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Slart RHJA, Punda M, Ali DS, Bazzocchi A, Bock O, Camacho P, Carey JJ, Colquhoun A, Compston J, Engelke K, Erba PA, Harvey NC, Krueger D, Lems WF, Lewiecki EM, Morgan S, Moseley KF, O'Brien C, Probyn L, Rhee Y, Richmond B, Schousboe JT, Shuhart C, Ward KA, Van den Wyngaert T, Zhang-Yin J, Khan AA. Updated practice guideline for dual-energy X-ray absorptiometry (DXA). Eur J Nucl Med Mol Imaging 2024:10.1007/s00259-024-06912-6. [PMID: 39316095 DOI: 10.1007/s00259-024-06912-6] [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: 07/02/2024] [Accepted: 08/28/2024] [Indexed: 09/25/2024]
Abstract
The introduction of dual-energy X-ray absorptiometry (DXA) technology in the 1980s revolutionized the diagnosis, management and monitoring of osteoporosis, providing a clinical tool which is now available worldwide. However, DXA measurements are influenced by many technical factors, including the quality control procedures for the instrument, positioning of the patient, and approach to analysis. Reporting of DXA results may be confounded by factors such as selection of reference ranges for T-scores and Z-scores, as well as inadequate knowledge of current standards for interpretation. These points are addressed at length in many international guidelines but are not always easily assimilated by practising clinicians and technicians. Our aim in this report is to identify key elements pertaining to the use of DXA in clinical practice, considering both technical and clinical aspects. Here, we discuss technical aspects of DXA procedures, approaches to interpretation and integration into clinical practice, and the use of non-bone mineral density measurements, such as a vertebral fracture assessment, in clinical risk assessment.
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Affiliation(s)
- Riemer H J A Slart
- Medical Imaging Centre, Department of Nuclear Medicine & Molecular Imaging (EB50), University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO 9700 RB, Groningen, The Netherlands.
| | - Marija Punda
- Department of Oncology and Nuclear Medicine, University Hospital Centre Sestre Milosrdnice, Vinogradska 29, Zagreb, Croatia
| | - Dalal S Ali
- Department of Endocrinology, McMaster University, Hamilton, L8S 4L8, Canada
| | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G. C. Pupilli 1, Bologna, 40136, Italy
| | - Oliver Bock
- Department of Osteoporosis, Inselspital, Bern University Hospital, Switzerland, IG Osteoporose, Bern, Switzerland
| | - Pauline Camacho
- Loyola University Medical Center (LUMC), 2160 S 1st Ave, Maywood, IL, 60153, USA
| | | | - Anita Colquhoun
- Centre for Osteoporosis & Bone Health, Women's College Hospital, Toronto, ON, Canada
| | | | - Klaus Engelke
- Department of Medicine, Institute of Medical Physics, FAU University Erlangen-Nürnberg and Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Paola A Erba
- Department of Medicine and Surgery, Nuclear Medicine Unit, ASST Ospedale Papa Giovanni, University of Milan-Bicocca, Piazza, Bergamo, Italy
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton General Hospital, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital NHS Foundation Trust, Southampton, UK
| | - Diane Krueger
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Willem F Lems
- Department of Rheumatology, Amsterdam University Medical, Center, The Netherlands
| | - E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, 87106, USA
| | - Sarah Morgan
- The UAB Osteoporosis Prevention and Treatment Clinic, The University of Alabama at Birmingham, Birmingham, Al, USA
| | - Kendall F Moseley
- Division of Endocrinology, Johns Hopkins University, Baltimore, MD, 21201, USA
| | | | - Linda Probyn
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Toronto, ON, M4N 3M5, Canada
| | - Yumie Rhee
- Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Bradford Richmond
- Diagnostic Radiology, Cleveland Clinic Main Campus, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - John T Schousboe
- Park Nicollet Clinic and HealthPartners Institute, Minneapolis, MN, USA
| | - Christopher Shuhart
- Swedish Bone Health and Osteoporosis Center, 1600 E Jefferson St Ste 300, Seattle, WA, 98122, USA
| | - Kate A Ward
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton General Hospital, Southampton, UK
| | | | - Jules Zhang-Yin
- Department of Nuclear Medicine, Clinique Sud Luxembourg, Vivalia, B-6700, Arlon, Belgium
| | - Aliya A Khan
- Department of Endocrinology, McMaster University, Hamilton, L8S 4L8, Canada
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Sato H, Kondo N, Kurosawa Y, Hasegawa E, Wakamatsu A, Nozawa Y, Kobayashi D, Nakatsue T, Wada Y, Kazama JJ, Kuroda T, Nakano M, Endo N, Narita I. Incidence and clinical course of femoral localized periosteal thickening and atypical femoral fracture over a 10-year period in patients with autoimmune inflammatory rheumatic disease. JBMR Plus 2024; 8:ziae090. [PMID: 39119540 PMCID: PMC11307327 DOI: 10.1093/jbmrpl/ziae090] [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: 04/10/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 08/10/2024] Open
Abstract
Atypical femoral fracture (AFF) is generally a rare complication of long-term use of bisphosphonate (BP); glucocorticoid (GC) use and Asian race are also risk factors. Femoral localized periosteal thickening (LPT, also termed "beaking") of the lateral cortex often precedes AFF. This cohort study investigated the incidence of LPT and AFF and their clinical courses over 10 yr in patients with autoimmune inflammatory rheumatic diseases (AIRDs) treated with BP and GC. The study population consisted of 121 patients with AIRDs taking BP and GC. LPT was screened by X-ray, and the LPT shape was evaluated. Prednisolone (PSL) dose was 10 (8-12) mg/d at enrollment and 9 (6-10) mg/d at the last observation. LPT was evident in 10 patients at enrollment and increased linearly to 31 patients (26%) at the last observation. AFF occurred in 9 femurs of 5 patients with LPT. All patients with AFF had bilateral LPT, and the prevalence of pointed type and LPT height were higher in the AFF-positive group than in the AFF-negative group. AFF occurred before BP discontinuation in 2 patients, 1 yr after BP discontinuation in 1, after BP discontinuation followed by 7 yr of alfacalcidol use in 1, and after switching from alfacalcidol to denosumab in 1. The prevalence rates of AFF and LPT associated with long-term BP use with concomitant use of GC (mostly PSL ≥ 6 mg/d) in Japanese patients with AIRD increased over time. The selection of long-term osteoporosis treatment for LPT-positive patients is difficult in some cases.
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Affiliation(s)
- Hiroe Sato
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City 951-8510, Niigata, Japan
- Health Administration Center, Niigata University, 2-8050 Ikarashi, Nishi-ku, Niigata City 950-2181, Niigata, Japan
| | - Naoki Kondo
- Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City 951-8510, Niigata, Japan
| | - Yoichi Kurosawa
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City 951-8510, Niigata, Japan
| | - Eriko Hasegawa
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City 951-8510, Niigata, Japan
| | - Ayako Wakamatsu
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City 951-8510, Niigata, Japan
| | - Yukiko Nozawa
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City 951-8510, Niigata, Japan
- Health Administration Center, Niigata University, 2-8050 Ikarashi, Nishi-ku, Niigata City 950-2181, Niigata, Japan
| | - Daisuke Kobayashi
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City 951-8510, Niigata, Japan
| | - Takeshi Nakatsue
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City 951-8510, Niigata, Japan
| | - Yoko Wada
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City 951-8510, Niigata, Japan
| | - Junichiro James Kazama
- Department of Nephrology and Hypertension, Fukushima Medical University, 1 Hikariga-oka, Fukushima City 960-1295, Fukushima, Japan
| | - Takeshi Kuroda
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City 951-8510, Niigata, Japan
- Health Administration Center, Niigata University, 2-8050 Ikarashi, Nishi-ku, Niigata City 950-2181, Niigata, Japan
| | - Masaaki Nakano
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City 951-8510, Niigata, Japan
| | - Naoto Endo
- Division of Orthopedic Surgery, Tsubame Rosai Hospital, 633, Sawatari, Tsubame City 959-1228, Niigata, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City 951-8510, Niigata, Japan
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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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Lau A, Prout T, Malabanan A, Szalat A, Krueger D, Tanner SB, Rosen H, Shuhart C. Reporting of Full-Length Femur Imaging to Detect Incomplete Atypical Femur Fractures: 2023 Official Positions of the International Society for Clinical Densitometry. J Clin Densitom 2024; 27:101439. [PMID: 38000921 DOI: 10.1016/j.jocd.2023.101439] [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] [Indexed: 11/26/2023]
Abstract
Incomplete atypical femur fractures (iAFFs) are associated with the long-term use of anti-resorptive therapies. Although X-rays are typically used to screen for iAFFs, images from dual-energy X-ray absorptiometry (DXA) offer an alternate method for detecting iAFFs. Although a previous 2019 ISCD Official Position on this subject exists, our task force aimed to update the literature review and to propose recommendations on reporting findings related to iAFFs that may be observed on DXA images. The task force recommended that full-length femur imaging (FFI) from DXA can be used as a screening tool for iAFFs. The presence of focal lateral cortical thickening and transverse lucencies should be reported, if identified on the FFI. This task force proposed a classification system to determine the likelihood of an iAFF, based on radiographic features seen on the FFI. Lastly, the task force recommended that the clinical assessment of prodromal symptoms (pain) is not required for the assessment of FFI.
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Affiliation(s)
- Adrian Lau
- Division of Endocrinology and Metabolism, Department of Medicine, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Tyler Prout
- Radiology Department, University of Wisconsin, Madison, WI, United States
| | - Alan Malabanan
- Bone Health Clinic, Boston Medical Center, Boston, MA, United States
| | - Auryan Szalat
- Osteoporosis Center, Internal Medicine Ward, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Diane Krueger
- School of Medicine and Public Health, Osteoporosis Clinical Research Program, University of Wisconsin-Madison, Madison, WI, United States
| | - S Bobo Tanner
- Department of Medicine, Divisions of Rheumatology, Allergy & Immunology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Harold Rosen
- Osteoporosis Prevention and Treatment Center, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Christopher Shuhart
- Bone Health and Osteoporosis Center, Swedish Medical Group, Seattle, WA, United States
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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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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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AAOS Clinical Practice Guideline Summary: Treatment of Metastatic Carcinoma and Myeloma of the Femur. J Am Acad Orthop Surg 2023; 31:e118-e129. [PMID: 36656274 DOI: 10.5435/jaaos-d-21-00888] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 10/28/2022] [Indexed: 01/20/2023] Open
Abstract
The Musculoskeletal Tumor Society, in partnership with American Society of Clinical Oncology and American Society for Radiation Oncology, has developed a clinical practice guideline to assist providers with the care of patients with metastatic carcinoma and myeloma of the femur. The guideline was developed by an Expert Panel consisting of representatives of all three organizations by American Academy of Orthopaedic Surgeons (AAOS) methodologists using the AAOS standardized guideline development process. A systematic review of the available evidence was conducted, and the identified evidence was rated was rated for quality and potential for bias. Recommendations were developed based on this evidence in a standardized fashion. The guideline was approved by the guideline approval bodies of all three organizations. Thirteen recommendations were synthesized covering relevant subtopics such as imaging, use of bone-modifying agents, radiation therapy, and surgical reconstruction. The consensus of the expert panel was that bone-modifying agents may assist in reducing the incidence of femur fracture, regardless of tumor histology. The panel recommended the use of radiation therapy to decrease the rate of femur fractures for patients considered at increased risk. The panel recommended arthroplasty be considered to improve patient function and decrease the need of postoperative radiation therapy in patients with pathologic fractures in the femur.
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Recommendations on the post-acute management of the osteoporotic fracture - Patients with "very-high" Re-fracture risk. J Orthop Translat 2022; 37:94-99. [PMID: 36262963 PMCID: PMC9562437 DOI: 10.1016/j.jot.2022.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/28/2022] [Accepted: 09/20/2022] [Indexed: 11/20/2022] Open
Abstract
Osteoporosis is a systemic skeletal disease where there is low bone mass and deterioration of bone microarchitecture, leading to an increased risk of a fragility fracture. The aim of this clinical guideline from Fragility Fracture Network Hong Kong SAR, is to provide evidence-based recommendations on the post-acute treatment of the osteoporotic fracture patient that presents for clinical care at the Fracture Liaison Service (FLS). It is now well established that the incidence of a second fracture is especially high after the first 2 years of the initial osteoporotic fracture. Therefore, the recent osteoporotic fracture should be categorized as “very-high” re-fracture risk. Due to the significant number of silent vertebral fractures in the elderly population, it is also recommended that vertebral fracture assessment (VFA) should be incorporated into FLS. This would have diagnostic and treatment implications for the osteoporotic fracture patient. The use of a potent anti-osteoporotic agent, and preferably an anabolic followed by an anti-resorptive agent should be considered, as larger improvements in BMD is strongly associated with a reduction in fractures. Managing other risk factors including falls and sarcopenia are imperative during rehabilitation and prevention of another fracture. Although of low incidence, one should remain vigilant of the atypical femoral fracture. The aging population is increasing worldwide, and it is expected that the treatment of osteoporotic fractures will be routine. The recommendations are anticipated to aid in the daily clinical practice for clinicians. The Translational potential of this article Fragility fractures have become a common encounter in clinical practise in the hospital setting. This article provides recommendations on the post-acute management of fragility fracture patients at the FLS.
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Sato H, Kondo N, Takai C, Kurosawa Y, Hasegawa E, Wakamatsu A, Kobayashi D, Nakatsue T, Abe A, Kazama JJ, Kuroda T, Ito S, Ishikawa H, Endo N, Narita I. The Risks of Femoral Localized Periosteal Thickening in Patients with Autoimmune Inflammatory Rheumatic Diseases. Mod Rheumatol 2022:6610711. [PMID: 35715985 DOI: 10.1093/mr/roac062] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/08/2022] [Accepted: 06/14/2022] [Indexed: 11/12/2022]
Abstract
PURPOSE The incidence of femoral localized periosteal thickening (LPT), which can precede atypical femoral fracture (AFF), is not low (1-10%) in Japanese patients with autoimmune inflammatory rheumatic diseases (AIRDs). We explored the associations between underlying AIRDs and the prevalence of LPT. METHODS We conducted post-hoc analyses of two cohorts that included a total of 280 Japanese women, 105 of whom had AIRDs and had been taking bisphosphonate (BP) and prednisolone (PSL), and 175 of whom had rheumatoid arthritis (RA). RESULTS LPT was detected in a total of 18 patients (6.4%) and three (1.1%) developed AFFs. RA was negatively correlated with LPT. A disease other than RA requiring glucocorticoid treatment, BP use ≥ 5 years, PSL use ≥ 7 years, and a PSL dose ≥ 5.5 mg/day were positively correlated with LPT. After adjusting for age, diabetes mellitus, and BP duration or daily PSL dose, RA was no longer associated with LPT. CONCLUSION LPT in Japanese patients with AIRDs was associated with BP and glucocorticoid treatment rather than underlying AIRDs. When a PSL dose ≥ 5.5 mg/day is required long-term (typically combined with long-term BP treatment [≥ 5 years]), clinicians need to pay particular attention in case LPT and AFF, as well as glucocorticoid-induced osteoporosis.
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Affiliation(s)
- Hiroe Sato
- Health Administration Center, Niigata University, Niigata, JAPAN.,Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, JAPAN.,Department of Rheumatology, Niigata Rheumatic Center, Shibata, Niigata, JAPAN
| | - Naoki Kondo
- Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, JAPAN
| | - Chinatsu Takai
- Department of Rheumatology, Niigata Rheumatic Center, Shibata, Niigata, JAPAN
| | - Yoichi Kurosawa
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, JAPAN
| | - Eriko Hasegawa
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, JAPAN
| | - Ayako Wakamatsu
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, JAPAN
| | - Daisuke Kobayashi
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, JAPAN
| | - Takeshi Nakatsue
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, JAPAN
| | - Asami Abe
- Department of Rheumatology, Niigata Rheumatic Center, Shibata, Niigata, JAPAN
| | - Junichiro James Kazama
- Department of Nephrology and Hypertension, Fukushima Medical University, Fukushima, JAPAN
| | - Takeshi Kuroda
- Health Administration Center, Niigata University, Niigata, JAPAN
| | - Satoshi Ito
- Department of Rheumatology, Niigata Rheumatic Center, Shibata, Niigata, JAPAN
| | - Hajime Ishikawa
- Department of Rheumatology, Niigata Rheumatic Center, Shibata, Niigata, JAPAN
| | - Naoto Endo
- Division of Orthopedic Surgery, Tsubame Rosai Hospital, Tsubame, Niigata, JAPAN
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, JAPAN
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Laurent MR, Goemaere S, Verroken C, Bergmann P, Body JJ, Bruyère O, Cavalier E, Rozenberg S, Lapauw B, Gielen E. Prevention and Treatment of Glucocorticoid-Induced Osteoporosis in Adults: Consensus Recommendations From the Belgian Bone Club. Front Endocrinol (Lausanne) 2022; 13:908727. [PMID: 35757436 PMCID: PMC9219603 DOI: 10.3389/fendo.2022.908727] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/02/2022] [Indexed: 01/13/2023] Open
Abstract
Glucocorticoids are effective immunomodulatory drugs used for many inflammatory disorders as well as in transplant recipients. However, both iatrogenic and endogenous glucocorticoid excess are also associated with several side effects including an increased risk of osteoporosis and fractures. Glucocorticoid-induced osteoporosis (GIOP) is a common secondary cause of osteoporosis in adults. Despite availability of clear evidence and international guidelines for the prevention of GIOP, a large treatment gap remains. In this narrative review, the Belgian Bone Club (BBC) updates its 2006 consensus recommendations for the prevention and treatment of GIOP in adults. The pathophysiology of GIOP is multifactorial. The BBC strongly advises non-pharmacological measures including physical exercise, smoking cessation and avoidance of alcohol abuse in all adults at risk for osteoporosis. Glucocorticoids are associated with impaired intestinal calcium absorption; the BBC therefore strongly recommend sufficient calcium intake and avoidance of vitamin D deficiency. We recommend assessment of fracture risk, taking age, sex, menopausal status, prior fractures, glucocorticoid dose, other clinical risk factors and bone mineral density into account. Placebo-controlled randomized controlled trials have demonstrated the efficacy of alendronate, risedronate, zoledronate, denosumab and teriparatide in GIOP. We suggest monitoring by dual-energy X-ray absorptiometry (DXA) and vertebral fracture identification one year after glucocorticoid initiation. The trabecular bone score might be considered during DXA monitoring. Extended femur scans might be considered at the time of DXA imaging in glucocorticoid users on long-term (≥ 3 years) antiresorptive therapy. Bone turnover markers may be considered for monitoring treatment with anti-resorptive or osteoanabolic drugs in GIOP. Although the pathophysiology of solid organ and hematopoietic stem cell transplantation-induced osteoporosis extends beyond GIOP alone, the BBC recommends similar evaluation, prevention, treatment and follow-up principles in these patients. Efforts to close the treatment gap in GIOP and implement available effective fracture prevention strategies into clinical practice in primary, secondary and tertiary care are urgently needed.
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Affiliation(s)
- Michaël R. Laurent
- Centre for Metabolic Bone Diseases, Department of Geriatrics, University Hospitals Leuven, Leuven, Belgium
- Department of Geriatrics, Imelda Hospital, Bonheiden, Belgium
| | - Stefan Goemaere
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - Charlotte Verroken
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
- Department of Endocrinology and Metabolism, Ghent University Hospital, Ghent, Belgium
| | - Pierre Bergmann
- Department of Nuclear Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Olivier Bruyère
- WHO Collaborating Center for Public Health Aspects of Musculoskeletal Health and Ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège, CHU de Liège, Liège, Belgium
| | - Serge Rozenberg
- Department of Gynaecology and Obstetrics, Université Libre de Bruxelles, Brussels, Belgium
| | - Bruno Lapauw
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
- Department of Endocrinology and Metabolism, Ghent University Hospital, Ghent, Belgium
| | - Evelien Gielen
- Centre for Metabolic Bone Diseases, Department of Geriatrics, University Hospitals Leuven, Leuven, Belgium
- Gerontology and Geriatrics section, Department of Public Health and Primary Care, University Hospitals Leuven and KU Leuven, Leuven, Belgium
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11
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Cha SM, Shin HD, Ahn BK. Revision osteosynthesis after primary treatment of atypical ulnar fractures associated with bisphosphonate usage - Nonunion after ordinary open reduction and internal fixation. Arch Orthop Trauma Surg 2021; 141:1855-1862. [PMID: 32797295 DOI: 10.1007/s00402-020-03567-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 08/02/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND We performed revision surgeries to treat nonunion of bisphosphonate-associated ulnar fractures that had originally been treated, after misdiagnosis, using the typical open reduction/internal fixation (ORIF). METHODS Of nine cases of ulnar nonunion initially treated at other institutions, we performed revision surgeries on four that met our inclusion/exclusion criteria. All previous implants were removed; the areas of nonunion were resected, and strut bone grafts were inserted and fixed with locking plates. Radiological assessments were performed monthly for 3 months after surgery and then every 3 months for 1 year. RESULTS All patients were female, with a mean age of 71.8 years. All patients had been taking bisphosphonate for a mean of 7.2 years. The primary fixation methods used at other institutions were intra-medullary nailing (n = 1) and placement of 3.5-mm locking plates (n = 3). In one patient (patient 1), the contralateral (right) ulna developed a new fracture at 1 month after revision surgery on the left ulna. Another patient (patient 3) exhibited an incomplete fracture in the contralateral (right) ulna. All four patients exhibited hip fractures (bilateral in three). All revisions resulted in final union at a mean of 4.8 months postoperatively. CONCLUSION Atypical ulnar fractures should be suspected in elderly women on long-term bisphosphonate treatment. Union will fail with standard ORIF for atypical ulnar fractures, because the fracture occurred due to compromised normal bone metabolism as reflected in the bone resorption, remodeling, and healing processes. Revision osteosynthesis using a locking plate with callus resection and strut/cancellous bone graft provided satisfactory results. LEVEL OF EVIDENCE Therapeutic level IV.
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Affiliation(s)
- Soo Min Cha
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, 266 Munwha-ro, Jung-Gu, Daejeon, Korea
| | - Hyun Dae Shin
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, 266 Munwha-ro, Jung-Gu, Daejeon, Korea.
| | - Byung Kuk Ahn
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, 266 Munwha-ro, Jung-Gu, Daejeon, Korea
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12
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The Treatment Gap in Osteoporosis. J Clin Med 2021; 10:jcm10133002. [PMID: 34279485 PMCID: PMC8268346 DOI: 10.3390/jcm10133002] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/28/2021] [Accepted: 07/02/2021] [Indexed: 11/17/2022] Open
Abstract
Worldwide, there are millions of people who have been diagnosed with osteoporosis, a bone disease that increases the risk of fracture due to low bone mineral density and deterioration of bone architecture. In the US alone, there are approximately ten million men and women diagnosed with osteoporosis and this number is still growing. Diagnosis is made by measuring bone mineral density. Medications used for the treatment of osteoporosis are bisphosphonates, denosumab, raloxifene, and teriparatide. Recently, romosozumab has been added as well. In recent years, a number of advances have been made in the field of diagnostic methods and the diverse treatment options for osteoporosis. Despite these advances and a growing incidence of osteoporosis, there is a large group being left undertreated or even untreated. This group of the under/untreated has been called the treatment gap. Concerns regarding rare side effects of the medications, such as osteonecrosis of the jaw, have been reported to be one of the many causes for the treatment gap. Also, this group seems not to be sufficiently informed of the major benefits of the treatment and the diversity in treatment options. Knowledge of these could be very helpful in improving compliance and hopefully reducing the gap. In this paper, we summarize recent evidence regarding the efficacy of the various treatment options, potential side effects, and the overall benefit of treatment.
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13
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Sawicki P, Tałałaj M, Życińska K, Zgliczyński WS, Wierzba W. Current Applications and Selected Technical Details of Dual-Energy X-Ray Absorptiometry. Med Sci Monit 2021; 27:e930839. [PMID: 34131097 PMCID: PMC8216008 DOI: 10.12659/msm.930839] [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] [Indexed: 11/09/2022] Open
Abstract
The application of dual-energy X-ray absorptiometry (DXA) examinations in the assessment of bone mineral density (BMD) in the lumbar spine, hip, and forearm is the basic diagnostic method for recognition of osteoporosis. The constant development of DXA technique is due to the aging of societies and the increasing importance of osteoporosis as a public health problem. In order to assess the degree of bone demineralization in patients with hyperparathyroidism, forearm DXA examination is recommended. The vertebral fracture assessment (VFA) of the thoracic and lumbar spine, performed by a highly-skilled technician, is an interesting alternative to the X-ray examination. The DXA total body examination can be useful in the evaluation of fat redistribution among patients after bariatric surgery, in patients infected with HIV and receiving antiretroviral therapy, and in patients with metabolic diseases and suspected to have sarcopenia. The assessment of visceral adipose tissue (VAT) and detection of abdominal aortic calcifications may be useful in the prediction of cardiovascular events. The positive effect of anti-resorptive therapy may affect some parameters of DXA hip structure analysis (HSA). Long-term anti-resorptive therapy, especially with the use of bisphosphonates, may result in changes in the DXA image, which may herald atypical femur fractures (AFF). Reduction of the periprosthetic BMD in the DXA measurements can be used to estimate the likelihood of loosening the prosthesis and periprosthetic fractures. The present review aims to present current applications and selected technical details of DXA.
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Affiliation(s)
- Piotr Sawicki
- Department of Rheumatology, Systemic Connective Tissue Diseases and Rare Diseases, Central Clinical Hospital MSWiA in Warsaw, Warsaw, Poland
| | - Marek Tałałaj
- Department of Geriatrics, Internal Medicine and Metabolic Bone Diseases, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Katarzyna Życińska
- Department of Rheumatology, Systemic Connective Tissue Diseases and Rare Diseases, Central Clinical Hospital MSWiA in Warsaw, Warsaw, Poland.,Department of Family Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | - Waldemar Wierzba
- Central Clinical Hospital MSWiA in Warsaw, Warsaw, Poland.,UHE Satellite Campus in Warsaw, University of Humanities and Economics in Łódź, Warsaw, Poland
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14
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Meier ME, van der Bruggen W, van de Sande MA, Appelman-Dijkstra NM. Regression of fibrous dysplasia in response to denosumab therapy: A report of two cases. Bone Rep 2021; 14:101058. [PMID: 33912627 PMCID: PMC8066421 DOI: 10.1016/j.bonr.2021.101058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/22/2021] [Accepted: 03/23/2021] [Indexed: 12/13/2022] Open
Abstract
We present two patients with fibrous dysplasia who showed a decrease in lesional size and activity after denosumab therapy. Both patients also experienced a reduction in pain and bone turnover markers, which had not been accomplished during previous bisphosphonate therapy. These cases highlight the potential of denosumab to decrease lesional size in fibrous dysplasia. This finding has been reported in mice, but not in humans. Denosumab may be considered when bisphosphonates are not tolerated or not effective (enough), or in severe cases as neoadjuvant therapy to improve surgical possibilities and outcome. In addition, these results show that Na[18F]F PET-CT is suitable for detecting change in each fibrous dysplasia lesion distinctively.
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Affiliation(s)
- Maartje E. Meier
- Department of Orthopedic Surgery, Center for Bone Quality, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333ZA Leiden, the Netherlands
- Corresponding author.
| | - Wouter van der Bruggen
- Section of Nuclear Medicine, Department of Radiology, LUMC, Albinusdreef 2, 2333ZA Leiden, the Netherlands
- Department of Nuclear Medicine, Slingeland Hospital, Kruisbergseweg 25, 7009 BL Doetinchem, the Netherlands
| | - Michiel A.J. van de Sande
- Department of Orthopedic Surgery, Center for Bone Quality, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Natasha M. Appelman-Dijkstra
- Department of Internal Medicine, Division of Endocrinology, Center for Bone Quality, LUMC, Albinusdreef 2, 2333ZA Leiden, the Netherlands
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15
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Sato H, Takai C, Kondo N, Kurosawa Y, Hasegawa E, Wakamatsu A, Kobayashi D, Nakatsue T, Abe A, Ito S, Ishikawa H, Kazama JJ, Kuroda T, Suzuki Y, Endo N, Narita I. Cumulative incidence of femoral localized periosteal thickening (beaking) preceding atypical femoral fractures in patients with rheumatoid arthritis. Osteoporos Int 2021; 32:363-375. [PMID: 32885317 DOI: 10.1007/s00198-020-05601-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/12/2020] [Indexed: 11/29/2022]
Abstract
UNLABELLED The incidence of localized periosteal thickening (LPT, also termed beaking) of the lateral cortex that often precedes an atypical femoral fracture (AFF) was not high in patients with rheumatoid arthritis (RA) but incomplete AFFs developed in two patients. Higher-dose prednisolone was a significant risk factor for LPT in patients with RA. INTRODUCTION Atypical femoral fractures (AFFs) are stress fractures; bisphosphonate (BP) use is a major risk factor for the development of such fractures. Localized periosteal thickening (LPT, also termed beaking) of the lateral cortex often precedes a complete or incomplete AFF. We evaluated the incidence of latent LPT in patients with rheumatoid arthritis (RA), to evaluate LPT progression, and to define LPT risk factors. METHODS A total of 254 patients with RA were included; all underwent annual X-ray evaluation, dual-energy X-ray absorptiometry, and analyses of serum and bone metabolic markers for 2-3 years. LPT of the lateral cortex was sought in femoral X-rays. RESULTS The incidence of LPT was 2.4% (6/254). Among patients on both BP and prednisolone (PSL) at enrollment, the incidence was 2.3% (3/131). Two femurs of two patients with LPT developed incomplete AFFs; LPT was extensive and associated with endosteal thickening. One patient had been on BP and PSL and microscopic polyangiitis was comorbidity. The other was on a selective estrogen receptor modulator and PSL. A daily PSL dose >5 mg (OR 11.4; 95%CI 2.15-60.2; p = 0.004) and higher-dose methotrexate (OR 1.22; 95%CI 1.01-1.49; p = 0.043) were significant risk factors for LPT. CONCLUSIONS The incidence of latent LPT was not high (2.4%) but incomplete AFFs developed in two RA patients. Higher-dose PSL because of a comorbid disease requiring glucocorticoid treatment other than RA or refractory RA were risk factors for LPT; X-ray screening for latent LPT would usefully prevent complete AFFs.
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Affiliation(s)
- H Sato
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Honcho, Shibata City, 957-0054, Japan.
- Health Administration Center, Niigata University, 2-8050 Ikarashi, Nishi-ku, Niigata City, 950-2181, Japan.
| | - C Takai
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Honcho, Shibata City, 957-0054, Japan
| | - N Kondo
- Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
| | - Y Kurosawa
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
| | - E Hasegawa
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
| | - A Wakamatsu
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
| | - D Kobayashi
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
| | - T Nakatsue
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
| | - A Abe
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Honcho, Shibata City, 957-0054, Japan
| | - S Ito
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Honcho, Shibata City, 957-0054, Japan
| | - H Ishikawa
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Honcho, Shibata City, 957-0054, Japan
| | - J J Kazama
- Department of Nephrology and Hypertension, Fukushima Medical University, 1 Hikariga-oka, Fukushima City, 960-1295, Japan
| | - T Kuroda
- Health Administration Center, Niigata University, 2-8050 Ikarashi, Nishi-ku, Niigata City, 950-2181, Japan
| | - Y Suzuki
- Health Administration Center, Niigata University, 2-8050 Ikarashi, Nishi-ku, Niigata City, 950-2181, Japan
| | - N Endo
- Division of Orthopedic Surgery, Tsubame Rosai Hospital, 633, Sawatari, Tsubame City, 959-1228, Japan
| | - I Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
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16
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Matsumoto T, Endo I. RANKL as a target for the treatment of osteoporosis. J Bone Miner Metab 2021; 39:91-105. [PMID: 33057808 DOI: 10.1007/s00774-020-01153-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 08/23/2020] [Indexed: 12/11/2022]
Abstract
Osteoporosis is characterized by compromised bone strength, predisposing to an increased risk of fracture. Because bone is constantly remodeled, and bone mass and structure are determined by the balance between bone resorption and bone formation, it is important to maintain normal bone turnover. Therefore, therapies that reduce bone resorption have been the mainstream of osteoporosis treatment. Receptor activator of nuclear factor-kappa B ligand (RANKL)-RANK signaling was found to play a pivotal role in the regulation of osteoclastic bone resorption, and inhibition of RANKL-RANK system has become an important therapeutic target for the treatment of osteoporosis. Denosumab, a fully human monoclonal anti-RANKL neutralizing antibody, is developed as a drug for the treatment of osteoporosis. This review summarized pharmacokinetic and pharmacodynamic properties of denosumab, clinical studies including phase 2 dose-ranging and its extension study, phase 3 fracture prevention study (FREEDOM) with extension up to 10 years, studies on male osteoporosis (ADAMO study), and on glucocorticoid-induced osteoporosis, along with relevant clinical studies in Japan. In addition, mechanism of denosumab action that can explain its long-term sustained effects, combination and sequential treatment as well as the problems in discontinuation of denosumab, and finally safety of denosumab therapy is discussed.
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Affiliation(s)
- Toshio Matsumoto
- Fujii Memorial Institute of Medical Sciences, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima-shi, Tokushima, 770-8503, Japan.
| | - Itsuro Endo
- Department of Bioregulatory Sciences, Tokushima University Graduate School of Medical Sciences, Tokushima, Japan
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17
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Noble JA, McKenna MJ, Crowley RK. Should denosumab treatment for osteoporosis be continued indefinitely? Ther Adv Endocrinol Metab 2021; 12:20420188211010052. [PMID: 34104392 PMCID: PMC8072936 DOI: 10.1177/20420188211010052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 03/24/2021] [Indexed: 12/15/2022] Open
Abstract
Denosumab was approved for the treatment of postmenopausal osteoporosis in 2010, based on the FREEDOM study, which indicated a benefit in terms of increased bone mineral density and reduced risk of major osteoporotic fracture. In the initial clinical studies it was noted that discontinuation of denosumab can lead to a rebound of bone turnover markers and loss of accrued bone mineral density. An increased risk of fractures (multiple vertebral fractures in particular) associated with discontinuation was noted after approval and marketing of denosumab. For many patients experiencing gain in bone mineral density and fracture prevention while taking denosumab, there is no reason to stop therapy. However, discontinuation of denosumab may happen due to non-adherence; potential lack of efficacy in an individual; where reimbursement for therapy is limited to those with bone mineral density in the osteoporosis range, when assessment reveals this has been exceeded; or patient or physician concern regarding side effects. This review paper aims to discuss these concerns and to summarize the data available to date regarding sequential osteoporosis therapy following denosumab cessation to reduce the risk of multiple vertebral fracture.
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Affiliation(s)
- Jane A. Noble
- Department of Endocrinology, St Vincent’s University Hospital, Dublin, Ireland
| | - Malachi J. McKenna
- St Vincent’s Private Hospital, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Belfield, Dublin, Ireland
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18
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Kennel KA, Sfeir JG, Drake MT. Optimizing DXA to Assess Skeletal Health: Key Concepts for Clinicians. J Clin Endocrinol Metab 2020; 105:5902552. [PMID: 32894765 DOI: 10.1210/clinem/dgaa632] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 09/01/2020] [Indexed: 02/13/2023]
Abstract
CONTEXT The diagnosis of osteoporosis and assessment of fracture risk prior to a sentinel fracture was transformed by the widespread clinical use of dual-energy X-ray absorptiometry (DXA) for the assessment of bone mineral density (BMD). EVIDENCE ACQUISITION This review is based on a collection of primary and review literature gathered from a PubMed search of "dual energy X-ray absorptiometry," "trabecular bone score," and "atypical femur fracture" among other keywords. PubMed searches were supplemented by the authors' prior knowledge of the subject. EVIDENCE SYNTHESIS While uncertainty exists for some aspects of osteoporosis care, patient and clinician familiarity with BMD assessment for screening and monitoring is firmly established. Beyond BMD, lateral spine images obtained with DXA can diagnose osteoporosis and refine fracture risk through the detection of unrecognized vertebral fractures. In addition, analysis of DXA lumbar spine images can reflect changes in trabecular bone microarchitecture, a component of bone "quality" that predicts risk of fracture independent of BMD. Finally, monitoring of bone health by DXA may be extended to include assessment of the femoral cortices for rare but serious adverse effects associated with antiresorptive therapies. CONCLUSIONS Increasing technologic sophistication requires additional consideration for how DXA imaging is performed, interpreted and applied to patient care. As with any test, clinicians must be familiar with DXA performance, pitfalls in analysis, and interpretation within each clinical context in which DXA is applied. With this perspective, care providers will be well positioned to contribute to continuous improvement of DXA performance and, in turn, quality of osteoporosis care.
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Affiliation(s)
- Kurt A Kennel
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota
| | - Jad G Sfeir
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota
- Division of Geriatric Medicine and Gerontology, Mayo Clinic, Rochester, Minnesota
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, Minnesota
| | - Matthew T Drake
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, Minnesota
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
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19
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Tile L, Cheung AM. Atypical femur fractures: current understanding and approach to management. Ther Adv Musculoskelet Dis 2020; 12:1759720X20916983. [PMID: 32913448 PMCID: PMC7443989 DOI: 10.1177/1759720x20916983] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 02/24/2020] [Indexed: 01/19/2023] Open
Abstract
Osteoporosis and resulting osteoporotic fractures are responsible for
significant morbidity, excess mortality, and health care costs in the
developed world. Medical therapy for osteoporosis has been shown in
multiple randomized controlled trials to reduce the risk of vertebral
and non-vertebral fractures and hip fractures, and in some studies
bisphosphonate medications have been associated with improved
survival. Although the overall benefit to risk ratio of osteoporosis
medications remains favorable, there have been concerns raised about
the long-term safety of these treatments. Atypical femur fracture,
which is a rare type of fracture that has been associated with the
long-term use of potent antiresorptive bone medications, is a
potentially devastating consequence of osteoporosis treatment. This
paper reviews our current understanding of atypical femur fractures,
their relationship to antiresorptive osteoporosis medications, and
proposed strategies for management, in order to inform clinical
decision making about the optimal use and duration of medical therapy
for the treatment of patients with osteoporosis or at high risk for
osteoporotic fractures.
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Affiliation(s)
- Lianne Tile
- EN7-222 Toronto General Hospital, 200 Elizabeth St, Toronto, Ontario, Canada M5G 2C4
| | - Angela M Cheung
- Divisions of General Internal Medicine and Endocrinology and Metabolism, Osteoporosis Program, Department of Medicine; Centre of Excellence in Skeletal Health Assessment, Joint Department of Medical Imaging; University Health Network and University of Toronto. Toronto, ON, Canada
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20
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Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition. J Orthop Trauma 2020; 34:e125-e141. [PMID: 32195892 DOI: 10.1097/bot.0000000000001743] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Osteoporosis-related fractures are undertreated, due in part to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines. To help bridge this gap and improve patient outcomes, the American Society for Bone and Mineral Research assembled a multistakeholder coalition to develop clinical recommendations for the optimal prevention of secondary fractureamong people aged 65 years and older with a hip or vertebral fracture. The coalition developed 13 recommendations (7 primary and 6 secondary) strongly supported by the empirical literature. The coalition recommends increased communication with patients regarding fracture risk, mortality and morbidity outcomes, and fracture risk reduction. Risk assessment (including fall history) should occur at regular intervals with referral to physical and/or occupational therapy as appropriate. Oral, intravenous, andsubcutaneous pharmacotherapies are efficaciousandcanreduce risk of future fracture.Patientsneededucation,however, about thebenefitsandrisks of both treatment and not receiving treatment. Oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated; otherwise, intravenous zoledronic acid and subcutaneous denosumab can be considered. Anabolic agents are expensive butmay be beneficial for selected patients at high risk.Optimal duration of pharmacotherapy is unknown but because the risk for second fractures is highest in the earlypost-fractureperiod,prompt treatment is recommended.Adequate dietary or supplemental vitaminDand calciumintake shouldbe assured. Individuals beingtreatedfor osteoporosis shouldbe reevaluated for fracture risk routinely, includingvia patienteducationabout osteoporosisandfracturesandmonitoringfor adverse treatment effects.Patients shouldbestronglyencouraged to avoid tobacco, consume alcohol inmoderation atmost, and engage in regular exercise and fall prevention strategies. Finally, referral to endocrinologists or other osteoporosis specialists may be warranted for individuals who experience repeated fracture or bone loss and those with complicating comorbidities (eg, hyperparathyroidism, chronic kidney disease).
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Conley RB, Adib G, Adler RA, Åkesson KE, Alexander IM, Amenta KC, Blank RD, Brox WT, Carmody EE, Chapman-Novakofski K, Clarke BL, Cody KM, Cooper C, Crandall CJ, Dirschl DR, Eagen TJ, Elderkin AL, Fujita M, Greenspan SL, Halbout P, Hochberg MC, Javaid M, Jeray KJ, Kearns AE, King T, Koinis TF, Koontz JS, Kužma M, Lindsey C, Lorentzon M, Lyritis GP, Michaud LB, Miciano A, Morin SN, Mujahid N, Napoli N, Olenginski TP, Puzas JE, Rizou S, Rosen CJ, Saag K, Thompson E, Tosi LL, Tracer H, Khosla S, Kiel DP. Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition. J Bone Miner Res 2020; 35:36-52. [PMID: 31538675 DOI: 10.1002/jbmr.3877] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/08/2019] [Accepted: 09/11/2019] [Indexed: 12/13/2022]
Abstract
Osteoporosis-related fractures are undertreated, due in part to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines. To help bridge this gap and improve patient outcomes, the American Society for Bone and Mineral Research assembled a multistakeholder coalition to develop clinical recommendations for the optimal prevention of secondary fracture among people aged 65 years and older with a hip or vertebral fracture. The coalition developed 13 recommendations (7 primary and 6 secondary) strongly supported by the empirical literature. The coalition recommends increased communication with patients regarding fracture risk, mortality and morbidity outcomes, and fracture risk reduction. Risk assessment (including fall history) should occur at regular intervals with referral to physical and/or occupational therapy as appropriate. Oral, intravenous, and subcutaneous pharmacotherapies are efficacious and can reduce risk of future fracture. Patients need education, however, about the benefits and risks of both treatment and not receiving treatment. Oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated; otherwise, intravenous zoledronic acid and subcutaneous denosumab can be considered. Anabolic agents are expensive but may be beneficial for selected patients at high risk. Optimal duration of pharmacotherapy is unknown but because the risk for second fractures is highest in the early post-fracture period, prompt treatment is recommended. Adequate dietary or supplemental vitamin D and calcium intake should be assured. Individuals being treated for osteoporosis should be reevaluated for fracture risk routinely, including via patient education about osteoporosis and fractures and monitoring for adverse treatment effects. Patients should be strongly encouraged to avoid tobacco, consume alcohol in moderation at most, and engage in regular exercise and fall prevention strategies. Finally, referral to endocrinologists or other osteoporosis specialists may be warranted for individuals who experience repeated fracture or bone loss and those with complicating comorbidities (eg, hyperparathyroidism, chronic kidney disease). © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
| | | | | | | | - Ivy M Alexander
- UConn School of Nursing, University of Connecticut, Storrs, CT, USA
| | - Kelly C Amenta
- Department of Physician Assistant Studies, Mercyhurst University, Erie, PA, USA
| | - Robert D Blank
- Department of Endocrinology, Metabolism and Clinical Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA.,Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
| | | | - Emily E Carmody
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Bart L Clarke
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Douglas R Dirschl
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Medicine, Chicago, IL, USA
| | | | - Ann L Elderkin
- American Society for Bone and Mineral Research, Washington, DC, USA
| | - Masaki Fujita
- Science Department, International Osteoporosis Foundation, Nyon, Switzerland
| | - Susan L Greenspan
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Marc C Hochberg
- Division of Rheumatology, University of Maryland School of Medicine and VA Maryland Health Care System, Baltimore, MD, USA
| | - Muhammad Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, USA
| | - Kyle J Jeray
- Prisma Health - Upstate (formerly Greenville Health System), Greenville, SC, USA
| | - Ann E Kearns
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Toby King
- US Bone and Joint Initiative, Rosemont, IL, USA
| | | | - Jennifer Scott Koontz
- Orthopedics & Sports Medicine, Newton Medical Center, Newton, KS, USA.,Department of Family and Community Medicine, University of Kansas School of Medicine, Wichita, KS, USA
| | - Martin Kužma
- 5th Department of Internal Medicine, University Hospital, Comenius University, Bratislava, Slovakia
| | - Carleen Lindsey
- Bones, Backs and Balance, LLC, Bristol Physical Therapy, LLC, Bristol, CT, USA
| | - Mattias Lorentzon
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia.,Department of Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden.,Geriatric Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | | | | | | | - Nadia Mujahid
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Nicola Napoli
- Department of Nutrition and Metabolic Disorders, Campus Bio-Medico University of Rome, Rome, Italy.,Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | | | - J Edward Puzas
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Clifford J Rosen
- Tufts University School of Medicine, Boston, MA, USA.,Maine Medical Center Research Institute, Portland, ME, USA
| | - Kenneth Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Laura L Tosi
- Department of Orthopaedic Surgery and Sports Medicine, Children's National Hospital, Washington, DC, USA
| | - Howard Tracer
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, MD, USA
| | - Sundeep Khosla
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Douglas P Kiel
- Harvard Medical School, Musculoskeletal Research Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
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22
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Abstract
PURPOSE OF REVIEW This article summarizes the risk factors for atypical femur fractures (AFF), discusses current and emerging imaging modalities for early identification of AFF, and offers recommendations for prevention and management of AFFs based on the current concepts. RECENT FINDINGS Antiresorptive therapies are widely recommended for prevention and treatment of osteoporosis. Despite their well established effectiveness to reduce fracture risk, emerging concerns related to potential adverse effects have led to a substantial decline in the use of bisphosphonates. Although, the pathogenesis of AFF has not yet been elucidated, the bulk of evidence supports that the well known therapeutic benefits of bisphosphonate far outweigh the relatively low risk of AFFs. Recommendations for early identification of patients at risk for AFF using radiographic imaging have been established. Consensus on the management of AFF and osteoporosis in patients with AFF needs to be formulated. SUMMARY AFF is a rare event associated with long-term bisphosphonate therapy, which represents an apparent paradox in the management of osteoporosis. Improved understanding of pathogenetic mechanisms will be helpful in further refining of screening guidelines and standardization of management and treatment strategies.
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Affiliation(s)
- Vidita Divan
- Metabolic Bone Disease Center, State University of New York Upstate Medical University, Syracuse, New York
| | - Sudhaker D Rao
- Bone and Mineral Research Laboratory, Henry Ford Hospital, Detroit, Michigan, USA
| | - Ruban Dhaliwal
- Metabolic Bone Disease Center, State University of New York Upstate Medical University, Syracuse, New York
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23
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Cheung AM, McKenna MJ, van de Laarschot DM, Zillikens MC, Peck V, Srighanthan J, Lewiecki EM. Detection of Atypical Femur Fractures. J Clin Densitom 2019; 22:506-516. [PMID: 31377055 DOI: 10.1016/j.jocd.2019.07.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/08/2019] [Indexed: 12/14/2022]
Abstract
The 2019 International Society for Clinical Densitometry (ISCD) Position Development Conference Task Force for monitoring with dual-energy X-ray absorptiometry (DXA) identified detection of atypical femur fractures (AFFs) as an important topic and established this working group to answer key questions in this area. The authors conducted a systematic review of the literature and deliberated on proposed ISCD positions, which were then reviewed by an external expert panel and vetted at the 2019 ISCD Position Development Conference in Kuala Lumpur on March 23, 2019. This paper summarizes the final ISCD positions and the rationale for supporting these positions. Default-length femur imaging or extended-length femur imaging as well as full-length femur imaging (FFI), both single-energy and dual-energy scans, by DXA can detect abnormalities in the spectrum of AFF. It is important to visually inspect all DXA scans of the hip and femur, and report on findings of focal periosteal and endosteal thickening at the lateral cortex (grade: Good, A, W). FFI is the preferred DXA scan mode for detecting abnormalities in the spectrum of AFF. The FFI report should state the absence or presence of abnormalities in the spectrum of AFF. If focal thickening is present on the lateral cortex, the report should state whether a lucent line is seen (grade: Fair, C, W). The ISCD recommends considering the use of bilateral FFI in patients who are currently or have been in the past year on potent antiresorptive therapy (ie, oral or intravenous bisphosphonate or subcutaneous denosumab therapy) for a cumulative period of 3 or more years, especially those on long-term glucocorticoid therapy (grade: Fair, B, W). More research is needed to determine the role of repeat testing and the optimal time interval for follow-up DXA scans, whether an automated measuring tool would perform better than visual inspection, whether FFI would change patient management and outcomes, and the cost-effectiveness of FFI.
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Affiliation(s)
- Angela M Cheung
- Centre of Excellence in Skeletal Health Assessment, University of Toronto, Toronto, Ontario, Canada; Osteoporosis Program, University Health Network and Sinai Health System, Toronto, Ontario, Canada.
| | - Malachi J McKenna
- DXA Unit, St. Vincent's University Hospital, Dublin, Ireland; School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Denise M van de Laarschot
- Bone Centre, Department of Internal Medicine, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - M Carola Zillikens
- Bone Centre, Department of Internal Medicine, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Valerie Peck
- Osteoporosis and Metabolic Bone Disease Program, Department of Medicine, NYU Langone Health, New York, NY, USA
| | - Jeevitha Srighanthan
- Centre of Excellence in Skeletal Health Assessment, University of Toronto, Toronto, Ontario, Canada; Osteoporosis Program, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
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24
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Atypical femoral fractures from bisphosphonate in cancer patients - Review. J Bone Oncol 2019; 18:100259. [PMID: 31497503 PMCID: PMC6722257 DOI: 10.1016/j.jbo.2019.100259] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/13/2019] [Accepted: 08/21/2019] [Indexed: 02/08/2023] Open
Abstract
Bisphosphonates are commonly used in patients with metastatic bone disease to prevent skeletal related events. Atypical femur fracture is a known complication of long-term bisphosphonate use but the incidence in cancer patients and pathogenesis are not well known. Several mechanisms of pathogenesis have been proposed including altered angiogenesis, altered bone mechanical properties, micro damage and bone remodeling suppression. Atypical femur fractures are atraumatic or minimally traumatic fractures in the sub trochanteric region or the femoral shaft. Awareness of atypical femur fractures is critical to diagnose and treat them in a timely manner. There is a paucity of data regarding the management of atypical femur fracture in patients with malignancy. Management options of atypical femur fractures include stopping bisphosphonates, initiating calcium/vitamin D supplementation and either surgery with internal fixation or conservative management. In the future, it will be important to explore the effect of continuous vs. intermittent exposure, cumulative dose and length of exposure on the incidence of this complication. Herein, we review the epidemiology, risk factors, management options and proposed mechanisms of pathogenesis of atypical femur fractures.
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Key Words
- AFF, atypical femur fracture
- AGE, advanced glycation end products
- ASBMR, American Society of Bone and Mineral Research
- Atypical femur fracture
- BP, bisphosphonate
- Bisphosphonates
- Bone metastasis
- Bone remodeling
- CI, confidence interval
- CT, computed tomography
- Denosumab
- GGPPS, geranyl geranyl pyrophosphate synthase Her2, human epidermal growth factor receptor
- IM, intramedullary
- IV, intravenous
- MGUS, monoclonal gammopathy of unknown significance
- MRI, magnetic resonance imaging
- ONJ, osteonecrosis of the jaw
- OR, odds ratio
- ORIF, open reduction internal fixation
- RCT, randomized clinical trial
- VEGF, vascular endothelial growth factor
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25
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Park YC, Yoon SP, Yang KH. Localization of Atypical Femoral Fracture on Straight and Bowed Femurs. J Bone Metab 2019; 26:123-131. [PMID: 31223609 PMCID: PMC6561849 DOI: 10.11005/jbm.2019.26.2.123] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/08/2019] [Accepted: 05/15/2019] [Indexed: 12/15/2022] Open
Abstract
Background To elucidate the effect of anterolateral bowing on the fracture height of atypical femoral fractures (AFFs), we separated the AFFs into 2 groups according to the presence of anterolateral femoral bowing (straight group and bowing group) and analyzed the fracture height. The aims of this study were to evaluate the clinical and radiological features of AFFs in the straight group and bowing group, and to determine which factors were associated with the fracture height of AFFs in the total cohort and each subgroup. Methods Ninety-nine patients with AFFs were included in this study (43 patients in the bowing group and 56 patients in the straight group). Clinical and radiological characteristics were compared between the groups. Multivariable linear regression analysis was performed to determine the effect of factors on fracture height. Results Patients in the straight group were younger, heavier, and taller, and had a higher bone mineral density, smaller anterior and lateral bowing angles, and more proximal fracture height than those in the bowing group. Multivariable analysis showed that the presence of anterolateral bowing itself and height were associated with fracture height in the total cohort. In the subgroup analysis, the lateral bowing angle in the straight group and the estimated apex height in the bowing group were associated with fracture height. The lateral bowing angle was not significantly associated with fracture height in the total cohort and the bowing group. Conclusions The presence of anterolateral bowing and the level of the apex of the bowed femur were important factors for the fracture height of AFFs.
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Affiliation(s)
- Young-Chang Park
- Department of Orthopaedic Surgery, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Soon-Phil Yoon
- Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu Hyun Yang
- Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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26
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Black DM, Abrahamsen B, Bouxsein ML, Einhorn T, Napoli N. Atypical Femur Fractures: Review of Epidemiology, Relationship to Bisphosphonates, Prevention, and Clinical Management. Endocr Rev 2019; 40:333-368. [PMID: 30169557 DOI: 10.1210/er.2018-00001] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 05/08/2018] [Indexed: 12/18/2022]
Abstract
Bisphosphonates (BPs) are highly effective in treating osteoporosis and reducing hip, vertebral, and other fractures by as much as 50% to 70%. However, since 2006, atypical femur fractures (AFFs) emerged as potential side effects of BPs and other treatments. These fractures have unusual radiologic features and occur with little trauma. Public concern has led to a >50% decrease in BP usage. AFFs are rare: for each AFF, >1200 fractures, including 135 hip fractures, are prevented. Case definition criteria were updated by the American Society of Bone and Mineral Research in 2014. Many epidemiologic studies have been reported, and although methodologically challenging, generally support a BP-AFF association. However, the magnitude of the association between BPs and AFFs is uncertain: estimates of relative risk for AFFs among BP users vs nonusers range from 1 to 65 with a meta-analysis estimate of 1.7. Although mechanistic studies have proposed several hypotheses explaining how BPs might decrease bone strength, AFF pathogenesis remains uncertain and cannot explain the paradox of efficacy of reduction of common fractures while increasing risk for rare fractures at one site. There are several consistent risk factors, including Asian race (in North America), femoral bowing, and glucocorticoid use, whereas others remain unclear. Consensus is emerging about strategies to prevent AFFs in BP users (including drug holidays after 5 years' use in some patients). In conclusion, AFFs can be devastating, but even under the most pessimistic assumptions, the benefit/risk ratio is highly positive for BPs, particularly during 3 to 5 years of use. As understanding of AFFs increases, it is becoming increasingly possible to maximize BP benefits while minimizing AFF risk.
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Affiliation(s)
- Dennis M Black
- University of California, San Francisco, San Francisco, California
| | | | | | | | - Nicola Napoli
- Università Campus Bio-Medico di Roma, Rome, Italy.,IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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27
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Buitendijk SKC, van de Laarschot DM, Smits AAA, Koromani F, Rivadeneira F, Beck TJ, Zillikens MC. Trabecular Bone Score and Hip Structural Analysis in Patients With Atypical Femur Fractures. J Clin Densitom 2019; 22:257-265. [PMID: 29661684 DOI: 10.1016/j.jocd.2018.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 03/13/2018] [Indexed: 01/03/2023]
Abstract
Bisphosphonate use has declined dramatically in recent years, partly because of fear of rare side effects like atypical femur fractures (AFFs). It is therefore desirable to have a diagnostic method to identify those at risk of AFF to prevent this serious complication. We compared trabecular microarchitecture and hip geometry between 30 patients with AFF and 141 controls of similar age and sex, using bisphosphonates. Trabecular bone score (TBS) and hip structural analysis (HSA) were used to assess trabecular microarchitecture and macroscopic hip geometry from dual-energy X-ray absorptiometry images of the lumbar spine and hip, respectively. General characteristics, TBS, and HSA were compared between patients with AFF and controls using Student's t tests and chi-square statistics. Associations between AFF and TBS and femur geometric characteristics by HSA were adjusted for sex, age, height, weight, ethnicity, duration of bisphosphonate use, and glucocorticoid use. Additionally, the analysis of TBS was adjusted for lumbar spine bone mineral density and the time difference between dual-energy X-ray absorptiometry scanning and the diagnosis of AFF. Patients with AFF had significantly higher body mass index than controls, had used bisphosphonates longer, and glucocorticoids and proton pump inhibitors more frequently. Sex-specific T-score was significantly higher in patients with AFF at the lumbar spine (p = 0.004), but not at the femoral neck (p = 0.190) after adjustment for age, height, and weight. TBS did not differ significantly between patients with AFF and controls. Neither neck shaft angle nor any geometric variables at the femoral shaft measured by HSA differed between patients with AFF and controls. At the narrow neck, patients with AFF had lower buckling ratio and higher centroid position, consistent with a lower risk of classical fragility hip fractures. The findings at narrow neck and higher bone mineral density might be explained by the fact that the majority of patients with AFF used bisphosphonates to prevent glucocorticoid-induced osteoporosis. Based on our results, TBS and HSA do not appear to have value in detecting patients at risk of AFF.
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Affiliation(s)
- Sanne K C Buitendijk
- Bone Center, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | | | - Alexandra A A Smits
- Bone Center, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Fjorda Koromani
- Bone Center, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands; Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Fernando Rivadeneira
- Bone Center, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands; Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | | | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands.
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28
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Blaty T, Krueger D, Illgen R, Squire M, Heiderscheit B, Binkley N, Anderson P. DXA evaluation of femoral bone mineral density and cortical width in patients with prior total knee arthroplasty. Osteoporos Int 2019; 30:383-390. [PMID: 30171301 DOI: 10.1007/s00198-018-4682-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/19/2018] [Indexed: 01/07/2023]
Abstract
UNLABELLED Periprosthetic fractures after total knee arthroplasty (TKA) have devastating consequences. Osteoporosis increases periprosthetic fracture risk, but distal femur bone mineral density (BMD) is not measured post-TKA. This study measured distal femur BMD and cortical width; both were lower in the TKA compared to the non-operated leg. BMD measurement reproducibility was good. Standardized DXA regions of interest are proposed. INTRODUCTION Periprosthetic fractures following total knee arthroplasty (TKA) are not rare. We hypothesized that TKA is associated with low BMD, potentially increasing periprosthetic fracture risk. However, distal femur dual energy x-ray (DXA) measurement is virtually never performed after TKA due to lack of standardized approaches. Thus, this study's aims were to develop standard DXA femur regions of interest (ROIs), assess cortical width, and determine measurement reproducibility in TKA patients. METHODS Thirty adults (15 M/15 F) age 59-80 years with unilateral, primary TKA within 2-5 years had femoral DXA scans performed in duplicate using a Lunar iDXA densitometer. In prior work, we established that femur BMD was lowest in the distal metaphysis and highest in mid-shaft. Thus, BMD and cortical width were measured at 15%, 25%, and 60% of the femur length measured from the distal notch. Femur BMD and cortical width were compared between limbs (TKA vs. non-operated side) by paired t test. RESULTS BMD was 3.2-9.9% lower (p < 0.001) in the operated femur at all custom ROIs; substantial between individual differences existed with some up to 30% lower. Cortical width was lower (p < 0.05) at the 25% ROI on the TKA side. BMD reproducibility was excellent; CV 0.85-1.33%. CONCLUSIONS Distal femur BMD can be reproducibly measured using DXA and is ~ 10% lower on the TKA leg. Similarly, medial and lateral cortices are thinner at the 25% ROI. These bone changes likely increase periprosthetic fracture risk. Further work to define and mitigate periprosthetic fracture risk after TKA is needed.
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Affiliation(s)
- T Blaty
- Osteoporosis Clinical Research Program, University of Wisconsin School of Medicine and Public Health, 2870 University Ave. Ste. 100, Madison, WI, 53705, USA
| | - D Krueger
- Osteoporosis Clinical Research Program, University of Wisconsin School of Medicine and Public Health, 2870 University Ave. Ste. 100, Madison, WI, 53705, USA
| | - R Illgen
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - M Squire
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - B Heiderscheit
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - N Binkley
- Osteoporosis Clinical Research Program, University of Wisconsin School of Medicine and Public Health, 2870 University Ave. Ste. 100, Madison, WI, 53705, USA.
| | - P Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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29
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Abstract
PURPOSE OF REVIEW To summarize reports published since the 2013 American Society of Bone and Mineral Research Task Force Report on atypical femoral fractures (AFF). RECENT FINDINGS The absolute incidence of AFFs remains low. AFFs are primarily associated with prolonged bisphosphonate (BP) exposure, but have also been reported in unexposed patients and those receiving denosumab for osteoporosis and metastatic bone disease. Asians may be more susceptible to AFFs. Lateral femoral bowing and varus hip geometry, which increase loading forces on the lateral femoral cortex, may increase AFF risk. Altered bone material properties associated with BP therapy may predispose to AFFs by permitting initiation and increasing propagation of micro-cracks. Relevant genetic mutations have been reported in patients with AFFs. Single X-ray absorptiometry femur scans permit early detection of incomplete and/or asymptomatic AFFs. Orthopedists recommend intramedullary rods for complete AFFs and for incomplete, radiologically advanced AFFs associated with pain and/or marrow edema on MRI. Teriparatide may advance AFF healing but few data support its efficacy. Greater understanding of biological and genetic predisposition to AFF may allow characterization of individual risk prior to initiating osteoporosis therapy and help allay fear in those at low risk for this complication, which remains rare in comparison to the osteoporotic fractures prevented by antiresorptive therapy.
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Affiliation(s)
- Jessica Starr
- Division of Endocrinology, Department of Medicine, Columbia University Irving Medical Center, 180 Fort Washington Avenue, Room 9-910, New York, NY, 10032, USA
| | | | - Elizabeth Shane
- Division of Endocrinology, Department of Medicine, Columbia University Irving Medical Center, 180 Fort Washington Avenue, Room 9-910, New York, NY, 10032, USA.
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