The effect of osteoporosis and its treatment on fracture healing a systematic review of animal and clinical studies

Abstract

Introduction Osteoporosis is characterised by low bone mass and micro-architectural deterioration of bone structure. Its treatment is directed at the processes of bone formation or resorption, that are of utmost importance in fracture healing. We provide a comprehensive review of the literature aiming to summarize and clarify the effects of osteoporosis and its treatment on fracture healing. Material and methods A literature search was conducted in PubMed and Embase (OVID version). In vivo animal and human studies on long bone fractures were included. A total of 93 articles were included for this review; 23 studies on the effect of osteoporosis (18 animal and 5 clinical studies) and 70 studies on the effect of osteoporosis treatment (41 animal, 26 clinical studies and 3 meta-analyses) on fracture healing. Results In animal fracture models osteoporosis was associated with decreased callus formation and bone growth, bone mineral density, biomechanical strength and delayed cellular and differentiation processes during fracture healing. Two large databases identified osteoporosis as a risk factor for non-union whereas three other studies did not. One of those three studies however found a prolonged healing time in patients with osteoporosis. Anti-osteoporosis medication showed inconsistent effects on fracture healing in both non-osteoporotic and osteoporotic animal models. Only the parathyroid hormone and anti-resorption medication were related to improved fracture healing and delayed remodelling respectively. Clinical studies performed in predominantly hip and distal radius fracture patients showed no effect of bisphosphonates on fracture healing. Parathyroid hormone reduced time to union in several clinical trials performed in mainly hip fracture patients, but this did not result in decreased delayed or non-union rates. Conclusion Evidence that substantiates the negative influence of osteoporosis on fracture healing is predominantly from animal studies and to a lesser extent from clinical studies, since convincing clinical evidence lacks. Bisphosphonates and parathyroid hormone may be used during fracture healing, since no clear negative effect has been shown. Parathyroid hormone might even decrease time to fracture union, without decreasing union rate.

Hybrid Fixation of Failed Internally Fixed Distal Femoral Fracture with an Extramedullary Locking Plate and an Intramedullary Cortical Strut Allograft Construct- A Case Report

“…Fracture fixation in an osteoporotic bone can be a surgical challenge. Failure of fixation and delayed fracture healing are recognized complications [2,5]. Bone allografts and bone supplements have been used with excellent results in hip…”

“…Long bone fractures in Osteoporotic bones are a common source of morbidity and increasing mortality in the elderly population [1,2]. Osteoporotic bones are characterized by decrease in bone mineralization leading to reduced cortical thickness [2].…”

“…Fixation of fractures in osteoporotic bones can be a surgical challenge and they are often associated with delayed healing [3,4]. Poor quality of bone, pattern and configuration of the fracture, non-union of the fracture, rigidity of fixation and implant-bone construct fatigue may result in failure of fixation [1,2].…”

Insuffizienzfraktur der Klavikula nach Implantation einer inversen Schulterendoprothese

“…Die Begleiterkrankungen, konkret der Morbus Parkinson mit erhöhtem Sturzrisiko und die rheumatoide Arthritis, deren erforderliche Therapie sowie das myelodysplastische Syndrom und die konsekutiv langjährig bestehende Osteoporose sollten aus Sicht der Autoren als komplizierende Faktoren beachtet werden. Angesichts der langjährigen antiresorptiven Vorbehandlung in Verbindung mit der für die Knochenregeneration kritischen Glukokortikoid- [ 7 ] und MTX- [ 12 ] Therapie, erscheint pathophysiologisch eine osteoanabole Therapiesequenz zunächst naheliegend, wenngleich die Datenlage dahingehend inkonsistent ist [ 6 ]. Angesichts des Risikos einer Progression des myelodysplastischen Syndroms im Zuge einer forcierten Zellpropagation unter dem Einsatz von Teriparatid sowie des erhöhten Risikos für kardiovaskuläre Endpunkte bei entsprechendem Ausgangsrisiko unter Romosozumab entschieden wir uns gegen einen solchen Behandlungsansatz.…”

Research progress on the mechanism of interleukin-1β on epiphyseal plate chondrocytes

“…It is therefore necessary to properly assess and manage growth plate injuries. The procedure of fracture healing involves complex processes such as inflammation inflammatory reaction, endochondral ossification and bone reconstruction [ 1 , 2 ]. The immune response at the injured site is of critical importance to affect fracture healing, which rapidly forms hematoma, chemotactic and recruit a large number of inflammatory cells [ 3 ], releasing the cytokine IL-1β, TNF-α, etc.…”