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Rzeszutek U, Allerton F, Au C, Bras I, Briggs A, Broome H, Gamston T, Parton S, Raj J, Rossell GM, Russell O, Sparks T, Bazelle J. Assessment of alendronate and dietary treatment in the management of feline idiopathic ionised hypercalcaemia and ionised hypercalcaemia associated with chronic kidney disease: 29 cases (2016-2022). J Small Anim Pract 2024. [PMID: 38961721 DOI: 10.1111/jsap.13755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 04/04/2024] [Accepted: 05/28/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVES This retrospective cohort multicentre study aimed to characterise the signalment, clinicopathologic data, complications and the association between treatment and outcome (the reduction in ionised calcium concentration) in cats with idiopathic or chronic kidney disease-associated ionised hypercalcaemia managed with alendronate and standard treatment or standard treatment alone, and to compare the outcome between the two groups. MATERIALS AND METHODS Medical records for cats diagnosed with idiopathic or chronic kidney disease-associated ionised hypercalcaemia were retrospectively reviewed. Cats treated with alendronate and standard treatment were assigned to the alendronate group and cats treated with standard treatment alone were assigned to the control group. The standard treatment was defined as dietary modification and/or monitoring of ionised calcium concentrations and management of complications secondary to hypercalcaemia. The follow-up period was selected as 6 months. RESULTS Twenty-nine cats were enrolled in the study. Nine cats were included in the control group and 20 cats in the alendronate group. A significant reduction in serum ionised calcium was observed in both groups between the baseline and the follow-up visit; however, this reduction did not differ significantly between both groups (the mean change in the ionised calcium concentration in alendronate and control group was -0.18 and -0.17, respectively). Suspected bisphosphate-related osteonecrosis of the jaw was reported in one cat receiving alendronate. CLINICAL SIGNIFICANCE In this study, similar reduction in serum ionised calcium concentration was observed in cats with ionised hypercalcaemia treated with diet alone and in cats treated with diet and alendronate. These results should be interpreted with caution, as the study was underpowered for meaningful statistical comparison. Cats receiving alendronate should be monitored for the development of adverse reactions, including osteonecrosis of the jaw.
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Affiliation(s)
- U Rzeszutek
- Davies Veterinary Specialists, Shillington, UK
| | - F Allerton
- Willows Veterinary Specialists, Solihull, UK
| | - C Au
- Eastcott Veterinary Hospital, Swindon, UK
| | - I Bras
- North Downs Specialist Referrals, Bletchingley, UK
| | | | - H Broome
- University of Liverpool Small Animal Teaching Hospital, Liverpool, UK
| | - T Gamston
- Dick White Referrals, Six Mile Bottom, UK
| | | | - J Raj
- Southfields Veterinary Specialists, Basildon, UK
| | - G M Rossell
- Northwest Veterinary Specialists, Runcorn, UK
| | - O Russell
- University of Cambridge Queen's Veterinary School Hospital, Cambridge, UK
| | - T Sparks
- Waltham Petcare Science Institute, Waltham, UK
| | - J Bazelle
- Davies Veterinary Specialists, Shillington, UK
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Song G, Jeong Y, Nam WD, Kim KH. Teriparatide Does not Have Beneficial Effects on Bone Healing in Complete Atypical Femur Fractures. Calcif Tissue Int 2024:10.1007/s00223-024-01244-x. [PMID: 38907093 DOI: 10.1007/s00223-024-01244-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/01/2024] [Indexed: 06/23/2024]
Abstract
Teriparatide is an anabolic drug sometimes administered to patients who have atypical femoral fracture (AFF). However, whether teriparatide has beneficial effects on bone healing remains uncertain. The present study aimed to analyze the association between teriparatide and bone healing in complete AFF. A total of 59 consecutive cases (58 patients) who underwent intramedullary nailing for complete AFF were categorized based on postoperative use of teriparatide into the non-teriparatide (non-TPTD, n = 34) and teriparatide groups (TPTD, n = 25). Time-to-bone union was evaluated and compared between the two groups. Additionally, multiple regression analysis was performed to evaluate factors affecting time-to-bone union. All participants were women, with a mean age of 77.6 years (range: 62-92). No significant difference in time-to-bone union was found between the non-TPTD and TPTD groups (5.5 months vs. 5.8 months, p = 0.359). Two patients in the non-TPTD group underwent reoperation (p = 0.503) due to failure caused by inadequate fixation, and both achieved bone healing after additional fixation with blocking screws. Multiple regression analysis revealed that the anterior gap of the fracture site postoperatively was a factor affecting time-to-bone union (p = 0.014). The beneficial effect of teriparatide on bone healing in complete AFF could not be confirmed. Additional randomized controlled trials are required. Nonetheless, appropriate techniques, including efforts to reduce the gap on the tensile side during the surgery, are important for reliable bone healing.
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Affiliation(s)
- Gill Song
- Department of Orthopaedic Surgery, College of Medicine Kangwon National University, Kangwon National University Hospital, Baengnyeong-Ro 156, Chuncheon-si, Gangwon-do, 24289, Republic of Korea
| | - Yerang Jeong
- Department of Orthopaedic Surgery, College of Medicine Kangwon National University, Kangwon National University Hospital, Baengnyeong-Ro 156, Chuncheon-si, Gangwon-do, 24289, Republic of Korea
| | - Woo Dong Nam
- Department of Orthopaedic Surgery, College of Medicine Kangwon National University, Kangwon National University Hospital, Baengnyeong-Ro 156, Chuncheon-si, Gangwon-do, 24289, Republic of Korea
| | - Keong-Hwan Kim
- Department of Orthopaedic Surgery, College of Medicine Kangwon National University, Kangwon National University Hospital, Baengnyeong-Ro 156, Chuncheon-si, Gangwon-do, 24289, Republic of Korea.
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Hashimoto J, Oh Y, Yamamoto K, Yoshii T, Fukushima K, Kitagawa M, Okawa A. Frequency and pathogenesis of periprosthetic atypical femoral fractures associated with total knee arthroplasty: A multicenter prospective study with complementary histopathological and biomechanical analysis. Injury 2024; 55:111136. [PMID: 37867026 DOI: 10.1016/j.injury.2023.111136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/04/2023] [Accepted: 10/14/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Although the diagnostic criteria for atypical femoral fracture (AFF) exclude periprosthetic fractures, reports of periprosthetic femoral fractures with characteristics of AFF are rapidly increasing. In this study, we investigated the frequency and pathogenesis of periprosthetic AFF associated with total knee arthroplasty (TKA) based on a theory of AFF subtypes that divides AFFs into two main types: fragility stress fractures of the bowed femoral shaft in the mid-shaft and "typical" subtrochanteric AFFs due to suppression of bone turnover (e.g., by bisphosphonates). PATIENTS AND METHODS This multicenter prospective study of AFFs was conducted from 2015 through 2022. Clinical, pathological, and morphological characteristics were investigated in patients with periprosthetic AFFs associated only with non-stem TKA. Then, biomechanical investigation of the periprosthetic AFF was performed by computer tomography-based finite element analysis (CT/FEA) using two models with different load axes to examine how the correction of lower limb alignment by TKA influences the tensile stress distribution of the femur and the location of the AFF. RESULTS Four of 61 AFFs (6.6%) were identified to be periprosthetic AFF (1 mid-shaft; 3 subtrochanteric). Periprosthetic AFFs had characteristics including mechanical stress due to bowing deformity and potentially suppressed bone turnover due to long-term exposure to specific drugs (e.g., bisphosphonates and glucocorticoids). Although 2 periprosthetic AFFs appeared to involve a bowed femur, one with both of the aforementioned characteristics occurred in the subtrochanteric region, which would be an unusual site for a bowed AFF, and it was demonstrated histologically to have biological activity at the fracture site, suggesting a stress fracture. Furthermore, CT/FEA revealed that tensile stress distribution changed proximally as load axis was shifted laterally according to correction of lower limb alignment by TKA. CONCLUSION Orthopedic surgeons should recognize the presence of TKA-associated periprosthetic AFF caused by various factors including specific drugs, bowing deformity, and lower limb alignment. X-rays of the full-length femurs should be checked regularly after TKA, especially in patients with bowed femurs or long-term exposure to specific drugs.
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Affiliation(s)
- Jun Hashimoto
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoto Oh
- Department of Orthopaedic and Trauma Research, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Kouhei Yamamoto
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Masanobu Kitagawa
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Okawa
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Bliemel C, Birkelbach R, Knauf T, Pass B, Craiovan B, Schoeneberg C, Ruchholtz S, Bäumlein M. Surgical management and outcomes following atypical subtrochanteric femoral fractures - results from a matched-pair analysis of the registry for geriatric trauma of the German Trauma Society. Arch Orthop Trauma Surg 2024; 144:2561-2572. [PMID: 38642159 PMCID: PMC11211164 DOI: 10.1007/s00402-024-05297-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 03/24/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND AND OBJECTIVES The outcomes of patients with atypical subtrochanteric fractures (ASFs) remain unclear. Data from a large international geriatric trauma registry were analysed to examine the outcome of patients with ASFs compared to patients with typical osteoporotic subtrochanteric fractures (TSFs). MATERIALS AND METHODS Data from the Registry for Geriatric Trauma of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie [DGU]) (ATR-DGU) were analysed. All patients treated surgically for ASFs or TSFs were included in this analysis. Across both fracture types, a paired matching approach was conducted, where statistical twins were formed based on background characteristics sex, age, American Society of Anesthesiologists (ASA) score and walking ability. In-house mortality and mortality rates at the 120-day follow-up, as well as mobility at 7 and 120 days, the reoperation rate, hospital discharge management, the hospital readmission rate at the 120-day follow-up, health-related quality of life, type of surgical treatment and anti-osteoporotic therapy at 7 and 120 days, were assessed as outcome measures using a multivariate logistic regression analysis. RESULTS Amongst the 1,800 included patients, 1,781 had TSFs and 19 had ASFs. Logistic regression analysis revealed that patients with ASFs were more often treated with closed intramedullary nailing (RR = 3.59, p < 0.001) and had a higher probability of vitamin D supplementation as osteoporosis therapy at 120 days (RR = 0.88, p < 0.002). Patients with ASFs were also more likely to live at home after surgery (RR = 1.43, p < 0.001), and they also tended to continue living at home more often than patients with TSFs (RR = 1.33, p < 0.001). Accordingly, patients with TSFs had a higher relative risk of losing their self-sufficient living status, as indicated by increased rates of patients living at home preoperatively and being discharged to nursing homes (RR = 0.19, p < 0.001) or other hospitals (RR = 0.00, p < 0.001) postoperatively. CONCLUSIONS Surgical treatment of ASFs was marked by more frequent use of closed intramedullary fracture reduction. Furthermore, patients with ASFs were more likely to be discharged home and died significantly less often in the given timeframe. The rate of perioperative complications, as indicated by nonsignificant reoperation rates, as well as patient walking abilities during the follow-up period, remained unaffected.
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Affiliation(s)
- Christopher Bliemel
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, 35043, Baldingerstrasse, Marburg, Germany.
- Philipps University of Marburg, Marburg, Germany.
| | | | - Tom Knauf
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, 35043, Baldingerstrasse, Marburg, Germany
| | - Bastian Pass
- Department of Orthopedic and Emergency Surgery, Alfried Krupp Hospital, Essen, Germany
| | - Benjamin Craiovan
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, 35043, Baldingerstrasse, Marburg, Germany
| | - Carsten Schoeneberg
- Department of Orthopedic and Emergency Surgery, Alfried Krupp Hospital, Essen, Germany
| | - Steffen Ruchholtz
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, 35043, Baldingerstrasse, Marburg, Germany
- Philipps University of Marburg, Marburg, Germany
| | - Martin Bäumlein
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, 35043, Baldingerstrasse, Marburg, Germany
- Philipps University of Marburg, Marburg, Germany
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Yasukawa T, Lee SY, Hasegawa H, Tsuchiya K, Shirahata T, Yoshimura M, Kudo Y. Successful treatment of atypical femoral fracture with autogenous bone grafting in a patient on denosumab for bone metastasis from breast cancer: A case report. Trauma Case Rep 2024; 51:101005. [PMID: 38590922 PMCID: PMC10999851 DOI: 10.1016/j.tcr.2024.101005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2024] [Indexed: 04/10/2024] Open
Abstract
Atypical femoral fractures (AFFs) occur with minor trauma and are believed to be a potential complication of the prolonged use of antiresorptive agents, such as bisphosphonate and denosumab, for the treatment of bone metastasis. In comparison with typical femoral fractures, AFFs have a higher incidence of complications, including implant failure and delayed union or nonunion. This report describes the case of a 42-year-old woman who developed denosumab-associated AFF after denosumab therapy for bone metastasis from breast cancer. Surgical treatment with IMN was performed after open anatomical reduction. To reduce the risk of delayed union and nonunion, the autogenous bone graft obtained from the iliac crest was conducted. The radiograph taken 5 weeks after surgery showed callus formation. Full weight bearing was allowed 3 months after surgery. Six months postoperatively, radiographs and computed tomography images demonstrated bone union. Twelve months after surgery, the patient was able to walk easily without pain. For cancer patients with bone metastasis whose life expectancy may be limited, a decline in physical activity can be fatal. Consequently, it is crucial to avoid a decrease in activities of daily living brought about by delayed union or nonunion. In this regard, autogenous bone grafting is a viable and effective technique for the treatment of AFFs in patients with bone metastases.
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Affiliation(s)
- Taiki Yasukawa
- Department of Orthopedic Surgery, Takatsu General Hospital, 1-16-7 Mizonokuchi, Kawasaki-ku, Kanagawa, Japan
- Department of Orthopedic Surgery, Showa University School of Medicine, 1-5-8 Hatano-dai, Shinagawa-ku, Tokyo, Japan
| | - Sang Yang Lee
- Department of Orthopedic Surgery, Showa University School of Medicine, 1-5-8 Hatano-dai, Shinagawa-ku, Tokyo, Japan
- Department of Orthopedic Surgery, Keijinkai Shiroyama Hospital, 1 Iizuka-cho, Ota city, Gunma, Japan
| | - Hiro Hasegawa
- Department of Orthopedic Surgery, Takatsu General Hospital, 1-16-7 Mizonokuchi, Kawasaki-ku, Kanagawa, Japan
- Department of Orthopedic Surgery, Showa University School of Medicine, 1-5-8 Hatano-dai, Shinagawa-ku, Tokyo, Japan
| | - Koki Tsuchiya
- Department of Orthopedic Surgery, Showa University School of Medicine, 1-5-8 Hatano-dai, Shinagawa-ku, Tokyo, Japan
| | - Toshiyuki Shirahata
- Department of Orthopedic Surgery, Showa University School of Medicine, 1-5-8 Hatano-dai, Shinagawa-ku, Tokyo, Japan
| | - Makoto Yoshimura
- Department of Orthopedic Surgery, Takatsu General Hospital, 1-16-7 Mizonokuchi, Kawasaki-ku, Kanagawa, Japan
- Department of Orthopedic Surgery, Showa University School of Medicine, 1-5-8 Hatano-dai, Shinagawa-ku, Tokyo, Japan
| | - Yoshifumi Kudo
- Department of Orthopedic Surgery, Showa University School of Medicine, 1-5-8 Hatano-dai, Shinagawa-ku, Tokyo, Japan
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Mashiko R, Hakozaki M, Kaneuchi Y, Nikaido T, Matsumoto Y. Atypical Fracture of the Scapular Spine: A Case Report. Cureus 2024; 16:e60237. [PMID: 38872707 PMCID: PMC11169745 DOI: 10.7759/cureus.60237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 06/15/2024] Open
Abstract
Atypical fractures are gaining attention as a severe potential side effect of long-term treatment with bone-modifying agents (e.g., bisphosphonate and denosumab) for osteoporosis. Most atypical fractures occur in weight-bearing bones; the femur is the most frequent site. Atypical fractures occurring in non-weight-bearing bones are extremely rare. We describe an atypical fracture of the scapular spine in a 92-year-old Japanese woman with osteoporosis who had been treated with minodronate for ~7 years. Although the dislocation of the fracture site remained after conservative treatment, there was no obstacle to her daily life.
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Affiliation(s)
- Ryosuke Mashiko
- Department of Orthopaedic Surgery, Fukushima Prefectural Minami-Aizu Hospital, Fukushima, JPN
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, JPN
| | - Michiyuki Hakozaki
- Higashi-Shirakawa Orthopaedic Academy, Fukushima Medical University School of Medicine, Fukushima, JPN
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, JPN
| | - Yoichi Kaneuchi
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, JPN
| | - Takuya Nikaido
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, JPN
| | - Yoshihiro Matsumoto
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, JPN
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Lippuner K, Kyuchukova M, Schwab P, Rizzoli R. Differences in femoral fracture localizations in men and women in Switzerland between 1998 and 2021-reversal of the secular trend? Osteoporos Int 2024; 35:893-902. [PMID: 38396306 PMCID: PMC11031489 DOI: 10.1007/s00198-024-07016-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 12/28/2023] [Indexed: 02/25/2024]
Abstract
Number and age-standardized incidences of femoral fractures by sex and localization were determined annually between 1998 and 2021 in subjects aged 45 years or older living in Switzerland. The number and incidences of femoral neck, pertrochanteric, subtrochanteric, and femoral shaft fractures followed distinct unexpected trend patterns. INTRODUCTION Long-term incidence trends for femoral fractures by individual localizations are unknown. METHODS Annual absolute number of hospitalizations and median age at hospital admission between 1998 and 2021 were extracted from the medical database of the Swiss Federal Office of Statistics by sex and 10-year age groups for the following 10th International Classification of Diseases (ICD-10) codes: femoral neck (ICD-10 S72.0), pertrochanteric (S72.1), subtrochanteric (S72.2), and femoral shaft fractures (S72.3). Age-standardized incidence rates (ASI) and corresponding trends were calculated. RESULTS Over 24 years, the number of femoral neck fractures increased in men (+ 45%) but decreased in women (- 7%) with ASI significantly decreasing by 20% and 37% (p < 0.001 for trend for both), respectively. By contrast, the number of pertrochanteric fractures increased by 67% and 45% in men and women, respectively, corresponding to a horizontal ASI-trend in men (n.s.) and a modest significant decreasing ASI-trend in women (p < 0.001). The number of subtrochanteric fractures increased in both sexes with corresponding modest significant reductions in ASI-trends (p = 0.015 and 0.002, respectively). Femoral shaft fractures almost doubled in men (+ 71%) and doubled in women (+ 100%) with corresponding significant increases in ASI-trends (p = 0.001 and p < 0.001, respectively). Age at admission increased for all fracture localizations, more so in men than in women and more so for subtrochanteric and shaft fractures than for "typical" hip fractures. CONCLUSION Incidence changes of pertrochanteric fractures and femoral shaft fractures deserve increased attention, especially in men. Pooling diagnostic codes for defining hip fractures may hide differing patterns by localization and sex.
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Affiliation(s)
- Kurt Lippuner
- Department of Osteoporosis, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Mariya Kyuchukova
- Department of Osteoporosis, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patrick Schwab
- Swiss Federal Statistical Office, Neuchâtel, Switzerland
| | - René Rizzoli
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Morita A, Iida Y, Inaba Y, Tezuka T, Kobayashi N, Choe H, Ike H, Kawakami E. Preoperative prediction for periprosthetic bone loss and individual evaluation of bisphosphonate effect after total hip arthroplasty using artificial intelligence. Bone Joint Res 2024; 13:184-192. [PMID: 38631686 PMCID: PMC11023718 DOI: 10.1302/2046-3758.134.bjr-2023-0188.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
Aims This study was designed to develop a model for predicting bone mineral density (BMD) loss of the femur after total hip arthroplasty (THA) using artificial intelligence (AI), and to identify factors that influence the prediction. Additionally, we virtually examined the efficacy of administration of bisphosphonate for cases with severe BMD loss based on the predictive model. Methods The study included 538 joints that underwent primary THA. The patients were divided into groups using unsupervised time series clustering for five-year BMD loss of Gruen zone 7 postoperatively, and a machine-learning model to predict the BMD loss was developed. Additionally, the predictor for BMD loss was extracted using SHapley Additive exPlanations (SHAP). The patient-specific efficacy of bisphosphonate, which is the most important categorical predictor for BMD loss, was examined by calculating the change in predictive probability when hypothetically switching between the inclusion and exclusion of bisphosphonate. Results Time series clustering allowed us to divide the patients into two groups, and the predictive factors were identified including patient- and operation-related factors. The area under the receiver operating characteristic (ROC) curve (AUC) for the BMD loss prediction averaged 0.734. Virtual administration of bisphosphonate showed on average 14% efficacy in preventing BMD loss of zone 7. Additionally, stem types and preoperative triglyceride (TG), creatinine (Cr), estimated glomerular filtration rate (eGFR), and creatine kinase (CK) showed significant association with the estimated patient-specific efficacy of bisphosphonate. Conclusion Periprosthetic BMD loss after THA is predictable based on patient- and operation-related factors, and optimal prescription of bisphosphonate based on the prediction may prevent BMD loss.
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Affiliation(s)
- Akira Morita
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | - Yuta Iida
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
- Medical Sciences Innovation Hub Program, RIKEN, Yokohama, Japan
- Advanced Data Science Project, RIKEN Information R&D and Strategy Headquarters, RIKEN, Yokohama, Japan
| | - Yutaka Inaba
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | - Taro Tezuka
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | - Naomi Kobayashi
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Hyonmin Choe
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | - Hiroyuki Ike
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | - Eiryo Kawakami
- Medical Sciences Innovation Hub Program, RIKEN, Yokohama, Japan
- Advanced Data Science Project, RIKEN Information R&D and Strategy Headquarters, RIKEN, Yokohama, Japan
- Department Artificial Intelligence Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
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Wong CH, Kan AKC, Tsoi KH, Chan SSY, Jiang NS, Loong CHN, Fong CHY, Wong JSH, Shea GKH, Cheung CL, Lee CH, Tan KCB, Woo YC, Lui DTW. Clinical characteristics, densitometric parameters and outcomes of patients with atypical femoral fractures related to bisphosphonate treatment for osteoporosis. Endocrine 2024; 84:223-235. [PMID: 37985574 DOI: 10.1007/s12020-023-03608-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 11/10/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE We described the clinical and densitometric characteristics and treatment outcomes of patients who developed atypical femoral fractures (AFF) while on bisphosphonate for osteoporosis. METHODS We performed a retrospective cohort study including all adults aged ≥50 years who developed AFF while on bisphosphonates between 1 January 2008 and 31 December 2020, and subsequently managed in the Osteoporosis Centre at Queen Mary Hospital in Hong Kong. A control group of patients who developed fragility hip fractures while on bisphosphonates in the same period was included for comparison. We compared the clinical and densitometric characteristics between the two groups, and described the clinical outcomes for the AFF group. RESULTS In total, 75 patients were included (AFF: n = 35; fragility hip fracture: n = 40). All were related to oral bisphosphonates. The AFF group was characterised by a longer duration of bisphosphonate use (median of 5 years), higher bone mineral density (BMD) and more acute neck-shaft angle (all p < 0.05). Following AFF, 8 patients (22.9%) did not receive any subsequent bone-active agents: due to refusal to use an injectable, or BMD out of osteoporotic range. Most of those who received bone-active agents were given teriparatide, followed by raloxifene, and achieved stable BMD. However, subsequent fragility risk remained high. Nonetheless, AFF did not confer excess morbidity and mortality. CONCLUSION AFF was characterised by usually long duration of bisphosphonate use, higher BMD and more acute neck-shaft angle. AFF did not confer significant impairment in mobility or mortality. Nonetheless, further research work is necessary to optimise bone health among patients who develop AFF.
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Affiliation(s)
- Chun Ho Wong
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Andy Ka Chun Kan
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Kimberly Hang Tsoi
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Stacey Sheung Yi Chan
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Nancy Su Jiang
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Connie Hong Nin Loong
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Carol Ho Yi Fong
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Janus Siu Him Wong
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Graham Ka Hon Shea
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Ching Lung Cheung
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Chi Ho Lee
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Kathryn Choon Beng Tan
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Yu Cho Woo
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.
| | - David Tak Wai Lui
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.
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Park JW, Yoo JH, Lee YK, Park JS, Won YY. Treatment of Osteoporosis after Hip Fracture: Survey of the Korean Hip Society. Hip Pelvis 2024; 36:62-69. [PMID: 38420739 DOI: 10.5371/hp.2024.36.1.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 07/10/2023] [Accepted: 07/12/2023] [Indexed: 03/02/2024] Open
Abstract
Purpose To assess current practice in the treatment of osteoporosis in patients who underwent treatment for hip fracture in South Korea. Materials and Methods A survey of 97 members of the Korean Hip Society, orthopedic hip surgeons who administer treatment for hip fractures in South Korea, was conducted. The survey was conducted for assessment of demographic data and perceptions regarding the management of osteoporosis in patients who have undergone treatment for hip fracture. Analysis of the data was performed using descriptive statistical methods. Results The majority of participants were between the age of 41 and 50 years, and 74% were practicing in tertiary hospitals. Testing for serum vitamin D levels (82%) was the most commonly performed laboratory test. Calcium and vitamin D were prescribed for more than 80% of patients by 47% and 52% of participants, respectively. Denosumab was the most commonly used first-line treatment option for osteoporosis in hip fracture patients. Bisphosphonate was most often perceived as the cause of atypical femoral fractures, and the most appropriate time for reoperation was postoperative 12 months. Teriparatide was most preferred after cessation of bisphosphonate and only prescribing calcium and vitamin D was most common in high-risk patients for prevention of atypical femoral fracture. Conclusion The results of this study that surveyed orthopedic hip surgeons showed that most participants followed the current strategy for management of osteoporosis. Because the end result of osteoporosis is a bone fracture, active involvement of orthopedic surgeons is important in treating this condition.
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Affiliation(s)
- Jung-Wee Park
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Je-Hyun Yoo
- Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Young-Kyun Lee
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong-Seok Park
- Department of Orthopedic Surgery, Soonchunhyang University Hospital Cheonan, Cheonan, Korea
| | - Ye-Yeon Won
- Department of Orthopedic Surgery, Ajou University College of Medicine, Suwon, Korea
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11
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Lo JC, Grimsrud CD. Identifying Complete Atypical Femur Fractures in Adults with Bisphosphonate Exposure. Endocr Pract 2024; 30:278-281. [PMID: 38110088 PMCID: PMC10950361 DOI: 10.1016/j.eprac.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 12/20/2023]
Affiliation(s)
- Joan C Lo
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Endocrinology, the Permanente Medical Group, Kaiser Permanente Oakland Medical Center, Oakland, California.
| | - Christopher D Grimsrud
- Department of Orthopedic Surgery, the Permanente Medical Group, Kaiser Permanente Oakland Medical Center, Oakland, California
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12
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Xing H, Zou R, Tang X, Yi M, Xie Z, You S, Liu J, Zhang Q, Qin Y. Segmental femoral fracture malunion: evidence and prognostic analysis of medical intervention in the third century BC. Sci Rep 2024; 14:4930. [PMID: 38418534 PMCID: PMC10902296 DOI: 10.1038/s41598-024-55300-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 02/22/2024] [Indexed: 03/01/2024] Open
Abstract
We examined the remains of an individual who was unearthed from the Tuchengzi site and was believed to be from the Warring States period in China. The remains exhibited segmental femoral fracture. We aimed to deduce the cause of fracture, medical interventions, healing process, and motion behavior after fracture healing using several techniques, including macroscopic observation, computed tomography (CT), and finite element analysis. Based on the morphology of the long bones, it appeared that the individual was male. The fractures resulted in an adduction angle of 5.47° and an anterior flexion angle of 21.34° in the proximal femur, while the femoral neck anteversion angle had been replaced by a retroversion angle of 10.74°. Additionally, the distal femur formed an abnormal anterior convex angle of 144.60°. CT revealed mature callus formation and visible trabecular bundles. The finite element analysis indicated that the maximum von Mises stress in the femur was 17.44 MPa during standing and 96.46 MPa during walking. We suggest that medical practitioners in the Warring States period possessed a good knowledge of thigh anatomy, enabling them to perform fracture reduction and fixation. Reasonable medical intervention facilitated fracture healing and load recovery. Satisfactory fracture healing ensured that the individual could engage in normal standing and walking activities after rehabilitation.
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Affiliation(s)
- Haiyang Xing
- The Orthopaedic Medical Center, Second Hospital of Jilin University, Changchun, Jilin Province, China
- Jilin University, Joint International Research Laboratory of Ageing Active Strategy and Bionic Health in Northeast Asia of Ministry of Education, Changchun, China
| | - Ruiqi Zou
- School of Archaeology, Jilin University, Changchun, Jilin Province, China
| | - Xiongfeng Tang
- The Orthopaedic Medical Center, Second Hospital of Jilin University, Changchun, Jilin Province, China
- Jilin University, Joint International Research Laboratory of Ageing Active Strategy and Bionic Health in Northeast Asia of Ministry of Education, Changchun, China
| | - Min Yi
- The Orthopaedic Medical Center, Second Hospital of Jilin University, Changchun, Jilin Province, China
- Jilin University, Joint International Research Laboratory of Ageing Active Strategy and Bionic Health in Northeast Asia of Ministry of Education, Changchun, China
| | - Zhuoting Xie
- The Orthopaedic Medical Center, Second Hospital of Jilin University, Changchun, Jilin Province, China
- Jilin University, Joint International Research Laboratory of Ageing Active Strategy and Bionic Health in Northeast Asia of Ministry of Education, Changchun, China
| | - Sen You
- School of Archaeology, Jilin University, Changchun, Jilin Province, China
| | - Jianhua Liu
- Department of Radiology, Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Quanchao Zhang
- School of Archaeology, Jilin University, Changchun, Jilin Province, China.
| | - Yanguo Qin
- The Orthopaedic Medical Center, Second Hospital of Jilin University, Changchun, Jilin Province, China.
- Jilin University, Joint International Research Laboratory of Ageing Active Strategy and Bionic Health in Northeast Asia of Ministry of Education, Changchun, China.
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13
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Nishino T, Hyodo K, Matsumoto Y, Yanagisawa Y, Yamazaki M. Bisphosphonate-Related Atypical Femoral Fractures in Patients with Autoimmune Disease Treated with Glucocorticoids: Surgical Results for 20 Limbs. J Clin Med 2024; 13:1027. [PMID: 38398341 PMCID: PMC10889292 DOI: 10.3390/jcm13041027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Glucocorticoids induce osteoporosis, while bisphosphonates treat it, yet both can lead to atypical femoral fractures. Patients on both agents may face challenges in healing from such fractures due to their pathophysiology and pharmacological effects. METHODS Intramedullary nail surgery was performed on 20 limbs in 19 patients with atypical femoral fractures and autoimmune diseases, who had received bisphosphonates for GC-induced osteoporosis. The average durations of glucocorticoid and bisphosphonate use were 17 and 9 years (standard deviation: 7.59 and 4.35), respectively, and the mean follow-up period was 66 months. Fifteen and five limbs were fractured at the subtrochanter and diaphysis, respectively. The surgical techniques (type of nail) and additional procedures performed in these cases were examined. The post-operative alignment and reduction status on radiographs were examined to determine their relationship with post-operative outcomes. RESULTS Cephalomedullary long nails were inserted in nine limbs and antegrade intramedullary nails in 11 limbs. As an additional surgical procedure, open reduction, bone grafting and drilling were carried out on six, two, and five limbs, respectively. Regarding malalignment on radiographs, AP images showed varus in four limbs, and lateral images showed extension in two limbs. Regarding the cortical discontinuity, the distal fragment of the 11th limb shifted posteriorly in the lateral view. Gaps at the fracture sites were observed in 11 limbs. As a result, bone union was confirmed in 13 limbs. Five of the seven nonunion limbs required additional surgery. When comparing union and nonunion, open reduction and drilling were involved in nonunion limbs. CONCLUSION The surgical outcomes of atypical femoral fractures in patients with autoimmune disease and on long-term glucocorticoids and bisphosphonates were poor. Although it is not possible to affirm for sure based on these results alone, management with prophylactic surgery before complete fracture is considered to be required to improve outcomes.
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Affiliation(s)
- Tomofumi Nishino
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Ibaraki, Japan; (K.H.); (Y.M.); (Y.Y.); (M.Y.)
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14
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Mayor J, Birgel V, Clausen JD, Aktas G, Sehmisch S, Einfeldt AK, Giannoudis V, Abdelaal AHK, Liodakis E. Lessons learned from biomechanical studies on cephalomedullary nails for the management of intertrochanteric fractures. A scoping review. Injury 2024; 55:111180. [PMID: 37972488 DOI: 10.1016/j.injury.2023.111180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 10/29/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION The increasing socioeconomic need for optimal treatment of hip fractures in combination with the high diversity of available implants has raised numerous biomechanical questions. This study aims to provide a comprehensive overview of biomechanical research on the treatment of intertrochanteric fractures using cephalomedullary devices. METHODS Following the PRISMA-P guidelines, a systematic literature search was performed on 31.12.2022. The databases PubMed/MEDLINE and Web of Science were searched. Scientific papers published between 01.01.2000 - 31.12.2022 were included when they reported data on implant properties related to the biomechanical stability for intertrochanteric fractures. Data extraction was undertaken using a synthesis approach, gathering data on criteria of implants, sample size, fracture type, bone material, and study results. RESULTS The initial search identified a total of 1459 research papers, out of which forty-three papers were considered for final analysis. Due to the heterogeneous methods and parameters used in the included studies, meta-analysis was not feasible. A comprehensive assessment of implant characteristics and outcome parameters was conducted through biomechanical analysis. Various factors such as proximal and distal locking, nail diameter and length, fracture model, and bone material were thoroughly evaluated. CONCLUSION This scoping review highlights the need for standardization in biomechanical studies on intertrochanteric fractures to ensure reliable and comparable results. Strategies such as avoiding varus, maintaining a sufficient tip-apex-distance, cement augmentation, and optimizing lesser trochanteric osteosynthesis enhance construct stability. Synthetic alternatives may offer advantages over cadaveric bone. Further research and meta-analyses are required to establish standardized protocols and enhance reliability.
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Affiliation(s)
- Jorge Mayor
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany.
| | - Vera Birgel
- Hannover Medical School, Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover, Germany
| | - Jan-Dierk Clausen
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany
| | - Gökmen Aktas
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany
| | - Stephan Sehmisch
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany
| | - Ann-Kathrin Einfeldt
- Laboratory for Biomechanics and Biomaterials, Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Str. 1-7, Hannover 30625, Germany
| | - Vasilis Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, United Kingdom
| | - Ahmed H K Abdelaal
- Department of Orthopedic Surgery, Faculty of Medicine, Sohag University, Sohag 82524, Egypt
| | - Emmanouil Liodakis
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany
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15
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Schilcher J, Nilsson A, Andlid O, Eklund A. Fusion of electronic health records and radiographic images for a multimodal deep learning prediction model of atypical femur fractures. Comput Biol Med 2024; 168:107704. [PMID: 37980797 DOI: 10.1016/j.compbiomed.2023.107704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/15/2023] [Accepted: 11/07/2023] [Indexed: 11/21/2023]
Abstract
Atypical femur fractures (AFF) represent a very rare type of fracture that can be difficult to discriminate radiologically from normal femur fractures (NFF). AFFs are associated with drugs that are administered to prevent osteoporosis-related fragility fractures, which are highly prevalent in the elderly population. Given that these fractures are rare and the radiologic changes are subtle currently only 7% of AFFs are correctly identified, which hinders adequate treatment for most patients with AFF. Deep learning models could be trained to classify automatically a fracture as AFF or NFF, thereby assisting radiologists in detecting these rare fractures. Historically, for this classification task, only imaging data have been used, using convolutional neural networks (CNN) or vision transformers applied to radiographs. However, to mimic situations in which all available data are used to arrive at a diagnosis, we adopted an approach of deep learning that is based on the integration of image data and tabular data (from electronic health records) for 159 patients with AFF and 914 patients with NFF. We hypothesized that the combinatorial data, compiled from all the radiology departments of 72 hospitals in Sweden and the Swedish National Patient Register, would improve classification accuracy, as compared to using only one modality. At the patient level, the area under the ROC curve (AUC) increased from 0.966 to 0.987 when using the integrated set of imaging data and seven pre-selected variables, as compared to only using imaging data. More importantly, the sensitivity increased from 0.796 to 0.903. We found a greater impact of data fusion when only a randomly selected subset of available images was used to make the image and tabular data more balanced for each patient. The AUC then increased from 0.949 to 0.984, and the sensitivity increased from 0.727 to 0.849. These AUC improvements are not large, mainly because of the already excellent performance of the CNN (AUC of 0.966) when only images are used. However, the improvement is clinically highly relevant considering the importance of accuracy in medical diagnostics. We expect an even greater effect when imaging data from a clinical workflow, comprising a more diverse set of diagnostic images, are used.
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Affiliation(s)
- Jörg Schilcher
- Department of Orthopedics and Experimental and Clinical Medicine, Faculty of Health Science, Linköping University, Linköping, Sweden; Wallenberg Centre for Molecular Medicine, Linköping University, Linköping, Sweden; Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | - Alva Nilsson
- Department of Biomedical Engineering, Linköping University, Linköping, Sweden
| | - Oliver Andlid
- Department of Biomedical Engineering, Linköping University, Linköping, Sweden
| | - Anders Eklund
- Department of Biomedical Engineering, Linköping University, Linköping, Sweden; Division of Statistics and Machine Learning, Department of Computer and Information Science, Linköping University, Linköping, Sweden; Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.
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16
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Toro G, Braile A, Liguori S, Moretti A, Landi G, Cecere AB, Conza G, De Cicco A, Tarantino U, Iolascon G. The role of the fracture liaison service in the prevention of atypical femoral fractures. Ther Adv Musculoskelet Dis 2023; 15:1759720X231212747. [PMID: 38035253 PMCID: PMC10685792 DOI: 10.1177/1759720x231212747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/29/2023] [Indexed: 12/02/2023] Open
Abstract
Osteoporosis and fragility fractures (FFs) are considered critical health problems by the World Health Organization (WHO) because of high morbidity, mortality, and healthcare costs. The occurrence of a FF raises the risk of a subsequent fracture (refracture). The hip is the most common site of fragility refracture, and its onset is associated with a further increase in patient's morbidity, mortality, and socioeconomic burden. Therefore, the prevention of refracture is essential. In this context, fracture liaison service (FLS) demonstrated to be able to reduce FF risk and also improve patients' adherence to anti-osteoporotic treatments, particularly for bisphosphonates (BPs). However, long-term and high adherence to BPs may lead to atypical femoral fractures (AFFs). These latter are tensile side stress fractures of the femur, with high rates of complications, including delayed and non-healing. An effective FLS should be able to prevent both FF and AFF. A comprehensive and interdisciplinary approach, through the involvement and education of a dedicated team of healthcare professionals (i.e. orthopedic, geriatrician, primary care physician, rehabilitation team, and bone nurse) for evaluating both FF and AFF risks might be useful to improve the standard of care.
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Affiliation(s)
- Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, Naples 80138, Italy
| | - Adriano Braile
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
- Unit of Orthopaedics and Traumatology, Ospedale del Mare, Naples, Italy
| | - Sara Liguori
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Antimo Moretti
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Giovanni Landi
- Unit of Orthopaedics and Traumatology, Santa Maria della Speranza Hospital, Battipaglia, Italy
| | | | - Gianluca Conza
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Annalisa De Cicco
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
- Unit of Orthopaedics and Traumatology, Santa Maria delle Grazie Hospital, Pozzuoli, Italy
| | - Umberto Tarantino
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
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17
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Gehrke B, Alves Coelho MC, Brasil d'Alva C, Madeira M. Long-term consequences of osteoporosis therapy with bisphosphonates. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2023; 68:e220334. [PMID: 37948565 PMCID: PMC10916794 DOI: 10.20945/2359-4292-2022-0334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/10/2022] [Indexed: 11/12/2023]
Abstract
Bisphosphonates (BPs) are medications widely used in clinical practice to treat osteoporosis and reduce fragility fractures. Its beneficial effects on bone tissue have been consolidated in the literature for the last decades. They have a high affinity for bone hydroxyapatite crystals, and most bisphosphonates remain on the bone surface for a long period of time. Benefits of long-term use of BPs: Large and important trials (Fracture Intervention Trial Long-term Extension and Health Outcomes and Reduced Incidence with Zoledronic acid Once Yearly-Pivotal Fracture Trial) with extended use of alendronate (up to 10 years) and zoledronate (up to 6 years) evidenced significant gain of bone mineral density (BMD) and vertebral fracture risk reduction. Risks of long-term use of BPs: The extended use of antiresorptive therapy has drawn attention to two extremely rare, although severe, adverse events. That is, atypical femoral fracture and medication-related osteonecrosis of the jaw are more common in patients with high cumulative doses and longer duration of therapy. BPs have demonstrated safety and effectiveness throughout the years and evidenced increased BMD and reduced fracture risks, resulting in reduced morbimortality, and improved quality of life. These benefits overweight the risks of rare adverse events.
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Affiliation(s)
- Bárbara Gehrke
- Programa de Pós-graduação em Fisiopatologia Clínica e Experimental (FISCLINEX), Universidade Estadual do Rio de Janeiro, Rio de Janeiro, RJ, Brasil,
- Centro de Pesquisa Clínica Multiusuário (CePeM), Universidade Estadual do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
- Divisão de Endocrinologia, Departamento de Medicina Interna, Faculdade de Ciências Médicas, Universidade Estadual do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Maria Caroline Alves Coelho
- Programa de Pós-graduação em Fisiopatologia Clínica e Experimental (FISCLINEX), Universidade Estadual do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
- Centro de Pesquisa Clínica Multiusuário (CePeM), Universidade Estadual do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
- Divisão de Endocrinologia, Departamento de Medicina Interna, Faculdade de Ciências Médicas, Universidade Estadual do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Catarina Brasil d'Alva
- Núcleo de Atendimento Multidisciplinar às Doenças Osteometabólicas, Departamento de Medicina Clínica, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | - Miguel Madeira
- Divisão de Endocrinologia, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brasil
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18
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Kline GA, Morin SN, Lix LM, Leslie WD. A Population-Based Registry Study of Extended Bisphosphonate Use: Minimal Shift After Landmark Publications About Shorter Treatment Duration. J Bone Miner Res 2023; 38:1435-1442. [PMID: 37462900 DOI: 10.1002/jbmr.4885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 06/27/2023] [Accepted: 07/14/2023] [Indexed: 08/15/2023]
Abstract
Optimal duration of bisphosphonate therapy was unknown until the FLEX study was published in 2006 showing a 5-year course to be adequate for most women. In 2008, a link between long-term bisphosphonate and atypical femoral fractures was reported and confirmed in later studies. We hypothesized these landmark observations should have led to a decrease in use of bisphosphonates for >5 or 10 years, from 2010 onward. The Manitoba Bone Mineral Density (BMD) Registry with linkage to provincial pharmacy data was used to determine the percentage of long- and very long-term bisphosphonate users from therapy start. The cohort comprised women aged >50 years with BMD between 1995 and 2018 with oral bisphosphonate first prescribed for >90 days with adherence >75% in the first year. For each calendar year of continued therapy, the percentage of patients and medication possession rate was tabulated. The percentage of users beyond 5 years was compared among patients who started therapy in 1998-2004 (those taking 5 years of therapy still finish before 2010) versus 2005-2012 (all new therapy starts overlap 2010 in those taking ≥5 years of treatment). The cohort included 2991 women with mean follow-up 8.8 (1.3) years, 64.9% of whom took continuous oral bisphosphonate for >5 years and 41.9% for >10 years. In the earlier versus later era, there were 74.4% versus 70.2% who completed 5 years. With respect to longer treatment, there were 68.0% and 60.5% of patients treated for 6 or more years (p < 0.0001) and 46.6% versus 33.5% treated for >10 years (p = 0.08). Medication possession rate was >79% in every year of therapy. Landmark studies leading to more limited bisphosphonate courses may have slightly reduced longer-term treatment, but up to one-third of adherent patients in the modern era still receive continuous bisphosphonate therapy for >10 years. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Gregory A Kline
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Lisa M Lix
- Department of Community Health Science, University of Manitoba, Winnipeg, Canada
| | - William D Leslie
- Department of Community Health Science, University of Manitoba, Winnipeg, Canada
- Departments of Medicine and Radiology, University of Manitoba, Winnipeg, Canada
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Nakajima T, Ohno K, Yokota A, Yasuda E, Neo M. Atypical Fracture of Radial Diaphysis After Sauvé-Kapandji Procedure: A Retrospective Radiographic Evaluation of Fracture Progression. Orthopedics 2023; 46:e317-e320. [PMID: 36067050 DOI: 10.3928/01477447-20220831-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The Sauvé-Kapandji procedure (SK), which combines distal radioulnar joint arthrodesis with creation of an ulnar pseudarthrosis, achieves good outcomes with few complications for patients with distal radioulnar joint instability or arthritis. The authors describe a case of atypical fracture of the radial diaphysis that occurred in a 79-year-old woman with rheumatoid arthritis who had undergone SK 18 years earlier. The patient had taken alendronate for osteoporosis for 13 years but had discontinued treatment 2 years before onset of symptoms. Retrospective review of serial radiographs revealed focal cortical thickening at the fracture site beginning 18 months before the onset of prodromal pain and becoming more evident over time. The patient underwent surgical repair of the fracture, which had occurred at the attachment of the pronator teres. Histopathological examination of bone excised from the fracture site and from the iliac graft used for fracture repair revealed markedly fewer trabecular osteoblasts than normal and no osteoclasts, indicating severe suppression of bone turnover. It is important to evaluate the radial diaphysis on radiographs taken after SK for early signs of atypical fracture, especially in patients with rheumatoid arthritis and a history of bisphosphonate use. Given the patient's history of bisphosphonate use and the similar radiographic appearance to atypical femoral fractures, the authors applied the term atypical radial fracture to this case. [Orthopedics. 2023;46(5):e317-e320.].
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20
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Watanabe M, Yahagi T, Kamikura R, Kotani H, Miyake K, Matsuzaki K. Methoxyflavones isolated from the whole plant of Scutellaria rubropunctata Hayata var. rubropunctata promote osteoblast differentiation in MC3T3-E1 cells. J Nat Med 2023; 77:748-760. [PMID: 37329417 DOI: 10.1007/s11418-023-01716-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 05/31/2023] [Indexed: 06/19/2023]
Abstract
In this study, we isolated two new methoxyflavones (1 and 2) and eight known methoxyflavones (3-10) from the whole plant of Scutellaria rubropunctata Hayata var. rubropunctata (SR). Based on spectroscopic analyses, the methoxyflavones were identified as 5,8,2',6'-tetramethoxy-6,7-methylenedioxyflavone (1) and 5,2',6'-trimethoxy-6,7-methylenedioxyflavone (2). We reported SR might have effects on promoting osteoblast differentiation and stimulating estrogen receptor (ER) in the previous study. Then, the effects of 1-10 on pre-osteoblast MC3T3-E1 cells were investigated, and 1, 2, and 9 were observed to promote alkaline phosphatase activity. To evaluate their effect on osteogenesis-related genes, we performed gene expression analysis using quantitative real-time PCR after treatment of MC3T3-E1 cells with these compounds. Although 2 was only effective at lower concentrations, 1 and 9 upregulated the mRNA levels of Runx2, Osterix, Osteopontin, Osteocalcin, Smad1, and Smad4. These results indicate that 1 and 9 may induce osteoblast differentiation by activating Runx2 via the BMP/Smad pathway and may play a central role in the promotion of osteoblast differentiation by SR. The ER agonist activity of 1-10 were tested using a luciferase reporter assay in HEK293 cells. However, none of the compounds exhibited remarkable activity. Thus, SR may contain other compounds that contribute to its ER agonist activity.
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Affiliation(s)
- Misaki Watanabe
- Laboratory of Pharmacognosy and Natural Product Chemistry, School of Pharmacy, Nihon University, 7-7-1 Narashinodai, Funabashi, Chiba, 274-8555, Japan
| | - Tadahiro Yahagi
- Laboratory of Pharmacognosy and Natural Product Chemistry, School of Pharmacy, Nihon University, 7-7-1 Narashinodai, Funabashi, Chiba, 274-8555, Japan.
| | - Rina Kamikura
- Laboratory of Pharmacognosy and Natural Product Chemistry, School of Pharmacy, Nihon University, 7-7-1 Narashinodai, Funabashi, Chiba, 274-8555, Japan
| | - Hitoshi Kotani
- Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan
| | - Katsunori Miyake
- School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo, 192-0392, Japan
| | - Keiichi Matsuzaki
- Laboratory of Pharmacognosy and Natural Product Chemistry, School of Pharmacy, Nihon University, 7-7-1 Narashinodai, Funabashi, Chiba, 274-8555, Japan.
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21
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Foessl I, Dimai HP, Obermayer-Pietsch B. Long-term and sequential treatment for osteoporosis. Nat Rev Endocrinol 2023; 19:520-533. [PMID: 37464088 DOI: 10.1038/s41574-023-00866-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2023] [Indexed: 07/20/2023]
Abstract
Osteoporosis is a skeletal disorder that causes impairment of bone structure and strength, leading to a progressively increased risk of fragility fractures. The global prevalence of osteoporosis is increasing in the ageing population. Owing to the chronic character of osteoporosis, years or even decades of preventive measures or therapy are required. The long-term use of bone-specific pharmacological treatment options, including antiresorptive and/or osteoanabolic approaches, has raised concerns around adverse effects or potential rebound phenomena after treatment discontinuation. Imaging options, risk scores and the assessment of bone turnover during initiation and monitoring of such therapies could help to inform individualized treatment strategies. Combination therapies are currently used less often than 'sequential' treatments. However, all patients with osteoporosis, including those with secondary and rare causes of osteoporosis, as well as specific patient populations (for example, young adults, men and pregnant women) require new approaches for long-term therapy and disease monitoring. New pathophysiological aspects of bone metabolism might therefore help to inform and revolutionize the diagnosis and treatment of osteoporosis.
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Affiliation(s)
- Ines Foessl
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Hans P Dimai
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Barbara Obermayer-Pietsch
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University Graz, Graz, Austria.
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22
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Sing CW, Lin TC, Bartholomew S, Bell JS, Bennett C, Beyene K, Bosco-Levy P, Bradbury BD, Chan AHY, Chandran M, Cooper C, de Ridder M, Doyon CY, Droz-Perroteau C, Ganesan G, Hartikainen S, Ilomaki J, Jeong HE, Kiel DP, Kubota K, Lai ECC, Lange JL, Lewiecki EM, Lin J, Liu J, Maskell J, de Abreu MM, O'Kelly J, Ooba N, Pedersen AB, Prats-Uribe A, Prieto-Alhambra D, Qin SX, Shin JY, Sørensen HT, Tan KB, Thomas T, Tolppanen AM, Verhamme KMC, Wang GHM, Watcharathanakij S, Wood SJ, Cheung CL, Wong ICK. Global Epidemiology of Hip Fractures: Secular Trends in Incidence Rate, Post-Fracture Treatment, and All-Cause Mortality. J Bone Miner Res 2023; 38:1064-1075. [PMID: 37118993 DOI: 10.1002/jbmr.4821] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 04/20/2023] [Accepted: 04/26/2023] [Indexed: 04/30/2023]
Abstract
In this international study, we examined the incidence of hip fractures, postfracture treatment, and all-cause mortality following hip fractures, based on demographics, geography, and calendar year. We used patient-level healthcare data from 19 countries and regions to identify patients aged 50 years and older hospitalized with a hip fracture from 2005 to 2018. The age- and sex-standardized incidence rates of hip fractures, post-hip fracture treatment (defined as the proportion of patients receiving anti-osteoporosis medication with various mechanisms of action [bisphosphonates, denosumab, raloxifene, strontium ranelate, or teriparatide] following a hip fracture), and the all-cause mortality rates after hip fractures were estimated using a standardized protocol and common data model. The number of hip fractures in 2050 was projected based on trends in the incidence and estimated future population demographics. In total, 4,115,046 hip fractures were identified from 20 databases. The reported age- and sex-standardized incidence rates of hip fractures ranged from 95.1 (95% confidence interval [CI] 94.8-95.4) in Brazil to 315.9 (95% CI 314.0-317.7) in Denmark per 100,000 population. Incidence rates decreased over the study period in most countries; however, the estimated total annual number of hip fractures nearly doubled from 2018 to 2050. Within 1 year following a hip fracture, post-hip fracture treatment ranged from 11.5% (95% CI 11.1% to 11.9%) in Germany to 50.3% (95% CI 50.0% to 50.7%) in the United Kingdom, and all-cause mortality rates ranged from 14.4% (95% CI 14.0% to 14.8%) in Singapore to 28.3% (95% CI 28.0% to 28.6%) in the United Kingdom. Males had lower use of anti-osteoporosis medication than females, higher rates of all-cause mortality, and a larger increase in the projected number of hip fractures by 2050. Substantial variations exist in the global epidemiology of hip fractures and postfracture outcomes. Our findings inform possible actions to reduce the projected public health burden of osteoporotic fractures among the aging population. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Chor-Wing Sing
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Tzu-Chieh Lin
- Center for Observational Research, Amgen Inc, Thousand Oaks, CA, USA
| | - Sharon Bartholomew
- Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Canada
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Corina Bennett
- Center for Observational Research, Amgen Inc, Thousand Oaks, CA, USA
| | - Kebede Beyene
- Department of Pharmaceutical and Administrative Sciences, University of Health Sciences and Pharmacy, St Louis, MO, USA
| | - Pauline Bosco-Levy
- Bordeaux PharmacoEpi, INSERM CIC-P1401, Univ. Bordeaux, Bordeaux, France
| | - Brian D Bradbury
- Center for Observational Research, Amgen Inc, Thousand Oaks, CA, USA
| | - Amy Hai Yan Chan
- School of Pharmacy, The University of Auckland, Auckland, New Zealand
| | - Manju Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Cyrus Cooper
- Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - Maria de Ridder
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, Netherlands
| | - Caroline Y Doyon
- Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Canada
| | | | | | | | - Jenni Ilomaki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Han Eol Jeong
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - Douglas P Kiel
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife and Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jeff L Lange
- Center for Observational Research, Amgen Inc, Thousand Oaks, CA, USA
| | | | - Julian Lin
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Jiannong Liu
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Joe Maskell
- Center for Observational Research, Amgen Inc, Thousand Oaks, CA, USA
| | - Mirhelen Mendes de Abreu
- Rheumatology Service, Internal Medicine Department, School of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - James O'Kelly
- Center for Observational Research, Amgen Inc, Thousand Oaks, CA, USA
| | - Nobuhiro Ooba
- School of Pharmacy, The Nihon University, Chiba, Japan
| | - Alma B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Albert Prats-Uribe
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Daniel Prieto-Alhambra
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Simon Xiwen Qin
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Kelvin Bryan Tan
- School of Public Health, National University of Singapore, Singapore, Singapore
| | - Tracy Thomas
- Center for Observational Research, Amgen Inc, Thousand Oaks, CA, USA
| | | | - Katia M C Verhamme
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, Netherlands
| | - Grace Hsin-Min Wang
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | | | - Stephen J Wood
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Ching-Lung Cheung
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Ian C K Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
- Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
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23
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Nashi N, Kagda FHY. Current concepts of bone grafting in trauma surgery. J Clin Orthop Trauma 2023; 43:102231. [PMID: 37636005 PMCID: PMC10448478 DOI: 10.1016/j.jcot.2023.102231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 08/03/2023] [Indexed: 08/29/2023] Open
Abstract
Bone graft in trauma surgery is commonly used in managing bone defects, non-union, fracture related infections, arthrodesis or to provide structural support in fractures. A variety of bone grafts are made available to the treating physician, which includes autograft, allograft and bone graft substitutes. The future of bone grafting in trauma surgery is exciting with the incorporation of technological advancement such as gene therapy, 3D-printing and tissue engineering. Regardless, there are still limitations to what we understand regarding current bone grafting techniques with conflicting literature on their clinical utility and indication. The aim of this review article therefore is to take a step back and critically evaluate the current concepts of bone grafting in trauma surgery, with special emphasis made on reviewing the types of bone graft, biology of bone graft incorporation and indication for its use in various clinical scenarios.
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Affiliation(s)
- Nazrul Nashi
- University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System, Singapore, 1E Kent Ridge Road, 119228, Singapore
| | - Fareed HY. Kagda
- Department of Orthopaedic Surgery, Ng Teng Fong General Hospital, National University Health System, Singapore, 1 Jurong East Street 21, 609606, Singapore
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24
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Nho JH, Jang BW, Lee DW, Kim JH, Lim TK, Cha SM, Seo DK, Park YG, Kang DG, Lee YK, Ha YC. Position Statement: Atypical Femoral Fracture from the Korean Society for Bone and Mineral Research in 2023. J Bone Metab 2023; 30:209-217. [PMID: 37718899 PMCID: PMC10509028 DOI: 10.11005/jbm.2023.30.3.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/06/2023] [Accepted: 07/21/2023] [Indexed: 09/19/2023] Open
Abstract
As the aging population increases, the number of patients with osteoporosis is gradually rising. Osteoporosis is a metabolic bone disease characterized by low bone mass and the microarchitectural deterioration of bone tissue, resulting in reduced bone strength and an increased risk of low-energy or fragility fractures. Thus, the use of anti-resorptive agents, such as bisphosphonates (BPs), to prevent osteoporotic fractures is growing annually. BPs are effective in reducing hip and other fractures. However, the longer a patient takes BPs, the higher the risk of an atypical femoral fracture (AFF). The exact mechanism by which long-term BP use affects the development of AFFs has not yet been clarified. However, several theories have been suggested to explain the pathogenesis of AFFs, such as suppressed bone remodeling, impaired bone healing, altered bone quality, and femoral morphology. The management of AFFs requires both medical and surgical approaches. BPs therapy should be discontinued immediately, and calcium and vitamin D levels should be evaluated and supplemented if insufficient. Teriparatide can be used for AFFs. Intramedullary nailing is the primary treatment for complete AFFs, and prophylactic femoral nailing is recommended if signs of an impending fracture are detected.
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Affiliation(s)
- Jae-Hwi Nho
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul,
Korea
| | - Byung-Woong Jang
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul,
Korea
| | - Dong Woo Lee
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul,
Korea
| | - Jae-Hyun Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon,
Korea
| | - Tae Kang Lim
- Department of Orthopaedic Surgery, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul,
Korea
| | - Soo Min Cha
- Department of Orthopaedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon,
Korea
| | - Dong-Kyo Seo
- Department of Orthopaedic Surgery, Gangneung Asan Hospital, Ulsan University College of Medicine, Gangneung,
Korea
| | - Yong-Geun Park
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju,
Korea
| | - Dong-Geun Kang
- Department of Orthopaedic Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Jinju,
Korea
| | - Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam,
Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Seoul Bumin Hospital, Seoul,
Korea
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25
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Xiao Y, Chen Y, Huang Y, Xiao Y. Atypical femur fracture associated with common anti-osteoporosis drugs in FDA adverse event reporting system. Sci Rep 2023; 13:10892. [PMID: 37407650 DOI: 10.1038/s41598-023-37944-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 06/30/2023] [Indexed: 07/07/2023] Open
Abstract
Atypical femur fracture (AFF) is a rare but catastrophic adverse event first reported in the long-term use of alendronate, one of the most commonly used drugs for osteoporosis currently. However, further evidence is needed to learn more regarding other common anti-osteoporosis drugs and the risk for AFF. In this study, reports of AFF were identified from Food and Drug Administration Adverse Event Reporting System database. Disproportionality analyses were performed to examine the reporting odds ratio (ROR), information component (IC) and adjusted ROR (adj. ROR) signals for AFF for common anti-osteoporosis drugs. A total of 1692 unique AFF reports were identified. The disproportionality signals (the lower bound of 95% confidence interval > 1 for ROR and adjusted ROR, and > 0 for IC) were detected for alendronate, denosumab, pamidronate, risedronate, zoledronate, ibandronate, and teriparatide while no signal was detected for raloxifene, abaloparatide, and romosozumab. When restricted in patients with osteoporosis, the disproportionality signals were still detected for alendronate, pamidronate, risedronate, denosumab, and ibandronate. Our results suggest that alendronate has the largest risk signal, while the risks varied among different bisphosphonates. In addition, denosumab was found statistically associated with AFF in both the entire database and patients with osteoporosis.
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Affiliation(s)
- Yao Xiao
- Department of Endocrinology, Endocrinology Research Center, Xiangya Hospital of Central South University, Changsha, 410008, Hunan, China
| | - Yiqian Chen
- Department of Gastroenterology, Xiangya Hospital of Central South University, Changsha, 410008, Hunan, China
| | - Yan Huang
- Department of Endocrinology, Endocrinology Research Center, Xiangya Hospital of Central South University, Changsha, 410008, Hunan, China
| | - Yuan Xiao
- Department of Endocrinology, Endocrinology Research Center, Xiangya Hospital of Central South University, Changsha, 410008, Hunan, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, 410008, Hunan, China.
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26
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Kaku T, Oh Y, Sato S, Koyanagi H, Funauchi Y, Hirai T, Yuasa M, Matsukura Y, Yoshii T, Nakagawa T, Miyake S, Okawa A. Prevalence of Precursory Signs of Atypical Femoral Fractures in Patients Receiving Bone-Modifying Agents for Bone Metastases: A Cross-Sectional Study. JBMR Plus 2023; 7:e10749. [PMID: 37457876 PMCID: PMC10339079 DOI: 10.1002/jbm4.10749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 03/23/2023] [Accepted: 04/01/2023] [Indexed: 07/18/2023] Open
Abstract
Patients on bone-modifying agents (BMAs) for bone metastases are at risk of atypical femoral fractures (AFFs), which can lead to a sudden deterioration in performance status. In this study, we sought to determine the prevalence of radiographic precursory signs of AFF in patients on oncologic BMAs. Forty-two patients (23 men, 19 women; mean age 68.8 ± 10.0 years) on oncologic BMAs (zoledronate for >3 years and/or denosumab for >1 year) and without clinical symptoms were enrolled between 2019 and 2021. All patients were receiving denosumab at enrollment and 5 had previously used zoledronate. The mean duration of BMA use was 31.2 ± 18.5 months. Radiographs of both femurs were screened for precursory signs of AFF (e.g., thickening of the lateral cortex). The patients were divided into two groups according to thickening status and compared by duration of BMA use. They were also divided into three groups by duration of BMA use (12-23 months, n = 18; 24-59 months, n = 19; ≥60 months, n = 5), and the prevalence of apparent thickenings was examined. As a result, 18 patients (42.9%) showed minute local or diffuse thickening and 10 (23.8%) showed apparent local thickening. The duration of BMA use was significantly longer in patients with apparent thickening than in those without (47.3 ± 23.6 months [n = 10] versus 26.2 ± 13.5 months [n = 32]; p < 0.05). The prevalence of apparent thickening increased with increasing duration of BMA use (12-23 months, 5.6%; 24-59 months, 31.6%; ≥60 months, 60.0%). In conclusion, radiographic precursory signs of AFF are common in patients on oncologic BMAs. Radiographic screening for AFF could be relevant in patients who have been on long-term oncologic BMAs, even if asymptomatic. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Takumi Kaku
- Department of Orthopaedic and Spinal SurgeryGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
| | - Yoto Oh
- Department of Orthopaedic and Trauma ResearchGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
| | - Shingo Sato
- Center for Innovative Cancer Treatment, Tokyo Medical and Dental University Medical HospitalTokyoJapan
| | - Hirotaka Koyanagi
- Department of Orthopaedic and Spinal SurgeryGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
| | - Yuki Funauchi
- Department of Orthopaedic and Spinal SurgeryGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
| | - Takashi Hirai
- Department of Orthopaedic and Spinal SurgeryGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
| | - Masato Yuasa
- Department of Orthopaedic and Spinal SurgeryGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
| | - Yu Matsukura
- Department of Orthopaedic and Spinal SurgeryGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
| | - Toshitaka Yoshii
- Department of Orthopaedic and Spinal SurgeryGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
| | - Tsuyoshi Nakagawa
- Department of Breast SurgeryTokyo Medical and Dental University Medical HospitalTokyoJapan
| | - Satoshi Miyake
- Department of Clinical OncologyGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
| | - Atsushi Okawa
- Department of Orthopaedic and Spinal SurgeryGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
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27
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Migliaccio S, Moretti A, Biffi A, Ronco R, Porcu G, Adami G, Alvaro R, Bogini R, Caputi AP, Cianferotti L, Frediani B, Gatti D, Gonnelli S, Lenzi A, Leone S, Nicoletti T, Paoletta M, Pennini A, Piccirilli E, Michieli R, Tarantino U, Rossini M, Corrao G, Brandi ML, Iolascon G. Medication holidays in osteoporosis: evidence-based recommendations from the Italian guidelines on 'Diagnosis, risk stratification, and continuity of care of fragility fractures' based on a systematic literature review. Ther Adv Musculoskelet Dis 2023; 15:1759720X231177110. [PMID: 37359175 PMCID: PMC10286165 DOI: 10.1177/1759720x231177110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 04/24/2023] [Indexed: 06/28/2023] Open
Abstract
Background Noncommunicable, chronic diseases need pharmacological interventions for long periods or even throughout life. The temporary or permanent cessation of medication for a specific period, known as a 'medication holiday,' should be planned by healthcare professionals. Objectives We evaluated the association between continuity (adherence or persistence) of treatment and several outcomes in patients with fragility fractures in the context of the development of the Italian Guidelines. Design Systematic review. Data Sources and Methods We systematically searched PubMed, Embase, and the Cochrane Library up to November 2020 for randomized clinical trials (RCTs) and observational studies that analyzed medication holidays in patients with fragility fracture. Three authors independently extracted data and appraised the risk of bias of the included studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Effect sizes were pooled in a meta-analysis using random effects models. Primary outcomes were refracture and quality of life; secondary outcomes were mortality and treatment-related adverse events. Results Six RCTs and nine observational studies met our inclusion criteria, ranging from very low to moderate quality. The adherence to antiosteoporotic drugs was associated with a lower risk of nonvertebral fracture [relative risk (RR) 0.42, 95% confidence interval (CI) 0.20-0.87; three studies] than nonadherence, whereas no difference was detected in the health-related quality of life. A reduction in refracture risk was observed when continuous treatment was compared to discontinuous therapy (RR 0.49, 95% CI 0.25-0.98; three studies). A lower mortality rate was detected for the adherence and persistence measures, while no significant differences were noted in gastrointestinal side effects in individuals undergoing continuous versus discontinuous treatment. Conclusion Our findings suggest that clinicians should promote adherence and persistence to antiosteoporotic treatment in patients with fragility fractures unless serious adverse effects occur.
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Affiliation(s)
- Silvia Migliaccio
- Department of Movement, Human and Health Sciences, Foro Italico University, Rome, Italy
| | - Antimo Moretti
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli,” Napoli, Italy
| | - Annalisa Biffi
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
| | - Raffaella Ronco
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
| | - Gloria Porcu
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
| | | | - Rosaria Alvaro
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | | | | | - Bruno Frediani
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, Azienda Ospedaliero-Universitaria Senese, University of Siena, Siena, Italy
| | - Davide Gatti
- Rheumatology Unit, University of Verona, Verona, Italy
| | - Stefano Gonnelli
- Department of Medicine, Surgery and Neuroscience, Policlinico Le Scotte, University of Siena, Siena, Italy
| | - Andrea Lenzi
- Department of Experimental Medicine, Viale del Policlinico, Sapienza University of Rome, Rome, Italy
| | - Salvatore Leone
- AMICI Onlus, Associazione nazionale per le Malattie Infiammatorie Croniche dell’Intestino, Milan, Italy
| | - Tiziana Nicoletti
- CnAMC, Coordinamento nazionale delle Associazioni dei Malati Cronici e rari di Cittadinanzattiva, Rome, Italy
| | - Marco Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli,” Napoli, Italy
| | - Annalisa Pennini
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Eleonora Piccirilli
- Department of Clinical Sciences and Translational Medicine, University of Rome “Tor Vergata,” Rome, Italy
- Department of Orthopedics and Traumatology, “Policlinico Tor Vergata” Foundation, Rome, Italy
| | - Raffaella Michieli
- Italian Society of General Medicine and Primary Care (SIMG), Florence, Italy
| | - Umberto Tarantino
- Department of Clinical Sciences and Translational Medicine, University of Rome “Tor Vergata,” Rome, Italy
- Department of Orthopedics and Traumatology, “Policlinico Tor Vergata” Foundation, Rome, Italy
| | | | - Giovanni Corrao
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
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28
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Fukui T, Oe K, Kawamoto T, Morishita M, Fujita I, Takahara S, Sakurai A, Iwakura T, Yoshida K, Ito K, Shoda E, Hiranaka T, Tsunoda M, Kuroda R, Niikura T. Multicenter study on atypical femoral fractures in patients with bone metastases taking bone- modifying agents. J Bone Oncol 2023; 40:100478. [PMID: 37180736 PMCID: PMC10173009 DOI: 10.1016/j.jbo.2023.100478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/02/2023] [Accepted: 04/08/2023] [Indexed: 05/16/2023] Open
Abstract
Bone-modifying agents (BMAs), with bone-resorptive inhibitory effects, such as zoledronic acid and denosumab, are widely used at higher doses for bone-related events caused by bone metastasis of malignant tumors. These drugs have been suggested to be associated with atypical femoral fractures (AFFs), and the relationship between BMAs and AFFs has attracted attention. To investigate the clinical features including bone union time of AFFs in patients administered BMA for bone metastasis, we conducted a retrospective multicenter study. Thirty AFFs from 19 patients were enrolled in this study. Thirteen patients had bilateral AFFs, and nineteen AFFs had prodromal symptoms. Eighteen AFFs underwent surgery after complete fracture, three failed to achieve bone union and required nonunion surgery, and 11 AFFs that achieved bone union had an average period until bone union of 16.2 months, which was much longer than that previously reported for ordinary AFFs. Seven patients discontinued the BMAs, but not due to AFFs. Stopping BMAs in patients with bone metastasis would make it difficult to secure their performance of activities of daily living, and AFF with BMA administration might require a longer time for union. Therefore, it would be important to prevent incomplete AFF from becoming complete AFF via prophylactic internal fixation.
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Affiliation(s)
- Tomoaki Fukui
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Keisuke Oe
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Teruya Kawamoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | | | - Ikuo Fujita
- Department of Orthopaedic Surgery, Hyogo Cancer Center, Japan
| | | | - Atsushi Sakurai
- Department of Orthopaedic Surgery, Awaji Medical Center, Japan
| | - Takashi Iwakura
- Department of Orthopaedic Surgery, Awaji Medical Center, Japan
- Department of Orthopaedic Surgery, Sanda City Hospital, Japan
| | - Keiji Yoshida
- Department of Orthopaedic Surgery, Kobe City Nishi-Kobe Medical Center, Japan
| | - Kenjiro Ito
- Department of Orthopaedic Surgery, Akashi Medical Center, Japan
| | - Etsuo Shoda
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, Japan
| | | | - Masaya Tsunoda
- Department of Orthopaedic Surgery, Sanda City Hospital, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Takahiro Niikura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, Japan
- Corresponding author at: Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan.
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29
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Whyte MP, McAlister WH, Dhiman V, Gopinathan NR, Bhadada SK. Drug-induced osteopetrosis. Bone 2023:116788. [PMID: 37172883 DOI: 10.1016/j.bone.2023.116788] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/03/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023]
Abstract
Osteopetrosis (OPT) denotes the consequences from failure of osteoclasts to resorb bone and chondroclasts to remove calcified physeal cartilage throughout growth. Resulting impairment of skeletal modeling, remodeling, and growth compromises widening of medullary spaces, formation of the skull, and expansion of cranial foramina. Thus, myelophthisic anemia, raised intracranial pressure, and cranial nerve palsies complicate OPT when severe. Osteopetrotic bones fracture due to misshaping, failure of remodeling to weave the collagenous matrix of cortical osteons and trabeculae, persistence of mineralized growth plate cartilage, "hardening" of hydroxyapatite crystals, and delayed healing of skeletal microcracks. Teeth may fail to erupt. Now it is widely appreciated that OPT is caused by germline loss-of-function mutation(s) usually of genes involved in osteoclast function, but especially rarely of genes necessary for osteoclast formation. Additionally, however, in 2003 we published a case report demonstrating that prolonged excessive dosing during childhood of the antiresorptive aminobisphosphonate pamidronate can sufficiently block osteoclast and chondroclast activity to recapitulate the skeletal features of OPT. Herein, we include further evidence of drug-induced OPT by illustrating osteopetrotic skeletal changes from repeated administration of high doses of the aminobisphosphonate zoledronic acid (zoledronate) given to children with osteogenesis imperfecta.
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Affiliation(s)
- Michael P Whyte
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children-St Louis, St. Louis, MO 63110, USA.
| | - William H McAlister
- Pediatric Radiology Section, Mallinckrodt Institute of Radiology at St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Vandana Dhiman
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nirmal Raj Gopinathan
- Department of Orthopedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay K Bhadada
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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30
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Yocom A, Contino E, Kawcak C. Review of the Mechanism of Action and Use of Bisphosphonates in Horses. J Equine Vet Sci 2023:104503. [PMID: 37120118 DOI: 10.1016/j.jevs.2023.104503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 04/13/2023] [Accepted: 04/24/2023] [Indexed: 05/01/2023]
Abstract
Bisphosphonates are a group of drugs that can reduce bone resorption by incorporating into the crystal structure of exposed hydroxyapatite where they are taken up by osteoclasts. Bisphosphonates have several other mechanisms of action including reducing pain and inflammation and altering macrophage function. There are two types of bisphosphonates - nitrogenous and non-nitrogenous, the latter of which is used in horses. This article provides a literature-based review of the proposed mechanisms of action and therapeutic uses of bisphosphonates including a brief review of bone response to disease. A review of the literature available in horses including safety data and current rules and regulations is also provided.
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Affiliation(s)
- Alicia Yocom
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, 300 West Drake Road, Fort Collins, CO 80523
| | - Erin Contino
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, 300 West Drake Road, Fort Collins, CO 80523
| | - Christopher Kawcak
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, 300 West Drake Road, Fort Collins, CO 80523.
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31
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Sun X, Kong M. Effects of posterior lumbar plexus block on anesthesia and sedation in postmenopausal patients with osteoporotic subtrochanteric comminuted fractures. Biotechnol Genet Eng Rev 2023:1-14. [PMID: 37037007 DOI: 10.1080/02648725.2023.2200988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
To study the effect of posterior lumbar plexus nerve block on anaesthesia and sedation in postmenopausal patients with osteoporotic subtrochanteric femoral comminuted fractures. The research subjects selected 48 patients with postmenopausal osteoporotic subtrochanteric comminuted fractures who were hospitalized between January 2020 and January 2022, and were allocated to clusters according to the random number TBL approach. The controlling cluster (24 situations) underwent dura mater Under external anesthesia, the test cluster (24 situations) underwent posterior lumbar plexus block, and the block effect, anesthesia effect, sedation effect, hemodynamics, vital signs and reactions of adverse nature were contrasted involving the two clusters. In comparison to the control group, the test group had a longer duration of anesthesia and motor block, higher oxygenation indices but lower ITBVI, GEDVI, and ScrO2 values, lower MAP levels, and lower BIS contraction values at 5, 15, and 30 minutes following anesthesia (P < 0.05). The test group had shorter induction time and block onset time compared to the control group (P < 0.05), and a lower incidence of adverse reactions (16.67% vs. 29.17% in the control group), but the variation was not noTBL (P < 0.05). Posterior lumbar plexus nerve block in postmenopausal patients with osteoporotic subtrochanteric femoral comminuted fractures has a better sedative effect, shortens the induction time of anaesthesia and the onset of block, promotes sTBL haemodynamic indexes and has fewer adverse effects to ensure safety.
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Affiliation(s)
- Xiaoshan Sun
- Anaesthesiology department, The Second Affiliated Hospital of Shandong First Medical University, Taian, Shandong, China
| | - Minmin Kong
- Anaesthesiology department, The Second Affiliated Hospital of Shandong First Medical University, Taian, Shandong, China
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Joo YB, Jeon YS, Lee WY, Chung HJ. Risk Factors Associated with Intraoperative Iatrogenic Fracture in Patients Undergoing Intramedullary Nailing for Atypical Femoral Fractures with Marked Anterior and Lateral Bowing. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040735. [PMID: 37109693 PMCID: PMC10143868 DOI: 10.3390/medicina59040735] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/05/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023]
Abstract
Background and objectives: Iatrogenic fractures are potential complications during intramedullary (IM) nailing for atypical femoral fractures (AFFs). The risk factors associated with iatrogenic fractures remain unclear, although excessive femoral bowing and osteoporosis are hypothesized to be contributing factors. The present study aimed to determine the risk factors for the occurrence of iatrogenic fractures during IM nailing in patients with AFFs. Materials and Methods: This retrospective cross-sectional study evaluated 95 patients with AFF (all female; age range: 49-87 years) who underwent IM nailing between June 2008 and December 2017. The patients were divided into two groups: Group I (with iatrogenic fracture: n = 20) and Group II (without iatrogenic fracture: n = 75). Background characteristics were retrieved from medical records and radiographic measurements were obtained. Univariate and multivariate logistic regression analyses were performed to identify risk factors for the occurrence of intraoperative iatrogenic fractures. Receiver operating curve (ROC) analysis was conducted to determine a cut-off value for the prediction of iatrogenic fracture occurrence. Results: Iatrogenic fractures occurred in 20 (21.1%) patients. The two groups exhibited no significant differences regarding age and other background characteristics. Group I exhibited significantly lower mean femoral bone mineral density (BMD) and significantly greater mean lateral and anterior femoral bowing angles than Group II (all p < 0.05). There were no significant differences in AFF location, nonunion, and IM nail diameter, length, or nail entry point between the two groups. In the univariate analysis, femoral BMD and lateral bowing of the femur differed significantly between the two groups. On multivariate analysis, only lateral bowing of the femur remained significantly associated with iatrogenic fracture occurrence. The ROC analysis determined a cut-off value of 9.3° in lateral bowing of the femur for prediction of iatrogenic fracture occurrence during IM nailing for AFF treatment. Conclusions: The lateral bowing angle of the femur is an important predictive factor for intraoperative iatrogenic fracture occurrence in patients undergoing IM nailing for AFF treatment.
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Affiliation(s)
- Yong Bum Joo
- Department of Orthopedic Surgery, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon 35015, Republic of Korea
| | - Yoo Sun Jeon
- Department of Orthopedic Surgery, Korea Worker's Compensation & Welfare Service Daejeon Hospital, 637, Gyejok-ro, Daedeok-gu, Daejeon 34384, Republic of Korea
| | - Woo Yong Lee
- Department of Orthopedic Surgery, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon 35015, Republic of Korea
| | - Hyung Jin Chung
- Department of Orthopedic Surgery, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Sejong 30099, Republic of Korea
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33
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Hart DA. Are secondary effects of bisphosphonates on the vascular system of bone contributing to increased risk for atypical femoral fractures in osteoporosis? Bioessays 2023; 45:e2200206. [PMID: 36807308 DOI: 10.1002/bies.202200206] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/22/2023]
Abstract
Osteoporosis (OP) is a bone disease which affects a number of post-menopausal females and puts many at risk for fractures. A large number of patients are taking bisphosphonates (BPs) to treat their OP and a rare complication is the development of atypical femoral fractures (AFF). No real explanations for the mechanisms underlying the basis for development of where AFF develop while on BPs has emerged. The present hypothesis will discuss the possibility that part of the risk for an AFF is a secondary effect of BPs on a subset of vascular cells in a genetically at-risk population, leading to localized deregulation of the endothelial cell (EC)-bone cell-matrix units in nutrient channels/canals of the femur and increased risk for AFF. This concept of targeting ECs is consistent with location of AFF in the femur, the bilateral risk for occurrence of AFF, and the requirement for long term exposure to the drugs.
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Affiliation(s)
- David A Hart
- Department of Surgery, Faculty of Kinesiology, McCaig Institute for Bone & Joint Health, University of Calgary, Calgary, Alberta, Canada
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34
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Hernandez CJ. Suppression of Remodeling and Bone Fragility. J Bone Miner Res 2023; 38:370-371. [PMID: 36754846 PMCID: PMC10023396 DOI: 10.1002/jbmr.4781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/17/2023] [Accepted: 01/25/2023] [Indexed: 02/10/2023]
Affiliation(s)
- Christopher J Hernandez
- Departments of Orthopaedic Surgery and Bioengineering and Therapeutic Sciences, University of California, San Francisco, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
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35
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Riancho JA. Diagnostic Approach to Patients with Low Serum Alkaline Phosphatase. Calcif Tissue Int 2023; 112:289-296. [PMID: 36348061 DOI: 10.1007/s00223-022-01039-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
Increased serum levels of alkaline phosphatase (ALP) are widely recognized as a biochemical marker of many disorders affecting the liver or bone. However, the approach for patients with low ALP phosphatase is not well-established. Low serum ALP is an epiphenomenon of many severe acute injuries and diseases. Persistently low serum ALP may be secondary to drug therapy (including antiresorptives) or a variety of acquired disorders, such as malnutrition, vitamin and mineral deficiencies, endocrine disorders, etc. Hypophosphatasia, due to pathogenic variants of the ALPL gene, which encodes tissue non-specific ALP, is the most common genetic cause of low serum ALP. Marked bone hypomineralization is frequent in severe pediatric-onset cases. However, adult forms of hypophosphatasia usually present with milder manifestations, such as skeletal pain, chondrocalcinosis, calcific periarthritis, dental problems, and stress fractures. The diagnostic approach to these patients is discussed. Measuring several ALP substrates, such as pyrophosphate, pyridoxal phosphate, or phosphoethanolamine, may help to establish enzyme deficiency. Gene analysis showing a pathogenic variant in ALPL may confirm the diagnosis. However, a substantial proportion of patients show normal results after sequencing ALPL exons. It is still unknown if those patients carry unidentified mutations in regulatory regions of ALPL, epigenetic changes, or abnormalities in other genes.
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Affiliation(s)
- Jose A Riancho
- Departamento de Medicina y Psiquiatría, Universidad de Cantabria, Servicio de Medicina Interna, Hospital UM Valdecilla-IDIVAL, Av Valdecilla sn, 39008, Santander, Spain.
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36
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Vasikaran SD, Miura M, Pikner R, Bhattoa HP, Cavalier E. Practical Considerations for the Clinical Application of Bone Turnover Markers in Osteoporosis. Calcif Tissue Int 2023; 112:148-157. [PMID: 34846540 DOI: 10.1007/s00223-021-00930-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/18/2021] [Indexed: 01/25/2023]
Abstract
Bone turnover markers (BTMs) are released during the bone remodelling cycle and are measurable in blood or urine, reflecting bone remodelling rate. They have been useful in elucidating the pharmacodynamics and effectiveness of osteoporosis medication in clinical trials and are increasingly used in routine clinical management of osteoporosis, especially for monitoring therapy, in addition to their use in other metabolic bone disease such as Paget's disease of bone and osteomalacia. Serum β isomerised C-terminal telopeptide of type I collagen and pro-collagen I N-terminal propeptide have been designated as reference BTMs for use in osteoporosis. In addition, bone-specific isoenzyme of alkaline phosphatase (B-ALP) secreted by osteoblasts and tartrate-resistant acid phosphatase 5b (TRACP-5b) secreted by osteoclasts are also found to be specific markers of bone formation and resorption, respectively. The concentrations of the latter enzymes in blood measured by immunoassay provide reliable measures of bone turnover even in the presence of renal failure. B-ALP is recommended for use in the assessment of renal bone disease of chronic kidney disease, and TRACP-5b shows promise as a marker of bone resorption in that condition. BTMs in blood do not suffer from biological variation to the same extent as the older BTMs that were measured in urine. Appropriate patient preparation and sample handling are important in obtaining accurate measures of BTMs for clinical use. Reference change values and treatment targets have been determined for the reference BTMs for their use in monitoring osteoporosis treatment. Further ongoing studies will enhance their clinical applications.
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Affiliation(s)
- Samuel D Vasikaran
- PathWest Laboratory Medicine, Fiona Stanley Hospital, Murdoch, WA, Australia.
| | - Masakazu Miura
- Faculty of Pharmaceutical Sciences, Hokuriku University/Hokuriku University Healthy Aging Research Group, 3 Ho Kanagawa-machi, Kanazawa City, Ishikawa, 9201181, Japan
| | - Richard Pikner
- Department of Clinical Biochemistry and Bone Metabolism, Klatovska Hospital, Klatovy, Czech Republic
- Department of Clinical Biochemistry and Haematology, Faculty of Medicine Pilsen, Charles University Prague, Pilsen, Czech Republic
- Faculty of Health Care Studies, University of West Bohemia, Pilsen, Czech Republic
| | - Harjit P Bhattoa
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège, CHU de Liège, Domaine du Sart-Tilman, 4000, Liège, Belgium
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37
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Gao J, Liu X, Wu X, Li X, Liu J, Li M. A brief review and clinical evidences of teriparatide therapy for atypical femoral fractures associated with long-term bisphosphonate treatment. Front Surg 2023; 9:1063170. [PMID: 36684309 PMCID: PMC9852062 DOI: 10.3389/fsurg.2022.1063170] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/07/2022] [Indexed: 01/07/2023] Open
Abstract
The risk of bisphosphonate (BP)-associated atypical femur fracture (AFF) has markedly increased over recent decades due to suppression of bone turnover, accumulation of structural micro-damage and reduction of bone remodeling consequent to long-term BP treatment. These medications further delay bone union and result in challenging clinical management. Teriparatide (TPTD), a synthetic human parathyroid hormone, exhibits unique anabolic effects and can increase bone remodeling and improve bone microarchitecture, further promoting fracture healing and reducing the rate of bone non-union. In this study, we briefly define AFF as well as the effects of BPs on AFFs, detailed the role of TPTD in AFF management and the latest clinical therapeutic findings. We have confirmed that TPTD positively promotes the healing of AFFs by reducing the time to bone union and likelihood of non-union. Thus, teriparatide therapy could be considered as an alternative treatment for AFFs, however, further research is required for the establishment of effective clinical guidelines of TPTD use in the management of AFF.
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Affiliation(s)
- Jianpeng Gao
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
| | - Xiao Liu
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
| | - Xiaoyong Wu
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China
| | - Xiaoya Li
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China
| | - Jianheng Liu
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China,Correspondence: Ming Li Jianheng Liu
| | - Ming Li
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China,Correspondence: Ming Li Jianheng Liu
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38
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Muacevic A, Adler JR, Bisbinas A, Markopoulos G, Bisbinas I. Simultaneous Bilateral Insufficiency Femoral Fractures After Long-Term Alendronate Treatment: A Lesson Not Yet Learned. Cureus 2023; 15:e33956. [PMID: 36814732 PMCID: PMC9939954 DOI: 10.7759/cureus.33956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 01/21/2023] Open
Abstract
Bisphosphonates have recently been used as a first-line treatment for osteoporosis. However, prolonged bisphosphonate use may be associated with insufficiency and atypical femoral fractures. In this case report, we present a patient with simultaneous bilateral insufficiency femoral fractures after using alendronate for 11 years, which were treated surgically. Our patient also had a history of a previous right femoral atypical fracture eight years before the latest ones, while on 3-year alendronate treatment. To our knowledge, it is the first patient reported with three atypical - insufficiency fractures covering all the anatomical areas of the proximal half of the femur after long-term bisphosphonate treatment.
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39
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Lo LWT, Koh JSB, Howe TS, Png MA, Lo NN. Incomplete Periprosthetic Atypical Femoral Fracture With Concomitant Hip and Knee Arthroplasties: A Case Report. JBJS Case Connect 2023; 13:01709767-202303000-00016. [PMID: 36706214 DOI: 10.2106/jbjs.cc.22.00211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 10/14/2022] [Indexed: 01/29/2023]
Abstract
CASE We present a case of an incomplete periprosthetic femoral fracture at the mid-distal third of the femoral stem after 11 months of bisphosphonate use. It is 1 of 4 cases of mid-distal periprosthetic atypical femoral fractures (PAFFs) found in our literature review. She was treated with protected weight-bearing, cessation of bisphosphonates, and teriparatide. Eighteen months after diagnosis, follow-up radiographs showed a bridging callus and reduction of a transverse fracture line. CONCLUSION The incomplete PAFF was contributed by both decreased bone turnover from bisphosphonate use and increased mechanical stress at the lateral femoral cortex. Her previous left bipolar hemiarthroplasty and subsequent Total Knee Arthroplasty shifted the mechanical alignment medially, hence increasing tensile stress.
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40
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Tsuchiya K, Okano I, Shiose K, Kudo Y, Hayakawa C, Kuroda T, Toyone T, Inagaki K. Atypical femoral fracture mimicking lumbar radiculopathy in two patients taking bisphosphonate long-term: A case report. BMC Musculoskelet Disord 2022; 23:1103. [PMID: 36528778 PMCID: PMC9758855 DOI: 10.1186/s12891-022-05990-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Atypical femoral fracture (AFF) is a rare complication in patients with osteoporosis undergoing long-term bisphosphonate therapy. The most common symptom of incomplete AFF is nonspecific thigh pain, which is often difficult to distinguish from other causes. CASE PRESENTATION We present two cases of AFF misdiagnosed as lumbar radiculopathy. Both patients visited our hospital for thigh pain, and in both cases the findings of lumbar spine magnetic resonance imaging showed substantial nerve compression. These patients had been treated for lumbar radiculopathy, but localized symptoms became conspicuous and femoral radiographs revealed complete AFF. The initial radiographs were reviewed retrospectively and revealed slight lateral cortical thickening in the affected femur, denoting a missed incomplete AFF. Internal fixation with intramedullary nails was performed. CONCLUSIONS AFF may mimic lumbar radiculopathy. Therefore, clinicians should consider AFF as a differential diagnosis in older patients with lumbar canal stenosis who are undergoing long-term bisphosphonate therapy and present with thigh pain.
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Affiliation(s)
- Koki Tsuchiya
- grid.410714.70000 0000 8864 3422Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666 Japan ,Department of Orthopaedic Surgery, Yamanashi Red Cross Hospital, 6663-1 Funatsu, Fujikawaguchiko, Yamanashi, 401-0301 Japan
| | - Ichiro Okano
- grid.410714.70000 0000 8864 3422Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666 Japan
| | - Katsuyuki Shiose
- grid.410714.70000 0000 8864 3422Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666 Japan
| | - Yoshifumi Kudo
- grid.410714.70000 0000 8864 3422Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666 Japan
| | - Chikara Hayakawa
- grid.410714.70000 0000 8864 3422Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666 Japan
| | - Takuma Kuroda
- grid.410714.70000 0000 8864 3422Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666 Japan
| | - Tomoaki Toyone
- grid.410714.70000 0000 8864 3422Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666 Japan
| | - Katsunori Inagaki
- grid.410714.70000 0000 8864 3422Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, 142-8666 Japan
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Lessons learned from long-term side effects after zoledronic acid infusion following denosumab treatment: a case report and review of the literature. J Med Case Rep 2022; 16:473. [PMID: 36522673 PMCID: PMC9754987 DOI: 10.1186/s13256-022-03695-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 11/26/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Zoledronic acid is an intravenous, highly potent aminobisphosphonate for use in patients with primary or secondary osteoporosis. Zoledronic acid-induced prolonged side-effects are well known and quite common. However, severe side-effects can be a threat to life. We report a case of severe side-effects induced by zoledronic acid infusion, and its positive effect on long-term back pain. CASE PRESENTATION In 2012, a 62-year-old white native Finnish woman was operated on for an estrogen and progesterone receptor-positive breast cancer. After radiotherapy, an aromatase inhibitor (letrozole) was started. Nine months after the operation, the patient suffered a low-energy compression fracture of Th XII. She received denosumab to prevent fragility fractures and to improve bone mineral density. Letrozole was discontinued after 5.5 years, and the last denosumab injection was given after 7 years. Six months later, at the age of 71 years, the patient received a single intravenous zoledronic acid infusion. Suddenly, at 10 hours from the infusion, she complained of severe trismus, muscle twitching, spasms, and tingling, matching hypocalcemia and several other symptoms. Her serum 25-hydroxyvitamin D concentration was high (163 nmol/L), the concentration of serum calcium and calcium-ion was normal (2.32 mmol/L and 1.23 mmol/L, respectively). However, the neutrophil to lymphocyte ratio (NLR) was low (1.6). A complete recovery took 2 months. Zoledronic acid infusion also had a positive effect: for many years, the patient had suffered low back pain and strain, which came to an end after this single infusion. CONCLUSION It is important that the potential patients receive sufficient information about the possibility of side-effects following the administration of intravenous zoledronic acid. To ensure that a zoledronic acid infusion is given as safely as possible, the safety information should include that the patient should not be left without monitoring for a minimum 24 hours after the infusion. Being alone and experiencing serious side-effects may lead to acute cardiac problems. Furthermore, the chronic low back pain and strain that our patient suffered for many years has clearly reduced for 16 months after infusion, so far. We conclude that this is a positive effect of zoledronic acid.
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Advancement in the Treatment of Osteoporosis and the Effects on Bone Healing. J Clin Med 2022; 11:jcm11247477. [PMID: 36556093 PMCID: PMC9781093 DOI: 10.3390/jcm11247477] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022] Open
Abstract
Osteoporosis (OP) is a major global health concern, with aging being one of the most important risk factors. Osteoarthritis (OA) is also an age-related disorder. Patients with OP and/or OA may be treated surgically for fractures or when their quality of life is impaired. Poor bone quality due to OP can seriously complicate the stability of a bone fixation construct and/or surgical fracture treatment. This review summarizes the current knowledge on the pathophysiology of normal and osteoporotic bone healing, the effect of a bone fracture on bone turnover markers, the diagnosis of a low bone mineral density (BMD) before surgical intervention, and the effect of available anti-osteoporosis treatment. Interventions that improve bone health may enhance the probability of favorable surgical outcomes. Fracture healing and the treatment of atypical femoral fractures are also discussed.
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Hadjiargyrou M. Effects of bisphosphonates on appendicular fracture repair in rodents. Bone 2022; 164:116542. [PMID: 36041726 DOI: 10.1016/j.bone.2022.116542] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/24/2022] [Accepted: 08/24/2022] [Indexed: 11/09/2022]
Abstract
The balance between osteoclastic bone resorption and osteoblastic bone formation is ultimately responsible for maintaining a structural and functional skeleton. Despite their strength, bones do break and the main cause of fractures are trauma and decreased bone mineral density as a result of aging and/or pathology that weakens the bone's microarchitecture and subsequently, its material properties. Osteoporosis is a disease marked by increased osteoclast activity and decreased osteoblastic activity tipping the remodeling balance in favor of bone resorption and can be caused by aging, glucocorticoids, disuse and estrogen-deficiency. Ultimately, this leads to brittle and weaker bones which become more prone to trauma or stress-induced fractures. The current treatment for preventing and treating osteoporotic fractures is the use of antiresorptive drugs such as bisphosphonates (BPs) and denosumab, but unfortunately, their long-term use, especially with alendronate and ibandronate, has been associated with increased risk of atypical femoral fractures (AFFs); femoral diaphyseal fractures distal to the lesser trochanter but proximal to the supracondylar flare. The purpose of this review is to examine the information that exists in the literature examining the effects of BPs on fracture repair of long bones in rodent (rat and mouse) models. The focus on rodents stems from the scientific community's unresolved need to develop small animal models to examine the molecular, cellular, tissue and biomechanical mechanisms responsible for the development of AFFs and how best they can be treated.
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Affiliation(s)
- Michael Hadjiargyrou
- Department of Biological & Chemical Sciences, New York Institute of Technology, Old Westbury, NY 11568, United States of America.
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Glyn-Jones S, Javaid MK, Beard D, Newton J, Kerslake R, McBryde C, Board T, Dutton SJ, Dritsaki M, Khanduja V, Akanni M, Sexton S, Skinner J, Peckham N, Knight R, Rombach I, Davies L, Barber V. Assessing a 12-month course of oral alendronate for adults with avascular necrosis of the hip: MANTIS RCT with internal pilot. Health Technol Assess 2022; 26:1-58. [DOI: 10.3310/avzv0799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background
People with avascular necrosis of the hip have very limited treatment options currently available to stop the progression of this disease; this often results in the need for a hip replacement. There is some weak evidence that a class of drugs called bisphosphonates may delay the course of the disease, and this trial was commissioned and set up to provide robust evidence regarding the use of bisphosphonates in adults aged ≥ 18 years with this condition.
Objectives
The aim of the Managing Avascular Necrosis Treatments: an Interventional Study (MANTIS) trial was to evaluate the clinical effectiveness and cost-effectiveness of a 12-month course of alendronate in the treatment of avascular necrosis.
Design
This was a 66-month, definitive, multisite, two-arm, parallel-group, placebo-controlled, double-blind, randomised controlled trial, with an internal pilot phase.
Setting
Eight secondary care NHS hospitals across the UK.
Participants
Planned trial size – 280 adult patients with avascular necrosis.
Intervention
Participants in the intervention group received 70 mg of alendronate (an oral bisphosphonate) weekly for 12 months.
Main outcomes
The main outcomes were Oxford Hip Score at 12 months (short-term outcome) and the time to decision that a hip replacement is required at 36 months (long-term outcome).
Results
Twenty-one patients were recruited and randomised to receive either the intervention drug, alendronate, or a placebo-matched tablet.
Limitations
This trial was principally limited by low disease prevalence. Other limitations included the late disease stage at which participants were identified and the rapid progression of the disease.
Future work
This trial was limited by a low recruitment rate. Avascular necrosis of the hip should be treated as a rare disease. Future trials would need to recruit many more sites and recruit over a longer time period, and, for this reason, a registry may provide a more effective means of collecting data pertaining to this disease.
Conclusions
The MANTIS trial was terminated at the end of the pilot phase, because it did not meet its go/no-go criteria. The main issue was a poor recruitment rate, owing to a lower than expected disease prevalence and difficulties in identifying the condition at a sufficiently early stage. Those patients who were identified and screened either were too advanced in their disease progression or were already taking medication. We would not recommend that a short-term interventional study is conducted on this condition until its prevalence, geographic foci and natural history and better understood. The difficulty of acquiring this understanding is likely to be a barrier in most health-care markets. One means of developing this understanding would be the introduction of a database/registry for patients suffering from avascular necrosis of the hip.
Trial registration
The trial is registered as ISRCTN14015902.
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 43. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Sion Glyn-Jones
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Muhammad K Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Surgical Intervention Trials Unit, University of Oxford, Oxford, UK
| | - Julia Newton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Robert Kerslake
- Trauma and Orthopaedic Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Callum McBryde
- Orthopaedic Department, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Tim Board
- Orthopaedic Hip Unit, Wrightington Hospital, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Susan J Dutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Melina Dritsaki
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Vikas Khanduja
- Trauma and Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Magbor Akanni
- Trauma and Orthopaedics, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | - Shaun Sexton
- Trauma & Orthopaedics, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - John Skinner
- Orthopaedic Department, Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK
| | - Nicholas Peckham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Ruth Knight
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Ines Rombach
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Loretta Davies
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Surgical Intervention Trials Unit, University of Oxford, Oxford, UK
| | - Vicki Barber
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
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The importance of reconstruction nailing for diaphyseal atypical femoral fractures: a comparative study with standard nailing. Arch Orthop Trauma Surg 2022; 142:2677-2683. [PMID: 34244873 DOI: 10.1007/s00402-021-04057-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Subtrochanteric atypical femoral fractures (AFFs) usually require long cephalomedullary or reconstruction nailing to achieve satisfactory healing. Recently, this type of nailing has also been recommended to fix diaphyseal AFFs and prevent fragility fractures around the proximal femur, although standard antegrade nailing seems sufficient from a biomechanical perspective. This study aimed to compare treatment outcomes and complications between reconstruction and standard nailing for diaphyseal AFFs. MATERIALS AND METHODS A retrospective comparative study of 48 female patients with diaphyseal AFFs who underwent surgical treatment with either reconstruction or standard nailing was conducted. The reconstruction nailing group comprised 23 patients with a mean age of 74.4 years and included 16 complete and 7 incomplete AFFs. The mean follow-up period was 30 months. The standard nailing group comprised 25 patients with a mean age of 71.1 years and included 16 complete and 9 incomplete AFFs. The mean follow-up period was 57.8 months. The healing rate, time to union, and complications were analyzed and compared between the two groups. RESULTS Bony union was achieved in all 23 cases (100%) of the reconstruction nailing group by a mean of 19.3 weeks postoperative. In the standard nailing group, 23 of 25 cases healed (92%) by a mean of 16 weeks postoperative. The standard nailing group included two delayed fragility fractures of the femoral neck (5 and 10 years after the initial surgery), four cases of newly developed subtrochanteric AFFs at the distal screw of the proximal interlocking screws of the nail (one complete and three incomplete fractures), and two cases of nonunion. Complications only occurred in the standard nailing group (p = 0.01, Fisher's exact test). CONCLUSIONS In diaphyseal AFFs, reconstruction nailing may achieve a satisfactory outcome and can also decrease delayed peri-implant fragility fractures of the hip, newly developed subtrochanteric AFFs, and nonunion.
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Mishra D, Mohanty T, Nanda SN, Gulia A, Konchada S, Samant S, Gachhayat A, Goyal D, Sandeep B, Mohanty SA. Functional and Radiological Outcome in Atypical Subtrochanteric Femur Fracture After Surgical Fixation: A Retrospective Observational Study. Cureus 2022; 14:e29201. [PMID: 36258929 PMCID: PMC9569151 DOI: 10.7759/cureus.29201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2022] [Indexed: 11/11/2022] Open
Abstract
Background: Treatment for osteoporosis can have catastrophic side effects, including the uncommon fracture known as an atypical femur fracture (AFF), which is related to the long-term usage of antiresorptive agents. Bisphosphonate therapy may lead to significant and chronic suppression of bone turnover, impairing the bone's remodelling property and finally leading to incomplete or complete atypical femur fracture. AFF was defined by the American Society for Bone and Mineral Research (ASBMR) Task Force in 2010 and is far less prevalent than proximal femur (hip) fracture, with an incidence of 2 to 78 per 100,000 patients per year following two to eight years of bisphosphonate therapy, respectively. Due to the rarity of the fracture, it is still not clear what the functional and radiological outcome will be after surgery. Aim: To identify the functional and radiological outcomes of surgical fixation of atypical femur fractures. Methods: The study was conducted in a tertiary healthcare centre after scientific and ethical clearance from the competent authority. Between January 2018 and December 2021, individuals who were diagnosed with an atypical subtrochanteric femoral fracture associated with the use of bisphosphonates and treated surgically were retrospectively evaluated. The study's inclusion and exclusion criteria were used to include 20 patients. The features of an atypical subtrochanteric fracture were congruent with the radiographic findings. Most of the patients were treated with internal fixation with intramedullary osteosynthesis in standard with or without plate osteosynthesis. They were then followed up for a year to look at the functional and radiological outcomes. Results: All of the 20 patients who were included had an atypical subtrochanteric fracture, with 15 of them being female and 5 of them being male. The patients' mean age at surgery was 65.12 (range 49 to 82) years, and their average history of bisphosphonate use was 3 (range 2.5 to 5) years. All patients were treated surgically. We found that five months was the mean period for bone union (p = 0.990). Within six months, bone union was achieved in 11 patients (55 %) (p = 0.884). Five patients (about 25%) had implant failure and non-union, requiring two to three revision surgeries. At three, six, and nine months, the mean visual analogue score (VAS) was 4.14, 3.12, and 1.85, respectively. The modified Hip Harris Score had a mean of 72.66 and 15 patients (about 75% of them) could walk normally again after a fracture. The mean of the modified HHS was 72.66, and the VAS at three, six, and nine months was 4.14, 3.12, and 1.85, respectively. Conclusion: AFFs are rare fractures that must be treated effectively, and most of them require surgery. Successful treatment of AFF is possible by the use of intramedullary fixation, which enhances axial stability, serves as an internal splint, and lessens the likelihood of implant failure. A good functional and radiological prognosis can come from a stable fixation and a fracture that has been reduced anatomically.
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Current use of bone turnover markers in the management of osteoporosis. Clin Biochem 2022; 109-110:1-10. [PMID: 36096182 DOI: 10.1016/j.clinbiochem.2022.09.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/21/2022]
Abstract
The adult bone is continuously being remodelled to repair microdamage, preserve bone strength and mechanical competence as well as maintain calcium homeostasis. Bone turnover markers are products of osteoblasts (bone formation markers) and osteoclasts (bone resorption markers) providing a dynamic assessment of remodelling (turnover). Resorption-specific bone turnover markers are typically degradation products of bone collagen molecules (N- [NTX] and C-telopeptide cross-linked type 1 collagen [CTX]), which are released into the circulation and excreted in urine; or enzymatic activities reflecting osteoclastic resorption, tartrate-resistant acid phosphatase [TRACP]. Formation-specific bone turnover markers embrace different osteoblastic activities: type 1 collagen synthesis (Procollagen type I N- propeptide [PINP]), osteoblast enzymes (bone-specific alkaline phosphatase [BALP]), or bone matrix proteins [osteocalcin]. Among individuals not receiving osteoporosis treatment, resorption and formation markers are tightly linked and highly correlated (r= 0.6-0.8). Significant biological variability was reported in the past, but these issues have been greatly improved with automated assays and attention to pre-analytical and analytical factors that are known to influence bone turnover marker levels. Bone turnover markers are not useful in the diagnosis of osteoporosis, the individual prediction of bone loss, fracture, or rare complications, or in the selection of pharmacological treatment. Despite remaining issues with reference intervals and assays harmonization, bone turnover markers have proven to be useful in elucidating the pharmacodynamics and effectiveness of osteoporosis medications in clinical trials. As an alternative to BMD testing, BTMs may be useful to monitor osteoporosis therapies.
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Everts‐Graber J, Bonel H, Lehmann D, Gahl B, Häuselmann H, Studer U, Ziswiler H, Reichenbach S, Lehmann T. Incidence of Atypical Femoral Fractures in Patients on Osteoporosis Therapy – a Registry‐based Cohort Study. JBMR Plus 2022; 6:e10681. [PMID: 36248270 PMCID: PMC9549725 DOI: 10.1002/jbm4.10681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/01/2022] [Indexed: 11/17/2022] Open
Abstract
Atypical femoral fractures (AFFs) have been reported in patients taking bisphosphonates (BPs) for osteoporosis therapy but also in patients with no exposure to these drugs. In contrast, less is known about the incidence of AFFs in patients taking denosumab. This registry‐based cohort study analyzed the incidence of AFFs in patients with suspected or confirmed osteoporosis who were included in the osteoporosis register of the Swiss Society of Rheumatology between January 2015 and September 2019. Statistical analyses included incidence rates, rate ratios, and hazard ratios for AFFs, and considered sequential therapies and drug holidays as time‐dependent covariates. Among the 9956 subjects in the cohort, 53 had subtrochanteric or femoral shaft fractures. Ten fractures occurred under BP or denosumab treatment and two under teriparatide therapy. Five fractures were classified as AFFs based on the revised American Society of Bone and Mineral Research case definition of AFFs from 2014. Three AFFs occurred in women being treated with denosumab at the time of diagnosis, all with prior BP use (10, 7, and 1 years, respectively). One AFF developed in a woman receiving ibandronate and one arose in a woman receiving glucocorticoids rather than antiresorptive therapy. The incidence of AFFs per 10,000 observed patient‐years was 7.1 in patients receiving denosumab and 0.9 in patients with BP‐associated AFFs, yielding a rate ratio of 7.9 (95% confidence interval [CI] 0.63–413), p = 0.073. The risk of AFFs was not significantly higher in patients receiving denosumab therapy compared with BP therapy (hazard ratio = 7.07, 95% CI 0.74–68.01, p = 0.090). We conclude that the risk of AFFs is low in patients taking BPs, denosumab, or both sequentially. All three patients with AFFs under denosumab therapy had undergone prior BP therapy. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Judith Everts‐Graber
- OsteoRheuma Bern, Bahnhofplatz 1 Bern Switzerland
- Department of Rheumatology and Immunology, Inselspital, Bern University Hospital University of Bern Switzerland
| | - Harald Bonel
- Campus Stiftung Lindenhof Bern Swiss Institute for Translational and Entrepreneurial Medicine Bern Switzerland
- Department of Radiology Lindenhof Hospital Bern Switzerland
- Department of Radiology, Inselspital University of Bern Switzerland
| | | | | | - HansJörg Häuselmann
- Zentrum für Rheuma‐ und Knochenerkrankungen, Klinik Im Park, Hirslanden Zürich Switzerland
| | - Ueli Studer
- OsteoRheuma Bern, Bahnhofplatz 1 Bern Switzerland
| | | | - Stephan Reichenbach
- Department of Rheumatology and Immunology, Inselspital, Bern University Hospital University of Bern Switzerland
- Institute for Social and Preventive Medicine University of Bern Switzerland
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KIM SH, RAMANI PS, JAHAGIRDAR VR, ROITBERG B, ZILELI M. Endocrine assessment, chemotherapy, nonsurgical treatment, and rehabilitation for osteoporotic spine fractures: WFNS spine committee recommendations. J Neurosurg Sci 2022; 66:300-310. [DOI: 10.23736/s0390-5616.22.05641-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Lee JM, Park CH, Yoo JI, Kim JT, Cha Y. Atypical periprosthetic femoral fracture with stem breakage: a case report. Osteoporos Int 2022; 33:2043-2047. [PMID: 35688896 DOI: 10.1007/s00198-022-06463-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/01/2022] [Indexed: 11/27/2022]
Abstract
Although the American Society for Bone and Mineral Research definition of atypical femoral fracture excludes periprosthetic fractures, fractures around the prosthesis with clinical features of atypical femoral fractures have been reported in the literature. All fractures reported thus far have been distal to the prosthetic segment; however, we encountered a case of a stress fracture in the middle of the femoral component segment. An 86-year-old woman with a history of bisphosphonate osteoporosis treatment and revisional total hip arthroplasty visited our outpatient clinic complaining of pain in the left thigh and groin. We diagnosed an incomplete atypical femoral fracture around the hip prosthesis; medical treatment was implemented. Two months later, the patient visited the emergency department with a complete subtrochanteric fracture with stem breakage. Without revision of the broken stem, two plates were applied after reduction. In this case, we recognized the possibility of a stress fracture but overlooked the possibility of stem breakage in an atypical femoral fracture. Even if it is not evident on the radiograph before complete fracture, clinicians should be alert to the signs of stress fracture in the middle of the femoral component segment, as they may be clues to atypical periprosthetic femoral fracture with stem failure. Isolated medical treatment plans are not recommended for incomplete subtrochanteric atypical periprosthetic femoral fracture. Instead, concomitant prophylactic plate fixation is recommended.
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Affiliation(s)
- J M Lee
- Department of Orthopedic Surgery, Ajou University School of Medicine, Ajou Medical Center, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, South Korea
| | - C H Park
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Daegu, South Korea
| | - J-I Yoo
- Department of Orthopedics, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - J-T Kim
- Department of Orthopedic Surgery, Ajou University School of Medicine, Ajou Medical Center, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, South Korea.
| | - Y Cha
- Department of Orthopedic Surgery, Daejeon Eulji Medical Center, Eulji University School of Medicine, 95 Dunsan-Seoro, Seo-gu, Daejeon, 302-799, South Korea.
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