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Forty-Nine Year-Old Female With Subtrochanteric Nonunion

Forty-Nine Year-Old Female With Subtrochanteric Nonunion. Chris Estes, PGY 2 August 11, 2008 Adult Reconstruction Conference Mayo Clinic Phoenix, AZ. History of RA, SLE, chronic steroids One year s/p subtrochanteric stress fracture at presentation Multiple procedures at outlying facility

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Forty-Nine Year-Old Female With Subtrochanteric Nonunion

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  1. Forty-Nine Year-Old Female With Subtrochanteric Nonunion Chris Estes, PGY 2 August 11, 2008 Adult Reconstruction Conference Mayo Clinic Phoenix, AZ

  2. History of RA, SLE, chronic steroids • One year s/p subtrochanteric stress fracture at presentation • Multiple procedures at outlying facility • Referred for management of nonunion

  3. Subjective: • Currently FWB LLE • Lateral hip pain with wt. bearing • Objective: • 5’1” 160 lbs • Antalgic gait • Incisions are well healed • Painful ROM • 100/20/10 • NV intact • What do you see? • How would you manage this patient?

  4. Taken to OR two months later: • Hardware removal • Subtrochanteric valgus osteotomy • DCS fixation • Autologous bone grafting

  5. Seen in clinic @ 3 weeks post op: • Complains of hip pain • LLE Shortening • Minor central wound breakdown What is your plan?

  6. Our plan: • Sent home on doxycycline • Conversion to THA once wound controlled

  7. Four days later: • Seen in ED for increased pain and drainage • Wound with erythema, purulence Now what?

  8. Admitted & taken to OR two days later for Stage I PROSTALAC Cultures grew Staph aureus Patient discharged home on six weeks of IV vancomycin and PO rifampin

  9. Patient doing well nine months post op. Inflammatory markers within normal limits.

  10. Two weeks later was converted to THA

  11. Six weeks post op: • Incision well-healed • ESR = 6 • CRP = 2.2

  12. Literature review • Corticosteroid use and: • Secondary osteoporosis • Relative risk of hip fractures • Impaired bone healing • Role of rhBMP • Retrospective review of subtrochanteric nonunions

  13. In vivo effect of Glucocorticoids • O’Brien & Jia. Endocrinology 2004, 2006. • Transgenic mice were created in which cells of interest (osteoblasts or osteoclasts) expressed 11 beta-hydroxysteroid dehydrogenase type 2 • This enzyme inactivates glucocorticoids • Osteoblasts/cytes: • Glucocorticoids directly stimulate osteoblasts in vivo triggering them to undergo apoptosis • Osteoclasts: • Glucocorticoids directly stimulate osteoclasts in vivo • Prolongs life span of osteoclasts

  14. Corticosteroid Use & Hip Fx Risk • Van Staa et al, 2000 • Cohort study of 244,235 corticosteroid users and equal number of controls • Relative risk of hip fracture was dose-dependent • <2.5mg = RR of 0.99 • 2.5-7.5mg = RR of 1.77 • >7.5mg = RR of 2.27

  15. Effect of Prednisone on Fracture Healing • Waters, 2000 • Rabbit ulnar osteotomy, n=18 • 0.15 mg/kg prednisone 2 mo prior to and 6 wks after bilateral ulnar osteotomy • Union: • Prednisone: 3/20 • Control: 13/16 • Osseous continuity across >25% cross section • Torsional Stiffness: • Prednisone: 218 N-m/rad • Control: 567 N-m/rad Bilateral ulnae of rabbit receiving Prednisone at six weeks Bilateral ulnae of rabbit in control group at six weeks

  16. Role of rhBMP • Luppen et al, 2002 • 49 mature rabbits • 26 received prednisolone (0.35 mg/kg qd) 6 weeks prior to and 6-8 weeks after bilateral ulnar osteotomy • 23 controls • Each rabbit received unilateral local rhBMP at time of fracture. • Prednisolone group: • 0/26 reached radiographic union • (vs. 8/23 controls) • rhBMP-Treated Prednisolone group • 20/26 achieved radiographic union • p=<0.001 • Callus area increased by 40% • 165% increase in torsional strength

  17. Subtrochanteric Nonunions • Haidukewych & Berry. CORR 2004. • Retrospective review of 23 consecutive subtroch nonunions • Revision results: • 20/21 healed (95%) • Nonunion persisted in a 56 y/o smoker tx’d w/ blade plate and allograft • Discussion: • This study was mostly a cohort of younger patients. • Elderly w/ low physical demand w/ poor remaining bone stock inadequate for ORIF, multiple failed attempts at union or implant cut-out w/ resultant articular damage were (and are) treated with arthroplasty.

  18. References • Jia D, O'Brien CA, Stewart SA, Manolagas SC, Weinstein RS. Glucocorticoids act directly on osteoclasts to increase their life span and reduce bone density. Endocrinology. 2006 Dec;147(12):5592-9. • Luppen CA, Blake CA, Ammirati KM, Stevens ML, Seeherman HJ, Wozney JM, Bouxsein ML. Recombinant human bone morphogenetic protein-2 enhances osteotomy healing in glucocorticoid-treated rabbits. J Bone Miner Res. 2002 Feb;17(2):301-10. • O'Brien CA, Jia D, Plotkin LI, Bellido T, Powers CC, Stewart SA, Manolagas SC, Weinstein RS. Glucocorticoids act directly on osteoblasts and osteocytes to induce their apoptosis and reduce bone formation and strength. Endocrinology. 2004 Apr;145(4):1835-41. Epub 2003 Dec 22. • Van Staa TP, Leufkens HG, Abenhaim L, Zhang B, Cooper C. Use of oral glucocorticoids and risk of fractures. J Bone Mineral Research 2000;15:993-1000. • Waters RV, Gamradt SC, Asnis P, Vickery BH, Avnur Z, Hill E, Bostrom M. Systemic corticosteroids inhibit bone healing in a rabbit ulnar osteotomy model. Acta Orthop Scand. 2000 Jun;71(3):316-21.

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