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Osteoporotic Fractures of the Pelvis, Hip and Femur: Current Challenges and New Perspectives

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: closed (10 April 2025) | Viewed by 10257

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Dr. Andreas Hoch

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Guest Editor

Department for Orthopaedics, Trauma Surgery and Plastic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany
Interests: pelvic fracture; geriatric acetabular fracture; osteoporotic fractures of the pelvis; polytrauma; periprosthetic fracture; proximal femoral fracture

Special Issue Information

Dear Colleagues,

We cordially invite your expert contributions to our Special Issue of the Journal of Clinical Medicine. Osteoporotic fractures, particularly pelvic, periprosthetic and proximal femoral fractures, present intricate healthcare burdens globally. This issue delves into the latest advancements and novel approaches in managing these fractures and non-operative supportive therapies, including osteoporosis treatment. We encourage submissions showcasing innovative diagnostic techniques, surgical interventions, rehabilitation strategies and pharmaceutical approaches aimed at enhancing patient outcomes and quality of life. As Guest Editors, we aim to cultivate a deep understanding of the multifaceted aspects surrounding osteoporotic fractures, providing a platform for insightful discussions and evidence-based research. Your invaluable contributions will play a pivotal role in shaping the future landscape of osteoporotic fracture management. We eagerly anticipate your insights.

Dr. Andreas Hoch
Guest Editor

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Keywords

osteoporosis
fracture management
pelvic fractures
periprosthetic fractures
proximal femoral fractures
non-operative therapies

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Published Papers (9 papers)

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Research

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13 pages, 761 KiB

Open AccessArticle

Fragility Fractures of the Pelvic Ring: Analysis of Epidemiology, Treatment Concepts, and Surgical Strategies from the Registry of the German Pelvic Multicenter Study Group

by David B. Osche, Emmanouil Liodakis, Stefan Huber, Tim Pohlemann, Christian Kleber, Steven C. Herath and Andreas Höch

J. Clin. Med. 2025, 14(9), 2935; https://doi.org/10.3390/jcm14092935 - 24 Apr 2025

Viewed by 187

Abstract

Background: Fragility fractures of the pelvic ring (FFPs) represent a fast-growing entity in geriatric traumatology with increasing incidence worldwide. This study aimed to analyze the epidemiology, treatment concepts, and surgical strategies for FFPs based on data collected by the German Pelvic Multicenter Study Group documented in the German Pelvic Fracture Registry. It is the largest cohort study of its kind. Methods: This retrospective cohort study included patients aged 65 years or older after FFPs, as classified according to the Rommens and Hofmann classification. Data were collected from July 2018 onward and analyzed for demographics; fracture classifications; treatment modalities (operative vs. non-operative); and details of surgery, including timing and choice of implants. Patients after high-energy trauma were excluded. Statistical analyses included descriptive metrics and subgroup comparisons. Results: Among 1242 patients (84% female; median age 83.4 years), FFP Type II was the most common fracture type (50.8%), followed by Type IV (21.1%). Non-operative management was employed in 68.8% of cases, while 30.9% underwent surgery. Surgical intervention was more frequent in higher-grade FFPs (e.g., 72.1% in Type IV). The most common surgical technique for the posterior pelvic ring was percutaneous screw fixation (61.3%), with navigation used in 47.4% of cases. Conclusions: This study highlights the variability in treatment strategies for FFPs, with conservative management predominating in lower-grade fractures and surgical approaches increasingly utilized for more complex cases. The findings underscore the need for standardized, evidence-based guidelines and further research to optimize treatment and long-term outcomes for geriatric patients with FFPs. Full article

(This article belongs to the Special Issue Osteoporotic Fractures of the Pelvis, Hip and Femur: Current Challenges and New Perspectives)

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10 pages, 1607 KiB

Open AccessArticle

Triangular Screw Placement to Treat Dysmorphic Sacral Fragility Fractures in Osteoporotic Bone Results in an Equivalent Stability to Cement-Augmented Sacroiliac Screws—A Biomechanical Cadaver Study

by Isabel Graul, Ivan Marintschev, Antonius Pizanis, Marcel Orth, Mario Kaiser, Tim Pohlemann, Working Group on Pelvic Fractures of The German Trauma Society and Tobias Fritz

J. Clin. Med. 2025, 14(5), 1497; https://doi.org/10.3390/jcm14051497 - 24 Feb 2025

Viewed by 399

Abstract

Background: Sacroiliac screw fixation in elderly patients with pelvic fractures remains a challenging procedure for stabilization due to impaired bone quality. To improve it, we investigated the biomechanical properties of combined oblique sacroiliac and transiliosacral screw stabilization versus the additional cement augmentation of this construct in a cadaver model of osteoporotic bone, specifically with respect to the maximal force stability and fracture-site motion in the displacement and rotation of fragments. Methods: Standardized complete sacral fractures with intact posterior ligaments were created in osteoporotic cadaver pelvises and stabilized with a triangle of two oblique sacroiliac screws from each side with an additional transiliosacral screw in S1 (n = 5) and using the same pelvises with additional cement augmentation (n = 5). A short cyclic loading protocol was applied, increasing the axial force up to 125 N. Sacral fracture-site motion in displacement and rotation of the fragments was measured by optical motion tracking. Results: A maximum force of 65N +/− 12.2 N was achieved using the triangular screw stabilization of the sacrum. Cement augmentation did not provide any significant gain in maximum force (70 N +/− 29.2 N). Only low fragment displacement was observed (2.6 +/− 1.5 mm) and fragment rotation (1.3 +/− 1.2°) without increased stability (3.0 +/− 1.5 mm; p = 0.799; 1.7 +/− 0.4°; p = 0.919) following the cement augmentation. Conclusions: Triangular stabilization using two obliques and an additional transiliosacral screw provides sufficient primary stability of the sacrum. Still, the stability achieved seems very low, considering the forces acting in this area. However, additional cement augmentation did not increase the stability of the sacrum. Given its lack of beneficial abilities, it should be used carefully, due to related complications such as cement leakage or nerve irritation. Improving the surgical methods used to stabilize the posterior pelvic ring will be a topic for future research. Full article

(This article belongs to the Special Issue Osteoporotic Fractures of the Pelvis, Hip and Femur: Current Challenges and New Perspectives)

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12 pages, 665 KiB

Open AccessArticle

An Additional Certification as a Centre for Geriatric Trauma Had No Benefit on Mortality Among Seriously Injured Elderly Patients—An Analysis of the TraumaRegister DGU^® with Data of the Registry for Geriatric Trauma (ATR-DGU)

by Bastian Pass, Rene Aigner, Rolf Lefering, Sven Lendemans, Bjoern Hussmann, Teresa Maek, Dan Bieler, Christopher Bliemel, Carl Neuerburg, Carsten Schoeneberg and the TraumaRegister DGU

J. Clin. Med. 2024, 13(22), 6914; https://doi.org/10.3390/jcm13226914 - 17 Nov 2024

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Abstract

Background/Objectives: The number of seriously injured elderly patients is continuously rising. Several studies have underlined the benefit of orthogeriatric co-management in treating older patients with a proximal femur fracture. The basis of this orthogeriatric co-management is a certification as a Centre for Geriatric Trauma (ATZ). Data of seriously injured patients are collected in the TraumaRegister DGU^® (TR-DGU) from participating trauma centres. We hypothesise that if a certified trauma centre is also a certified Centre for Geriatric Trauma, a benefit can be measured. Methods: Retrospective cohort analysis was conducted from 1 January 2016 to 31 December 2021. The TraumaRegister DGU^® collected the data prospectively. This retrospective multicentre registry study included patients 70 years or older with an abbreviated injury scale of ≥3 and intensive care unit treatment from 700 certified Trauma Centres and 110 Centres for Geriatric Trauma in Germany, Austria and Switzerland. The primary outcome was mortality in in-hospital stays. Other outcome parameters were days of intubation, the length of stay in ICU, and in-hospital stays. Furthermore, the discharge target and the Glasgow Outcome Scale (GOS) were analysed. Results: The inclusion criteria were met by 27,531 patients. The majority of seriously injured patients (n = 23,007) were transported to certified trauma centres without certification as ATZ. A total of 4524 patients were transported to a trauma centre with additional ATZ certifications. Mortality and the Revised Injury Severity Classification II (RISC-II) model for prediction of mortality after trauma were higher in ATZ hospitals. Logistic regression analysis showed no effect on mortality by a certification as a centre for geriatric trauma in treating seriously injured elderly patients. Conclusions: We assume that the additional ATZ certification does not positively influence the treatment of seriously injured elderly patients. A potential side effect could not be measured. Full article

(This article belongs to the Special Issue Osteoporotic Fractures of the Pelvis, Hip and Femur: Current Challenges and New Perspectives)

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8 pages, 1574 KiB

Open AccessArticle

Comparison of Spectral CT and MRI in Pelvic Ring Fragility Fractures: A Prospective Diagnostic Accuracy Study

by Mark Unthan, Bernhard W. Ullrich, Camilla Heinen, Felix C. Kohler, Philipp Schenk, Tobias Franiel and Florian Bürckenmeyer

J. Clin. Med. 2024, 13(18), 5446; https://doi.org/10.3390/jcm13185446 - 13 Sep 2024

Cited by 1 | Viewed by 1473

Abstract

Background/Objectives: Fragility fractures of the pelvis (FFP) are characterized by inadequate trauma to a structurally compromised bone, primarily in osteoporosis. Conventional CT studies can be inadequate in identifying FFPs. An MRI of the pelvis is considered the gold standard in diagnosing FFPs. Spectral CT or Dual-Energy CT may have comparable diagnostic accuracy. It provides additional insights into associated bone marrow edema. The aim of this prospective monocentric study is to evaluate the diagnostic accuracy of Spectral CT compared to the gold standard MRI in diagnosing FFP. Methods: Over a 2-year period, patients presenting in the emergency department with clinical suspicion of an FFP were consecutively included. They underwent Spectral CT (GE Revolution 16 cm GSI) upon admission, followed by an MRI. The gold standard for diagnosing FFP is pelvic MRI, showing sensitivity and specificity ranging from 97% to 100%. The acquired images were evaluated and classified using the osteoporotic fractures of the pelvis (OFP) classification. Results: Compared to the reference test, which was the MRI pelvis, the sensitivity of the CT pelvis was determined to be 86.8 (95% confidence interval (CI) 71.9–95.6%) with a specificity of 84.6% (95% CI: 54.6–98.1%, p = 0.453). Spectral CT could identify an additional FFP correctly, exhibiting a sensitivity of 89.5% (95% CI: 75.2–97.1%, p = 0.688), while maintaining the same specificity as the conventional CT. The inter-rater reliability assessment for Spectral CT, conducted by four independent raters, resulted in a Fleiss’ Kappa value of 0.516 (95% CI: 0.450–0.582, p < 0.001). Conclusion: The sensitivity of Spectral CT in the detection of pelvic ring fragility fractures shows a slightly lower sensitivity compared to MRI. There were no statistically significant differences observed when compared to conventional CT or MRI. In conclusion, Spectral CT may be beneficial in distinguishing FFP, particularly in cases where a definitive diagnosis is uncertain. Level of Evidence: II. Full article

(This article belongs to the Special Issue Osteoporotic Fractures of the Pelvis, Hip and Femur: Current Challenges and New Perspectives)

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14 pages, 3474 KiB

Open AccessArticle

Lumbopelvic Stabilization with Two Methods of Triangular Osteosynthesis: A Biomechanical Study

by Niklas Grüneweller, Julia Leunig, Ivan Zderic, Boyko Gueorguiev, Christian Colcuc, Dirk Wähnert and Thomas Vordemvenne

J. Clin. Med. 2024, 13(16), 4744; https://doi.org/10.3390/jcm13164744 - 13 Aug 2024

Viewed by 1404

Abstract

(1) Background: Pelvic fractures, and particularly instabilities of the dorsal pelvic ring, are becoming increasingly prevalent, particularly in orthogeriatric patients. Spino-pelvic triangular osteosynthesis is an effective approach to achieve sufficient stabilization in vertically unstable fractures. This study compares two types of osteosynthesis: the conventional one and a novel instrumentation where the iliosacral screw is placed through a fenestrated iliac screw. (2) Methods: Sixteen artificial osteoporotic L5+pelvis models with an unstable sacral fracture have been instrumented with either an iliac screw connected with a rod to a L5 pedicle screw and an iliosacral screw (TF) or a fenestrated ilium screw connected with a rod to a L5 pedicle screw and an iliosacral screw passing through the fenestra of the iliac screw (TFS). Biomechanical testing was performed using cyclic loading until failure. (3) Results: Both configurations yielded comparable results with regard to initial stiffness, implant loosening, and cycles to failure. The TFS exhibited markedly higher values for cycles to failure and markedly lower values for loosening. However, due to the characteristics of the artificial bone model, these findings were not significant. (4) Conclusions: The novel triangular fixation systems demonstrated comparable results to the standard triangular osteosynthesis configuration. Full article

(This article belongs to the Special Issue Osteoporotic Fractures of the Pelvis, Hip and Femur: Current Challenges and New Perspectives)

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12 pages, 1772 KiB

Open AccessArticle

Early Hip Fracture Surgery in Patients Taking Direct Oral Anticoagulants Improves Outcome

by Benjamin K. Devlieger, Pol M. Rommens, Andreas Baranowski and Daniel Wagner

J. Clin. Med. 2024, 13(16), 4707; https://doi.org/10.3390/jcm13164707 - 11 Aug 2024

Cited by 1 | Viewed by 1342

Abstract

Background/Objectives: The increasing numbers of already endemic hip fractures in the elderly taking anticoagulants is a growing concern for daily surgical practice. Ample evidence demonstrates decreased morbidity and mortality in the general population when surgery is performed at the earliest possibility. Direct anticoagulants are relatively new drugs that can cause increased perioperative bleeding. Current guidelines propose stopping the drug to allow for elimination before performing elective surgery. Optimal management in urgent hip surgery is presently based on expert opinion with arbitrary cut-offs. In this study, we investigated whether patients taking direct anticoagulants would benefit from early surgical treatment, regardless of the timing since last intake. Methods: A total of 340 patients were included in the analysis, of which 59 took direct anticoagulants. The primary outcomes were time to surgery, postoperative transfusion rate, postoperative hemoglobin decrease, length of postoperative in-hospital stay (LOPS), revision rate, and complication rate (medical and surgical). Results: Our findings showed that the anticoagulated group was fit for discharge earlier when operated on within 24 h (p = 0.0167). Postoperative transfusion and medical complication rate tended to be lower when the operation was performed earlier. Revision rate due to hematomas were higher in the direct anticoagulant group without a relationship to time to surgery. Simple linear regression could not determine a relationship between postoperative hemoglobin change and time to surgery. Conclusions: We suggest that directly anticoagulated patients needing hip fracture surgery must be considered for early surgery. Full article

(This article belongs to the Special Issue Osteoporotic Fractures of the Pelvis, Hip and Femur: Current Challenges and New Perspectives)

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15 pages, 2809 KiB

Open AccessArticle

Treatment Trends and Epidemiologic Changes in Acetabular Fracture Management over the Course of 10 Years: An Analysis Based on 2853 Patients as Treated by the German Pelvic Multicenter Study Group

by Silvan Wittenberg, Daniel Rau, Melissa Paraskevaidis, Vera Jaecker, Ulrich Stöckle and Sven Märdian

J. Clin. Med. 2024, 13(16), 4601; https://doi.org/10.3390/jcm13164601 - 6 Aug 2024

Cited by 3 | Viewed by 1101

Abstract

Background/Objectives: Acetabular fractures, traditionally linked to high-impact trauma in younger adults, are increasingly observed in the elderly due to falls and poor bone quality. This demographic shift necessitates updated treatment approaches. This study analyzes demographic trends and treatment evolution over a decade using the German pelvic fracture registry. Methods: Data on acetabular fractures were analyzed from the German pelvic fracture registry of the German Trauma Society. Parameters included classification, demographics, treatment methods, and surgical details. Trends were assessed by grouping patients based on treatment intervals and age, comparing treatment methods, surgical approaches, and reduction quality across these groups, considering fracture types and treatment volume. Results: The study included 2853 unilateral acetabular fractures with a mean patient age of 61.5 years, showing an increasing age trend. A shift from simple to complex fractures involving the anterior acetabular column was observed. Operative treatment was performed in 62.5% of cases, more common in non-geriatric patients and those with posterior column involvement. The use of anterior intrapelvic approaches increased over time, replacing the Ilioinguinal extrapelvic approach. Anatomical reduction was achieved in 47.4% of cases, with 31.7% having imperfect reductions and 20.9% poor reductions. High-volume centers had significantly better reduction outcomes, particularly for simple fractures. Geriatric patients exhibited worse reduction quality compared to younger patients. In-hospital mortality was stable at 3.3%. Conclusions: The study highlights a demographic shift towards an older patient population, leading to more complex fracture patterns. Despite advancements in surgical techniques and new implant technologies, these demographic changes have resulted in lower reduction quality for complex fractures. Emphasis is placed on careful patient selection for reconstructive surgery or endoprosthetic replacement to ensure high-quality outcomes. Full article

(This article belongs to the Special Issue Osteoporotic Fractures of the Pelvis, Hip and Femur: Current Challenges and New Perspectives)

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Review

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14 pages, 32477 KiB

Open AccessReview

Treatment of Geriatric Acetabular Fractures Using the Modified Stoppa Approach: A Review Article of Technique, Tips, and Pitfalls

by Mikolaj Bartosik, Eckart Mayr and Ulf Culemann

J. Clin. Med. 2024, 13(19), 5867; https://doi.org/10.3390/jcm13195867 - 1 Oct 2024

Viewed by 1541

Abstract

The surgical treatment of geriatric acetabular fractures is becoming increasingly important due to a demographic change in age. While acetabular fractures used to occur more frequently in younger patients, they are currently more prevalent in geriatric patients. This change has also led to an increase in the frequency of anterior and combined anterior acetabular fractures. Surgery for geriatric acetabular fractures is very challenging, and surgeons need years of experience to be able to deal with the advantages and disadvantages of pelvic surgery. This is why a high level of surgical expertise is required. The aim of this article is to provide an insight into the topic of geriatric acetabular fractures with a critical narrative review of the current literature and a focus on minimally invasive surgical treatment using the modified Stoppa approach without patients’ own assessment. The modified Stoppa approach offers excellent visibility of the anterior structures of the acetabulum and can address the quadrilateral surface effectively. Pelvic surgery, in particular acetabular surgery, offers patients many advantages, such as rapid mobilization and the quick relief of pain symptoms. Total hip arthroplasty is currently being discussed as an alternative with good results for certain types of acetabular fractures in older patients, though it requires clarification of studies and recommendations. Full article

(This article belongs to the Special Issue Osteoporotic Fractures of the Pelvis, Hip and Femur: Current Challenges and New Perspectives)

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13 pages, 1605 KiB

Open AccessSystematic Review

Hemorrhage in Pelvic Ring Fractures After Low-Energy Trauma: A Systematic Review

by Alina Roßler, Lara Lukhaup, Max Seidelmann, Catharina Gaeth, Sven-Oliver Dietz, Christof Audretsch, Paul Grützner, Joachim Windolf and Anne Neubert

J. Clin. Med. 2024, 13(23), 7223; https://doi.org/10.3390/jcm13237223 - 28 Nov 2024

Cited by 2 | Viewed by 1051

Abstract

Background/Objectives: The aim was to investigate diagnostic, treatment and preventive options to establish an overview of the existing evidence on hemorrhage in pelvic fractures in older adults. Methods: A systematic review was conducted. Due to the rarity of this complication, only case reports and series with individuals older than 55 years with a pelvic ring fracture that is caused by a low-energy trauma or no apparent trauma, along with hemorrhage, were eligible. A search was performed on four databases. The CARE checklist was used to investigate the reporting integrity of the included studies. Analysis was performed narratively, and this study was registered on the Open Science Framework. Results: 21 patients from 19 studies were included (17 females and 4 males) with an average age of 82.1 years. The 21 patients suffered a total of 29 fractures. Pubic ramus fractures were present in 48.3% of all fractures. In 42.9%, an active hemorrhage was reported. Arterial vessels were injured in direct anatomical relationship to the fracture. Abdominal pain and hemorrhagic instability were the main red flag symptoms reported. Active arterial hemorrhage was diagnosed by CT with angiogram and treated by embolization with or without additional surgery. Conclusions: Clinically relevant hemorrhage in pelvic fractures due to low-energy trauma is rare. However, these fractures, combined with clinically relevant hemorrhage, account for an increased mortality and morbidity in elderly people. This systematic review was able to create a clinical decision tree for hemorrhage in ramus pubic fractures. Full article

(This article belongs to the Special Issue Osteoporotic Fractures of the Pelvis, Hip and Femur: Current Challenges and New Perspectives)

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