Biceps Tenotomy vs. Tenodesis - MS Orthopaedics (20 Marks)

Introduction

Anatomy of the Long Head of Biceps Tendon

• Originates from the supraglenoid tubercle and superior glenoid labrum (biceps-labral complex)
• Passes intra-articularly, then enters the bicipital groove (intertubercular groove) between the greater and lesser tuberosities
• Stabilised in the groove by the transverse humeral ligament, coracohumeral ligament (CHL), and the biceps pulley (formed by the rotator interval capsule)
• The LHBT contributes minimally to elbow flexion strength (~10-20%) and forearm supination (~20%), as these functions are largely taken over by the short head and the rest of the muscle belly

Pathology Requiring Surgical Management

Indications (when conservative management has failed for 3-6 months):

BICEPS TENOTOMY

Definition

Technique

1. Shoulder arthroscopy via standard anterior and posterior portals
2. LHBT identified at the biceps anchor; assessed for pathology
3. Released at the glenoid attachment using an arthroscopic electrode or scissors
4. An oblique tenotomy that maximises the proximal stump size may reduce the likelihood of tendon retraction and the resulting Popeye deformity - the thickened stump "hangs up" in the bicipital sling
5. No additional fixation required

Advantages

• Technically simpler and faster - lower operative time (meta-analysis: tenotomy ~15 min shorter than tenodesis)
• Lower cost - no implants needed
• Lower complication profile - no risk of groove pain, hardware failure, nerve injury, or fracture
• Can be done purely arthroscopically
• Equivalent functional and pain outcomes compared to tenodesis (no difference in Constant-Murley, ASES, or VAS scores in multiple RCTs and meta-analyses)
• Appropriate in elderly, low-demand, or sedentary patients

Disadvantages

• Popeye deformity in approximately 40-70% of patients (more common in lean, muscular males) - caused by distal retraction of the muscle belly
• Subjective cramping with heavy biceps loading in ~30% (compared to ~12% after tenodesis)
• Supination strength decrease of ~20% - clinically relevant in heavy labourers and athletes
• Higher subjective complaints: 59% tenotomy vs 37% tenodesis patients report at least one complaint
• Not ideal in patients with cosmetic concerns or high physical demands

BICEPS TENODESIS

Definition

Types by Location

Fixation Methods

• Interference screw (most common; strong initial fixation)
• Suture anchors (knotted or knotless)
• Cortical buttons (PITT procedure - percutaneous intraarticular transtendon technique)
• Soft-tissue fixation (tendon sutured to surrounding soft tissue)
• The method of fixation is less important than quality of tissue fixed and the tension at which the tendon is fixed (Campbell's 2026)

Technique (Mazzocca Subpectoral Mini-Open Tenodesis)

1. Arthroscopy performed first; LHBT released from glenoid
2. Skin incision in the axillary crease below the pectoralis major
3. Biceps tendon located by dissecting through superficial fascia
4. Tendon withdrawn and ~20 mm of diseased portion excised
5. Guidewire placed in centre of bicipital groove at junction of middle and distal thirds
6. 7-8 mm acorn reamer creates socket 15-20 mm deep
7. Tendon fixed with interference screw or suture anchor at appropriate tension

Advantages

• Eliminates Popeye deformity risk significantly (OR 0.29 vs. tenotomy in meta-analysis; 6.8% vs 23.3% deformity rates in RCTs)
• Maintains biceps resting length-tension relationship - preserves muscle contractile efficiency
• Maintains supination strength (may actually increase supination strength by ~22% vs a 20% decrease after tenotomy)
• Reduces cramping incidence
• Fewer subjective complaints (37% vs 59%)
• Higher patient satisfaction in physically active individuals
• Preferred in young, active, manual labourers, athletes, and those with cosmetic concerns

Disadvantages

• More technically demanding and time-consuming
• Higher cost - requires implants
• Risk of groove pain if the tenodesis retains tendon in the intertubercular groove - subpectoral technique reduces this risk
• Potential for brachial plexus or musculocutaneous nerve injury with aggressive medial retraction (open techniques)
• Risk of humeral diaphyseal stress fracture with inlay techniques or large drill holes - a unicortical drill hole/unicortical button minimises fracture risk
• Hardware failure, anchor pullout
• Longer rehabilitation

COMPARISON TABLE

PATIENT SELECTION CRITERIA

Prefer TENOTOMY in:

• Age >65 years or older, low-demand patients
• Obese patients (Popeye deformity less visible)
• Women (less muscle definition; deformity less apparent)
• Sedentary, non-manual workers
• Patients with significant comorbidities (shorten anaesthetic time)
• When cost is a concern

Prefer TENODESIS in:

• Young, active patients (<50 years, high-demand athletes)
• Manual labourers requiring forearm supination strength
• Males with cosmetic concerns (well-defined biceps)
• Throwing athletes (pitchers, cricketers) - though SLAP repair preferred in high-level throwers
• Patients requesting cosmesis preservation
• When concomitant subscapularis repair is performed

SLAP TEARS AND BICEPS MANAGEMENT

• Type I: Débridement only
• Type II: Controversy - repair vs. tenotomy/tenodesis; patients >40 years with degenerative labral changes - débridement + tenotomy/tenodesis preferred
• Type IV: >30% tendon involved - tenodesis preferred
• Concomitant rotator cuff tear: Modern studies recommend biceps tenotomy/tenodesis at the time of rotator cuff repair rather than isolated SLAP repair (reduces stiffness risk, better outcomes)

OUTCOMES - EVIDENCE SUMMARY

• No significant difference in patient-reported functional outcomes (SMD 0.14, 95% CI -0.04 to 0.32, p=0.13)
• No difference in pain (VAS) (p=0.21)
• Tenodesis has significantly lower Popeye deformity rate (OR 0.29, p<0.00001)
• Tenotomy has shorter operative time (MD 15.2 min, p<0.00001)

COMPLICATIONS

Tenotomy-specific:

• Popeye deformity (most common)
• Biceps cramping
• Supination weakness (usually subclinical, but significant in high-demand patients)

Tenodesis-specific:

• Groove pain (retained tendon in groove; prevented by subpectoral technique)
• Humeral stress fracture (minimised with unicortical fixation)
• Brachial plexus/musculocutaneous nerve injury (excessive medial retraction in open technique)
• Hardware failure, anchor loosening
• Infection, stiffness

POSTOPERATIVE REHABILITATION

After Tenotomy:

• Immediate pendulum exercises and passive ROM
• Sling for comfort ~2-4 weeks
• Active motion at 4-6 weeks
• Strengthening at 6-8 weeks
• Return to full activity at 3 months

After Tenodesis:

• Protected range of motion for 6 weeks (tendon healing at new site)
• No active biceps loading or supination resistance for 6 weeks
• Progressive strengthening from 6-12 weeks
• Return to full activity at 4-6 months

CONCLUSION

Recent Advances in Management of Osteoporotic Fractures - MS Orthopaedics (20 Marks)

Introduction

I. ADVANCES IN FRACTURE RISK ASSESSMENT

1. FRAX Tool (Fracture Risk Assessment Tool)

• WHO-developed algorithm incorporating clinical risk factors + femoral neck BMD to calculate 10-year probability of major osteoporotic fracture (MOF) and hip fracture
• Recent updates include additional risk factor adjustments for: recent MOF (upward adjustment of FRAX score by 10%), Parkinson's disease, falls history
• NOGG 2024 guidelines recommend FRAX with dynamic threshold adjustments for specific comorbidities

2. DEXA (Dual-Energy X-ray Absorptiometry) Advances

• Now used for opportunistic vertebral fracture assessment (VFA) in addition to BMD measurement
• Trabecular Bone Score (TBS) derived from DXA lumbar spine images - provides independent fracture risk prediction by analysing bone texture/microarchitecture (not density alone)
• Helps identify patients with secondary osteoporosis (e.g., hyperparathyroidism, glucocorticoid use) who have normal BMD but degraded trabecular architecture

3. Artificial Intelligence and Radiomics (Recent - 2026)

• AI and machine learning algorithms applied to plain radiographs, CT, and DXA images to predict osteoporotic fracture risk (Jayasuriya & Skie, Clin Radiol 2026 - Systematic Review [PMID 41955646])
• Opportunistic CT screening: AI analysis of routine abdominal CTs or chest CTs for vertebral fracture detection and BMD estimation - enables identification of undiagnosed osteoporosis incidentally

4. High-Resolution Peripheral Quantitative CT (HR-pQCT)

• Measures cortical and trabecular bone microarchitecture at distal radius and tibia
• Better predictor of fracture risk than DXA alone in certain populations
• Not yet standard, but increasingly used in research and specialist centres

II. ADVANCES IN PHARMACOLOGICAL MANAGEMENT

Classification of Anti-osteoporotic Drugs

A. Bisphosphonates (First-Line Antiresorptives)

• Oral: Alendronate (70 mg/week), Risedronate (35 mg/week or 150 mg/month)
• IV: Zoledronic acid (5 mg/year IV) - preferred when oral therapy is not tolerated; reduces hip fracture risk by 41%, vertebral fracture by 70%
• Recent advance: Drug holidays - bisphosphonates accumulate in bone; NOGG 2024 recommends a drug holiday after 5 years (oral) or 3 years (IV) in lower-risk patients due to risk of atypical femoral fractures
• Atypical femoral fracture (AFF) - newly well-characterised complication of prolonged bisphosphonate use; subtrochanteric or femoral shaft stress fracture with characteristic radiological "beak" sign; prophylactic IM nailing recommended

B. Denosumab

• Fully human IgG2 monoclonal antibody against RANKL - inhibits osteoclastogenesis
• Given as 60 mg SC every 6 months
• Reduces vertebral fractures by 68%, hip fractures by 40%, nonvertebral fractures by 20%
• Recent important advance: Rebound phenomenon - abrupt discontinuation of denosumab causes a rapid surge in bone turnover and multiple vertebral fractures. Current guidelines mandate sequential antiresorptive therapy (usually bisphosphonate) immediately after denosumab cessation to prevent rebound fractures
• Particularly useful in patients with renal impairment (bisphosphonates contraindicated when eGFR <35 mL/min)

C. Teriparatide (PTH 1-34) - Anabolic Agent

• Recombinant human parathyroid hormone (1-34), given as 20 mcg SC daily
• Stimulates new bone formation by activating PTH receptors on osteoblasts (anabolic window from intermittent administration)
• Reduces vertebral fractures by ~65% and clinical fractures compared with risedronate (VERO trial)
• Harrison's 22E (2025): "Because teriparatide and romosozumab have greater efficacy at reducing vertebral and clinical fractures compared with bisphosphonates, they are now being considered as first-line therapy for patients with severe osteoporosis"
• Duration: Limited to 24 months total lifetime use; must be followed by an antiresorptive agent
• NOGG 2024: Indicates teriparatide in patients with severe osteoporosis (T-score < -3.5), or after bisphosphonate failure

D. Abaloparatide (PTHrP 1-34 Analogue)

• Analogue of parathyroid hormone-related peptide (PTHrP); approved in USA (not yet globally available)
• In the ACTIVE trial (2463 postmenopausal women): reduced new vertebral fractures by 86% vs placebo (vs 80% with teriparatide)
• Reduced nonvertebral fractures by 43% (significant, unlike teriparatide's 28%)
• Greater hip BMD gain than teriparatide (4.2% vs 3.3%)
• Extension study showed benefit maintained after transition to alendronate
• Key advantage: lower hypercalcaemia risk than teriparatide (due to biased agonist receptor binding)

E. Romosozumab - Dual-Acting "Game Changer"

• Humanized monoclonal antibody against sclerostin (sclerostin normally inhibits bone formation via Wnt pathway)
• Dual mechanism: increases bone formation AND decreases bone resorption simultaneously
• Given as 210 mg SC monthly for 12 months, then switched to an antiresorptive agent
• FRAME trial (7180 postmenopausal women):
  • BMD increase: +13% spine, +7% hip in 1 year (largest of any drug)
  • Reduced new vertebral fractures by 73% vs placebo at 1 year
  • Reduced clinical fractures by 36%
• ARCH trial: Romosozumab vs alendronate - romosozumab reduced new vertebral fractures by 48% more than alendronate; reduced hip fractures by 38%
• Cardiovascular safety concern: Slightly increased risk of serious cardiovascular events in ARCH trial (not confirmed in FRAME); contraindicated in patients with prior MI or stroke within 1 year; network meta-analysis (Cheng et al. Drug Saf 2025 [PMID 39227560]) showed no significant increased risk vs other anti-osteoporosis medications in RCTs
• Updated 2025 meta-analysis (Ferrer et al. J Clin Rheumatol 2025 [PMID 40323656]) confirms superior efficacy of romosozumab in postmenopausal osteoporosis

F. Sequential Therapy (Treat-to-Target Strategy)

• Recent paradigm shift: anabolic therapy first, then antiresorptive consolidation
• Rationale: anabolics build new bone; antiresorptives then preserve the gain
• Systematic review (Nayak & Greenspan, Osteoporos Int 2026 [PMID 41105226]): sequential teriparatide/romosozumab followed by antiresorptive showed superior BMD outcomes vs single-agent strategies
• Recommended sequence for high-risk patients: Romosozumab (12 months) → Denosumab or Zoledronate
• For anti-osteoporosis medication in posterior spine fusion (Jin et al. Spine J 2025 [PMID 40280495]): anabolics improve fusion rates in osteoporotic spines

III. ADVANCES IN SURGICAL MANAGEMENT OF SPECIFIC OSTEOPOROTIC FRACTURES

A. Osteoporotic Hip Fractures

Orthogeriatric Co-management ("Hip Fracture Unit" Model)

• Multidisciplinary team: orthopaedic surgeon + geriatrician + anaesthesiologist + physiotherapist + pharmacist
• Early surgery within 24-48 hours (reduced mortality)
• Pre-operative optimisation: correction of anaemia, electrolytes, anticoagulation reversal
• Comprehensive geriatric assessment (CGA): targets delirium prevention, pressure ulcer care, nutritional supplementation
• WHO Benchmarks for Equitable Hip Fracture Care now define global quality standards

Surgical Techniques

• Cement augmentation of screws: PMMA injection via cannulated screws in osteoporotic intertrochanteric fractures significantly reduces fixation failure and cut-out
• Helical blade (in PFN-A, TFNA devices): greater rotational stability and reduced cut-out in osteoporotic proximal femoral bone compared to lag screws
• Augmented fixation systems: newer nails with injectable bone cement ports alongside blade/screw (e.g. TFNA-Advanced, Synthes) - directly addresses the problem of poor screw purchase in osteoporotic bone

B. Osteoporotic Vertebral Compression Fractures (OVCF)

Conservative Management

• Analgesia (WHO ladder), calcitonin for acute pain (short-term), bracing (thoracolumbar orthosis), early mobilisation
• Bed rest avoided beyond 2-3 days (worsens bone loss)

Vertebral Augmentation - Advances

• Injection of polymethylmethacrylate (PMMA) cement into fractured vertebral body through pedicular route under fluoroscopic/CT guidance
• Best performed within 4-6 weeks of fracture onset
• Pain relief success: 70-95% of patients
• Evidence: patients with severe pain treated within 6 weeks benefit significantly; reduced re-admission rates, reduced mortality (Grainger & Allison's Radiology)
• Cement complications: leakage (~10-40%), pulmonary embolism (rare), adjacent level fracture

• Balloon inflation first creates a cavity and partially restores vertebral height, then PMMA injected under lower pressure
• Advantages over vertebroplasty: lower cement leakage, greater kyphosis correction, higher viscosity cement reduces extravasation
• Meta-analysis: no difference in pain scores at any timepoint vs vertebroplasty; kyphoplasty better for kyphosis correction (Grainger & Allison)

• Highly viscous cement activated by radiofrequencies before injection
• Further reduces cement leakage vs standard balloon kyphoplasty
• StabiliT system (Dfine) - recent advance using radiofrequency-activated cement

• For burst fractures requiring posterior instrumentation in osteoporotic bone: cement injected through pedicle screws to improve pullout strength
• Fenestrated screws with PMMA augmentation - standard of care in osteoporotic instrumented fusion (NOGG 2024; Campbell's 2026)

• Titanium implant (expandable jack) inserted into vertebral body before cement injection
• Provides superior height restoration compared to balloon kyphoplasty
• ESR 2025 guidelines include SpineJack among recommended percutaneous bone consolidation techniques [PMID 40050453]

Vertebral Fracture Classification for Surgery

• AO/Magerl Classification + TLICS (Thoracolumbar Injury Classification and Severity Score) guide surgical decisions
• Surgery indicated when: neurological deficit, posterior column involvement (TLICS ≥5), failure of conservative management

C. Distal Radius Fractures

• Most common osteoporotic fracture in women <75 years
• Volar locking plates (VLP): remain standard of care for unstable patterns; augmented fixation with bone cement or allografting in comminuted osteoporotic bone
• Recent advance: Augmented VLP using injectable bone substitutes (calcium phosphate cement) to fill metaphyseal void - superior reduction maintenance vs VLP alone in RCTs
• Distal radius fracture as a "sentinel fracture": triggers systematic osteoporosis workup and initiation of bone-protective therapy

D. Proximal Humerus Fractures

• PHILOS plate with locking screws - standard for operative treatment
• Intramedullary nail (proximal humeral nail) - recent preference in 2/3-part fractures
• Calcar augmentation: cement or bone graft at medial calcar region reduces varus collapse/screw cut-out
• Reverse total shoulder arthroplasty (rTSA): now recommended for complex 3/4-part fractures in elderly patients with osteoporotic bone - superior functional outcomes vs ORIF with fewer re-operations

IV. ADVANCES IN BONE HEALING AUGMENTATION

1. Bone Substitutes and Grafts

• Calcium phosphate cements (e.g., Norian, ChronOS): bioresorbable, osteoconductive; used to fill metaphyseal voids in osteoporotic fractures
• Demineralised bone matrix (DBM): provides osteoinductive signals; used alone or with autograft
• Synthetic hydroxyapatite / tricalcium phosphate scaffolds: 3D-printed, patient-specific scaffolds now in clinical trials

2. Biologics and Growth Factors

• BMP-2 and BMP-7 (bone morphogenetic proteins): FDA-approved for recalcitrant non-unions; use limited by cost and ectopic ossification risk
• Platelet-rich plasma (PRP): evidence remains limited but used adjunctively
• Parathyroid hormone (teriparatide) given perioperatively: emerging evidence improves fracture healing rates and time to union in osteoporotic fragility fractures (Rockwood & Green 2025) - animal studies positive; human RCT data emerging

3. Low-Intensity Pulsed Ultrasound (LIPUS)

• Mechanical biostimulation that promotes fracture healing
• Meta-analysis: reduces time to radiological union; useful in delayed unions and non-unions in osteoporotic patients
• Non-invasive, applied externally over fracture site

4. Electromagnetic Stimulation (Bone Growth Stimulators)

• Pulsed electromagnetic field (PEMF) therapy
• FDA-approved for non-union treatment; increasingly used in osteoporotic fracture healing

V. SECONDARY FRACTURE PREVENTION - FRACTURE LIAISON SERVICE (FLS)

Concept

• Patients who sustain a fragility fracture have a dramatically increased risk of a second fracture (50% risk of subsequent fracture within the next 10 years; hip fracture doubles the risk of another hip fracture)
• Only 20% of fracture patients receive appropriate osteoporosis treatment post-fracture without a coordinated program

Fracture Liaison Service (FLS)

• Coordinator-based model: a dedicated FLS coordinator identifies all fragility fracture patients, performs risk assessment, initiates investigation (DXA, labs), and coordinates pharmacological treatment
• Evidence: FLS programmes significantly reduce secondary fracture rates (Fracture Liaison Service, Osteoporosis International 2003; WHO Benchmarks 2022)
• Capture the Fracture programme (IOF - International Osteoporosis Foundation): global best practice framework for FLS implementation
• Recent evidence: interdisciplinary FLS improves health-related outcomes and survival in older adults after hip fracture (Arch Osteoporos 2022)

"Own the Bone" Program

• American Orthopaedic Association (AOA) initiative encouraging orthopaedic surgeons to directly initiate osteoporosis treatment at the time of fracture care
• Orthopaedic surgeons identified as uniquely positioned to motivate post-fracture patients to initiate therapy - "teachable moment" concept
• 23% reduction in secondary fractures when osteoanabolics (vs 15% with antiresorptives) are given to vertebral compression fracture patients

VI. PERIOPERATIVE BONE HEALTH OPTIMISATION (BHO)

• Pre-operative anabolic therapy (teriparatide or romosozumab) for 2-3 months before elective total joint arthroplasty in patients with severe osteoporosis
• Goals: improve periprosthetic bone stock, reduce early component loosening, promote bone-implant integration
• Particularly relevant in revision arthroplasty where bone loss is significant

VII. SUMMARY TABLE - RECENT ADVANCES BY DOMAIN

Conclusion

Recent Advances in Management of Osteoporotic Fractures — MS Orthopaedics (20 Marks)

Introduction

I. ADVANCES IN FRACTURE RISK ASSESSMENT

1. FRAX Tool (Updated)

• WHO algorithm: 10-year probability of major osteoporotic fracture (MOF) and hip fracture using clinical risk factors + femoral neck BMD
• NOGG 2024 updates: additional risk factor adjustments for recent MOF (uplift FRAX score ×10%), Parkinson's disease, falls history

2. DXA Advances

• Vertebral Fracture Assessment (VFA): lateral spine images during DXA to identify undiagnosed vertebral fractures - finding a vertebral fracture upgrades therapy immediately
• Trabecular Bone Score (TBS): texture analysis of lumbar DXA image - predicts fracture risk independent of BMD; detects degraded microarchitecture in patients with normal BMD (e.g., glucocorticoid-induced osteoporosis)

3. Artificial Intelligence and Radiomics (2026)

• AI/ML applied to plain X-rays, CT, and DXA to predict fracture risk (Systematic Review, Clin Radiol 2026 [PMID 41955646])
• Opportunistic CT screening: AI analysis of routine abdominal/chest CTs for BMD estimation and vertebral fracture detection - identifies undiagnosed osteoporosis incidentally without additional radiation

4. HR-pQCT (High-Resolution Peripheral Quantitative CT)

• Measures cortical and trabecular microarchitecture at distal radius and tibia
• Better fracture predictor than DXA alone in certain populations; increasingly used in specialist centres

II. PHARMACOLOGICAL ADVANCES

Classification

A. Bisphosphonates - Updated Practice

• Oral: Alendronate (70 mg/week), Risedronate (35 mg/week); IV: Zoledronic acid (5 mg/year)
• Drug holidays: NOGG 2024 recommends after 5 years oral / 3 years IV zoledronate in lower-risk patients - reduces risk of atypical femoral fracture (AFF)
• Atypical Femoral Fracture (AFF): now well-characterised complication of prolonged use; subtrochanteric/femoral shaft stress fracture with "beak" sign on X-ray; prophylactic IM nailing recommended when prodromal thigh pain + cortical beaking seen

B. Denosumab

• Human IgG2 monoclonal antibody against RANKL - inhibits osteoclastogenesis; 60 mg SC every 6 months
• Reduces vertebral fractures 68%, hip fractures 40%, nonvertebral fractures 20%
• Critical recent advance - Rebound phenomenon: abrupt discontinuation causes rapid bone turnover surge and multiple vertebral fractures. Current guidelines mandate immediate sequential bisphosphonate or zoledronate on stopping denosumab
• Preferred in renal impairment (bisphosphonates contraindicated when eGFR <35)

C. Teriparatide (PTH 1-34) - Anabolic

• Recombinant human PTH (1-34); 20 mcg SC daily; max 24 months lifetime
• Reduces vertebral fractures ~65%, clinical fractures vs risedronate (VERO trial)
• Harrison's 22E (2025): "Teriparatide and romosozumab are now being considered as first-line therapy for patients with severe osteoporosis"
• Must be followed by antiresorptive agent after course completion

D. Abaloparatide (PTHrP 1-34 Analogue) - Newer Anabolic

• Analogue of PTH-related peptide; approved in USA; biased agonist with lower hypercalcaemia risk than teriparatide
• ACTIVE trial (2463 women):
  • Vertebral fracture reduction: 86% vs placebo (vs 80% teriparatide) - superior
  • Nonvertebral fractures reduced 43% (significant, unlike teriparatide 28%)
  • Greater total hip BMD gain: 4.2% vs 3.3% with teriparatide
  • Transition to alendronate after abaloparatide maintained fracture benefit

E. Romosozumab - Most Significant Recent Advance

• Humanised monoclonal antibody against sclerostin; sclerostin normally inhibits bone formation via Wnt pathway; blocking it gives dual effect
• Dual mechanism: simultaneously increases bone formation AND decreases bone resorption (unique among all osteoporosis drugs)
• Dose: 210 mg SC monthly × 12 months, then antiresorptive sequencing
• FRAME trial (7180 women):
  • Spine BMD: +13% in 1 year (largest gain of any drug)
  • New vertebral fractures reduced 73% vs placebo
  • Clinical fractures reduced 36%
• ARCH trial (vs alendronate):
  • Vertebral fractures: 48% fewer with romosozumab vs alendronate
  • Hip fractures: 38% fewer
• Cardiovascular concern: slightly increased serious CV events in ARCH trial; contraindicated within 1 year of MI or stroke
• Updated 2025 meta-analysis (Ferrer et al. J Clin Rheumatol [PMID 40323656]) confirms superior efficacy; network meta-analysis (Cheng et al. Drug Saf 2025 [PMID 39227560]) shows no significant CV risk vs other anti-osteoporotics in RCTs

F. Sequential Therapy - Paradigm Shift

• New treat-to-target strategy: anabolic first → antiresorptive consolidation
• Rationale: build new bone architecture first, then lock in gains
• Systematic review, Osteoporos Int 2026 [PMID 41105226]: sequential therapy superior to single-agent strategies for BMD outcomes
• Recommended for severe/very high-risk: Romosozumab (12 mo) → Denosumab or Zoledronate
• Anti-osteoporosis medication in spinal fusion (Jin et al. Spine J 2025 [PMID 40280495]): anabolics improve fusion rates in osteoporotic instrumented spines

III. SURGICAL ADVANCES BY FRACTURE TYPE

A. Hip Fractures (Most Consequential)

Orthogeriatric Co-management Model

• Dedicated Hip Fracture Unit: orthopaedic surgeon + geriatrician + anaesthesiologist + physiotherapist
• Surgery within 24-48 hours (reduces mortality, delirium, pressure sores)
• WHO Benchmarks for Equitable Hip Fracture Care define global quality standards

Surgical Advances

• Calcium phosphate cement augmentation in hip screw fixation: randomised trials show significantly reduced fixation failure in osteoporotic intertrochanteric fractures

B. Osteoporotic Vertebral Compression Fractures (OVCF)

Vertebral Augmentation Techniques

• PMMA cement injection through pedicular route under fluoroscopy/CT guidance
• Best results within 4-6 weeks of onset; pain relief in 70-95%
• Reduces re-admission and mortality in elderly patients (Grainger & Allison's)
• Complications: cement leakage (~10-40%), pulmonary embolism (rare), adjacent level fracture

• Balloon creates cavity first → partial height restoration → lower-pressure cement injection
• Advantages: lower cement leakage, greater kyphosis correction than vertebroplasty
• Meta-analysis: equivalent pain relief; superior height restoration

• Highly viscous RF-activated cement (e.g., StabiliT system, Dfine)
• Lowest cement leakage of all augmentation techniques
• ESR Essentials 2025 guidelines include RF-VP in recommended percutaneous consolidation techniques [PMID 40050453]

• Titanium expandable implant inserted before cement injection
• Superior vertebral height restoration vs balloon kyphoplasty
• Included in ESR 2025 practice recommendations as an established technique

• Fenestrated pedicle screws + PMMA: cement injected through screw fenestrations into cancellous vertebral bone
• Significantly increases pullout strength in osteoporotic vertebrae
• Now standard of care for instrumented fusion in osteoporotic spine (Campbell's 2026; Rockwood & Green 2025)

C. Distal Radius Fractures

• Volar Locking Plate (VLP): standard for unstable patterns
• Recent advance - Augmented VLP: injectable calcium phosphate cement fills metaphyseal void after reduction - superior maintenance of reduction vs VLP alone in RCTs
• Distal radius fracture = sentinel fracture: triggers systematic osteoporosis evaluation + bone-protective therapy initiation

D. Proximal Humerus Fractures

• Locking plate (PHILOS): standard ORIF; augmented with calcar screws and bone cement at medial calcar to prevent varus collapse
• Reverse Total Shoulder Arthroplasty (rTSA): now preferred for complex 3/4-part fractures in elderly osteoporotic patients; superior functional outcomes and fewer re-operations vs ORIF
• Intramedullary nail: increasingly used for 2/3-part fractures as less invasive alternative

IV. BIOLOGICAL AND PHYSICAL STIMULATION OF FRACTURE HEALING

Bone Substitutes

• Calcium phosphate cements (bioresorbable, osteoconductive): Norian, ChronOS; fill metaphyseal voids
• Demineralised Bone Matrix (DBM): osteoinductive; used with autograft or alone
• 3D-printed patient-specific synthetic scaffolds: hydroxyapatite/TCP composite; clinical trials ongoing

Growth Factors

• BMP-2 / BMP-7: FDA-approved for non-unions; high cost + risk of ectopic ossification limit routine use
• Perioperative teriparatide: emerging evidence from Rockwood & Green 2025 suggests improved fracture healing and union rates in osteoporotic bone; RCTs ongoing

Physical Stimulation

• Low-Intensity Pulsed Ultrasound (LIPUS): reduces time to union; non-invasive; useful in delayed/non-union in osteoporotic patients
• Pulsed Electromagnetic Field (PEMF): FDA-approved for non-union; increasingly used in osteoporotic fracture healing augmentation

V. SECONDARY FRACTURE PREVENTION

Fracture Liaison Service (FLS)

• The single most impactful systemic advance for reducing secondary fracture burden
• Coordinator-based model: identifies ALL fragility fracture patients, performs DXA + labs, initiates pharmacotherapy, monitors adherence
• Evidence: FLS significantly reduces secondary fracture rates (IOF Capture the Fracture Programme)
• Interdisciplinary FLS improves health outcomes and survival after hip fracture (Arch Osteoporos 2022)
• Only ~20% of fracture patients receive appropriate osteoporosis treatment without an organised FLS

"Own the Bone" (American Orthopaedic Association)

• Orthopaedic surgeons directly initiate osteoporosis treatment at time of fracture care - "teachable moment"
• 23% reduction in secondary fractures with osteoanabolics vs 15% with antiresorptives post-OVCF

Post-Fracture Immobilisation and Bone Loss

• Prolonged immobilisation worsens osteoporosis; early weight-bearing protocols and mobilisation are mandated
• Calcitonin: short-term use for acute OVCF pain (NOGG 2024 - parenteral use in immobilised patients discouraged)

VI. PERIOPERATIVE BONE HEALTH OPTIMISATION (BHO)

• Pre-operative anabolic therapy (teriparatide or romosozumab) 2-3 months before elective joint arthroplasty in severe osteoporosis
• Goals: improve periprosthetic bone stock, enhance bone-implant osseointegration, reduce aseptic loosening
• Particularly relevant in revision arthroplasty with significant bone loss

Summary of Recent Advances

Conclusion