Treat to target is the use of a physiologic marker as a monitor of effectiveness or compliance to an intervention. A recent example has been the progressive use of CTX-1 (Marker of osteoclastic activity) as a surrogate of bone resorptive activity in osteoporosis treatment. CTX-1 levels were demonstrated to be inversely related to drug efficacy in the suppression of bone resorption. As far as fragility fractures are concerned, no reference value of CTX-1 for any index fracture sites was found in the literature. In order to prevent subsequent fractures, efforts to better manage this chronic disease are to be explored. The main objective of this study was to compare and validate the use of serum CTX-1 to the perceived compliance to treatment.

Five hundred and forty three patients (men and women) 40 years of age or older who had been treated for a fragility fracture were enrolled. The purpose of this study was to correlate the measurement of CTX-1 with the perceived compliance to treatment of patients at the time of fracture and at six, 12 and 18 months after initiation of treatment. Our secondary objectives were to evaluate two different CTX-1 suppression target levels (CTX-1< 0.3 ng/mL and CTX-1<0.2 ng/mL), to determine CTX-1 values according to fracture sites, and to explore the profile of patients with subsequent fractures.

Considering index fractures, compliant patients under treatment at baseline had lower CTX-1 levels than non-compliant patients (p=0.052). Patients who were compliant to treatment at six, 12 and 18 months also had lower CTX-1 levels than non-compliant patients (p=0.000). When index fractures were divided into fracture sites, regardless of CTX-1 suppression target level (i.e. CTX-1< 0.3 or 0.2 ng/mL), significant CTX-1 suppression was observed in non-hip and non-vertebral (NHNV) fractures at six, 12 and 18 months (p0.05). No clinically relevant difference was observed between the profile of patients with and without subsequent fractures.

The correlation between serum CTX-1 at the time of fracture and at six, 12, 18 months and the perceived compliance to treatment was validated for NHNV fractures supporting the concept of the available treatments and their effects on bone remodeling for this type of fracture. The correlation was not validated for hip neither for vertebral fracture. There was no correlation between CTX-1 levels and subsequent fracture risk.

Although new locking plates allows for secure fixation of osteoporotic fractures in the proximal humerus, extensive soft tissue dissection is needed for their insertion. We report on a prospective clinical trial of the first thirty patients treated with plating of the proximal humerus though a minimally invasive percutaneous approach. All fractures healed within the first 6 months with no avascular necrosis or axillary nerve injury. At the latest follow-up, the median Constant score was sixty-eight and the mean DASH score was twenty-seven. This study suggests that percutaneous plating can be a safe and effective method of fixation.

To evaluate the safety and efficacy of minimally invasive plating of the proximal humerus using validated disease-specific measures.

Percutaneous insertion of a locking proximal humerus plate is safe and produces good early functional and radiologic outcomes.

Plate fixation of the proximal humerus fractures may now be more desirable with the use of a biological approach by limiting surgical insult and allowing accelerated rehabilitation.

All fractures healed within the first six months with no loss of correction. Two reoperations were needed to remove intra-articular screws placed too long. No infection or avascular necrosis were seen. At the lastest follow-up, the median Constant score was sixty-eight points, with an age ajusted score of seventy-six. The mean DASH score was twenty-seven points. Only age was independantly predictive of both the Constant and DASH functional scores.

During a period of one year, thirty patients were operated with use of the LCP proximal humerus plate (Synthes) through a 3cm lateral deltoid splitting approach and a second 2 cm incision at the deltoid insertion. The axillary nerve was palped and easily protected during insertion. Only two-part (N=22) and three-part impacted valgus type (N=8) were included in this study since they can be reduced indirectly thru this percutaneous technique. The average follow-up was thirteen months (eight to twenty months). All patients had the Constant and DASH evaluations.