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AO Dialogue 2|11
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AO Dialogue 2|11
AO Research Institute Davos Osteoporotic fracture treatment:
in Focus a systematic approach to a growing problem
Decision making –> Implant positioning –> Fracture stabilization –> Reinforcement
Nailing/Cephalic implants
Plating
Orthopedics
Anatomical fracture reduction
Screw insertions
X-inFig 1 Proximal Femoral Nail Antirotation augmented with bone cement
Fig 2 Denisprobe™ for application In Spine
Markus Windolf, Ladina Fliri, Matthias Forte, Lukas Kamer, An Sermon, R Geoff Richards, ARI, Switerland
Approximately 75 million people in Europe, Japan and the US suffer from osteoporosis resulting in over 5.5 million fractures every year. With an ageing population, the medical and socioeconomic effect of osteoporosis, particularly postmenopausal osteoporosis, will further increase. AO Trauma has, therefore, nominated osteoporotic fracture care as a research focus. The AO Research Institute Davos (ARI) has put this mandate into practice by systematically improving the various steps of fragility fracture treatment. These involve intraoperative decision making by assessment of local bone quality, enhancing accuracy of implant positioning, improving facture fixation in reduced bone mass by computer methods for systematic refinement of implant designs, and reinforcing implant purchase by cement augmentation techniques. Strengthening the different aspects of fragility fracture treatment and interlink-
ing them, carries future potential to prevent devastating and non-devastating complications in fracture care of the elderly. Intraoperative decision making: Assessment of local bone quality (Fig 2)
Bone quality is known as important indicator determining the biomechanical stability following fracture fixation. Intraoperative measurement of the bone quality carries potential to markedly support the decision making process regarding choice of fixation hardware or operational technique in order to optimize the fracture fixation. The concept of a handheld mechanical measurement probe was recently introduced (DensiProbe™) consisting of a specifically designed blade and an attached measuring unit. The device is manually inserted into the cancellous bone prior to osteosythesis to the aimed location of the implant. The torque, necessary
ne
Implant Positioning Assistance
to turn the blade about its axis and to break the local trabecular structure, is recorded. The measured value correlates with the local bone strength and suggests eg, the use of a specific implant or the application of bone cement for additional reinforcement.
site to avoid complications since internal body forces are high and bone stock is limited. Not only for the inexperienced surgeon, orientation in anatomical terrain remains difficult and is all too often associated with considerable exposure to radiation.
The concept was proven by several in vitro studies correlating the DensiProbe measurement with mechanical fatigue tests and image based parameters (CT). Prototypes were developed for several anatomical key regions, namely hip, spine, proximal humerus and hind-foot. A clinical multicenter study is currently ongoing to obtain threshold values for clinical decision making, preparing the ground for successful translation into clinical practice.
A novel concept for assisting implant placement is introduced to improve surgical routine interventions worldwide. Opposed to current navigation solutions, the concept utilizes a conventional C-arm as imaging and navigation means extracting hidden information from 2-dimensional radiographic projections. The new method is exemplified on intramedullary nailing using a cephalic hip implant. Application covers center-center positioning of the blade in the femoral head, adjusting anatomical leg rotation and distal interlocking with minimal requirements for radiation. Further applications are in the planning stage.
Implant positioning (Fig 3)
Particularly in reduced bone mass accurate placement of implants is of utmost importance. Adequate implant positioning is a prerequi-
Fig 3 Implant positioning assistance for various applications in trauma and orthopedics