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Background: Osteoporosis-associated fractures are of increasing importance in trauma surgery. Systematic diagnostics and treatment of osteoporosis during a hospital stay, however, remain inadequate. Therefore, a specific algorithm for diagnosing and treating osteoporosis in trauma surgery patients was developed based on the DVO (German Osteology Society) guideline for osteoporosis from 2014., Methods: In a first step, the individuals' age and risk profile for osteoporosis is identified considering specific fractures indicating osteoporosis and risk factors assessed by a specific questionnaire. In addition, physical activity, risk of falls, dietary habits and the individuals' medication are considered. Basic osteoporosis laboratory tests, a bone densitometry by dual-energy X-ray absorptiometry (DXA) and, if needed, X-rays of the spine are carried out to identify prevalent vertebral body fractures., Results: Based on the treatment algorithm adapted to the new guidelines for osteoporosis in the majority of proximal femoral fractures, treatment of osteoporosis could already be indicated without prior DXA. In case of preexisting glucocorticoid therapy, a history of previous fractures or other risk factors according to the risk questionnaire, the threshold of treatment has to be adjusted given the table of T-scores., Conclusions: The treatment algorithm for diagnosing and treating osteoporosis in in-patient trauma surgery patients can help identify high-risk patients systematically and efficiently. As a result, osteoporosis-associated fractures or failure of osteosynthesis could be reduced, yet a prospective validation of the algorithm has to be completed.

In the prevention and treatment of osteoporosis, movement with muscle strengthening and proprioceptive training plays a major role. This was taken into consideration in the guidelines by the governing body on osteoporosis (Dachverband Osteoporose, DVO) from 2014 on prophylaxis, diagnosis and treatment of osteoporosis and in the DVO guidelines from 2008 on physiotherapy and exercise therapy for osteoporosis. Increases in lumbar bone density of between 0.5 % and 2.5 % can be achieved in women by strengthening exercises with high resistance. With this combination and strengthening of the quadriceps muscle a reduction of falls and hence the fracture risk could also be achieved. In traumatology, training for muscle strengthening is not always possible, especially for elderly patients. Practically relevant alternatives are regular walking and aquatraining, which may also lead to a significant increase in bone mineral density. Furthermore, large effects can be achieved with alternating side whole-body vibration (WBV) training with whole body vibration plates with only 3 days of training per week and with short training periods (15-20 min). Rates of increase in leg strength between 20 % and almost 40 % and in bone density between 0.5 % and 4 % in 6 months have been described. Whether and with what intensity whole body vibration therapy could be used for e.g. more rapid healing of fractures, is currently unclear. Initial positive results have been described in animal models.

Osteoporosis-associated fractures represent a growing challenge in the treatment of orthopedic patients. In November 2014 a new revision of the guidelines on osteoporosis by the German Osteology Society (Dachverband Osteologie DVO) was adopted, in which additional risk factors for fractures and further treatment options have been included. On the one hand the existing model used to diagnose osteoporosis and estimate a high fracture risk as a guidance for the use of specific anti-osteoporotic therapy in patients without a fragility fracture was maintained and further refined. On the other hand the guideline includes the option to initiate a specific osteoporosis therapy without a prior bone densitometry in patients with typical radiographs of a proximal femur fracture and higher grade vertebral fractures, suspicious for osteoporosis, depending on the overall clinical context. This may reduce the treatment gap of osteoporosis in Germany. In this paper the changes in the DVO guidelines 2014 on osteoporosis are summarized, focusing on the most important changes with practical relevance for orthopedic surgeons.

Osteoporosis-associated fractures are of increasing importance in trauma surgery. The implementation of systematic diagnostics and treatment of osteoporosis during hospitalization, however, remains insufficient; therefore, a specific algorithm for the diagnosis and treatment of osteoporosis in trauma surgery patients was developed based on the German Osteology Society (Dachverband Osteologie, DVO) guidelines for osteoporosis from 2014. In a first step, the individual patient age and risk profile for osteoporosis are identified considering specific fractures indicative of osteoporosis. For these patients a questionnaire is completed which detects specific risk factors. In addition, the physical activity, risk of falls, dietary habits and the individual medication are collated as these can have a decisive influence on the subsequent therapy decisions. Prior to a specific treatment, laboratory osteoporosis tests, bone densitometry by dual energy X-ray absorptiometry (DXA) and if needed X-rays of the spine are carried out. For proximal femoral fractures the treatment of osteoporosis could already be indicated. With pre-existing glucocorticoid therapy, a history of previous fractures or other risk factors according to the risk questionnaire, the threshold of treatment has to be adjusted according to the table of T-scores detected by DXA. The treatment algorithm for diagnostics and treatment of osteoporosis in hospitalized trauma surgery patients can systematically and efficiently improve the identification of patients at risk. Thus, further fractures associated with osteoporosis or failure of internal fixation could be reduced in future. A prospective validation of the algorithm has already be initiated.

Background: Rotator cuff tears are of increasing clinical impact in the physically active elderly patients. Recent research revealed, that a high percentage of these patients present with significant loss of bone mineral density at the insertion site of the rotator cuff, thereby compromising suture anchorage for operative repair. We therefore hypothesized that augmentation of suture anchors improves biomechanical properties in low bone quality., Methods: 28 osteoporotic humeral heads were included in this biomechanical study. Bone quality at the anchor insertion sites (group 1: posterior-medial; group 2: anterior-lateral) within the greater tuberosity was analyzed using HR-pQCT (voxel size: 82μm). Anchor positions of identical quality were then randomized to either conventional screw anchorage or polymethylmethacrylat augmented screw anchorage. All anchors were cyclically ramp-loaded until pullout., Findings: Pullout strength accounted for 226N in group I for conventional anchorage and for 332N in augmented technique. In group 2 (anterior-lateral) the pullout strength was 209N (conventional) and 304N (augmented). Pull-out strength of augmented screw anchors was significantly higher in both groups (p<0.05)., Interpretation: Compared to conventional insertion techniques, the cement augmentation technique increases the pullout strength of suture anchors in low bone quality significantly. Cement augmentation could therefore be a helpful tool for improved suture anchor stability, especially in locations of low bone quality., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Osteoporosis-associated fractures represent a risk factor for developing further fragility fractures. Therefore, guideline-oriented osteoporosis intervention is of utmost importance during inpatient fracture treatment., Patients and Methods: Women >50 years and men >60 years with fractures of the lumbar or thoracic spine, proximal femur, proximal humerus and distal radius were included in a prospective study. We analyzed the initiation of diagnosis and treatment of osteoporosis during the inpatient stay., Results: A total of 455 patients were included and bone mineral density measurement (DXA) was carried out in 65.9 %. Women underwent DXA in 69.5 % and men significantly less frequently in 52.1 %. Osteoporosis was diagnosed in 56.6 %, where women were affected in 56.2 % and men in 59 % of cases. In 83.8 % osteoporosis had been previously unknown. Treatment according to the guidelines of the Organisation of German Scientific Osteology-related Societies (DVO) was initiated in 86.7 % and 77.1 % of women >70 years and men >80 years required anti-resorptive treatment after DXA., Conclusions: The majority of elderly patients with fractures also suffer from osteoporosis, independent of gender. Even nowadays, osteoporosis is predominantly not diagnosed until the incidence of a fracture. Therefore, the trauma surgeon is in a key position to initiate diagnosis and treatment of osteoporosis.

Fractures to the osteoporotic bone feature a delay in callus formation and reduced enchondral ossification. Human mesenchymal stem cells (hMSC), the cellular source of fracture healing, are recruited to the fracture site by cytokines, such as BMP-2 and BMP-7. Aim of the study was to scrutinize hMSC for osteoporosis associated alterations in BMP mediated migration and invasion as well as in extracellular matrix (ECM) binding integrin expression. HMSC were isolated from 18 healthy or osteoporotic donors. Migration was assessed using a collagen IV coated micro-slide linear gradient chamber and time-lapse microscopy. Invasion was analyzed utilizing an ECM coated transmembrane invasion assay. Quantitative real-time RT PCR was performed for the ECM binding integrins α1, α2, α3, α4, α5, α11, αv and β1. HMSC from osteoporotic patients showed a significant increase of migration upon BMP-2 or FCS stimulation, as well as a significant increase of invasion upon BMP-2, BMP-7 or FCS stimulation. Nevertheless, the migration and invasion capacity was significantly decreased compared to healthy controls. Out of all integrins analyzed, collagen binding integrin α2 was significantly downregulated in hMSC from osteoporotic patients. In conclusion, we here demonstrate for the first time osteoporosis associated alterations in BMP mediated hMSC recruitment. These findings may underlie the reduced healing of osteoporotic fractures. Nevertheless, the maintained migration and invasion response upon BMP stimulation illustrates the therapeutic potential of these clinically approved substances in the treatment of osteoporotic fractures. Another therapeutic target may be the downregulation of the collagen binding integrin α2 in hMSC from osteoporotic patients., (Copyright © 2014 The Authors. Published by Elsevier Inc. All rights reserved.)

Osteoporotic fractures show reduced callus formation and delayed bone healing. Cellular sources of fracture healing are mesenchymal stem cells (MSC) that differentiate into osteoblasts by stimulation with osteoinductive cytokines, such as BMP-2. We hypothesized that impaired signal transduction and reduced osteogenic differentiation capacity in response to BMP-2 may underlie the delayed fracture healing. Therefore, MSC were isolated from femoral heads of healthy and osteoporotic patients. Grouping was carried out by bone mineral densitometry in an age-matched manner. MSC were stimulated with BMP-2. Signal transduction was assessed by western blotting of pSMAD1/5/8 and pERK1/2 as well as by quantitative RT-PCR of Runx-2, Dlx5, and Osteocalcin. Osteogenic differentiation was assessed by quantifying Alizarin Red staining. Osteoporotic MSC featured an accurate phosphorylation pattern of SMAD1/5/8 but a significantly reduced activation of ERK1/2 by BMP-2 stimulation. Furthermore, osteoporotic MSC showed significantly reduced basal expression levels of Runx-2 and Dlx5. However, Runx-2, Dlx5, and Osteocalcin expression showed adequate up-regulation due to BMP-2 stimulation. The global osteogenic differentiation in standard osteogenic differentiation media was reduced in osteoporotic MSC. Nevertheless, osteoporotic MSC were shown to feature an adequate induction of osteogenic differentiation due to BMP-2 stimulation. Taken together, we here demonstrate osteoporosis associated alterations in BMP-2 signaling but sustained specific osteogenic differentiation capacity in response to BMP-2. Therefore, BMP-2 may represent a promising therapeutic agent for the treatment of fractures in osteoporotic patients., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The implementation of clinical pathways has a proven positive effect on the diagnostic workup and initiation of therapy in osteoporotic fracture patients. Unlike in most countries, fracture care in Germany is provided by so-called trauma surgeons. Therefore, it is essential to focus on the trauma surgeon for correct diagnostic workup and therapy initiation after a fragility fracture. A questionnaire was mailed to 409 departments of traumatology inquiring about the existence of a standardized clinical pathway for diagnosis and treatment of patients with fragility fractures. One of the central issues of the survey was whether those pathways comply with national guidelines. Only institutions that stated that they followed a clinical pathway were analyzed. 80% of institutions took part in our survey, 35% of which reported following a defined clinical pathway. Diagnostic workup is in concordance with the national guidelines in 30%, and therapy is guideline-based in 51%, with 12% basing both diagnostic workup and therapy on the guidelines. Thus, the vast majority of German traumatology departments do not follow national guidelines regarding osteoporosis diagnostics and therapy in patients with fragility fractures, leading to a great opportunity to improve fragility fracture care by means of both education and interdisciplinary cooperation.

Since the World Health Organisation's announcement of the "Bone and Joint Decade 2000-2010" diseases of the musculoskeletal system attract more and more attention throughout patients and professional health care providers. In an aging society especially osteoporosis represents a major public health concern. Fragility fractures are the most limiting condition in osteoporosis with the highest impact on both, life quality and health care systems worldwide. Orthopaedic surgeons play a key role in implementing primary diagnostics and therapy in patients with fragility fractures. Objective of this effort is the reduction of the common subsequent fractures in patients with osteoporosis. According to national and international guidelines implementation of contemporary clinical pathways to diagnose and treat patients with fractures due to diminished bone mineral density is fast, simple and proven to be effective.

Purpose: To evaluate the current bone mineral density (BMD) distribution in elderly patients hospitalized due to traumatic hip fracture and to assess the necessity of concomitant pharmacotherapy of underlying osteoporosis., Materials and Methods: 58 female patients > or = 50 years (mean 81 years) with proven hip fracture were included. The diagnosis of fracture was established either by conventional radiography (CR) or by computed tomography (CT). BMD was assessed prospectively by means of dual energy X-ray absorption (DXA) measurement of the lumbar spine and/or femoral neck. DXA data was routinely achieved by analysis of T- and Z-values of the BMD. Distribution of BMD was assessed. Results for both measurement sites were compared using T-test and Pearson correlation analysis., Results: 56/58 patients with proven hip fracture received DXA of the lumbar spine, 51 DXA of the femoral neck. The mean BMD was 0.829 +/- 0.137 g/cm (2) (lumbar spine) and 0.451 +/- 0.126 g/cm (2) (femur). T-values were - 2.8 +/- 1.14 (lumbar spine) and - 3.53 +/- 0.97 (femur). Compared to the normal distribution (lumbar spine), 53 patients (94.6 %) had diminished BMD (T < or = - 1). Of these 15 (26.8 %) had osteopenia (T > - 2.5) and 38 (67.9 %) had osteoporosis (T < or = - 2.5) according to WHO definition. With respect to femoral bone measurement, all patients (100 %) had diminished BMD (T < or = - 1), 9 patients (17.6 %) had osteopenia (T > - 2.5) and 42 patients (82.4 %) had osteoporosis (T < or = - 2.5). Results for different measurement sites differed significantly and were weakly correlated., Conclusion: This data indicate that diminished BMD in terms of osteopenia or osteoporosis is a frequent finding in hip fractures of elderly females. A large majority of these elderly patients therefore should be treated according to recent guidelines for treatment of osteoporosis. Our data indicate that this entity is potentially underdiagnosed and should be considered by radiologists as well as traumatologists.

Until about 20 years ago osteoporosis was considered an inevitable disease of ageing. Now the situation has completely changed and osteoporosis is classified as a disorder which is easily diagnosed and treated in the early stages of its development that is,before a skeletal fracture has occurred. Two types of medication are available today for prophylaxis and therapy of osteoporosis: the antiresorptive and the osteoanabolic drugs whose efficacy has been demonstrated in large randomized clinical trials (RCTs). These drugs are effective not only in the early stages of osteoporosis i.e. for prevention, but also when fractures have already occurred, to reduce the risk of further skeletal fractures. However, in this setting only about 7% of patients in Germany are being treated although all are at significant risk of sustaining additional fractures. Consequently all patients with osteoporosis-related fractures should be thoroughly investigated during their hospitalisation and effective treatment instituted. In addition, treatment should be continued and monitored by the family doctor. The strategy for the administration of therapy for successful prevention of secondary fractures in osteoporosis is presented.

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Copyright of Der Unfallchirurg is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Der Unfallchirurg is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Der Unfallchirurg is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)