¿mejora la pth (teriparatida) los resultados en fracturas pertrocantereas inestables osteoporóticas?

Abstract

Abstract INTRODUCTION. The increase in patients suffering from "unstable hip fractures, with osteoporotic profile" and the poor results that we usually observe in their recovery, pose a challenge for both the orthopaedic surgeons and socio-sanitary level. On the other hand, there are recent publications suggesting that teriparatide (1-34 PTH), due to its anabolic bone effect, could have a positive effect improving and accelerating fracture consolidation and patient recovery. However, the results are still controversial. HYPOTHESIS AND OBJECTIVES. Under the hypothesis of a positive anabolic effect of teriparatide on fracture consolidation, we set our main objective: to assess whether teriparatide, administered at the usual clinical dose for osteoporosis, improves the outcomes of patients undergoing osteoporotic unstable pertrochanteric hip fractures. METHODS. A clinical-therapeutic, observational, prospective and comparative study was designed. The study population would be formed by all patients, aged 75 years or older, who were previously ambulatory, attended at the University Hospital of Guadalajara during the year 2016, with the diagnosis of a pertrochanteric hip fracture, with unstable pattern (groups A22 to A33 of the AOOTA Classification), and osteoporotic profile, operated in the first week after the fracture with an intramedullary nail with sliding screw, gamma type. For the treatment of osteoporosis, according to the algorithm proposed by the SECOT-GEIOS, patients received teriparatide (PTH) or antiresorptive agents. We evaluated basal conditions of the patients before the fracture and their recovery at 4, 8 and 12 weeks and finally at 6 months. Pain, hip function, gait, quality of life and habitual place of residence were clinically evaluated with the following tools: EVA pain scale, TUG test and FAC, mobility and gait devices scales, WOMAC, Barthel, EQ-5D. At radiological level, we assessed the quality of the reduction and the osteosynthesis, with the SSS stability scale, and the fracture consolidation with the RUSH specific scale. In order to reduce the interference of the great clinical and functional variability of this type of patients, the "relative recovery" (RR) was also calculated for each variable with respect to its basal level. In addition, a "meta-outcome score" was created to reflect the patient's overall recovery, integrating the results of the previous variables. Medical, radiological and surgical complications were recorded. RESULTS. A total of 78 patients met the criteria for participating in the study. Because of their osteoporosis, 32 of them received teriparatide (PTH group) and the other 46 received antiresorptive treatment (control group). Both groups were comparable, except for the higher prevalence of fractures in the PTH group, the main reason for its indication. We observed statistically significant differences in favor of PTH patients in the following aspects: better Barthel score at 8 and 12 weeks, better mobility at 12 weeks, and better results at WOMAC and EQ5D at 6 Months; Radiological consolidation, according to the RUSH scale, was greater and faster at 8 and 12 weeks, achieving consolidation in all cases. Despite showing positive trends in favor of PTH, our study could not demonstrate statistical significance in the gait velocity test (TUG), in the FAC scale or in the final place of residence. We also found no differences in mortality or surgical complications (4 cases of cut-out at 4 weeks and a distal nail fracture at 13 weeks in the PTH ¿MEJORA LA PTH (TERIPARATIDA) LOS RESULTADOS EN FRACTURAS PERTROCANTEREAS INESTABLES OSTEOPORÓTICAS? Juan Oscar Romanillos Arroyo - UNIVERSIDAD AUTÓNOMA MADRID - Facultad Medicina – 2017 4 group; 2 cut-out cases at 4 weeks, 1 late cut-out/in, two peri-nail fractures, one contralateral acetabulum fracutre and one fall with costal fractures in the control group). No deep infection or material breakage was detected. DISCUSSION. Previously aware of the limitations of our study (small sample and open assessment of results), we put our effort into a careful design and methodology, choosing suitable measurement and assessment systems for this particular type of fracture and patients. PTH treatment was safe and we found no significant difference in medical complications or mortality. Nor could it be shown that PTH decreased surgical complications, which occurred mostly in the first month and coud be attributed more to a mechanical failure of surgical reduction and / or synthesis. Our results show benefits in several clinical and radiological aspects for the group treated with PTH (which is even more interesting considering the increased bone fragility in this group) and are logical and consistent with the hypothesis that teriparatide demonstrates a favorable effect in the recovery of this particular group of patients, as pointed out by other recent studies that we discuss in the work. CONCLUSIONS. Our study showed statistically significant differences in favor of PTH in the recovery of patients with unstable osteoporotic pertrochanteric hip fractures in several aspects, listed below: 1. Greater and more rapid radiological consolidation, according to the RUSH scale, at 8 and 12 weeks. 2. Greater and faster recovery of personal autonomy, valued by the Barthel index, at 8 and 12 weeks. 3. Improved mobility of patients at 12 weeks. 4. Improvement in overall hip function, according to the WOMAC scale, at 6 months. 5. Improvement in self-perception of health, according to the EQ-D5 scale, at 6 months. 6. We have not observed significant differences in mortality or in medical or surgical complications. DESCRIPTORS: Osteoporotic Fracture, Fragility fracture, Pertrochanteric hip fracture, Fracture healing, Intramedullary Nail, Osteoporosis, Antiosteoporotic therapy, PTH, Parathyroid hormone, Teriparatide, Prospective comparative observational study, Recovery, Results ¿MEJORA LA PTH (TERIPARATIDA) LOS RESULTADOS EN FRACTURAS PERTROCANTEREAS INESTABLES OSTEOPORÓTICAS? Juan Oscar Romanillos Arroyo - UNIVERSIDAD AUTÓNOMA MADRID - Facultad Medicina – 2017 5