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Treatment of Spine and Pelvic Fractures in Patients with Osteoporosis

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

Deadline for manuscript submissions: closed (25 April 2022) | Viewed by 26642

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Prof. Dr. Philipp Kobbe

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Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany
Interests: pelvic and spine surgery; traumatology; seriously injured care
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Prof. Dr. René Hartensuer

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Center for Orthopaedic, Traumatology, Handsurgery, and Sportsmedicine, Klinikum Aschaffenburg-Alzenau, 63739 Aschaffenburg, Germany
Interests: pelvic and spine surgery; traumatology; trauma network; seriously injured care; telemedicine; augmented reality
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Dr. Marc Dreimann

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Spine Center, Department of Trauma-and Orthopedic Surgery, University Hospital Eppendorf, 20246 Hamburg, Germany
Interests: spine surgery; traumatology
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Osteoporosis is one of the most challenging co-incidences in traumatology of an aging population. In addition to fractures to the extremities, the spine and pelvis are affected. This often leads to pain, reduction in mobility, and reduced quality of life.

A better understanding of treatment options is mandatory in both osteoporosis, and in traumatic injuries in patients with decreased bone quality. Additionally, new treatment strategies will increase the quality and outcome of patient care.

So far, we are in the early stages of understanding the mechanisms, biomechanics and clinical options in patients with osteoporosis with or without an adequate trauma.

This Special Issue will focus on all types of research that provide a better understanding of pathophysiology, biomechanics, and clinical outcome from treatment of spine and pelvic fractures in patients with osteoporosis. Fractures may result from adequate trauma with and co-existing bone weakness or from osteoporosis itself. In both cases, more knowledge is required to improve treatment.

We are soliciting state-of-the art works focused either on biomechanical ex vivo knowledge on implant anchorage or on clinical data. This Special Issue aims to bring together aspects of both experimental and clinical knowledge.

This Issue aims to collect any kind of knowledge to improve the treatment of fractures of the pelvis and spine in patients with osteoporosis. In that respect, we are calling for papers that refine our understanding in mechanisms of disease; biomechanics; and techniques to address pathologies, stabilize instabilities, reduce pain, and measure the outcomes.

Prof. Dr. Philipp Kobbe
Prof. Dr. René Hartensuer
Dr. Dreimann Marc
Guest Editors

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Keywords

fracture
osteoporosis
spine
pelvis

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Published Papers (7 papers)

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11 pages, 16016 KiB

Open AccessArticle

Sacroiliac Screw Placement with Ease: CT-Guided Pelvic Fracture Osteosynthesis in the Elderly

by Hannah Kress, Roman Klein, Tim Pohlemann and Christoph Georg Wölfl

Medicina 2022, 58(6), 809; https://doi.org/10.3390/medicina58060809 - 15 Jun 2022

Cited by 1 | Viewed by 2327

Abstract

Background and Objectives: The number of geriatric patients presenting with fragility fractures of the pelvis is increasing due to ageing Western societies. There are nonoperative and several operative treatment approaches. Many of which cause prolonged hospitalisation, so patients become bedridden and lose mobility and independence. This retrospective study evaluates the postoperative outcome of a computed tomography-guided (CT-guided) minimally invasive approach of sacroiliac screw osteosynthesis. The particular focus is to demonstrate its ease of use, feasibility with the equipment of virtually every hospital and beneficial outcomes to the patients. Materials and Methods: 28 patients (3 men, 25 women, age 80.5 ± 6.54 years) with fragility fractures of the pelvis types II-IV presenting between August 2015 and September 2021 were retrospectively reviewed. The operation was performed using the CT of the radiology department for intraoperative visualization of screw placement. Patients only received screw osteosynthesis of the posterior pelvic ring and cannulated screws underwent cement augmentation. Outcomes measured included demographic data, fracture type, postoperative parameters and complications encountered. The quality of life (QoL) was assessed using the German version of the EQ-5D-3L. Results: The average operation time was 32.4 ± 9.6 min for the unilateral and 50.7 ± 17.4 for the bilateral procedure. There was no significant difference between surgeons operating (p = 0.12). The postoperative CT scans were used to evaluate the outcome and showed only one case of penetration (by 1 mm) of the ventral cortex, which did not require operative revision. No case of major complication was reported. Following surgery, patients were discharged after a median of 4 days (Interquartile range 3–7.5). 53.4% of the patients were discharged home or to rehabilitation. The average score on the visual analogue scale of the EQ-5D-3L evaluating the overall wellbeing was 55.6 (Interquartile range (IQR) 0–60). Conclusions: This study shows that the operative method is safe to use in daily practice, is readily available and causes few complications. It permits immediate postoperative mobilization and adequate pain control. Independence and good quality of life are preserved. Full article

(This article belongs to the Special Issue Treatment of Spine and Pelvic Fractures in Patients with Osteoporosis)

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12 pages, 1006 KiB

Open AccessArticle

Impact of Sarcopenia and Bone Mineral Density on Implant Failure after Dorsal Instrumentation in Patients with Osteoporotic Vertebral Fractures

by Harald Krenzlin, Leon Schmidt, Dragan Jankovic, Carina Schulze, Marc A. Brockmann, Florian Ringel and Naureen Keric

Medicina 2022, 58(6), 748; https://doi.org/10.3390/medicina58060748 - 31 May 2022

Cited by 8 | Viewed by 3822

Abstract

Background and Objectives: Age-related loss of bone and muscle mass are signs of frailty and are associated with an increased risk of falls and consecutive vertebral fractures. Management often necessitates fusion surgery. We determined the impacts of sarcopenia and bone density on implant failures (IFs) and complications in patients with spondylodesis due to osteoporotic vertebral fractures (OVFs). Materials and Methods: Patients diagnosed with an OVF according to the osteoporotic fracture classification (OF) undergoing spinal instrumentation surgery between 2011 and 2020 were included in our study. The skeletal muscle area (SMA) was measured at the third lumbar vertebra (L3) level using axial CT images. SMA z-scores were calculated for the optimal height and body mass index (BMI) adjustment (zSMA_HT). The loss of muscle function was assessed via measurement of myosteatosis (skeletal muscle radiodensity, SMD) using axial CT scans. The bone mineral density (BMD) was determined at L3 in Hounsfield units (HU). Results: A total of 68 patients with OVFs underwent instrumentation in 244 segments (mean age 73.7 ± 7.9 years, 60.3% female). The median time of follow-up was 14.1 ± 15.5 months. Sarcopenia was detected in 28 patients (47.1%), myosteatosis in 45 patients (66.2%), and osteoporosis in 49 patients (72%). The presence of sarcopenia was independent of chronological age (p = 0.77) but correlated with BMI (p = 0.005). The zSMA_HT was significantly lower in patients suffering from an IF (p = 0.0092). Sarcopenia (OR 4.511, 95% CI 1.459–13.04, p = 0.0092) and osteoporosis (OR 9.50, 95% CI 1.497 to 104.7, p = 0.014) increased the likelihood of an IF. Using multivariate analysis revealed that the zSMA_HT (p = 0.0057) and BMD (p = 0.0041) were significantly related to IF occurrence. Conclusion: Herein, we established sarcopenic obesity as the main determinant for the occurrence of an IF after instrumentation for OVF. To a lesser degree, osteoporosis was associated with impaired implant longevity. Therefore, measuring the SMA and BMD using an axial CT of the lumbar spine might help to prevent an IF in spinal fusion surgery via early detection and treatment of sarcopenia and osteoporosis. Full article

(This article belongs to the Special Issue Treatment of Spine and Pelvic Fractures in Patients with Osteoporosis)

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7 pages, 2000 KiB

Open AccessArticle

Prevention of Compression Fracture in Osteoporosis Patients under Minimally Invasive Trans-Foraminal Lumbar Interbody Fusion with Assistance of Bone-Mounted Robotic System in Two-Level Degenerative Lumbar Disease

by Hui-Yuan Su, Huey-Jiun Ko, Yu-Feng Su, Ann-Shung Lieu, Chih-Lung Lin, Chih-Hui Chang, Tai-Hsin Tsai and Cheng-Yu Tsai

Medicina 2022, 58(5), 688; https://doi.org/10.3390/medicina58050688 - 23 May 2022

Cited by 2 | Viewed by 2943

Abstract

Background and Objectives: Minimally invasive spine surgery reduces destruction of the paraspinal musculature and improves spinal stability. Nevertheless, screw loosening remains a challenging issue in osteoporosis patients receiving spinal fixation and fusion surgery. Moreover, adjacent vertebral compression fracture is a major complication, particularly in patients with osteoporosis. We assessed long-term imaging results to investigate the outcomes of osteoporosis patients with two-level degenerative spine disease receiving minimally invasive surgery with the assistance of a robotic system. Materials and Methods: We retrospectively analyzed consecutive osteoporosis patients who underwent minimally invasive surgery with the assistance of a robotic system at our institution during 2013–2016. All patients were diagnosed with osteoporosis according to the World Health Organization criteria. All patients were diagnosed with two levels of spinal degenerative disease, including L34, L45, or L5S1. The study endpoints included screw-loosening condition, cage fusion, and vertebral body heights of the adjacent, first fixation segment, and second fixation segments before and after surgery, including the anterior, middle, and posterior third parts of the vertebral body. Differences in vertebral body heights before and after surgery were evaluated using the F-test. Results: Nineteen consecutive osteoporosis patients were analyzed. A lower rate of screw loosening was observed in osteoporosis patients in our study. There were no significant differences between the preoperative and postoperative vertebral body heights, including adjacent and fixation segments. Conclusions: According to our retrospective study, we report that minimally invasive surgery with the assistance of a robotic system provided better screw fixation, a lower rate of screw loosening, and a lesser extent of vertebral compression fracture after spinal fixation and fusion surgery in osteoporosis patients. Full article

(This article belongs to the Special Issue Treatment of Spine and Pelvic Fractures in Patients with Osteoporosis)

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11 pages, 2116 KiB

Open AccessArticle

Outcome after Posterior Vertebral Column Resection in Patients with Severe Osteoporotic Fractures—A Retrospective Analysis from Two Centers

by Leon-Gordian Koepke, Lukas Weiser, Martin Stangenberg, Marc Dreimann, Annika Heuer, André Strahl and Lennart Viezens

Medicina 2022, 58(2), 277; https://doi.org/10.3390/medicina58020277 - 12 Feb 2022

Cited by 4 | Viewed by 2285

Abstract

Background and Objectives: In osteoporotic fractures of the spine with resulting kyphosis and threatening compression of neural structures, therapeutic decisions are difficult. The posterior vertebral column resection (pVCR) has been described by different authors as a surgical treatment in a single-stage posterior procedure. The aim of this study is to evaluate midterm outcomes of patients treated by pVCR due to severe osteoporotic fractures. Materials and Methods: Retrospective data analysis of all the patients treated for osteoporotic fractures by pVCR from 2012–2020 at two centers was performed. Demographic data, visual analog scale (VAS), Frankel scale (FS), Karnofsky performance status (KPS), radiological result and spinal fusion rates were evaluated. Results: A total of 17 patients were included. The mean age was 70 ± 10.2 y. The mean VAS decreased significantly from 7.7 ± 2.8 preoperatively to 3.0 ± 1.6 at last follow-up (p < 0.001) and the segmental kyphosis decreased from 29.4 ± 14.1° to 7.9 ± 8.0° (p < 0.001). The neurologic function on the FS did not worsen in any and improved in four of the patients. The median KPS remained stable over the whole observation period (70% vs. 70%). Spinal fusion was observed in nine out of nine patients who received CT follow-up >120 days after index surgery. Conclusions: This study showed that pVCR is a safe surgical technique with few surgical complications and no neurological deterioration considering the cohort. The patients’ segmental kyphosis and VAS improved significantly, while the KPS remained stable. Full article

(This article belongs to the Special Issue Treatment of Spine and Pelvic Fractures in Patients with Osteoporosis)

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12 pages, 29695 KiB

Open AccessArticle

Does Cement Augmentation of the Sacroiliac Screw Lead to Superior Biomechanical Results for Fixation of the Posterior Pelvic Ring? A Biomechanical Study

by Moritz F. Lodde, J. Christoph Katthagen, Clemens O. Schopper, Ivan Zderic, R. Geoff Richards, Boyko Gueorguiev, Michael J. Raschke and René Hartensuer

Medicina 2021, 57(12), 1368; https://doi.org/10.3390/medicina57121368 - 16 Dec 2021

Cited by 11 | Viewed by 4335

Abstract

Background and Objectives: The stability of the pelvic ring mainly depends on the integrity of its posterior part. Percutaneous sacroiliac (SI) screws are widely implanted as standard of care treatment. The main risk factors for their fixation failure are related to vertical shear or transforaminal sacral fractures. The aim of this study was to compare the biomechanical performance of fixations using one (Group 1) or two (Group 2) standard SI screws versus one SI screw with bone cement augmentation (Group 3). Materials and Methods: Unstable fractures of the pelvic ring (AO/OTA 61-C1.3, FFP IIc) were simulated in 21 artificial pelvises by means of vertical osteotomies in the ipsilateral anterior and posterior pelvic ring. A supra-acetabular external fixator was applied to address the anterior fracture. All specimens were tested under progressively increasing cyclic loading until failure, with monitoring by means of motion tracking. Fracture site displacement and cycles to failure were evaluated. Results: Fracture displacement after 500 cycles was lowest in Group 3 (0.76 cm [0.30] (median [interquartile range, IQR])) followed by Group 1 (1.42 cm, [0.21]) and Group 2 (1.42 cm [1.66]), with significant differences between Groups 1 and 3, p = 0.04. Fracture displacement after 1000 cycles was significantly lower in Group 3 (1.15 cm [0.37]) compared to both Group 1 (2.19 cm [2.39]) and Group 2 (2.23 cm [3.65]), p ≤ 0.04. Cycles to failure (Group 1: 3930 ± 890 (mean ± standard deviation), Group 2: 3676 ± 348, Group 3: 3764 ± 645) did not differ significantly between the groups, p = 0.79. Conclusions: In our biomechanical setup cement augmentation of one SI screw resulted in significantly less displacement compared to the use of one or two SI screws. However, the number of cycles to failure was not significantly different between the groups. Cement augmentation of one SI screw seems to be a useful treatment option for posterior pelvic ring fixation, especially in osteoporotic bone. Full article

(This article belongs to the Special Issue Treatment of Spine and Pelvic Fractures in Patients with Osteoporosis)

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9 pages, 1016 KiB

Open AccessArticle

Influence of Hyponatremia on Spinal Bone Quality and Fractures Due to Low-Energy Trauma

by Katharina Jäckle, Friederike Klockner, Daniel Bernd Hoffmann, Paul Jonathan Roch, Maximilian Reinhold, Wolfgang Lehmann and Lukas Weiser

Medicina 2021, 57(11), 1224; https://doi.org/10.3390/medicina57111224 - 10 Nov 2021

Cited by 3 | Viewed by 2181

Abstract

Background and Objectives: Hyponatremia is the most common electrolyte disorder in elderly and associated with increased risk of falls. Clinical studies as well as small animal experiments suggested an association between chronic hyponatremia and osteoporosis. Furthermore, it has been assumed that subtle hyponatremia may be an independent fracture risk in the elderly. Therefore, this study was designed to evaluate the possible influence of chronic hyponatremia on osteoporosis and low-energy fractures of the spine. Materials and Methods: 144 patients with a vertebral body fracture (mean age: 69.15 ± 16.08; 73 females and 71 males) due to low-energy trauma were treated in a level one trauma center within one year and were included in the study. Chronic hyponatremia was defined as serum sodium < 135 mmol/L at admission. Bone mineral density (BMD) of the spine was measured using quantitative computed tomography in each patient. Results: Overall, 19.44% (n = 28) of patients in the low-energy trauma group had hyponatremia. In the group with fractures caused by low-energy trauma, the proportion of hyponatremia of patients older than 65 years was significantly increased as compared to younger patients (p** = 0.0016). Furthermore, there was no significant gender difference in the hyponatremia group. Of 28 patients with chronic hyponatremia, all patients had decreased bone quality. Four patients showed osteopenia and the other 24 patients even showed osteoporosis. In the low-energy trauma group, the BMD correlated significantly with serum sodium (r = 0.396; p*** < 0.001). Conclusions: The results suggest that chronic hyponatremia affects bone quality. Patients with chronic hyponatremia have an increased prevalence of fractures after low-energy trauma due to a decreased bone quality. Therefore, physicians from different specialties should focus on the treatment of chronic hyponatremia to reduce the fracture rate after low-energy trauma, particularly with elderly patients. Full article

(This article belongs to the Special Issue Treatment of Spine and Pelvic Fractures in Patients with Osteoporosis)

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7 pages, 625 KiB

Open AccessSystematic Review

Efficacy of Bracing on Thoracic Kyphotic Angle and Functionality in Women with Osteoporosis: A Systematic Review

by Beatriz Sánchez-Pinto-Pinto, Carlos Romero-Morales, Daniel López-López, Carmen de-Labra and Guillermo García-Pérez-de-Sevilla

Medicina 2022, 58(6), 693; https://doi.org/10.3390/medicina58060693 - 24 May 2022

Cited by 8 | Viewed by 7223

Abstract

Background and purpose: Osteoporotic hyperkyphosis is associated with adverse outcomes, such as fatigue, back pain, or reduced back extensor strength, with a negative impact on functionality and quality of life. The purpose of this review is to assess the effectiveness of spinal orthosis on these adverse effects. Methods: A systematic review following the PRISMA guidelines was performed. Inclusion criteria were (1) women with osteoporosis; (2) randomized controlled trials only; and (3) type of intervention: spinal bracing. Exclusion criteria were (1) article not written in English; (2) full-text not available; and (3) no kyphosis assessment. Quality-of-life variables such as back pain, functional variables such as back extensor strength, and osteoporotic-related variables such as lumbar spine bone mineral density were extracted and recorded before and after the intervention. The characteristics of the intervention programs were also extracted and recorded. The characteristics of studies, interventions, and participants are summarized in a table. Then, the revised Cochrane risk-of-bias tool for randomized trials (RoB 2) was used to assess the quality of the studies. Results and Discussion: Four randomized controlled trials with a low risk of bias were included (n = 326 women with osteoporosis, aged 51–93 years). Interventions consisting of wearing a dynamic hyperextension orthosis for at least two hours per day for six months improved functionality, mobility, back extensor strength, respiratory function, and reduced the thoracic kyphosis angle. Conclusions: Spinal orthosis, especially dynamic hyperextension braces, seems effective in improving the adverse outcomes of osteoporotic hyperkyphosis. It does not seem necessary to wear the orthosis during all daily activities. Full article

(This article belongs to the Special Issue Treatment of Spine and Pelvic Fractures in Patients with Osteoporosis)

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Treatment of Spine and Pelvic Fractures in Patients with Osteoporosis

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