The fact that osteoporosis causes and aggravates fracture treatment is well known. Osteoporosis is defined as a skeletal disorder characterized by compromised bone strength predisposing an increased risk of fracture, according to the NIH consensus statement 2000 [5].
Plates act as stress shielding devices where the implant causes the creation of a stress riser at the end of the plate. This was the case with our patient whose initial fracture united in both the plating procedures but a new fracture was created at the stress riser. This problem is especially difficult in the osteoporotic bone. The elderly population is particularly vulnerable to low energy peri implant fractures attributed to osteopenia or osteoporosis leaving limited reconstruction options to the revision surgeon. In our case, it was difficult to envisage a modification in the initial surgery. Retrospective analysis indicated that use of a GSH nail at the outset might have prevented these complications [peri implant fractures].
In planning treatment in older patients with peri implant fractures of the osteoporotic bone, several important factors are to be considered. The functional demands of the elderly are different from young healthy and long term immobilization in bed must be avoided. Delaying treatment has been reported to increase mortality [5].
Our patient was particularly difficult to manage in view of the failure of the DCS method on two occasions. We did not go for a revision with the same implant due to one previous failure. Removing the implant and doing intramedullary fixation would mean denudation and devitalisation besides causing large amount of blood loss. The fact that a prior fracture is associated with an 86% increased risk of new fracture indicates that osteoporosis persists during the treatment of the first fracture [7].
The advantages of our method include,
1. No need of re-exposure and bone grafting
2. The benefits of closed reduction and a reamed nail
3. Easy locking by the external ilizarov device
4. Compression across the fracture by the Ilizarov device.
The disadvantages of an external fixation if any are negated by its limited period of application; we strongly recommend this procedure for such complicated fractures. However in employing such a procedure it is important for the surgeon to be well versed with intramedullary nailing as well as the Ilizarov methodology.