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Purpose: We propose a functional treatment strategy for fragility fractures of the pelvis (FFP) in geriatric patients; patients with such fractures normally undergo 10 days of conservative therapy with full-weight bearing within pain limits. Conservative therapy for FFP is continued for patients who can stand with assistance, and surgical stabilization is recommended for patients with difficulty in auxiliary standing at 10 day postadmission. This study aimed to compare the outcomes of functional treatment between geriatric patients with FFP type I/II and those with FFP type III/IV, as described by Rommens et al. METHODS: We conducted a retrospective study of 84 geriatric patients who underwent functional treatment for FFP. Based on the results of the first examination, the patients were allocated to the following FFP types: type I/II (n = 53) and type III/IV (n = 31). Change in functional mobility scale described by Graham et al. from before injury to the final follow-up were compared between the groups., Results: There was no significant difference in the functional mobility scale (0.25 ± 0.70 vs. 0.23 ± 0.56, p = 0.889) between FFP type I/II and FFP type III/IV., Conclusion: The outcomes of the functional treatment for FFP for the geriatric patients did not differ significantly between the radiographic classifications. Functional treatment could, therefore, be a treatment option for almost all radiographic types of FFP, especially for geriatric patients. Further investigations are warranted.

Purpose: The pathogenetic mechanism, progression, and instability in geriatric bilateral fragility fractures of the sacrum (BFFSs) remain poorly understood. This study investigated the hypothesis of sequential BFFS progression by analysing X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) datasets., Methods: Imaging data from 78 cases were retrospectively analysed. Fractures were categorized using the CT-based Fragility Fractures of the Pelvis classification. MRI datasets were analysed to detect relevant fracture location information. The longitudinal sacral fracture was graded as stage 1 (bone oedema) on MRI, stage 2 (recent fracture), stage 3 (healing fracture), or stage 4 (non-union) on CT. Ligamentous avulsions at the L5 transverse process and iliac crest were also captured., Results: Contralateral sacral lesions were only recognized by initial bone oedema on MRI in 17/78 (22%) cases. There were 22 cases without and 56 cases with an interconnecting transverse fracture component (TFC) [between S1/S2 (n = 39) or between S2/S3 (n = 17)]. With 30/78 patients showing bilateral fracture lines at different stages (1/2: n = 13, 2/3: n = 13, 1/3: n = 4) and 38 at similar stages, Wilcoxon tests showed a significant stage difference (p < 0.001). Forty cases had a coexistent L5 transverse process avulsion, consistent with a failing iliolumbar ligament. Analysis of variance revealed significant increases in ligamentous avulsions with higher fracture stages (p < 0.001)., Conclusion: Our results support the hypothesis of stagewise BFFS progression starting with unilateral sacral disruption followed by a contralateral lesion. Loss of sacral alar support leads to a TFC. Subsequent bone disruption causes iliolumbar ligament avulsion. MRI is recommended to detect bone oedema.

Purpose: To investigate prognosis of patients with fragility fracture of the pelvis (FFP) treated in a single trauma unit in Japan., Methods: We retrospectively investigated 340 consecutive patients with FFP (40 men, 300 women; average age, 82.5 years) treated in our facility from April 2012 to April 2019. Fractures were categorized according to the Rommens classification. Patients' mechanism of injury, existence of hip implant, standing and walking abilities (using the Majeed score), and 1-year mortality rate were evaluated., Results: According to the Rommens classification, there were 84 type Ia, 2 type Ib, 24 type IIa, 78 type IIb, 51 type IIc, 40 type IIIa, 1 type IIIb, 4 type IIIc, 1 type IVa, 51 type IVb, and 3 type IVc fractures. Sixteen patients (4.7%) received surgical treatments. Twenty-eight patients (8.2%) had no memory of a traumatic event, and 61 (18%) had implants from a previous hip surgery. A total of 176 patients (52%) were followed up for ≥ 1 year, and 70 (39.8%) and 67 (38.1%) patients had recovery of standing and walking abilities, similar to those before the injury. The operative group (7/9 = 77.8%) had a higher proportion of patients who regained their standing and walking abilities at the 1-year follow-up than the conservative group. The 1-year mortality rate of the patients who could be followed for ≥ 1 year was 6.7%., Conclusion: According to our data, 4.7% of patients were indicated for surgery, and only < 40% of patients were able to regain their pre-injury standing and walking abilities at 1 year after the injury. FFP may greatly affect an elderly's activities of daily living and may lead to prognosis similar to patients with proximal hip fractures. To regain the walking ability of patients with FFP, more aggressive indication of surgical treatment may be considered depending on the patient's background. Further examinations are necessary to determine the surgical indications and treatment protocol for FFP.

Background: We propose a new classification system for chronic symptomatic osteoporotic thoracolumbar fracture (CSOTF) based on fracture morphology. Research on CSOTF has increased in recent years; however, the lack of a standard classification system has resulted in inconvenient communication, research, and treatment. Previous CSOTF classification studies exhibit different symptoms, with none being widely accepted., Methods: Imaging data of 368 patients with CSOTF treated at our hospital from January 2010 to June 2017 were systematically analyzed to develop a classification system. Imaging examinations included dynamic radiography, computed tomography scans, and magnetic resonance imaging. Ten investigators methodically studied the classification system grading in 40 cases on two occasions, examined 1 month apart. Kappa coefficients (κ) were calculated to determine intraobserver and interobserver reliability. Based on the radiographic characteristics, the patients were divided into 5 types, and different treatments were suggested for each type. Clinical outcome evaluation included using the visual analog score (VAS), the Oswestry disability index (ODI), and the American Spinal Injury Association (ASIA) impairment scale., Results: The new classification system for CSOTF was divided into types I-V according to whether the CSOTF exhibited dynamic instability, spinal stenosis or kyphosis deformity. Intra- and interobserver reliability were excellent for all types (κ = 0.83 and 0.85, respectively). The VAS score and ODI of each type were significantly improved at the final follow-up compared with those before surgery. In all patients with neurological impairment, the ASIA grading after surgery was significantly improved compared with that before surgery (P < 0.001)., Conclusions: The new classification system for CSOTF demonstrated excellent reliability in this initial assessment. The treatment algorithm based on the classification can result in satisfactory improvement of clinical efficacy for the patients of CSOFT.

The basis for assessing thoracolumbar vertebral body fractures are two established classification systems. Important, especially in terms of further treatment, is the distinction between osteoporotic and healthy bones. The AO Spine classification offers a comprehensive tool for healthy bones to reliably specify the morphological criterias (alignment, integrity of the intervertebral disc, fragment separation, stenosis of the spinal canal). In addition to the fracture morphology, the OF classification for osteoporotic fractures includes patient-specific characteristics to initiate adequate therapy. In general an adequate pain therapy is required for early rehabilitation. While in the bone healthy population, physiotherapy reduces the risk of muscle deconditioning, in the osteoporotic population it additionally serves to prevent subsequent fractures. Unlike osteoporotic patients, bone healthy patients with vertebral fractures should not undergo a corset/orthosis treatment., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: The classification and management of osteoporotic pelvic ring injuries (OPRI) remain challenging. The fragility fractures of the pelvis (FFP) classification system proposed by Rommens and Hofmann constitutes the first comprehensive classification system of OPRI and may contribute to a more thorough assessment and grading of these injuries. The reliability of the FFP classification system, however, has not been evaluated yet. The purpose of this study therefore was to determine the inter- and intraobserver reliability of the FFP classification system and to critically analyse its strengths and weaknesses., Materials and Methods: One-hundred pelvic CT scans obtained from a consecutive series of patients aged 70 years and older who sustained a low-energy pelvic ring injury were included in this study. Three orthopaedic traumatologists of varying levels of experience (one experienced pelvic surgeon, one consultant, one resident) and one musculoskeletal radiologist independently classified each OPRI according to the FFP classification in two different sessions. Intra- and interobserver reliability were determined using percentage agreement and Cohen's Kappa coefficients., Results: The observed relative distribution of FFP fracture types was comparable to that reported in the original study by Rommens and Hofmann. Overall interobserver reliability for all 100 cases was moderate with Kappa values from 0.42 to 0.59 (mean percentage agreement: 61% (54%-68%)), while intraobserver reliability was substantial with Kappa values from 0.68 to 0.72 (mean percentage agreement: 77% (76%-78%)). Subgroup analysis revealed lowest reliability for the classification of Type IIc, IIIc and IVb injuries (32 cases). Within this subgroup of combined anterior and posterior OPRI involving a complete nondisplaced or displaced (uni- or bilateral) sacral fracture, Kappa values for interobserver reliability ranged from 0.10 to 0.52, while those for intraobserver reliability ranged from 0.29 to 0.66., Conclusion: Overall interobserver reliability of the FFP classification system was moderate, while intraobserver reliability was substantial. Despite the acceptable overall reliability, classification of FFP subtypes involving a complete nondisplaced or displaced sacral fracture showed relatively poor reliability. The latter limits the usefulness of the FFP classification for both clinical and research purposes and needs to be addressed in future studies., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Proximal femoral fragility fractures are common and result in significant morbidity and mortality along with a considerable socioeconomic burden. The goals of this article are to review relevant proximal femoral anatomy together with imaging, classification, and management of proximal femoral fragility fractures, and their most common complications. Imaging plays an integral role in classification, management and follow-up of proximal femoral fragility fractures. Classification of proximal femoral fragility fractures is primarily based on anteroposterior hip radiographs. Pertinent imaging features for each category of proximal femoral fractures that would guide management are: differentiating nondisplaced from displaced femoral neck fractures, distinguishing stable from unstable intertrochanteric fractures, and determining the morphology and comminution of subtrochanteric fractures. Treatment of proximal femoral fragility fractures is primarily surgical with either arthroplasty or internal fixation. Intramedullary nailing is used in the treatment of some types of proximal femoral fragility fractures and may be associated with unique complications that become evident on postoperative follow-up radiographs.

Background: The ankle fracture is one of the most common fractures, increasing in an ageing population, but not generally seen as an osteoporotic fracture. The aim of this study was to examine the relationship between different AO/OTA classes of ankle fractures, age, sex and type of trauma., Methods: Ankle fractures, treated at any of the hospitals in Norrbotten County in Sweden between 2009 and 2013, were retrospectively identified and classified according to the AO/OTA-classification system. Information about the trauma mechanism was also obtained., Results: In Norrbotten County, 1756 ankle fractures in 1735 patients aged 20 years or older were identified. This gave an incidence in the county of 179 per 100,000 person-years. Of these patients, 34.6% were 65 years or older, 58.4% were women and 68.2% of the trauma leading to a fracture was defined as low-energy. In 1.5% of the cases the fractures were open. Incidences of type B fractures increased substantially with age, from 62 (95% CI 50-77) at 30-39 years of age to 158 (95% CI 131-190) in patients older than 80 years of age per 100,000 person-years. Type B fractures showed a slightly higher proportion of low-energy trauma while type C showed a lower mean age and proportion of women., Conclusions: This study shows an incidence of 179 adult ankle fractures annually per 100,000 persons. More than two thirds of the fractures were caused by a low-energy trauma and ankle fractures are more frequent among females. Females generally have an increased incidence during their life, mainly between the ages of 30 and 60. This is in contrast to men who have more of an even distribution throughout their life. Classification according to AO/OTA reveals some heterogeneity among the classes of ankle fractures in age and gender as well as the energy involved in the trauma.

Introduction: Standard radiographs are still considered as the gold standard for the early assessment of thoraco-lumbar osteoporotic vertebral fractures (OVFs), although several studies demonstrated superior accuracy of magnetic resonance imaging (MRI) in the diagnostic process of OVFs. The aim of this study was to quantify the misdiagnosis rate of OVFs and analyse the impact of MRI on early diagnosis and classification, compared to standard radiographs alone., Materials and Methods: A total of 173 patients were enrolled in this study. All participants were 55 years of age or older (60 years for men) and complained acute back pain with suspected thoracolumbar OVFs without history of high-energy trauma. Diagnosis of OVF was initially performed on standard radiographs obtained in the emergency room. Then, all the patients underwent MRI scan with short-tau inversion recovery (STIR) sequencing within 7 days. We compared the level and number of fractures identified on standard radiographs with the MRI scan results. The discordance between radiographic and MRI diagnosis was quantified. Fractures were classified according to AO Spine Classification., Results: Mean age of the study participant was 74.2 years (range 55-92). They were 100 males and 73 females. MRI modified initial diagnosis in 52% (90/173) of our patients: in 43.9% of patients MRI identified one or more new thoracolumbar fracture. In 14 cases (8.1%) MRI disproved the evidence of any thoracolumbar fracture, even those recognized at plain X-rays. Bone bruise was detected by MRI in 19 vertebral bodies in 8 patients (4.6%) at levels that were classified as unremarkable on X-ray alone. In addition, 63 patients (36.4%) presented a total of 93 old fractures. The classification of fracture pattern after MRI changed in 28.90% of the patients (changes mostly involved AO type A1 patterns)., Conclusions: Underdiagnosis of osteoporotic vertebral fractures is a common problem due to a lack of radiographic detection. Our results showed that the extensive use of MRI imaging allows better accuracy in the diagnostic process and in the classification assessment, compared to conventional radiographs. Further investigation should provide additional information about the impact of early MRI on treatment and management of elderly patients with suspected OVFs, including the decision to hospitalize or not, and how it could affect clinical outcome and social costs., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

This study analyzed data on 87,224 osteoporotic patients with up to 18 years of computerized medical history. Patients with osteoporosis and type 2 diabetes had higher bone density yet more fractures than non-diabetic osteoporotic patients. Fracture incidence among the diabetic patients was associated with retinopathy and cardiovascular disease, but not with diabetes duration., Purpose: Little is known about the association between type 2 diabetes mellitus (T2DM) and fragility fractures or the mechanism(s) involved. We examined fracture correlates among T2DM patients with osteoporosis., Methods: We used electronic health records of an osteoporosis (OP) registry cross-linked with a diabetes registry of a large payer provider healthcare organization in Israel. A cross-sectional analysis compared osteoporosis patients with and without T2DM, and a longitudinal Cox proportional hazard regression was used to identify incident fracture correlates., Results: As of December 2015 a total of 87,224 current OP patients were identified, of whom 15,700 (18%) had T2DM. The T2DM OP patients were characterized by older age (mean 74.6 vs. 69.5), more males (20.3 vs. 14.0%), and a higher rate of chronic comorbidities compared to OP without diabetes. All major OP fractures (hip, spine, humerus, and forearm) were significantly more prevalent among T2DM OP patients (44 vs. 32%), with an overall age-standardized ratio of 1.22 (95% CI 1.19 to 1.25) and 1.15 (95% CI 1.10 to 1.21) for females and males respectively. The average T-scores were higher (femur neck - 1.8 vs. - 1.9, total hip - 1.2 vs. - 1.6, and vertebrae - 1.3 vs. - 1.7) for the T2DM OP patients compared to the non-T2DM OP patients. Among women with coexisting T2DM and osteoporosis (n = 10,812), fracture incidence was significantly associated with retinopathy (HR = 1.24, 95% CI 1.05 to 1.47) and cardiovascular disease (HR = 1.22, 95% CI 1.10 to 1.36) after controlling for age, bone mineral density T-score, rheumatoid arthritis, glucocorticoids, alcohol, and smoking)., Conclusion: This large population-based study confirms the higher fracture risk of osteoporotic patients with T2DM, as compared to osteoporotic patients without T2DM, despite higher bone mineral density levels. The presence of micro- and macrovascular disease appears to increase this risk.

Background: The estimated incidence of osteoporotic pelvic fractures among persons over age 60 in Germany is 224 per 100 000 persons per year, and rising. A number of surgical treatment options are available, but clinical long-term data are lacking., Methods: This review is based on pertinent publications and guidelines retrieved by a selective literature search, and on the authors' clinical experience., Results: Patients often report one or more relatively trivial traumatic incidents leading up to the fracture. They complain of pain in the hip, groin, or lower lumbar region, or of low back pain and sciatica. A new classification scheme entitled Fragility Fractures of the Pelvis (FFP) takes the morphology of the fracture into account and can be used as an aid to therapeutic decision-making (evidence level IV). The goal of treatment is early mobilization with adequate pain relief. Isolated anterior pelvic ring fractures (FFP I) and nondisplaced posterior pelvic ring fractures (FFP II) are usually stable and can be treated conservatively. Type III and IV injuries are unstable and should generally be treated surgically., Conclusion: Retrospective analyses have shown that osteoporotic pelvic fractures are associated with decreased mobility and independence and with a one-year mortality ranging from 9.5% to 27%. Prospective therapeutic trials are urgently needed.

Osteoporosis is a multifactorial disease resulting in reduced bone strength and increased bone fragility. The cause of osteoporosis is underexplored. The manifestation of osteoporosis makes a significant contribution to the development of bone fractures. In the medical assessment, the question arises to what extent osteoporosis is considered to be a previous disability or in particular as a contributory factor. In particular, there are some uncertainties relating to the degree of possible participation, as there are only insufficient scientific evaluation systems. From the authors' point of view no valid assessment of the degree of participation exists on the basis of technical examinations or even the severity of the trauma. At the current time there is no possibility to indicate the level of contribution in 10% or 20% steps. Taking the total picture, including clinical and radiological findings into consideration, it seems possible to assess the contribution only in larger percentage steps (e.g. 0%, 50% or ≥80%). The mere diagnosis of osteoporosis does not justify a participation rate unless its effects can be pathomorphologically proven.

Thoracolumbar fractures in the elderly are frequently associated with osteoporosis. Osteoporosis can cause fractures or be a significant comorbidity in traumatic fractures. The OF classification is based on conventional X‑ray, computed tomography (CT) scan and magnetic resonance imaging (MRI). It is easy to use and provides a clinically relevant classification of the fractures. Therapeutic decisions are made based on the clinical and radiological situation by using the OF score. The score takes the current clinical situation including patient-specific comorbidities into consideration. The treatment recommendations are based on an expert consensus opinion and include conservative and operative options. If surgery is indicated, vertebral body augmentation, percutaneous stabilization and even open surgery can be used.

Osteoporotic vertebral fractures constitute at least 50% of the osteoporotic fractures that happen worldwide. Occurrence of osteoporotic fractures make the elderly patient susceptible for further fractures and increases the morbidity due to kyphosis and pain; the mortality risk is also increased in these patients. Most fractures occur in the thoracic and thoracolumbar region and are often stable. Different descriptive and prognostic classification systems have been described, but none are universally accepted. Radiographs, computed tomography, and magnetic resonance imaging are useful in imaging the fracture and evaluating the bone density. In acute stages, the fractures are well treated with conservative measures including short bed rest, analgesics, bracing, and exercises. Although most fractures heal well, up to 30% of fractures can develop painful nonunion, progressive kyphosis, and neurological deficit. For patients who develop severe pain not responding to nonoperative measures and painful nonunion, percutaneous cement augmentation procedures including vertebroplasty or kyphoplasty have been suggested. For fractures with severe collapse and that lead to neurological deficit and increasing kyphosis, instrumented stabilization is advised. Prevention and management of osteoporosis is the key element in the management of osteoporotic fractures in the elderly. Guidelines for essential adequate dietary and supplemental calcium and vitamin D, and antiosteoporotic medications have been described.

The incidence of fragility fractures of the pelvis is increasing quickly. The characteristics of these fractures are different from pelvic ring disruptions in adults. Fragility fractures of the pelvis are the consequence of a low-energy trauma which occurs in a patient with an important decrease of bone mineral density. Due to a consistent pattern of alteration of bone mass distribution in the sacrum, other fracture morphologies occur than in younger adults. The leading symptom is immobilizing pain in the lower back, in the buttocks, in the inguinal region and/or at the pubic symphysis. Conventional radiographs and CT will show the presence and localization of the fractures in the anterior and posterior pelvic ring. A new, comprehensive classification system distinguishes four categories of instability. This first criterion is most important, because it also gives hints for the preferred type of treatment. The second criterion, leading to the subtypes in the four categories, is the localization of the instability in the posterior pelvic ring. This criterion points the way towards the type of the surgical procedure to be used. When a surgical treatment is chosen, the procedure should be as minimal invasive as possible. Different techniques for percutaneous or less invasive fixation of the posterior pelvic ring have been developed. Their advantages and limitations are presented: sacroplasty, iliosacral screw osteosynthesis, cement augmentation, transiliac internal fixation, trans-sacral osteosynthesis, lumbopelvic fixation. Fractures of the anterior pelvic ring also need special attention. Retrograde transpubic screw fixation is recommended for pubic rami fractures. Fractures of the pubic body and instabilities of the pubic symphysis need bridging plate osteosynthesis. We do not recommend anterior pelvic external fixation in elderly because of the risk of pin track infection and pin loosening., (Celsius.)

Osteoporotic fractures present a significant social and economic burden, which is set to rise commensurately with the aging population. Greater understanding of the physicochemical differences between osteoporotic and normal conditions will facilitate the development of diagnostic technologies with increased performance and treatments with increased efficacy. Using coherent X-ray scattering we have evaluated a population of 108 ex vivo human bone samples comprised of non-fracture and fracture groups. Principal component fed linear discriminant analysis was used to develop a classification model to discern each condition resulting in a sensitivity and specificity of 93% and 91%, respectively. Evaluating the coherent X-ray scatter differences from each condition supports the hypothesis that a causal physicochemical change has occurred in the fracture group. This work is a critical step along the path towards developing an in vivo diagnostic tool for fracture risk prediction.

Background: Some children with cerebral palsy (CP) have frequent fractures due to low bone mineral density and receive treatment with pamidronate, an intravenous bisphosphonate. Our review evaluates the outcome of pamidronate treatment in these children., Methods: A retrospective chart review was performed, and 32 patients (14 girls and 18 boys) with CP Gross Motor Function Classification System level III (2 patients), IV (3 patients), and V (27 patients) treated with 5 courses of pamidronate for low mineral density were identified. Patients with a minimum of 2 years of follow-up were included in the study. Data collection was a review of the demographics and pretreatment, peritreatment, and posttreatment fracture history., Results: The mean age at treatment was 11.6 years (range, 2.9 to 19.6 y). There were 102 fractures (mean duration 2.5 y) pretreatment and 28 fractures posttreatment. With an average follow-up of 6.4 years, posttreatment rate of fracture decreased to 0.10 fractures per year from the pretreatment rate of 2.4 fractures per year (P<0.001). The femur was the most common bone fractured both pretreatment (54%) and posttreatment (61%); the major site was the distal third of the femur. There were 11 fractures during the course of pamidronate treatment at a rate of 0.33 fractures per year. Only 11 patients (34%) sustained fracture posttreatment. No correlation with fracture pattern or occurrence was found with patient age, number of pretreatment fractures, or sex. Most fractures were caused by low-energy injuries, and most were managed nonoperatively., Conclusions: In patients with CP and disuse osteoporosis, the most common fracture sustained involved the distal femur via low-velocity injury, and most fractures were treated nonoperatively. Although the fracture pattern and the treatment remained unchanged, reoccurring fractures in these children can be effectively treated medically to interrupt the fracturing tendency.

Objective: To investigate the classification and treatment strategies of symptomatic severe osteoporotic vertebral fracture and collapse., Methods: Between August 2010 and January 2014, 42 patients with symptomatic severe osteoporotic vertebral fracture and collapse were treated, and the clinical data were retrospectively analyzed. According to clinical symptom and imaging materials, 23 cases were classified as type I (local pain, limitation of motion, no neurological symptom, and no obvious deformity), 12 cases as type II (slight neurological symptom and kyphotic Cobb angle < or = 30 degrees), and 7 cases as type III (severe neurological symptom and kyphotic Cobb angle >30 degrees). In 23 type I patients, 17 underwent percutaneous vertebral augmentation, 6 underwent posterior pedicle screw fixation strengthened with bone cement combined with percutaneous vertebral augmentation. In 12 type II patients, they were treated with local spinal decompression and internal fixation strengthened with bone cement. In 7 type III patients, 5 underwent posterior osteotomy, and 2 underwent one stage posterior approach of vertebral resection and reconstruction. The visual analogue scale (VAS), Oswestry disability index (ODI), and local kyphotic Cobb angle were used to evaluate the neurological function. The complications were recorded., Results: The operation was successfully completed in all patients. Wound infection and ketoacidosis secondary to stress blood glucose rise occurred in 1 case of type III patients respectively, and were cured after corresponding treatment; primary healing of wound was obtained in the other patients. The patients were followed up from 6 to 36 months (mean, 11.6 months). The nerve function was improved in 17 cases, and micturition disability was observed in 2 cases. Asymptomatic cement leakage occurred in 13 cases (30.95%) (7 cases in type I, 4 cases in type II, and 2 cases in type III). No bone cement dislocation and internal fixation failure were found during follow-up. The VAS score, ODI, and the local kyphotic Cobb angle at 1 week and last follow-up were significantly improved when compared with preoperative ones (P<0.05), but no significant difference was found between at 1 week and last follow-up (P>0.05)., Conclusion: In order to improve the effectiveness and reduce the risk and complications of operation, individualized strategies should be performed according to different types of severe osteoporotic vertebral fracture and collapse.

Purpose: Osteoporosis is considered to be a relative contraindication for anterior screw fixation of odontoid fractures because of reduced screw purchase. In the presence of osteoporosis, the most frequent mode of implant failure is via cut-out through the anterior wall of C2. Under in vitro conditions, cement-augmented odontoid screws show significant biomechanical advantages as compared to non-augmented screws. Against this background, we present our prospectively collected data on cement-augmented anterior screw fixation of osteoporotic odontoid fractures in elderly patients., Methods: 11 patients (8 female, 3 male, median age 83 years, range 73-89 years) with an isolated, osteoporotic type II odontoid fracture were treated. After closed reduction and standard anterior approach to the C2/3 level, a self-tapping, short-threaded 3.5-mm lag screw was placed. High-viscosity polymethylmethacrylate cement was injected via a cannulated Jamshidi needle into the base of the C2 vertebral body around the screw shaft and the screw was further tightened. Thin slice CT reconstructions for follow-up evaluation were done consistently postop and 12 months after surgery., Results: Anatomic fracture reposition was achieved in all patients. Cement application was uneventful and well controllable. Cement leakage towards the fracture gap was not detectable. There were no major perioperative complications and no early revision surgeries. After 1 year, thin slice CT with three-dimensional reconstruction demonstrated solid osseous healing of the odontoid fracture in 8 out of 10 patients., Conclusions: Additional cement augmentation for anterior odontoid fracture repair is technically easy and safe. In elderly people with osteoporotic odontoid fractures, the procedure seems to be a useful supplementary option.

Objective: To compare fractures and fracture-related resource utilization (RU) among patients with a recent fracture and treated with teriparatide (TPTD) to a matched cohort of patients not treated with TPTD (non-TPTD)., Research Design and Methods: Women aged 50 years or older initiating TPTD (N = 5314; index date between 1 January 2007 and 31 December 2012) were identified in an insurance claims database. Patients with fragility fracture (hip, pelvis, clavicle, humerus, wrist, leg or spine) during the 12 months prior to the index date (N = 1164) were selected to control for unmeasured confounding due to absence of bone mineral density test levels. TPTD patients were matched to the non-TPTD cohort using propensity score and exact matching (N = 912). Relative risk (RR) of fracture and fracture-related RU were estimated by Cox proportional hazard modeling, adjusted for potential fracture risk factors., Results: Fractures were observed in 4.6%, 8.6%, 10.3%, and 11.3% of TPTD patients and in 9.2%, 15.2%, 19.2% and 21.7% of non-TPTD patients over 6, 12, 18, and 24 months, respectively. The adjusted RR reduction in TPTD was 36% (RR = 0.64, 95% CI: 0.44-0.94) during 6 months, 27% (RR = 0.73, 95% CI: 0.54-0.97) during 12 months, 28% (RR = 0.72, 95% CI: 0.55-0.93) during 18 months, and 28% (RR = 0.72, 95% CI: 0.56-0.92) during 24 months versus matched non-TPTD patients. Fracture-related RU followed a similar trend to that observed for fracture risk., Conclusions: This real-world study found TPTD to be more effective in reducing risk of fragility fractures as early as 6 months with continuous treatment benefit up to 24 months compared to a matched non-TPTD cohort. TPTD patients experienced lower rates of fracture-related RU than non-TPTD patients. Key study limitations include the inability to confirm reported diagnostic and procedural codes and the absence of uninsured and individually insured patients in the claims database.

Due to the aging population, there is an increasing number of fragility fractures of the pelvis (FFP). They are the result of low energy trauma. The bone breaks but the ligaments remain intact. Immobilizing pain at the pubic region or at the sacrum is the main symptom. Conventional radiographs reveal pubic rami fractures, but lesions of the dorsal pelvis are hardly visible and easily overlooked. CT of the pelvis with multiplanar reconstructions show the real extension of the lesion. Most patients have a history of osteoporosis or other fragility fractures. The new classification distinguishes between four categories of different and increasing instability. FFP Type I are anterior lesions only, FFP Type II are non-displaced posterior lesions, FFP Type III are displaced unilateral posterior lesions and FFP Type IV are displaced bilateral posterior lesions. Subgroups discriminate between the localization of the dorsal instability. FFP Type I lesions are treated non-operatively. FFP Type II lesions are fixed in a percutaneous procedure when a trial of conservative treatment was not successful. FFP Type III lesions are treated with open reduction and internal fixation (ORIF). FFP Type IV lesions are treated with bilateral ORIF or with a bridging osteosynthesis. Iliosacral screw osteosynthesis is widely used, but has an elevated risk of screw loosening due to diminished bine mineral density. Transsacral bar osteosynthesis enable interfragmentary compression and does not have this danger of loosening. Bridging plate osteosynthesis is used as an additional fixation to iliosacral screw osteosynthesis. Lumbopelvic fixation is restricted to highly unstable lumbopelvic dissociations. More studies are needed to find the optimal treatment for each type of instability. Key words: pelvis, fragility fracture, diagnosis, classification, treatment.

Objectives: To provide a national estimate of the incidence of hospitalizations due to osteoporotic fractures (OFs) in women; compare this with the incidence of myocardial infarction (MI), stroke, and breast cancer; and assess temporal trends in the incidence and length of hospitalizations., Patients and Methods: The study included all women 55 years and older at the time of admission, admitted to a hospital participating in the US Nationwide Inpatient Sample for an outcome of interest. We performed a retrospective analysis of hospitalizations for OFs (hip, forearm, spine, pelvis, distal femur, wrist, and humerus), MI, stroke, or breast cancer, using the US Nationwide Inpatient Sample, 2000-2011., Results: From 2000 to 2011, there were 4.9 million hospitalizations for OF, 2.9 million for MI, 3.0 million for stroke, and 0.7 million for breast cancer. Osteoporotic fractures accounted for more than 40% of the hospitalizations in these 4 outcomes, with an age-adjusted rate of 1124 admissions per 100,000 person-years. In comparison, MI, stroke, and breast cancer had age-adjusted incidence rates of 668, 687, and 151 admissions per 100,000 person-years, respectively. The annual total population facility-related hospital cost was highest for hospitalizations due to OFs ($5.1 billion), followed by MI ($4.3 billion), stroke ($3.0 billion), and breast cancer ($0.5 billion)., Conclusion: These data provide evidence that in US women 55 years and older, the hospitalization burden of OFs and population facility-related hospital cost is greater than that of MI, stroke, or breast cancer. Prioritization of bone health and supporting programs such as fracture liaison services is needed to reduce this substantial burden., (Copyright © 2015 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Complete fractures of the tibial pilon are rare and their treatment difficult. The pathophysiology includes three groups: (A) high-energy trauma (motor vehicle injuries), with severe articular and soft tissue lesions, (B) rotation trauma, (skiing accidents), with modest articular and soft tissue damage, and (C) low-energy trauma in elderly people. These three groups occasion very different problems and complications. In emergency situations, these fractures should be stabilized, most often using external fixation to restore length and prepare definitive fixation. The second stage can be applied once soft tissue healing is achieved. Two methods are discussed: internal plating and definitive external fixation. The first goal of treatment is to restore the articular surface, although this does not always prevent secondary arthritis. The second is to restore correct positioning of the foot as regard to the leg. The complication rate is high. Neither of the two fixation techniques has proven to be more effective. In group B, the two methods are similar, but external fixation seems to be safer in group A., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

The possibilities offered by kyphoplasty in the treatment of osteoporotic vertebral fractures have been widely described. Kyphoplasty is technically not very demanding, it can be easily learned and it is minimally invasive when compared to open surgical fracture treatment. Like many other simple surgical methods, it has spread rapidly and as a consequence of the above factors combined with its good reimbursement in many countries, it has experienced a widening in the indications for which it is being employed. The intial purpose of kyphoplasty was pain relief based on vertebral body stabilisation combined with restoration of vertebral body height. An increasingly uncritical use of the method can be observed and as a consequence, an increase in serious complications. During recent years, spinal surgery departments have received an increasing number of patients with serious complications following kyphoplasty, requiring major reconstructive spinal surgery. On the basis of 12 cases treated over the past 36 months, we aim to provide guidelines for the indications of the kyphoplasty procedure.

Unlabelled: In the Study of Osteoporotic Fractures (SOF), 18.5 % of incident hip fractures identified in Medicare Fee-for-Service claims data were not reported to or confirmed by the cohort. Cognitive impairment was a modest risk factor for false-negative hip fracture ascertainment via self-report., Introduction: Prospective cohort studies of fractures that rely on participant self-report to be the initial signal of an incident fracture could be prone to bias if a significant proportion of fractures are not self-reported., Methods: We used data from the SOF merged with Medicare Fee-for-Service claims data to estimate the proportion of participants who had an incident hip fracture identified in Medicare claims that was either not self-reported or confirmed (by review of radiographic reports) in SOF., Results: Between 1/1/1991 and 12/31/2007, 647 SOF participants had a hip fracture identified in Medicare claims, but 120 (18.5 %) were either not reported to or confirmed by the cohort. False-negative hip fracture ascertainment was associated with a reduced modified Mini-Mental State Exam (MMSE) score (odds ratio 1.31 per SD decrease, 95 % C.I. 1.06-1.63). Point estimates of associations of predictors of incident hip fracture were changed minimally when the misclassification of incident hip fracture status was corrected with use of claims data., Conclusions: A substantial minority of incident hip fractures were not reported to or confirmed in the SOF. Cognitive impairment was modestly associated with false-negative hip fracture ascertainment. While there was no evidence to suggest that misclassification of incident hip fracture status resulted in biased associations of potential predictors with hip fracture in this study, false-negative incident fracture ascertainment in smaller cohort studies with limited power may increase the risk of type 2 error (not finding significant associations of predictors with incident fractures).

The incidence of osteoporotic pelvic fractures is rapidly increasing. Following low energy trauma fractures are frequently classified as pelvic girdle fractures. Based on the pelvic expert group database of the German Trauma Society the estimated rate of osteoporotic pelvic ring fractures is about 51%. In cases of fractured pubic rami standard X-ray in anterior-posterior, inlet and outlet views should be carried out by computed tomography (CT) scanning to identify fractures of the sacrum. Only if pain persists and no fracture is evident with CT is magnetic resonance imaging (MRI) indicated. Therapy should be carried out under biomechanical instability aspects. Pubic rami fractures are stable and treated conservatively with sufficient pain medication, thromboembolic prophylaxis and physiotherapy. In cases of persisting pain or biomechanical instability operative treatment is indicated and stabilization methods should be chosen under biomechanical aspects. Therefore external fixator for pubic rami fractures and iliosacral screws, optionally with cement augmentation for posterior pelvic girdle fractures are the preferred techniques. Sacral fractures with severe osteolysis should be stabilized by lumbopelvic fixation techniques.

Fractures of the proximal humerus are typical osteoporotic fractures of the elderly with an increasing incidence. Computed tomography (CT) with 3D reconstruction plays a more and more decisive role in the diagnostics because of an improved understanding of fractures in 3D images. The resulting correct fracture classification has significance for the decision of the best therapy procedure. Currently an extended version of the Codman classification with its four and more fragments is used to give additive information about varus or valgus dislocation, impression or distraction. The comparison of conservative and operative treatment showed no predominance of one of the procedures, therefore both strategies are justified. An operative treatment is recommended in complex fractures. Thus, early functional mobilization, early self-dependence and return to the activities of daily living are possible. Intramedullary nailing is advised in 2-part fractures, in dislocated multipart fractures locking plating or a primary reverse shoulder arthroplasty with refixation of the tuberosities in patients over 75 years. However, the improved plate and nail systems with polyaxiality, calcar screws, modern plate and nails designs as well as the possibility of arthroscopy-assisted nail implantation or plate removal combined with arthroscopic arthrolysis are innovative.

This review considers the surgical treatment of displaced fractures involving the knee in elderly, osteoporotic patients. The goals of treatment include pain control, early mobilisation, avoidance of complications and minimising the need for further surgery. Open reduction and internal fixation (ORIF) frequently results in loss of reduction, which can result in post-traumatic arthritis and the occasional conversion to total knee replacement (TKR). TKR after failed internal fixation is challenging, with modest functional outcomes and high complication rates. TKR undertaken as treatment of the initial fracture has better results to late TKR, but does not match the outcome of primary TKR without complications. Given the relatively infrequent need for late TKR following failed fixation, ORIF is the preferred management for most cases. Early TKR can be considered for those patients with pre-existing arthritis, bicondylar femoral fractures, those who would be unable to comply with weight-bearing restrictions, or where a single definitive procedure is required.

The concept and terminology for bone fractures is now in some confusion between two academic fields, one of osteoporosis and the other of orthopedic fracture treatment, concerning the treatment of osteoporosis and the prevention of fragility fractures. In the former field, the terms of "incident or prevalent" fracture are commonly used ; by contrast, bone fracture simply means "fresh" fracture in the latter. Used to be based of X-ray films, diagnosis of osteoporotic fracture are now changing to depend on MRI, because its sensitivity and specificity of detecting fresh fracture of vertebral body is far better than other methods.

Background: Population-based administrative data have been used to study osteoporosis-related fracture risk factors and outcomes, but there has been limited research about the validity of these data for ascertaining fracture cases. The objectives of this study were to: (a) compare fracture incidence estimates from administrative data with estimates from population-based clinically-validated data, and (b) test for differences in incidence estimates from multiple administrative data case definitions., Methods: Thirty-five case definitions for incident fractures of the hip, wrist, humerus, and clinical vertebrae were constructed using diagnosis codes in hospital data and diagnosis and service codes in physician billing data from Manitoba, Canada. Clinically-validated fractures were identified from the Canadian Multicentre Osteoporosis Study (CaMos). Generalized linear models were used to test for differences in incidence estimates., Results: For hip fracture, sex-specific differences were observed in the magnitude of under- and over-ascertainment of administrative data case definitions when compared with CaMos data. The length of the fracture-free period to ascertain incident cases had a variable effect on over-ascertainment across fracture sites, as did the use of imaging, fixation, or repair service codes. Case definitions based on hospital data resulted in under-ascertainment of incident clinical vertebral fractures. There were no significant differences in trend estimates for wrist, humerus, and clinical vertebral case definitions., Conclusions: The validity of administrative data for estimating fracture incidence depends on the site and features of the case definition.

Hip fractures are common and serious consequence of osteoporosis. Bone mineral density (BMD) measurement and the World Health Organization (WHO) fracture risk assessment tool are considered to predict the hip osteoporotic fractures. In this study, their sensitivities in hip fracture cases are evaluated. BMD and WHO probability of fracture risk were determined in 71 hip fractures ≥ 50 years of old. Totally, 65% of patients had ≤-2.5 BMD T score. 81% of patients had above the upper interventional threshold of WHO fracture risk probability model. Sensitivities were low in 50-59 year age group with progression in older age groups. Results of BMD T score and fracture risk probabilities were not significant between men and women. There were 23% and 49% sensitivities of less than or equal to -2.5 T score in the 50-59 and 60-69 year age groups with a 31% sensitivity of greater than 3% probability of hip fracture risk in the 50-59 year age group, both of which were not valid for predicting hip fracture risk.

Background: Knowledge of the pathomechanism and the detailed extent of ankle joint lesions determines adequate therapy and success of treatment., Material and Methods: Supination external rotation lesions were induced in 29 human cadavera with a testing apparatus; 27 of these specimens were from elderly women. Bone mineral density was measured. The literature review includes experimental studies of this fracture entity., Results: We induced stage II in 42%; applying an additional lateral force on the fibula raised the incidence. The syndesmosis stayed intact in 50% although the fibula fractured at the level of the tibial plafond. Stage IV lesions were registered in 25%. The overall low bone mineral density showed a positive correlation to the angle at which the fibula fracture occurred., Conclusions: We reproduced supination external rotation lesions according to Lauge-Hansen in osteoporotic ankles. There is a certain discrepancy between the obligatory lesion of the inferior anterior tibiofibular syndesmosis at stage II according to Lauge-Hansen, as we observed an intact syndesmosis in 50% at stage II. Stage IV defining medial malleolar fractures were reproduced after Lauge-Hansen and Michelson et al.

There has been a significant increase in the incidence and severity of ankle fractures in the elderly population in the last few decades. Classification and diagnostic procedures in the elderly are not different from standards in younger patients. We provide an overview of the characteristic features of treatment of ankle fractures in the elderly. An algorithm for therapy of ankle fractures in the elderly is presented.