontal fracture line in the proximal right tibia. MRI confirmed these findings, along with surrounding edema. The laboratory results were mostly normal, but the bone formation marker osteocalcin was significantly reduced. The patient had a history of insufficiency fractures in the ipsilateral tibia and contralateral femur, previously treated conservatively with teriparatide. A similar conservative approach was attempted but failed, leading to surgical intervention with intramedullary nailing and supplementary plating. At the 8-month follow-up, the patient showed successful fracture union and resolution of symptoms. Conclusion: Long-term use of bisphosphonates, though effective for osteoporosis, can lead to atypical insufficiency fractures, primarily in the femur but also occasionally in the tibia. Clinicians should consider this possibility when patients present with pain in weight-bearing bones without a history of trauma. Prompt diagnosis through thorough history-taking, physical examination, and appropriate imaging is essential to ensure timely management. Full article
(This article belongs to the Special Issue New Strategies in the Management of Geriatric Bone Fracture)
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