Preventive surgical treatment


Considering the quality and reproducibility of the results obtained with femoral neck fractures, it was inevitable that the question of preventing these fractures would arise.

When we have the details of a problem, it is natural to try and provide a solution. What are these details? Osteoporosis is certainly a general disease as we repeat once more. From the sufferer's point of view, only the consequences which have a serious effect on her health are to be taken into account. Just as fractured ribs or wrists are events with almost no severity, in most cases, so one or more vertebral fractures, one, and even more, two femoral neck fractures will have a serious effect on the injured person's functions and often her life.

This must be said because, with a better lifestyle, certain drugs or techniques which improve cardiac longevity, humans live on average to 80 or more. As physicians, it is our duty to help them live their full life-span under the best possible conditions. One of these consists of protecting the "erect position". This is the job of all traumatologists...

Take the hip. What are the known facts (the problem data):

 

- Epidemiological studies on osteoporosis have revealed the incidence of first fractures (of the
wrist and/or vertebrae) on the later occurrence of hip fractures. And they have shown the risk of a fracture on the opposite side.

INCREASE OF THE FRACTURE RISK
ON THE OPPOSITE HIP WITH AGE
From 55 to 64 years + 35
From 65 to 74 years + 12
From 75 to 84 years + 4
85 years and over + 1,3

 

- The risk factors are known (ethnic, nutritional and environmental).

- We know that osteoporosis leads to bone rarefaction affecting the container (walls or cortical bone) and the content (inside or spongy bone).

- The wall thin progressively

- The phenomenon is more complex for the contents. Two kinds of bone loss lead to:
 

either a modification of bone trabeculae (they grow thinner and are reduced in number)
 

or real holes develop (in different numbers, sites and sizes).
To consolidate these ideas, take the case of a forest. There are trees and clearings. The trees are the bone trabeculae and the clearings are holes. You can thin the trees, they may be of different ages. There may be several clearings, large or small .
 


- Bone loss cannot be measured quantitatively, but loss of the bone's mineral component can. Bone Mineral Density (BMD) is measured using instruments. A lost quantity can then be defined and compared with the BMD of a young person (whose bone mineralisation is at its maximum level, the T-score) as well as with the BMD of a person of the same age (the Z-score).

- A quantity of bone mineral loss has been defined below which there is a risk of fracture in the event of a fall (this fracture threshold is 0.600 g/cm²).

- Statistical evaluation of fracture risk relative to bone mineral loss has been calculated.

Thirty years ago, a fracture on the opposite side was "expected". Thirty years ago we occasionally operated on hip fractures in people aged over eighty. Nobody was eager to do it because the results were disappointing.
Today we cannot and must not maintain this passive, fearful attitude, considering the information we now have on the state of the bone.

Can diagnosis be improved technically?

Considering what we have just said, it is essential to know the bone's densitometric condition. It would obviously be too random an event to expect to count on a BMD measurement of two hips which had, fortuitously been requested just a few days before a fracture.

Today, it is impossible – technically and practically – to request a bone densitometry for the opposite healthy hip in a patient who has just fractured a hip.

It would only take a major medical imaging industrial group to combine – either in one or two machines – a standard X-ray (for the fractured hip) and a 3D densitometer (for the controlateral hip) so that, without moving the fractured patient who is in pain, we could study the fracture and measure the mineral status of the healthy bone.

We could then, under highly specific conditions, treat both hips at the same time, with two teams, to avoid prolonging the operation time.

What technique should be used for preventive treatment?

As things stand at present, the technique consists of injecting a variable quantity of natural coral into the neck of the non-fractured femur. Bone densitometry having given – as an indication – the site of greatest bone mineral loss. Six to eighteen grams of natural coral can be injected.

For further information: coral injection technique

It is essential to emphasis this next point: as long as the natural coral has not been resorbed, the "solidity" of the implanted hip will not be altered. It is not the injection of a "stone" (even from the skeleton of a madrepore) – let's use this image and apologise to the coral – into a bone which will alter its strength under impact, as long as there is no "biological connection" between them...

On the other hand, as the coral is transformed into bone, the mechanical strength of the implanted bone increases. When this transformation is complete, the new bone and the pre-existing bone provide a femur which is all the stronger, the higher its bone densitometry .

The patient must therefore be warned of this inevitable delay which involves the implementation of biological events. As soon as the graft is in place, it is vital for the patient to walk bearing her full weight. It is vital for her to walk as often and for as long as possible. Why? Because we are working with biological phenomena. Natural coral needs a cellular input in order to transform (biodegrade). Only vascularisation can carry these cells to the heart of the biomaterial. Everyone knows that physical exercise stimulates and develops this vascularisation if it is practised regularly and for long periods of time. It's true for the muscles – cardiac patients know – and it's true for the bones.

Yes for walking, no for falling during the months following the graft.

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