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February 13, 2002 at the AAOS Meeting in Dallas Texas, USA
FOREWORD BY PROF. S. PERREN
Fractures in the elderly have recently seen a marked increase in frequency and severity. The pain and disability result in diminished quality of life and suffering for the patient. For the community the disability creates immense costs because, according to recent reports, an important percentage of patients with proximal femoral fractures, for example, remain bedridden or require continuous assistance. In the acute phase immediately after the fracture bed rest must be minimized to avoid the lethal risk of circulatory and pulmonary complications. Therefore, the main goal of treatment for fractures of the lower limb, pelvis and spine is to achieve early ambulation. Clinical experience has shown that the faster pain is reduced and mobility and ambulation is restored, the better are the chances of survival. This in turn requires a high quality of internal fixation in a difficult setting.Osteoporotic bone is not only less strong but lacks toughness. Brittle bone is less forgiving. The problem is compounded by the fact that as bone softens the brain hardens, that is, it loses control of locomotor function resulting in increased incidence of fractures and more importantly in loss of control of loading after fracture treatment. The weakness and brittleness of the osteoporotic bone limit its load-bearing capacity while the internal fixation must withstand higher, uncontrolled loads. Stronger implants paradoxically do not help; they are mostly more rigid and rigid implants increase the stress at the interface between implant and bone, a real vicious circle. To improve internal fixation, therefore, animal models allowing research into internal fixation in osteoporotic bone are of basic importance. They should lead to finding the proper balance between stability for painless function and controlled instability for prompt healing.
The healing quality of the elderly and osteoporotic bone seems to be clinically less important, provided the fracture can be properly fixed. Still, any possibility to improve the healing process is of interest. Furthermore, to reduce suffering and cost, research into avoidance of osteoporosis based on a better understanding of molecular biology to supplement the knowledge of conventional biochemistry is a priority item.
The present book extensively deals with both the biomechanical and the biological aspects of surgical treatment of fractures in osteoporotic bone. A outstanding balance between the "mechanistic" and "molecular" world and between clinical and research aspects has been achieved. The wealth of direct and quoted information given is a valuable contribution to the researcher and clinician alike. The many methods of research and the sometimes impressive variety of techniques, tools and implants indicate that we are still in search of desperately needed improvements. In some areas, such as in fractures of the humeral head, the variety of procedures is proportional to the difficulty of the treatment. In respect to the frequent fractures of the forearm, interesting new developments allowing maintenance of mobility are reported.
The editor, Yuehuei H. An, has added one more outstanding contribution in the field of applied research and clinical treatment. We congratulate and wish well-deserved success!
PREFACE Metabolic bone diseases, such as osteoporosis, osteomalacia, hyperparathyroidism, and Paget's disease, are usually associated with osteoporotic or soft skeleton, especially in the elderly patient. Orthopaedic procedures in elderly patients are costly and with the increasing age of the population these cost will continue to escalate. Great challenges are often encountered when internal fixation is needed for fractures or osteotomies to osteoporotic bone. This book is designed to carry both the current clinical techniques and the cutting-edge knowledge in pre-clinical research on internal fixation of osteoporotic bone. Potential readers include orthopaedic surgeons, orthopaedic residents, orthopaedic researchers, fellows, and graduate students, as well as implant designers who work in orthopaedic departments or companies. The book will also be of interest to anyone working in the fields of clinical orthopaedics, orthopaedic research, or implant manufacture, and to internal medicine physicians who see osteoporotic patients.
The book is organized into seven parts. Part I &emdash; "Basic Science" introduces the nature, models, and measurements of osteoporotic conditions, fracture healing, and how internal fixation works; Part II &emdash; "Current Clinical Techniques in General" reviews the current status of routine clinical techniques for fixation of osteoporotic bone; and Part III to VI &emdash; "New Clinical Applications and Novel Concepts" covers the new clinical and novel concepts of internal fixation in osteoporotic bone using screws, plates, and intramedullary nails, and other fixation devices in osteoporotic spine and pelvis. The text is simple and straightforward. A large number of diagrams, tables, line drawings, and photographs is used to help readers better understand the content. Full bibliographies at the end of each chapter guide readers to more detailed information.
This is the first inclusive and organized reference book on internal fixation of osteoporotic bone, a topic that has not been covered adequately by any existing books. The book is planned to stay at the frontier of internal fixation of osteoporotic bone. Future editions, hopefully every five years, will always introduce new development and novel concepts in the field. Readers will be able to follow the progress of every new concept from in vitro and in vivo stages to clinical applications.
Yuehuei H. An, MD
2001 in Charleston, SC, USA
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PART I. ESSENTIALS OF OSTEOPOROSIS
1. Pathogenesis and Histomorphology of Osteoporosis
2. Biomechanics of Osteoporotic Bone and Fractures
3. Bone Healing in Pathologic Conditions
4. Mechanisms of Internal Fixation
5. Imaging and Densitometry of Osteoporotic Bone
PART II. CURRENT CLINICAL TECHNIQUES
6. Current Methods and Trends in Fixation of Osteoporotic Bone
7. Basic Principles and Technical Aspects of Internal Fixation in Osteoporotic Bone
8. Internal Fixation of Osteoporotic Long Bone
9. Internal Fixation of Osteoporotic Spine
10. Internal Fixation of Osteoporotic Acetabular and Pelvic Fractures
11. Bone Fixation in Patients with Paget's Disease
12. Bone Fixation in Patients with Osteogenesis Imperfecta
13. Internal Fixation in Patients with Bone Tumors
14. External Fixator &endash; Today and Tomorrow
15. Fracture Prevention and Medical Treatment of Osteoporosis
PART III. NEW CLINICAL APPLICATIONS AND NOVEL CONCEPTS &emdash; BONE SCREWS, PINS, AND AUGMENTATION
16. Resorbable Cement for Augmentation of Internal Fixation of Hip Fractures
17. Fixation of Unstable Osteoporotic Intertrochanteric Fractures Using the DHS and a Glass-Ionometric Cement
18. Enhancing Stability of External-Fixation Pins with Hydroxyapatite Coating
19. Enhancing Internal Fixation with Novel Device and Hydroxyapatite Granules in Osteosynthesis of Proximal Femoral Fracture with Osteoporosi
20. An Interlocking Screw for Fixation in Osteoporotic Bone
21. An Injectable Cement Screw for Fixation in Osteoporotic Bone
22. A Cement Screw for Fixation in Osteoporotic Metaphyseal Bone
PART IV. NEW CLINICAL APPLICATIONS AND NOVEL CONCEPTS &emdash; BONE PLATES
23. Resorbable Implants for Augmenting Metal Plate fixation in Osteoporotic Bone
24. Interlocked Blade Plates in the Treatment of Osteoporotic Metaphyseal Fractures
25. LISS Plate for Fracture Fixation of Long Bones
26. An Axially Mobile Plate for Fracture Fixation
PART V. NEW CLINICAL APPLICATIONS AND NOVEL CONCEPTS &emdash; INTRAMEDULLARY NAILS
27. The Huckstep Nail for Fixation of Mechanically Deficient Femoral Bone
28. Cement Fixation of Proximal Humeral Fractures in the Elderly Patient
29. A Synthes Spiral Blade Intramedullary Nail System for Proximal Humeral Fractures
30. An Expandable Intramedullary Nail for Fixation in Osteoporotic Bone
31. Improving the Distal Fixation of Intramedullary Nails in Osteoporotic Bone
PART VI. NEW CLINICAL APPLICATIONS AND NOVEL CONCEPTS &emdash; SPINAL FIXATION
32. Percutaneous Vertebroplasty Using Bone Cement
33. Transpedicular Vertebroplasty with CaP Cement
34. Percutaneous Kyphoplasty (Balloon Tamp) Reduction and Stabilization of Compression Vertebral Fractures
35. A Self-Guided Pedicle Screw for Anterior Fixation of Cervical Spine
36. TPS Devices for Treatment of Vertebral Tumors and Compression Fractures