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Team Approach puts Barnes-Jewish patient on road to recovery

  • February 1, 2006
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Like most people, Sharon Heffner, 60, didn''t notice she had osteoporosis until it led to serious injury.

It took a team approach to patient care at Barnes-Jewish Hospital to put her on the road to recovery.

When Heffner suffered from a wrist fracture in 2002 and underwent surgery at a hospital near her home in High Ridge, Mo., she and her physician expected her to recover fully. Instead, the fracture became a recurring problem. The internal fixation plates attached to the radius around the fracture broke, making the deformity recur.

She had to be hospitalized four times for replacement of the plates and for bone grafting. Bone grafting is a surgical procedure in which healthy bone is placed around a fractured bone to help it heal.

The recurring problem left Heffner unable to use her right hand. Family members had to help her with tasks she usually could do on her own such as dressing, eating, and even writing checks.

"After several bone grafts I just didn''t want to take it anymore," Heffner said.

When she realized that the repeated bone grafts had failed to heal the fracture, she visited Richard Gelberman, MD, Washington University chairman of the department of orthopedic surgery at Barnes-Jewish who specializes in hand and wrist problems.

"I was concerned that Ms. Heffner might have a particularly severe form of osteoporosis and felt that she needed to be evaluated by an endocrinologist," Dr. Gelberman said.

Dwight Towler, MD, PhD, Washington University director of the bone and mineral diseases division at Barnes-Jewish, performed a full history and physical evaluation, biochemical studies, and bone density test. The tests revealed that many factors were inhibiting Heffner''s bone''s healing process.

Prior surgeries had treated her goiter and hyperparathyroidism, but the treatments had inadvertently caused hypothyroidism and a mild hypoparathyroidism—endocrine disorders that cause bone-forming cells to become dormant. Some of her medications only worsened these endocrine problems.

Heffner''s internal fixation plates caused another complication: they were shielding the bone from the body''s natural electric impulses needed for healing.

"Osteoporosis is a silently progressive disease that is usually not discovered until a fracture occurs," Dr. Towler said. "In many patients, hormone deficiencies, endocrine dysfunction, medications, or nutritional shortcomingsparticularly vitamin D and calciumcontribute to a decline in bone health."

Dr. Towler recommends every patient with an osteoporotic fracture that results in a loss of height of more than 2 inches should be evaluated for nutritional, endocrine, and musculoskeletal contributions to their bone disease.

"A prior fracture as an adult should be seen as call for evaluation and interventionbecause the most significant risk for a future fracture is the presence of prior fracture," Dr. Towler said.

Before Heffner''s next surgery, Dr. Towler made sure that she received proper medication to get her thyroid function back to normal. He stopped all her medications that inhibited bone formation and started her on daily injections of teriparatide, a parathyroid-like hormone that promotes bone formation.

In January 2005, Dr. Gelberman inserted new fixation plates and performed bone grafting on her wrist. After the operation, she wore an electrical bone stimulator—a device that reproduces the body''s electric impulses—to help in healing the fracture.

By April, Heffner''s bone had healed and she could use her right hand again. "When Dr. Gelberman showed me the x-ray, I saw that my bone was growing so fast," she said.

Under the Bone Health Program, Heffner''s endocrine and nutritional status is monitored every six months. After 18 months of bone-formation therapy with daily teriparatide injections—a routine that she herself administers at homeshe will be placed on maintenance therapy to sustain her bone health. Annual visits for bone density testing and physician evaluation will ensure that the improvements in her bone health are not lost.

"When patients over 50 years of age sustain a fracture they should be evaluated for osteoporosis," Dr. Gelberman said. "Without adequate treatment of the underlying osteoporotic condition, a second fracture occurs within two years in a high percentage of patients. Only by comprehensive care in a team approach could we have helped Ms. Heffner achieve a successful outcome."

Indeed, Heffner is delighted that her life is back to normal. "I was handicapped for two years so I didn''t think I was ever going to get well, but these doctors got me to where I am today," she said.

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