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Anderson PA, Kates SL, Watts ND. Update on Atypical Femoral Fractures. J Bone Joint Surg Am 2024:00004623-990000000-01182. [PMID: 39172879 DOI: 10.2106/jbjs.23.01439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
➤ Atypical femoral fractures (AFFs) are stress fractures between the lesser trochanter and the metaphyseal flare that are most commonly related to prolonged (3 to 5 years) antiresorptive medication use.➤ An important finding is a visible transverse line in the lateral cortex, known as the "dreaded black line." Complete fractures are transverse and have minimal comminution.➤ Prodromal symptoms including hip, groin, thigh, and knee pain are present in more than one-half of cases and are usually misdiagnosed.➤ Nonoperative treatment for all patients with AFF includes withdrawal of bisphosphonates, assessment for secondary causes of osteoporosis, and optimization of vitamin D and calcium.➤ Incomplete fractures without a visible line can initially be treated nonoperatively with protected weight-bearing.➤ Intramedullary nailing is indicated for complete fractures and incomplete fractures with a visible fracture line. Delayed healing after fixation should be anticipated.➤ Treatment with parathyroid hormone (PTH) analogs (teriparatide and abaloparatide) after AFF prevents other fractures in high-risk patients, but the effect on healing of the fracture is unclear.
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Affiliation(s)
- Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Nelson D Watts
- Osteoporosis and Bone Health Services, Mercy Health, Cincinnati, Ohio
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Khalil AB, Yammine R, Rameh V, Zadeh C, Saad R, Mallah H, Khoury NJ, El-Hajj Fuleihan G. Prevalence and risk factors for atypical femoral fracture among Lebanese patients with hip and shaft fractures. JBMR Plus 2024; 8:ziae069. [PMID: 38957400 PMCID: PMC11215537 DOI: 10.1093/jbmrpl/ziae069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/30/2024] [Accepted: 05/24/2024] [Indexed: 07/04/2024] Open
Abstract
This retrospective study investigates the prevalence of atypical femoral fractures (AFFs) among patients admitted with hip and shaft fractures at a tertiary referral center in Beirut, Lebanon. We analyzed electronic medical records and radiology studies of patients aged above 40 admitted with hip and shaft fractures between January 2006 and December 2019. Fractures were confirmed by ICD9 or ICD10 codes. All cases were reviewed by radiologists, and AFFs were identified according to the 2013 revised ASBMR criteria. We identified 1366 hip and shaft fracture patients, of which 14 female patients had 19 AFFs. This represents a prevalence of 1.0% among all hip and shaft fractures patients and 1.7% among all female hip and shaft fracture patients. Bilateral AFFs were found in 5 of the 14 patients. Patients with AFF tended to be younger, with a mean age of 74.3 (±8.6) yr compared to 78.0 (±10.6) for patients with non-AFF fractures. A total of 36% of AFF patients had a prior history of non-traumatic fracture at first admission. A high percentage of patients with AFFs reported intake of proton pump inhibitors (42.9%) and glucocorticoids (21.4%). Bisphosphonate exposure was noted in 64.3% of AFF patients. None of the AFF patients were active smokers or consumed alcohol regularly. BMD assessments were available for 7 AFF patients, indicating osteoporosis in 4 and osteopenia in 3 cases. Hip axis length measurements showed no significant difference between AFF patients (N = 7) and sex and age-matched controls (N = 21). The study underlines the prevalence and characteristics of AFFs in Lebanon, which is consistent with the numbers reported in the literature (0.32%-5%). A larger prospective study that includes hospitals across the nation is needed to gain a more comprehensive view of the prevalence of AFFs in the Lebanese population.
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Affiliation(s)
- Abir Bou Khalil
- Department of Medical Oncology, Sultan Qaboos Comprehensive Cancer Care and Research Center, Muscat, Seeb, PO 123, Oman
| | - Ryan Yammine
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, Division of Endocrinology and Metabolism, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Vanessa Rameh
- Department of Radiology, Boston Children's Hospital, Boston, MA, 02115USA
| | - Catherina Zadeh
- Department of Radiology, University of Iowa Health Care, Iowa City, IA 52242-1089USA
| | - Randa Saad
- Department of Research and Policy, Eastern Mediterranean Public Health Network (EMPHNET), Amman, Jordan
| | - Hasan Mallah
- Office of Innovation and Transformation, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nabil J Khoury
- Office of Innovation and Transformation, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ghada El-Hajj Fuleihan
- Office of Innovation and Transformation, American University of Beirut Medical Center, Beirut, Lebanon
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Huang K, Zeng Y, Zhang Q, Tan J, Li H, Yang J, Xie H, Shen B. Atypical Periprosthetic Femoral Fracture Might be Considered a Distinct Subtype of Atypical Femoral Fracture: A Retrospective Study. Orthop Surg 2024. [PMID: 39072929 DOI: 10.1111/os.14174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 07/05/2024] [Accepted: 07/08/2024] [Indexed: 07/30/2024] Open
Abstract
OBJECTIVE The exact relationship among atypical periprosthetic femoral fractures (APFFs), typical periprosthetic femoral fractures (PFFs), and atypical femur fractures (AFFs) remains unclear. This study aimed to investigate the prevalence of APFFs among PFFs and to identify the clinical characteristics, management, and prognosis that distinguish APFFs from typical PFFs and AFFs to further determine the relationship among these three fracture types. METHODS In this retrospective study, we reviewed the clinical data of 117 consecutive patients who had PFFs after hip arthroplasty between January 2012 and December 2022 and further classified them into an APFF group and a typical PFF group according to the revised ASBMR diagnostic criteria for AFF. Moreover, patients who had subtrochanteric or femoral shaft fractures in the same period and met the diagnostic criteria for AFF were recruited and classified into the AFF group. Demographic information, minor features of AFF, comorbidities, history of medication usage, management, and complications were collected and compared among patients with typical PFFs, APFFs, and AFFs. RESULTS Eleven PFFs were identified as APFFs, and the prevalence of APFFs among PFFs was 9.4%. Significant differences were found in generalized increase in cortical thickness (p = 0.019), prodromal symptoms (p < 0.001), and the incidence of bilateral fractures (p = 0.010) among the groups, where the incidences of these minor features in the APFF group and the AFF group were higher than those in the typical PFF group. Of note, the duration of fracture healing of APFFs was significantly longer than that of typical PFFs and AFFs (p < 0.001 and p = 0.004, respectively). In addition, the APFF group and the AFF group had higher proportions of patients with rheumatoid arthritis (p = 0.004 and p = 0.027, respectively), bisphosphonate (BP) usage (p = 0.026 and p < 0.001, respectively), and longer duration of BP usage (p = 0.003 and p = 0.007, respectively) than the typical PFF group. Furthermore, significant differences were found in management (p < 0.001) and complication rate (p = 0.020) among the groups, and the rate of complications in the APFF group and the AFF group was higher than that in the typical PFF group. CONCLUSIONS APFFs not only fulfilled the mandatory and major diagnostic criteria for AFF but also had many clinical characteristics, management and prognosis distinguishing them from typical PFFs but resembling AFFs; hence, the diagnostic criteria for AFF might be revised to incorporate APFF as a distinct subtype of the condition.
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Affiliation(s)
- Kai Huang
- Department of Orthopedics Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Stem Cell and Tissue Engineering, Orthopedic Research Institute, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Yi Zeng
- Department of Orthopedics Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Qingyi Zhang
- Department of Orthopedics Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Stem Cell and Tissue Engineering, Orthopedic Research Institute, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Jie Tan
- Department of Orthopedics Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Stem Cell and Tissue Engineering, Orthopedic Research Institute, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Hexi Li
- Department of Orthopedics Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Stem Cell and Tissue Engineering, Orthopedic Research Institute, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Jing Yang
- Department of Orthopedics Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Huiqi Xie
- Laboratory of Stem Cell and Tissue Engineering, Orthopedic Research Institute, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Bin Shen
- Department of Orthopedics Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
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Gibbons K, Merrell LA, Ganta A, Rivero S, Konda SR, Egol KA. Atypical Versus Typical Subtrochanteric Femoral Fractures: Disparate Patient Profiles, Similar Outcomes. J Bone Joint Surg Am 2024; 106:190-197. [PMID: 37992181 DOI: 10.2106/jbjs.23.00583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
BACKGROUND The purpose of the present study was to evaluate differences in demographic features and clinical outcomes between patients who sustained a typical versus atypical subtrochanteric femoral fracture. METHODS We reviewed the records for a cohort of consecutive patients who had undergone operative treatment of a subtrochanteric femoral fracture. Fractures were classified as either "typical" or "atypical" on the basis of the criteria of the American Society for Bone and Mineral Research (ASBMR). All patients were treated with a similar surgical algorithm and postoperative protocol. Groups were compared on the basis of demographic features, injury characteristics, operative quality measures, postoperative complications and outcomes, and radiographic time to healing. Comparative analyses were performed to compare the typical and atypical cohorts. RESULTS Of 220 subtrochanteric fractures, 165 (75.0%) were classified as typical and 55 (25.0%) were classified as atypical. The atypical cohort was predominately female and more likely to have bisphosphonate usage (odds ratio [OR], 7.975; [95% confidence interval (CI), 3.994-15.922]; p < 0.001) and fractures with lower-energy mechanisms (p < 0.001). Patients in the atypical cohort were more likely to be treated with a 10-mm cephalomedullary nail (CMN) (OR, 2.100 [95% CI, 1.119-3.939]; p = 0.020), whereas patients in the typical cohort were treated more frequently with an 11-mm CMN (OR, 0.337 [95% CI, 0.168-0.674]; p = 0.002). There were no differences between the groups in terms of other operative parameters; however, anatomic fracture reduction in neutral lateral alignment was achieved more frequently in the typical cohort (OR, 0.438 [95% CI, 0.220-0.875]; p = 0.018). There were no differences between the groups in terms of hospital quality measures, mortality rates, readmission rates, or complication rates (including implant failure [broken screw or nail] and fracture nonunion) (p = 1.00). Interestingly, there was no significant difference between the groups in terms of time to radiographic healing (260.30 ± 187.97 days in the typical group, compared with 246.40 ± 116.33 days in the atypical group) (OR, 0.999 [95% CI, 0.997-1.002]; p = 0.606). CONCLUSIONS Despite differences in terms of demographic and injury characteristics, patients who sustain a subtrochanteric femur fracture can expect similar outcome profiles regardless of fracture type. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kester Gibbons
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Lauren A Merrell
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Abhishek Ganta
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Richmond Hill, New York
| | - Steven Rivero
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Sanjit R Konda
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Richmond Hill, New York
| | - Kenneth A Egol
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Richmond Hill, New York
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Bal R, Ambade R, Singh N, Upadhyay P. Bisphosphonates and Atypical Femur Fractures: Is the Relationship Causal or Casual? Cureus 2023; 15:e48141. [PMID: 38046767 PMCID: PMC10692760 DOI: 10.7759/cureus.48141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/02/2023] [Indexed: 12/05/2023] Open
Abstract
Bisphosphonates (BPs) are a time-tested drug class with multivariate use cases. They are used in pathologies ranging from osteoporosis to Paget's disease, and also help in accelerated fracture healing. They have been used to treat both benign and malignant lesions of the skeletal system since a long time. However, there have been reports of increased incidences of atypical femoral fractures (AFFs) in patients exhibiting chronic use of bisphosphonates in the past years. This has led to the widespread dissuasion of physicians and practitioners from using the drug class. By means of this review of the literature, the authors aim to investigate the relationship between BP use and its association with AFFs. The review focuses on and elucidates the basic pharmacology of BPs and goes on to illustrate the indications of BPs in various pathologies of the musculoskeletal system, further exploring the effects of BPs on the healing of various bony fractures. The authors also explore the incidences of other pathologies, such as osteonecrosis of the jaw and nephropathies associated with BP use, and elaborate on their features. Through this review, the authors have tried to educate and induce critical thinking on the part of clinicians and medical professionals in regard to prescribing BPs to patients that need them, by keeping in mind the risk-reward relationship that accompanies their use.
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Affiliation(s)
- Rajeshwaree Bal
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Ratnakar Ambade
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Nihaal Singh
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Prateek Upadhyay
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Wang B, Vashishth D. Advanced glycation and glycoxidation end products in bone. Bone 2023; 176:116880. [PMID: 37579812 PMCID: PMC10529863 DOI: 10.1016/j.bone.2023.116880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/21/2023] [Accepted: 08/11/2023] [Indexed: 08/16/2023]
Abstract
Hyperglycemia and oxidative stress, enhanced in diabetes and aging, result in excessive accumulation of advanced glycation and glycoxidation end products (AGEs/AGOEs) in bone. AGEs/AGOES are considered to be "the missing link" in explaining increased skeletal fragility with diabetes, aging, and osteoporosis where increased fracture risk cannot be solely explained by bone mass and/or fall incidences. AGEs/AGOEs disrupt bone turnover and deteriorate bone quality through alterations of organic matrix (collagen and non-collagenous proteins), mineral, and water content. AGEs and AGOEs are also associated with bone fragility in other conditions such as Alzheimer's disease, circadian rhythm disruption, and cancer. This review explains how AGEs and AGOEs accumulate in bone and impact bone quality and bone fracture, and how AGES/AGOEs are being targeted in preclinical and clinical investigations for inhibition or removal, and for prediction and management of diabetic, osteoporotic and insufficiency fractures.
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Affiliation(s)
- Bowen Wang
- Shirley Ann Jackson Ph.D. Center of Biotechnology and Interdisciplinary Studies, Troy, NY 12180, USA; Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY 12180, USA
| | - Deepak Vashishth
- Shirley Ann Jackson Ph.D. Center of Biotechnology and Interdisciplinary Studies, Troy, NY 12180, USA; Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY 12180, USA; Rensselaer - Icahn School of Medicine at Mount Sinai Center for Engineering and Precision Medicine, New York, NY 10019, USA.
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Fang C, Shen WY, Wong JSH, Yee DKH, Yung CSY, Fang E, Lai YS, Woo SB, Cheung J, Chau JYM, Ip KC, Li W, Leung F. Should nails be locked dynamically or statically in atypical femoral fractures? - A radiological analysis of time to union and reoperations in 236 displaced fractures with 4 years average follow-up. Injury 2023; 54:110909. [PMID: 37393776 DOI: 10.1016/j.injury.2023.110909] [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: 03/22/2023] [Revised: 05/26/2023] [Accepted: 06/18/2023] [Indexed: 07/04/2023]
Abstract
INTRODUCTION Atypical femoral fractures (AFFs) are associated with delayed union and higher reoperation rates. Axial dynamization of intramedullary nails is hypothesized to reduce time-to-union (TTU) and fixation failure as compared to static locking. METHODS Consecutive acutely displaced AFFs fixed with long intramedullary nails across five centres between 2006 and 2021 with a minimum postoperative follow-up of three months were retrospectively reviewed. The primary outcome was TTU, compared between AFFs treated with dynamically or statically locked intramedullary nails. Fracture union was defined as a modified Radiographic Union Score for Tibial fractures score of 13 or greater. Secondary outcomes involved revision surgery and treatment failure, defined as non-union beyond 18 months or revision internal fixation for mechanical reasons. RESULTS A total of 236 AFFs (127 dynamically locked and 109 statically locked) were analysed with good interobserver reliability of fracture union assessment (intraclass correlation coefficient = 0.89; 95% CI = 0.82-0.98). AFFs treated with dynamized nails had significantly shorter median TTU (10.1 months; 95% CI = 9.24-10.96 vs 13.0 months; 95% CI = 10.60-15.40) (log-rank test, p = 0.019). Multivariate Cox regression revealed that dynamic locking was independently associated with greater likelihood of fracture union within 24 months (p = 0.009). Reoperations were less frequent in the dynamic locking group (18.9% vs 28.4%), although the difference was not statistically significant (p = 0.084). Static locking was an independent risk factor for reoperation (p = 0.049), as were varus reduction and lack of teriparatide use within three months of surgery. Static locking also demonstrated a higher frequency of treatment failure (39.4% vs 22.8%, p = 0.006) and was an independent predictor of treatment failure in logistic regression (p = 0.018). Other factors associated with treatment failure included varus reduction and open reduction. CONCLUSIONS Dynamic locking of intramedullary nails in AFFs is associated with faster time to union, lower rate of non-union, and fewer treatment failures.
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Affiliation(s)
- Christian Fang
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Wan Yiu Shen
- Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Janus Siu Him Wong
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong.
| | - Dennis King-Hang Yee
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Colin Shing-Yat Yung
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Evan Fang
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Yuen Shan Lai
- Department of Orthopaedics and Traumatology, Kwong Wah Hospital, Yau Ma Tei, Hong Kong
| | - Siu Bon Woo
- Department of Orthopaedics and Traumatology, Kwong Wah Hospital, Yau Ma Tei, Hong Kong
| | - Jake Cheung
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Jackie Yee-Man Chau
- Department of Orthopaedics and Traumatology, Kwong Wah Hospital, Yau Ma Tei, Hong Kong
| | - Ka Chun Ip
- Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Wilson Li
- Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Frankie Leung
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
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Fukui T, Oe K, Kawamoto T, Morishita M, Fujita I, Takahara S, Sakurai A, Iwakura T, Yoshida K, Ito K, Shoda E, Hiranaka T, Tsunoda M, Kuroda R, Niikura T. Multicenter study on atypical femoral fractures in patients with bone metastases taking bone- modifying agents. J Bone Oncol 2023; 40:100478. [PMID: 37180736 PMCID: PMC10173009 DOI: 10.1016/j.jbo.2023.100478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/02/2023] [Accepted: 04/08/2023] [Indexed: 05/16/2023] Open
Abstract
Bone-modifying agents (BMAs), with bone-resorptive inhibitory effects, such as zoledronic acid and denosumab, are widely used at higher doses for bone-related events caused by bone metastasis of malignant tumors. These drugs have been suggested to be associated with atypical femoral fractures (AFFs), and the relationship between BMAs and AFFs has attracted attention. To investigate the clinical features including bone union time of AFFs in patients administered BMA for bone metastasis, we conducted a retrospective multicenter study. Thirty AFFs from 19 patients were enrolled in this study. Thirteen patients had bilateral AFFs, and nineteen AFFs had prodromal symptoms. Eighteen AFFs underwent surgery after complete fracture, three failed to achieve bone union and required nonunion surgery, and 11 AFFs that achieved bone union had an average period until bone union of 16.2 months, which was much longer than that previously reported for ordinary AFFs. Seven patients discontinued the BMAs, but not due to AFFs. Stopping BMAs in patients with bone metastasis would make it difficult to secure their performance of activities of daily living, and AFF with BMA administration might require a longer time for union. Therefore, it would be important to prevent incomplete AFF from becoming complete AFF via prophylactic internal fixation.
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Affiliation(s)
- Tomoaki Fukui
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Keisuke Oe
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Teruya Kawamoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | | | - Ikuo Fujita
- Department of Orthopaedic Surgery, Hyogo Cancer Center, Japan
| | | | - Atsushi Sakurai
- Department of Orthopaedic Surgery, Awaji Medical Center, Japan
| | - Takashi Iwakura
- Department of Orthopaedic Surgery, Awaji Medical Center, Japan
- Department of Orthopaedic Surgery, Sanda City Hospital, Japan
| | - Keiji Yoshida
- Department of Orthopaedic Surgery, Kobe City Nishi-Kobe Medical Center, Japan
| | - Kenjiro Ito
- Department of Orthopaedic Surgery, Akashi Medical Center, Japan
| | - Etsuo Shoda
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, Japan
| | | | - Masaya Tsunoda
- Department of Orthopaedic Surgery, Sanda City Hospital, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Takahiro Niikura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, Japan
- Corresponding author at: Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan.
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Muacevic A, Adler JR, Bisbinas A, Markopoulos G, Bisbinas I. Simultaneous Bilateral Insufficiency Femoral Fractures After Long-Term Alendronate Treatment: A Lesson Not Yet Learned. Cureus 2023; 15:e33956. [PMID: 36814732 PMCID: PMC9939954 DOI: 10.7759/cureus.33956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 01/21/2023] Open
Abstract
Bisphosphonates have recently been used as a first-line treatment for osteoporosis. However, prolonged bisphosphonate use may be associated with insufficiency and atypical femoral fractures. In this case report, we present a patient with simultaneous bilateral insufficiency femoral fractures after using alendronate for 11 years, which were treated surgically. Our patient also had a history of a previous right femoral atypical fracture eight years before the latest ones, while on 3-year alendronate treatment. To our knowledge, it is the first patient reported with three atypical - insufficiency fractures covering all the anatomical areas of the proximal half of the femur after long-term bisphosphonate treatment.
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10
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Zhang YW, Cao MM, Li YJ, Zhang RL, Wu MT, Yu Q, Rui YF. Fecal microbiota transplantation as a promising treatment option for osteoporosis. J Bone Miner Metab 2022; 40:874-889. [PMID: 36357745 PMCID: PMC9649400 DOI: 10.1007/s00774-022-01375-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/04/2022] [Indexed: 11/12/2022]
Abstract
Osteoporosis is a systemic metabolic bone disease characterized by the descending bone mass and destruction of bone microstructure, which tends to result in the increased bone fragility and associated fractures, as well as high disability rate and mortality. The relation between gut microbiota and bone metabolism has gradually become a research hotspot, and it has been verified that gut microbiota is closely associated with reduction of bone mass and incidence of osteoporosis recently. As a novel "organ transplantation" technique, fecal microbiota transplantation (FMT) mainly refers to the transplantation of gut microbiota from healthy donors to recipients with gut microbiota imbalance, so that the gut microbiota in recipients can be reshaped and play a normal function, and further prevent or treat the diseases related to gut microbiota disorder. Herein, based on the gut-bone axis and proven regulatory effects of gut microbiota on osteoporosis, this review expounds relevant basic researches and clinical practice of FMT on osteoporosis, thus demonstrating the potentials of FMT as a therapeutic option for osteoporosis and further providing certain reference for the future researches.
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Affiliation(s)
- Yuan-Wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, 210009, Jiangsu, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
- School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Mu-Min Cao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, 210009, Jiangsu, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
- School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Ying-Juan Li
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
- Department of Geriatrics, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Ruo-Lan Zhang
- School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Meng-Ting Wu
- School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Qian Yu
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
- Department of Gastroenterology, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, 210009, Jiangsu, People's Republic of China.
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China.
- School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China.
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China.
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11
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Bisphosphonate Drug Holiday and Fracture Risk: Reviewing the Evidence. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2022. [DOI: 10.1007/s40674-022-00191-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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12
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Troiano E, Giacché T, Facchini A, Orlandi NC, Cacioppo M, Saviori M, Bottai V, Muratori F, Mondanelli N, Giannotti S. Surgical and Pharmacological Management of Periprosthetic Atypical Femoral Fractures: A Narrative Literature Review. Geriatr Orthop Surg Rehabil 2022; 13:21514593221090392. [PMID: 35433102 PMCID: PMC9006379 DOI: 10.1177/21514593221090392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 12/09/2021] [Accepted: 01/08/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction An increasing number of patients is annually undergoing total hip arthroplasty (THA), and a significant proportion of these patients are elderly and consequently at a higher risk of complications because of age, osteoporosis, and medical comorbidities. Periprosthetic femoral fractures (PFFs) are one of the worst complications of THA associated with high rates of unfavorable prognosis. Besides, in the last decade, a new independent disease entity called “atypical femoral fracture” (AFF) has been identified and defined by the American Society for Bone and Mineral Research (ASBMR) task force. Some PFFs present clinical history and radiographic aspect consistent with an AFF, meeting the ASBMR criteria for the diagnosis of AFF except that PFFs by themselves are an exclusion criterion for AFF. However, there is an increasing number of published studies suggesting that periprosthetic atypical femoral fractures (PAFFs) exist and should not be excluded by definition. Significance Nowadays, although there is an increasing interest in PAFFs, there are still very few studies published on the topic and a lack of consensus regarding their treatment. This narrative literature review aims to introduce this new emerging topic to a wider readership describing the characteristics of PAFFs and the state-of-the-art in their management. Conclusions Many authors agree that PAFFs should be considered as a subgroup of PFFs that have atypical characteristics; they also show a significant correlation with prolonged bisphosphonate use. A correct diagnosis is paramount for proper treatment of the disease that requires both surgical and medical actions to be taken.
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Affiliation(s)
- Elisa Troiano
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Tiziano Giacché
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Andrea Facchini
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Nicholas Crippa Orlandi
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Matteo Cacioppo
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Marco Saviori
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Vanna Bottai
- Second Clinic of Orthopedic and Traumatology, University of Pisa, Pisa, Italy
| | - Francesco Muratori
- Section of Orthopedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Nicola Mondanelli
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Stefano Giannotti
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
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13
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GOLFIERI FERNANDADACOSTA, ZANON MAURÍCIO, PERCIO PEDROPAULOVERONA. ATYPICAL FEMORAL FRACTURES DUE TO THE USE OF BISPHOSPHONATES: EPIDEMIOLOGIC STUDY IN A TERTIARY HOSPITAL. ACTA ORTOPEDICA BRASILEIRA 2022; 30:e238821. [PMID: 35719180 PMCID: PMC9177062 DOI: 10.1590/1413-785220223002238821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 11/19/2021] [Indexed: 11/22/2022]
Abstract
Objective: Show the relationship between atypical femoral fractures and prolonged use of
bisphosphonates and analyze the limit of its beneficial use. Methods: Retrospective cohort study (level of evidence 2B). From Atypical fracture
cases, patients who used bisphosphonates were selected and the time period
of their use was analyzed. Additionally, the variables sex, age, and the
side most affected were studied. Results: Nine atypical femur fractures were found, all associated with the use of
bisphosphonates. The average period of use of this medication was nine years
(minimum of three years; maximum of 14 years). The patients’ mean age was of
78 years (69-88 years) and all were women, with the right member being the
most affected. Conclusion: The use of bisphosphonates to prevent osteoporotic fractures has been
increasingly frequent and, when used for a prolonged period, it has been
related to atypical fractures. Further scientific studies on doses, maximum
periods of treatment, and risk-benefit in the indication of these
medications are needed to assist in therapeutic management for each case. Level of Evidence II, Retrospective Study.
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14
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Spanyer J, Barber LA, Lands H, Brown A, Bouxsein M, Heng M, Yakkanti M. Health-related quality of life outcomes after surgical treatment of atypical femur fractures: a multicenter retrospective cohort study. JBMR Plus 2021; 5:e10514. [PMID: 34761142 PMCID: PMC8567490 DOI: 10.1002/jbm4.10514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 04/24/2021] [Accepted: 04/27/2021] [Indexed: 11/10/2022] Open
Abstract
The objective of this study was to examine the health-related quality of life (HRQOL) outcomes for surgically-treated atypical femur fractures (AFFs) compared to typical femoral diaphyseal fractures. Two large trauma center databases were retrospectively queried for surgically-treated femur fractures. Fractures were grouped into AFFs and compared to a control cohort. Controls for the AFF group included women with diaphyseal fractures without additional AFF characteristics. Patients were contacted for administration of the Short Form-36v2 Health Survey. Surveys were completed an average of 30.3 months (range, 6-138 months) and 25.5 months (range, 5-77 months) postoperatively for the AFF and non-AFF groups, respectively. All patients were female, with 46 patients in the AFF and 26 patients in the non-AFF group. The average age of the AFF group was 70.1 years compared with an average age of 67.4 years in the non-AFF group (p = 0.287). Over 90% (91.3%) of patients in the AFF group had a history of bisphosphonate use while 26.9% of patients in the non-AFF group had used bisphosphonates (p < 0.0001). Patients with AFF reported their postoperative physical and mental health to be no different than similarly aged patients with femoral diaphyseal fractures, as measured by the Short Form 36, version 2 (SF-36v2) Health Survey. These data suggest that mid-term patient-reported quality of life outcomes are similar among women who sustain an AFF compared to a cohort of more typical femoral diaphyseal fractures. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
| | - Lauren A Barber
- Hospital for Special Surgery Orthopaedic Surgery New York New York USA
| | - Harrison Lands
- Dartmouth-Hitchcock Health System Lebanon New Hampshire USA
| | - Alexander Brown
- Andrews Sports Medicine and Orthopaedic Center Birmingham Alabama USA
| | - Mary Bouxsein
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | - Marilyn Heng
- Orthopaedic Trauma Surgery Massachusetts General Hospital Boston Massachusetts USA
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15
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Zhou W, van Rooij JGJ, Ebeling PR, Verkerk AJMH, Zillikens MC. The Genetics of Atypical Femur Fractures-a Systematic Review. Curr Osteoporos Rep 2021; 19:123-130. [PMID: 33587247 PMCID: PMC8016774 DOI: 10.1007/s11914-021-00658-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Atypical femur fractures (AFFs) are rare subtrochanteric or diaphyseal fractures regarded as side effects of bisphosphonates (BPs), possibly with a genetic background. Here, we summarize the most recent knowledge about genetics of AFFs. RECENT FINDINGS AFF has been reported in 57 patients with seven different monogenic bone disorders including hypophosphatasia and osteogenesis imperfecta; 56.1% had never used BPs, while 17.5% were diagnosed with the disorder only after the AFF. Gene mutation finding in familial and sporadic cases identified possible AFF-related variants in the GGPS1 and ATRAID genes respectively. Functional follow-up studies of mutant proteins showed possible roles in AFF. A recent small genome-wide association study on 51 AFF cases did not identify significant hits associated with AFF. Recent findings have strengthened the hypothesis that AFFs have underlying genetic components but more studies are needed in AFF families and larger cohorts of sporadic cases to confirm previous results and/or find novel gene variants involved in the pathogenesis of AFFs.
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Affiliation(s)
- Wei Zhou
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeroen G J van Rooij
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Neurology & Alzheimer Center, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Australia
| | - Annemieke J M H Verkerk
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
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16
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Histopathological Finding of Microdamage Accumulation in Atypical Subtrochanteric Femoral Fracture. Case Rep Orthop 2021; 2021:6624414. [PMID: 33824769 PMCID: PMC8007382 DOI: 10.1155/2021/6624414] [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] [Received: 10/08/2020] [Revised: 02/28/2021] [Accepted: 03/09/2021] [Indexed: 11/17/2022] Open
Abstract
Atypical femoral fracture is a low-energy stress fracture in the subtrochanteric region or the femoral shaft and is a complication of the long-term use of bisphosphonates. Histopathological findings of atypical femoral fractures have not been clarified. Herein, we report the case of a 61-year-old woman who fell while walking, which prompted her to visit our facility. She had a 7-year history of alendronate use to treat osteoporosis. A radiograph showed an atypical subtrochanteric femoral fracture, following which she underwent a primary surgery, where an intramedullary femoral nail was used. Implant breakage was discovered 8 weeks after the primary surgery. The patient underwent a revision surgery in which the entry point for the revised intramedullary hole was created to prevent varus position. The lag screw was successfully inserted into the center of the femoral head. Cancellous bone, isolated from the right ilium, was autogenously implanted into the fracture site. Fracture healing was promoted using low-intensity pulse ultrasonography. Callus formation was detected on a radiograph, and full weight-bearing was advised 12 weeks after the revision surgery. The fracture had healed completely at 13 months after the revision surgery. The patient was able to walk without support and could independently perform activities of daily life. Laboratory findings suggested that the concentrations of her bone formation markers were normal, while those of bone resorption markers were elevated. Iliac bone histomorphometry did not reveal severely suppressed bone turnover. In the cortex of fracture site, the lacunar density was markedly lower than the osteocyte density, and microcracks were detected, suggesting impaired osteocyte function and a low potential for fracture healing. This case is notable because it helps to clarify the histopathological findings of atypical femoral fractures.
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17
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Coffman AA, Basta-Pljakic J, Guerra RM, Ebetino FH, Lundy MW, Majeska RJ, Schaffler MB. A Bisphosphonate With a Low Hydroxyapatite Binding Affinity Prevents Bone Loss in Mice After Ovariectomy and Reverses Rapidly With Treatment Cessation. JBMR Plus 2021; 5:e10476. [PMID: 33869992 PMCID: PMC8046044 DOI: 10.1002/jbm4.10476] [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: 01/13/2021] [Accepted: 02/04/2021] [Indexed: 12/30/2022] Open
Abstract
Bisphosphonates (BPs) are a mainstay of osteoporosis treatment; however, concerns about bone health based on oversuppression of remodeling remain. Long‐term bone remodeling suppression adversely affects bone material properties with microdamage accumulation and reduced fracture toughness in animals and increases in matrix mineralization and atypical femur fractures in patients. Although a “drug holiday” from BPs to restore remodeling and improve bone quality seems reasonable, clinical BPs have long functional half‐lives because of their high hydroxyapatite (HAP) binding affinities. This places a practical limit on the reversibility and effectiveness of a drug holiday. BPs with low HAP affinity and strong osteoclast inhibition potentially offer an alternative approach; their antiresorptive effect should reverse rapidly when dosing is discontinued. This study tested this concept using NE‐58025, a BP with low HAP affinity and moderate osteoclast inhibition potential. Young adult female C57Bl/6 mice were ovariectomized (OVX) and treated with NE‐58025, risedronate, or PBS vehicle for 3 months to test effectiveness in preventing long‐term bone loss. Bone microarchitecture, histomorphometry, and whole‐bone mechanical properties were assessed. To test reversibility, OVX mice were similarly treated for 3 months, treatment was stopped, and bone was assessed up to 3 months post‐treatment. NE‐58025 and RIS inhibited long‐term OVX‐induced bone loss, but NE‐58025 antiresorptive effects were more pronounced. Withdrawing NE‐58025 treatment led to the rapid onset of trabecular resorption with a 200% increase in osteoclast surface and bone loss within 1 month. Cessation of risedronate treatment did not lead to increases in resorption indices or bone loss. These results show that NE‐58025 prevents OVX‐induced bone loss, and its effects reverse quickly following cessation treatment in vivo. Low‐HAP affinity BPs may have use as reversible, antiresorptive agents with a rapid on/off profile, which may be useful for maintaining bone health with long‐term BP treatment. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Abigail A Coffman
- Department of Biomedical Engineering The City College of New York New York NY USA
| | - Jelena Basta-Pljakic
- Department of Biomedical Engineering The City College of New York New York NY USA
| | - Rosa M Guerra
- Department of Biomedical Engineering The City College of New York New York NY USA
| | - Frank H Ebetino
- Department of Chemistry University of Rochester Rochester NY USA.,BioVinc, LLC Pasadena CA USA
| | - Mark W Lundy
- BioVinc, LLC Pasadena CA USA.,Department of Anatomy and Cell Biology Indiana University Indianapolis IN USA
| | - Robert J Majeska
- Department of Biomedical Engineering The City College of New York New York NY USA
| | - Mitchell B Schaffler
- Department of Biomedical Engineering The City College of New York New York NY USA
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18
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Evaluation and management of atypical femoral fractures: an update of current knowledge. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:825-840. [PMID: 33590316 DOI: 10.1007/s00590-021-02896-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 01/29/2021] [Indexed: 12/12/2022]
Abstract
Atypical femoral fractures are often attributed to the use of anti-resorptive medications such as bisphosphonates (BP). Whilst they have proven effects on fragility fracture prevention, clinical and laboratory evidence is evolving linking BP-related suppression of bone remodelling to the development of atypical stress-related sub-trochanteric fractures (Shane et al. in JBMR 29:1-23, 2014; Odvina et al. in JCEM 90:1294-301, 2005; Durchschlag et al. in JBMR 21(10):1581-1590, 2006; Donnelly et al. in JBMR 27:672-678, 2012; Mashiba et al. in Bone 28(5):524-531, 2001; Dell et al. in JBMR 27(12):2544-2550, 2012; Black et al. in Lancet 348:1535-1541, 1996; Black et al. in NEJM 356:1809-1822, 2007; Black et al. in JAMA 296:2927-2938, 2006; Schwartz et al. in JBMR 25:976-82, 2010). Injuries may present asymptomatically or with prodromal thigh pain and most can be successfully managed with cephalomedullary nailing and discontinuation of BP therapy. Such injuries exhibit a prolonged time to fracture union with high rates of non-union and metal-work failure when compared to typical subtrochanteric osteoporotic femoral fractures. Despite emerging literature on AFFs, their management continues to pose a challenge to the orthopaedic and extended multi-disciplinary team. The purpose of this review includes evaluation of the current evidence supporting the management of AFFs, clinical and radiological features associated with their presentation and a review of reported surgical strategies to treat and prevent these devastating injures.
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19
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Abeynayake N, Arthur A, Gronthos S. Crosstalk between skeletal and neural tissues is critical for skeletal health. Bone 2021; 142:115645. [PMID: 32949783 DOI: 10.1016/j.bone.2020.115645] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 12/24/2022]
Abstract
Emerging evidence in the literature describes a physical and functional association between the neural and skeletal systems that forms a neuro-osteogenic network. This communication between bone cells and neural tissues within the skeleton is important in facilitating bone skeletal growth, homeostasis and repair. The growth and repair of the skeleton is dependent on correct neural innervation for correct skeletal developmental growth and fracture repair, while pathological conditions such as osteoporosis are accelerated by disruptions to sympathetic innervation. To date, different molecular mechanisms have been reported to mediate communication between bone and neural populations. This review highlights the important role of various cell surface receptors, cytokines and associated ligands as potential regulators of skeletal development, homeostasis, and repair, by mediating interactions between the skeletal and nervous systems. Specifically, this review describes how Bone Morphogenetic Proteins (BMPs), Eph/ephrin, Chemokine CXCL12, Calcitonin Gene-related Peptide (CGRP), Netrins, Neurotrophins (NTs), Slit/Robo and the Semaphorins (Semas) contribute to the cross talk between bone cells and peripheral nerves, and the importance of these interactions in maintaining skeletal health.
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Affiliation(s)
- Nethmi Abeynayake
- Mesenchymal Stem Cell Laboratory, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia; Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Agnieszka Arthur
- Mesenchymal Stem Cell Laboratory, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia; Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Stan Gronthos
- Mesenchymal Stem Cell Laboratory, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia; Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia.
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20
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Yuan S, Shen J. Bacteroides vulgatus diminishes colonic microbiota dysbiosis ameliorating lumbar bone loss in ovariectomized mice. Bone 2021; 142:115710. [PMID: 33148507 DOI: 10.1016/j.bone.2020.115710] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/29/2022]
Abstract
There is a need to discover additional kinds of intestinal microbiota to supplement the probiotic-treatment of postmenopausal osteoporosis. Increasing evidence has indicated that Bacteroides vulgatus has potential as a probiotic for ameliorating postmenopausal bone loss. In this study, ovariectomized female C57/BL6 mice were treated with B. vulgatus ATCC 8482 gavage to investigate the differences in colonic microbiota composition, inflammation signal pathways, inflammatory cytokines, bone turnover markers, and lumbar vertebrae microstructure compared with the control group. Our results show that B. vulgatus ATCC 8482 diminished microbiota dysbiosis and subsequently down-regulated the colonic lipopolysaccharide/TLR-4/p-NF-κB pathway leading to decreased serum TNF-α. This reduced TNF-α/RANKL expression and induced ALP and Runx-2 expression in the 5th lumbar vertebra, leading to amelioration of bone loss and microstructure destruction in the lumbar vertebra of ovariectomized mice. Taken together, these results indicate that B. vulgatus could be a probiotic for treatment of postmenopausal lumbar osteoporosis.
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Affiliation(s)
- Sijie Yuan
- Department of Endocrinology and Metabolic diseases, The Third Affiliated Hospital, Southern Medical University, Guangzhou, Guangdong 510630, China
| | - Jie Shen
- Department of Endocrinology and Metabolic diseases, The Third Affiliated Hospital, Southern Medical University, Guangzhou, Guangdong 510630, China.
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21
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Sakka SD, Cheung MS. Management of primary and secondary osteoporosis in children. Ther Adv Musculoskelet Dis 2020; 12:1759720X20969262. [PMID: 33224280 PMCID: PMC7649886 DOI: 10.1177/1759720x20969262] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 10/05/2020] [Indexed: 12/13/2022] Open
Abstract
Osteoporosis in children differs from adults in terms of definition, diagnosis, monitoring and treatment options. Primary osteoporosis comprises primarily of osteogenesis imperfecta (OI), but there are significant other causes of bone fragility in children that require treatment. Secondary osteoporosis can be a result of muscle disuse, iatrogenic causes, such as steroids, chronic inflammation, delayed or arrested puberty and thalassaemia major. Investigations involve bone biochemistry, dual-energy X-ray absorptiometry scan for bone densitometry and vertebral fracture assessment, radiographic assessment of the spine and, in some cases, quantitative computed tomography (QCT) or peripheral QCT. It is important that bone mineral density (BMD) results are adjusted based on age, gender and height, in order to reflect size corrections in children. Genetics are being used increasingly for the diagnosis and classification of various cases of primary osteoporosis. Bone turnover markers are used less frequently in children, but can be helpful in monitoring treatment and transiliac bone biopsy can assist in the diagnosis of atypical cases of osteoporosis. The management of children with osteoporosis requires a multidisciplinary team of health professionals with expertise in paediatric bone disease. The prevention and treatment of fragility fractures and improvement of the quality of life of patients are important aims of a specialised service. The drugs used most commonly in children are bisphosphonates, that, with timely treatment, can give good results in improving BMD and reshaping vertebral fractures. The data regarding their effect on reducing long bone fractures are equivocal. Denosumab is being used increasingly for various conditions with mixed results. There are more drugs trialled in adults, but these are not yet licenced for children. Increasing awareness of risk factors for paediatric osteoporosis, screening and referral to a specialist team for appropriate management can lead to early detection and treatment of asymptomatic fractures and prevention of further bone damage.
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Affiliation(s)
- Sophia D Sakka
- Department of Endocrinology and Diabetes, Evelina London Children's Hospital, 3rd Floor, Becket House, Westminster Bridge Road, SE1 7EH, London, UK
| | - Moira S Cheung
- Department of Endocrinology and Diabetes, Evelina London Children's Hospital, London, UK
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22
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H. Pylori is related to osteoporosis but only in premenopausal female: a cross-sectional study. BMC Musculoskelet Disord 2020; 21:559. [PMID: 32811503 PMCID: PMC7433125 DOI: 10.1186/s12891-020-03586-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 08/13/2020] [Indexed: 12/19/2022] Open
Abstract
Background Recently, an increasing number of studies have focused on the extra-gastrointestinal effects of Helicobacter pylori (H. pylori), including metabolic syndrome, fatty liver, and rheumatic and skin diseases. Osteoporosis is an asymptomatic disease that can eventually lead to fractures and has a significant impact on the quality of life of elderly individuals. Sex is an influential factor that plays a crucial role in the development of osteoporosis. The aim of this study was to investigate the relationship between H. pylori infection and osteoporosis and to identify potential influencing factors. Methods We conducted a cross-sectional study of individuals older than 50 years old, who had undergone regular physical examinations at the Beijing Shijitan Hospital Health Examination Center from July to October 2018. We evaluated the associations of osteopenia and osteoporosis with H. pylori infection and related serum markers by using multiple linear regression and logistic regression. Then, we analysed the correlation between sex and potential serum biomarkers. Results There were significant relationships between H. pylori infection status and bone density in premenopausal females but not in males (P = 0.381) according to Fisher’s exact test. In females, H. pylori positivity (OR = 0.132, P = 0.023), Body Mass Index (BMI) (OR = 28.163, P = 0.021), and homocysteine (HCY) (OR = 17.218, P = 0.045) were associated with osteoporosis. Calcium had a trend but no statistically significant (OR = 0.060, P = 0.076) relationship with osteoporosis. Furthermore, the waist-to-hip ratio (OR = 5.783, P = 0.029), BMI (OR = 0.152, P = 0.014) and triglyceride levels (OR = 0.201, P = 0.036) were significantly different by sex, after adjusting for age as a confounder. Conclusion H. pylori positivity, BMI and HCY are associated with osteoporosis in premenopausal females. Chronic inflammation may be involved in the relationship between H. pylori and osteoporosis.
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Camacho PM, Petak SM, Binkley N, Diab DL, Eldeiry LS, Farooki A, Harris ST, Hurley DL, Kelly J, Lewiecki EM, Pessah-Pollack R, McClung M, Wimalawansa SJ, Watts NB. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS/AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS-2020 UPDATE. Endocr Pract 2020; 26:1-46. [PMID: 32427503 DOI: 10.4158/gl-2020-0524suppl] [Citation(s) in RCA: 468] [Impact Index Per Article: 117.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Objective: The development of these guidelines is sponsored by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs). Methods: Recommendations are based on diligent reviews of the clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols. Results: The Executive Summary of this 2020 updated guideline contains 52 recommendations: 21 Grade A (40%), 24 Grade B (46%), 7 Grade C (14%), and no Grade D (0%). These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world care of patients. The evidence base presented in the subsequent Appendix provides relevant supporting information for the Executive Summary recommendations. This update contains 368 citations: 123 (33.5%) evidence level (EL) 1 (highest), 132 (36%) EL 2 (intermediate), 20 (5.5%) EL 3 (weak), and 93 (25%) EL 4 (lowest). New or updated topics in this CPG include: clarification of the diagnosis of osteoporosis, stratification of the patient according to high-risk and very-high-risk features, a new dual-action therapy option, and transitions from therapeutic options. Conclusion: This guideline is a practical tool for endocrinologists, physicians in general, regulatory bodies, health-related organizations, and interested laypersons regarding the diagnosis, evaluation, and treatment of post-menopausal osteoporosis. Abbreviations: 25(OH)D = 25-hydroxyvitamin D; AACE = American Association of Clinical Endocrinologists; ACE = American College of Endocrinology; AFF = atypical femoral fracture; ASBMR = American Society for Bone and Mineral Research; BEL = best evidence level; BMD = bone mineral density; BTM = bone turnover marker; CI = confidence interval; CPG = clinical practice guideline; CTX = C-terminal telopeptide type-I collagen; DXA = dual-energy X-ray absorptiometry; EL = evidence level; FDA = U.S. Food and Drug Administration; FRAX® = Fracture Risk Assessment Tool; GI = gastrointestinal; HORIZON = Health Outcomes and Reduced Incidence with Zoledronic acid ONce yearly Pivotal Fracture Trial (zoledronic acid and zoledronate are equivalent terms); ISCD = International Society for Clinical Densitometry; IU = international units; IV = intravenous; LSC = least significant change; NOF = National Osteoporosis Foundation; ONJ = osteonecrosis of the jaw; PINP = serum amino-terminal propeptide of type-I collagen; PTH = parathyroid hormone; R = recommendation; ROI = region of interest; RR = relative risk; SD = standard deviation; TBS = trabecular bone score; VFA = vertebral fracture assessment; WHO = World Health Organization.
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Loundagin LL, Haider IT, Cooper DM, Edwards WB. Association between intracortical microarchitecture and the compressive fatigue life of human bone: A pilot study. Bone Rep 2020; 12:100254. [PMID: 32258250 PMCID: PMC7110329 DOI: 10.1016/j.bonr.2020.100254] [Citation(s) in RCA: 10] [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: 07/29/2019] [Revised: 02/26/2020] [Accepted: 03/02/2020] [Indexed: 11/18/2022] Open
Abstract
Many mechanical properties of cortical bone are largely governed by the underlying microarchitecture; however, the influence of microarchitecture on the fatigue life of bone is poorly understood. Furthermore, imaging-based studies investigating intracortical microarchitecture may expose bone samples to large doses of radiation that may compromise fatigue resistance. The purpose of this pilot study was to 1) investigate the relationship between intracortical microarchitecture and the fatigue life of human bone in compression and 2) examine the effects of synchrotron irradiation on fatigue life measurements. Cortical samples were prepared from the femoral and tibial shafts of three cadaveric donors. A subset of samples was imaged using synchrotron X-ray microCT to quantify microarchitecture, including porosity, canal diameter, lacunar density, lacunar volume, and lacunar orientation. A second group of control samples was not imaged and used only for mechanical testing. Fatigue life was quantified by cyclically loading both groups in zero-compression until failure. Increased porosity and larger canal diameter were both logarithmically related to a shorter fatigue life, whereas lacunar density demonstrated a positive linear relationship with fatigue life (r2 = 45–73%, depending on measure). Irradiation from microCT scanning reduced fatigue life measurements by 91%, but relationships with microarchitecture measurements remained. Additional research is needed to support the findings of this pilot study and fully establish the relationship between intracortical microarchitecture and the compressive fatigue life of bone. Increased porosity and larger canal diameters were associated with a shorter compressive fatigue life. A higher lacunar density was related to a longer compressive fatigue life. Irradiation from synchrotron X-ray microCT scanning reduced fatigue life by 91%. The influence of microarchitecture on fatigue life exhibited similar trends for both irradiated and non-irradiated bone.
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Affiliation(s)
- Lindsay L. Loundagin
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1N4, Canada
- McCaig Institute for Bone and Joint Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB T2N 4Z6, Canada
- Corresponding author at: Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1N4, Canada.
| | - Ifaz T. Haider
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1N4, Canada
- McCaig Institute for Bone and Joint Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB T2N 4Z6, Canada
| | - David M.L. Cooper
- Department of Anatomy, Physiology and Pharmacology, University of Saskatchewan, 105 Administration Place, Saskatoon, SK S7N 5A2, Canada
| | - W. Brent Edwards
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1N4, Canada
- McCaig Institute for Bone and Joint Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB T2N 4Z6, Canada
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Sung CM, Kim RJ, Hah YS, Gwark JY, Park HB. In vitro effects of alendronate on fibroblasts of the human rotator cuff tendon. BMC Musculoskelet Disord 2020; 21:19. [PMID: 31926548 PMCID: PMC6955091 DOI: 10.1186/s12891-019-3014-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 12/19/2019] [Indexed: 12/16/2022] Open
Abstract
Background Bone mineral density of the humeral head is an independent determining factor for postoperative rotator cuff tendon healing. Bisphosphonates, which are commonly used to treat osteoporosis, have raised concerns regarding their relationships to osteonecrosis of the jaw and to atypical fracture of the femur. In view of the prevalence of rotator cuff tear in osteoporotic elderly people, it is important to determine whether bisphosphonates affect rotator cuff tendon healing. However, no studies have investigated bisphosphonates’ cytotoxicity to human rotator cuff tendon fibroblasts (HRFs) or bisphosphonates’ effects on rotator cuff tendon healing. The purpose of this study was to evaluate the cytotoxicity of alendronate (Ald), a bisphosphonate, and its effects on HRF wound healing. Methods HRFs were obtained from human supraspinatus tendons, using primary cell cultures. The experimental groups were control, 0.1 μM Ald, 1 μM Ald, 10 μM Ald, and 100 μM Ald. Alendronate exposure was for 48 h, except during a cell viability analysis with durations from 1 day to 6 days. The experimental groups were evaluated for cell viability, cell cycle and cell proliferation, type of cell death, caspase activity, and wound-healing ability. Results The following findings regarding the 100 μM Ald group contrasted with those for all the other experimental groups: a significantly lower rate of live cells (p < 0.01), a higher rate of subG1 population, a lower rate of Ki-67 positive cells, higher rates of apoptosis and necrosis, a higher number of cells with DNA fragmentation, higher caspase-3/7 activity (p < 0.001), and a higher number of caspase-3 positive staining cells. In scratch-wound healing analyses of all the experimental groups, all the wounds healed within 48 h, except in the 100 μM Ald group (p < 0.001). Conclusions Low concentrations of alendronate appear to have little effect on HRF viability, proliferation, migration, and wound healing. However, high concentrations are significantly cytotoxic, impairing cellular proliferation, cellular migration, and wound healing in vitro.
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Affiliation(s)
- Chang-Meen Sung
- Department of Orthopaedic Surgery, Gyeongsang National University College of Medicine, Jinju, South Korea
| | - Ra Jeong Kim
- Department of Convergence Medical Science, Gyeongsang National University, Jinju, South Korea
| | - Young-Sool Hah
- Institute of Health Sciences, Gyeongsang National University School of Medicine and Biomedical Research Institute, Gyeongsang National University Hospital, Jinju, South Korea
| | - Ji-Yong Gwark
- Department of Orthopaedic Surgery, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea, 51472
| | - Hyung Bin Park
- Department of Orthopaedic Surgery, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea, 51472.
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Spinelli MS, Marini E, Daolio PA, Piccioli A. Atypical diaphyseal femoral fractures: Considerations on surgical technique. Injury 2019; 50 Suppl 2:S65-S69. [PMID: 30782394 DOI: 10.1016/j.injury.2019.01.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In the last two decades bisphosphonates (BP) has become the mainstream therapy for osteoporosis and the benefit in reducing the incidence of fractures has been well demonstrated in several studies, together with the drug long term (5-10 years) efficacy and safety. A complication of the long-term use of bisphosphonates is a low-energy stress fractures located in the sub-trochanteric region and the femoral shaft called atypical femur fracture (AFF). These stress fractures can be seen on plain radiographs as simple transverse patterns, with unicortical beaking and hypertrophy of the diaphyseal lateral cortex. Usually a localized thigh pain in the prodromal phase may precede the fracture by months. The current surgical treatment of choice for AFFs is intramedullary nailing (IMN). However, the treatment of AFFs is associated with a higher rate of intra-operative and post-surgical complications. This is related to anatomical e biomechanical reasons. Iatrogenic fractures, deformities, medial gap opening, eccentric position of the distal nail tip with anterior cortex perforation, delayed or non-union are frequent complications of this procedure and healing rate of AFFs. The average healing time of almost 8 months for AFFs appeared to be longer than that for typical femoral fractures, which heal at an average of 3-6 months. The purpose of this study is to analyze the different surgical devices and techniques and to advance some considerations that can be useful to diminish the rate of failure and/or complications in the treatment of AFFs in both oncologic and osteoporotic patients.
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Affiliation(s)
- Maria Silvia Spinelli
- Orthopaedic and Traumatology Unit, "Fatebene Fratelli Hospital", Isola Tiberina, Rome, Italy.
| | - Eleonora Marini
- Orthopaedic Oncology Unit, Istituto Ortopedico "G. Pini", Milan, Italy
| | | | - Andrea Piccioli
- Department of Musculoskeletal Oncology, "Palazzo Baleani" Umberto I University Hospital, Rome, Italy
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Galanis D, Soultanis K, Lelovas P, Zervas A, Papadopoulos P, Galanos A, Argyropoulou K, Makropoulou M, Patsaki A, Passali C, Tsingotjidou A, Kourkoulis S, Mitakou S, Dontas I. Protective effect of Glycyrrhiza glabra roots extract on bone mineral density of ovariectomized rats. Biomedicine (Taipei) 2019; 9:8. [PMID: 31124454 PMCID: PMC6533940 DOI: 10.1051/bmdcn/2019090208] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 03/09/2019] [Indexed: 12/20/2022] Open
Abstract
Objective: The aim of this study was to evaluate the potential effect of the methanolic extract of plant Glycyrrhiza glabra roots on bone mineral density and femoral bone strength of ovariectomized rats. Methods: Thirty 10-month-old Wistar rats were randomly separated into three groups of ten, Control, Ovariectomy and Ovariectomy-plus-Glycyrrhiza in their drinking water. Total and proximal tibial bone mineral density was measured in all groups before ovariectomy (baseline) and after 3 and 6 months post ovariectomy. Three-point-bending of the femurs and uterine weight and histology were examined at the end of the study. Results: No significant difference was noted in bone density percentage change of total tibia from baseline to 3 months between Control and Ovariectomy-plus-Glycyrrhiza groups (+5.31% ± 4.75 and +3.30% ± 6.31 respectively, P = non significant), and of proximal tibia accordingly (+5.58% ± 6.92 and +2.61% ± 13.62, P = non significant) demonstrating a strong osteoprotective effect. There was notable difference in percentage change of total tibia from baseline to 6 months between groups Ovariectomy and Ovariectomy-plus-Glycyrrhiza (−13.03% ± 5.11 and −0.84% ± 7.63 respectively, P < 0.005), and of proximal tibia accordingly (−27.9% ± 3.69 and −0.81% ± 14.85 respectively, P < 0.001), confirming the protective effect of Glycyrrhiza glabra extract in preserving bone density of the Ovariectomy-plus-Glycyrrhiza group. Three-point-bending did not reveal any statistically significant difference between Ovariectomy and Ovariectomy-plus-Glycyrrhiza groups. Uterine weights of the Ovariectomy-plus-Glycyrrhiza group ranged between the other two groups with no statistically significant difference to each. Conclusions: Glycyrrhiza glabra root extract notably protected tibial bone mineral density loss in Ovariectomy-plus-Glycyrrhiza rats in comparison with ovariectomized rats, but did not improve biomechanical strength.
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Affiliation(s)
- Dimitrios Galanis
- Laboratory for Research of the Musculoskeletal System (LRMS), School of Medicine, National and Kapodistrian University of Athens, KAT Hospital, Athens, Greece
| | - Konstantinos Soultanis
- 1st Department of Orthopaedics, National and Kapodistrian University of Athens, Faculty of Medicine, Attiko Hospital, Athens, Greece
| | - Pavlos Lelovas
- Laboratory for Research of the Musculoskeletal System (LRMS), School of Medicine, National and Kapodistrian University of Athens, KAT Hospital, Athens, Greece
| | - Alexandros Zervas
- Laboratory for Research of the Musculoskeletal System (LRMS), School of Medicine, National and Kapodistrian University of Athens, KAT Hospital, Athens, Greece
| | - Panagiotis Papadopoulos
- Laboratory for Research of the Musculoskeletal System (LRMS), School of Medicine, National and Kapodistrian University of Athens, KAT Hospital, Athens, Greece
| | - Antonis Galanos
- Laboratory for Research of the Musculoskeletal System (LRMS), School of Medicine, National and Kapodistrian University of Athens, KAT Hospital, Athens, Greece
| | - Katerina Argyropoulou
- Department of Pharmacognosy and Natural Products Chemistry, Faculty of Pharmacy, National and Kapodistrian University of Athens, Greece
| | - Maria Makropoulou
- Department of Pharmacognosy and Natural Products Chemistry, Faculty of Pharmacy, National and Kapodistrian University of Athens, Greece
| | | | - Christina Passali
- Laboratory for Research of the Musculoskeletal System (LRMS), School of Medicine, National and Kapodistrian University of Athens, KAT Hospital, Athens, Greece
| | - Anastasia Tsingotjidou
- Lab. of Anatomy, Histology and Embryology, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki School of Veterinary Medicine,
| | - Stavros Kourkoulis
- Department of Mechanics, National Technical University of Athens (NTUA), National Technical University of Athens, Greece
| | - Sofia Mitakou
- Department of Pharmacognosy and Natural Products Chemistry, Faculty of Pharmacy, National and Kapodistrian University of Athens, Greece
| | - Ismene Dontas
- Laboratory for Research of the Musculoskeletal System (LRMS), School of Medicine, National and Kapodistrian University of Athens, KAT Hospital, Athens, Greece
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Naruphontjirakul P, Tsigkou O, Li S, Porter AE, Jones JR. Human mesenchymal stem cells differentiate into an osteogenic lineage in presence of strontium containing bioactive glass nanoparticles. Acta Biomater 2019; 90:373-392. [PMID: 30910622 DOI: 10.1016/j.actbio.2019.03.038] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 03/14/2019] [Accepted: 03/20/2019] [Indexed: 02/08/2023]
Abstract
While bioactive glass and ions released during its dissolution are known to stimulate osteoblast cells, the effect bioactive glass has on human stem cells is not clear. Here, we show that spherical monodispersed strontium containing bioactive nanoparticles (Sr-BGNPs) of composition 90.6 mol% SiO2, 5.0 mol% CaO, 4.4% mol% SrO (4.4%Sr-BGNPs) and 88.8 mol% SiO2, 1.8 mol% CaO, and 9.4 mol% SrO (9.4%Sr-BGNPs) stimulate bone marrow derived human stem cell (hMSC) differentiation down an osteogenic pathway without osteogenic supplements. The particles were synthesised using a modified Stӧber process and had diameters of 90 ± 10 nm. Previous work on similar particles that did not contain Sr (80 mol% SiO2, 20 mol% CaO) showed stem cells did not differentiate when exposed to the particles. Here, both compositions of the Sr-BGNPs (up to concentration of 250 μg/mL) stimulated the early-, mid-, and late-stage markers of osteogenic differentiation and accelerated mineralisation in the absence of osteogenic supplements. Sr ions play a key role in osteogenic stem cell differentiation. Sr-BGNP dissolution products did not adversely affect hMSC viability and no significant differences in viability were measured between each particle composition. Confocal and transmission electron microscopy (TEM) demonstrated that monodispersed Sr-BGNPs were internalised and localised within vesicles in the cytoplasm of hMSCs. Degradation of particles inside the cells was observed, whilst maintaining effective cations (Ca and Sr) in their silica network after 24 h in culture. The uptake of Sr-BGNPs by hMSCs was reduced by inhibitors of specific routes of endocytosis, indicating that the Sr-BGNPs uptake by hMSCs was probably via mixed endocytosis mechanisms. Sr-BGNPs have potential as injectable therapeutic devices for bone regeneration or treatment of conditions such as osteoporosis, because of their ability deliver a sustained release of osteogenic inorganic cations, e.g. calcium (Ca) or and strontium (Sr), through particle degradation locally to cells. STATEMENT OF SIGNIFICANCE: Here, we show that 90 nm spherical strontium containing bioactive nanoparticles of stimulate bone marrow derived human stem cell (hMSC) differentiation down an osteogenic pathway without the use of osteogenic supplements. While bioactive glass and its dissolution products are known to promote excellent bone regeneration in vivo and to stimulate osteoblast cells to produce bone matrix in vitro, their effect on human stem cells is not clear. Previously our nanoparticles that contained only SiO2 and CaO did not provoke human bone marrow or adipose derived stem cell differentiation.
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Suh YS, Jang BW, Nho JH, Won SH, Lee WS. Atypical incomplete femoral neck fracture in patients taking long-term bisphosphonate: Case report, a report of 2 cases. Medicine (Baltimore) 2019; 98:e14701. [PMID: 30817607 PMCID: PMC6831339 DOI: 10.1097/md.0000000000014701] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
RATIONALE We present 2 cases of lateral incomplete impending fracture of the femoral neck without trauma in elderly patients taking long-term bisphosphonate (BP) treatment, and we defined it as atypical femoral neck fracture (AFNF). To the best of our knowledge, this is the first report on the follow-up results of AFNF. PATIENT CONCERNS Patients in both cases had been taking BP drugs for a long time with osteoporosis. The duration of BP treatment was 6 years, and there was no history of repeated stresses. DIAGNOSES All fractures were linear at the lateral aspect of the mid portion of the femoral neck, and the BMD of the femoral neck was -0.9, and -1.8, respectively. INTERVENTIONS Internal fixation was performed in both cases (73 years, 68 years) using cannulated screws. OUTCOMES In both patients who underwent screw fixation, the fracture line started to extend distally at 4 weeks and 2 weeks following surgery. In the 3-month follow-up image, the length of the fracture increased by 20.1 mm and 9.9 mm, respectively. There was a problem with active rehabilitation, and the possibility of revision was also found to be a burden in terms of mortality and cost in older patients. LESSONS In the case of AFNF, guidelines for treatment should be set in consideration of the decreased bone healing, even when the fracture pattern is simple. Arthroplasty based on a wider indication may be worth considering.
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Affiliation(s)
| | | | | | | | - Won-Seok Lee
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Seoul, Republic of Korea
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30
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Camacho PM, Petak SM, Binkley N, Clarke BL, Harris ST, Hurley DL, Kleerekoper M, Lewiecki EM, Miller PD, Narula HS, Pessah-Pollack R, Tangpricha V, Wimalawansa SJ, Watts NB. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS - 2016. Endocr Pract 2019; 22:1-42. [PMID: 27662240 DOI: 10.4158/ep161435.gl] [Citation(s) in RCA: 310] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ABBREVIATIONS AACE = American Association of Clinical Endocrinologists AFF = atypical femur fracture ASBMR = American Society for Bone and Mineral Research BEL = best evidence level BMD = bone mineral density BTM = bone turnover marker CBC = complete blood count CI = confidence interval DXA = dual-energy X-ray absorptiometry EL = evidence level FDA = U.S. Food and Drug Administration FLEX = Fracture Intervention Trial (FIT) Long-term Extension FRAX® = Fracture Risk Assessment Tool GFR = glomerular filtration rate GI = gastrointestinal HORIZON = Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly IOF = International Osteoporosis Foundation ISCD = International Society for Clinical Densitometry IU = international units IV = intravenous LSC = least significant change NBHA = National Bone Health Alliance NOF = National Osteoporosis Foundation 25(OH)D = 25-hydroxy vitamin D ONJ = osteonecrosis of the jaw PINP = serum carboxy-terminal propeptide of type I collagen PTH = parathyroid hormone R = recommendation RANK = receptor activator of nuclear factor kappa-B RANKL = receptor activator of nuclear factor kappa-B ligand RCT = randomized controlled trial RR = relative risk S-CTX = serum C-terminal telopeptide SQ = subcutaneous VFA = vertebral fracture assessment WHO = World Health Organization.
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Leclerc JT, Michou L, Vaillancourt F, Pelet S, Simonyan D, Belzile EL. Prevalence and Characteristics of Atypical Periprosthetic Femoral Fractures. J Bone Miner Res 2019; 34:83-92. [PMID: 30280425 DOI: 10.1002/jbmr.3584] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/14/2018] [Accepted: 08/26/2018] [Indexed: 12/12/2022]
Abstract
Bisphosphonate use has been associated with atypical femoral fractures (AFFs), defined by the American Society of Bone and Mineral Research (ASBMR) Task Force criteria, which currently exclude periprosthetic fractures. The objectives of this study were to establish the prevalence of atypical periprosthetic femoral fractures (APFFs) in patients with hip and knee arthroplasties and to determine the clinical and radiological risk factors associated with these fractures. We performed a retrospective radiological review of all femoral fractures between January 1, 2006, and March 31, 2015, in Quebec City, Canada. Patients who sustained a periprosthetic femoral fracture (PFF) were identified and included in this study. We used the ASBMR Task Force criteria to identify atypical fractures and establish their prevalence. Data from medical records and radiological assessments of the femoral anatomy, the characteristics of the fracture, and the positioning of the prosthesis were collected. The prevalence of APFFs among PFFs was 8.3% (11/133). A strong association with bisphosphonates (p = 0.007) was observed, as well as an increased risk of APFFs among alendronate users compared to risedronate users (p = 0.04). A transverse fracture (p < 0.0001), a periosteal thickening of the lateral cortex at the fracture (p < 0.0001), a unicortical fracture (p = 0.02), and prodromal symptoms (p = 0.03) were associated with APFFs. The type of implant, its positioning, and the femoral geometry did not appear to be risk factors for APFFs compared to PFFs. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Jean-Thomas Leclerc
- Department of Orthopedic Surgery, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Quebec, QC, Canada
| | - Laëtitia Michou
- Division of Rheumatology, Department of Medicine, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Quebec, QC, Canada.,Centre de recherche Fonds de la recherche du Québec en santé (FRQS) du Centre Hospitalier Universitaire (CHU) de Québec, Quebec, QC, Canada
| | | | - Stéphane Pelet
- Department of Orthopedic Surgery, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Quebec, QC, Canada.,Centre de recherche Fonds de la recherche du Québec en santé (FRQS) du Centre Hospitalier Universitaire (CHU) de Québec, Quebec, QC, Canada
| | - David Simonyan
- Clinical and Evaluative Research Platform, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval Research Centre, Quebec, QC, Canada
| | - Etienne L Belzile
- Department of Orthopedic Surgery, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Quebec, QC, Canada.,Centre de recherche Fonds de la recherche du Québec en santé (FRQS) du Centre Hospitalier Universitaire (CHU) de Québec, Quebec, QC, Canada
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Kim SM, Rhyu KH, Lim SJ. Salvage of failed osteosynthesis for an atypical subtrochanteric femoral fracture associated with long-term bisphosphonate treatment using a 95° angled blade plate. Bone Joint J 2018; 100-B:1511-1517. [PMID: 30418051 DOI: 10.1302/0301-620x.100b11.bjj-2018-0306.r1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to evaluate the outcomes of a salvage procedure using a 95° angled blade plate for failed osteosynthesis of atypical subtrochanteric femoral fractures associated with the long-term use of bisphosphonates. These were compared with those for failed osteosynthesis of subtrochanteric fractures not associated with bisphosphonate treatment. PATIENTS AND METHODS Between October 2008 and July 2016, 14 patients with failed osteosynthesis of an atypical subtrochanteric femoral fracture were treated with a blade plate (atypical group). Their mean age was 67.8 years (60 to 74); all were female. During the same period, 21 patients with failed osteosynthesis of a typical subtrochanteric fracture underwent restabilization using a blade plate (typical group). Outcome variables included the time of union, postoperative complications, Harris Hip Score, and Sanders functional rating scale. RESULTS In the atypical group, union was achieved in 12 patients (85.7%) at a mean of 8.4 months (4 to 12). The mean follow-up was 31.2 months (12 to 92) The plate broke in one patient requiring further stabilization with a longer plate and strut-allograft. Another patient with failure of fixation and varus angulation at the fracture site declined further surgery. In the typical group, union was achieved in 18 patients (85.7%) at a mean of 7.9 months (4 to 12). There was no difference in the mean Harris Hip Score between the two groups (83.1 points vs 86.8 points; p = 0.522) at the time of final follow-up. Sanders functional rating scores were good or excellent in 78.6% of the atypical group and in 81.0% of the typical group. CONCLUSION The 95° angled blade plate was shown to be an effective fixation modality for nonunion of atypical subtrochanteric fractures with a high rate of union and functional improvement, comparable to those after fractures not associated with bisphosphonate treatment. Cite this article: Bone Joint J 2018;100-B:1511-17.
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Affiliation(s)
- S M Kim
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University School of Medicine, Seoul, South Korea
| | - K H Rhyu
- Department of Orthopedic Surgery, Kyung Hee University Hospital, College of Medicine, Kyung-Hee University, Seoul, South Korea
| | - S J Lim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Munro JT, Millar JS, Fernandez JW, Walker CG, Howie DW, Shim VB. Risk analysis of patients with an osteolytic acetabular defect after total hip arthroplasty using subject-specific finite-element modelling. Bone Joint J 2018; 100-B:1455-1462. [DOI: 10.1302/0301-620x.100b11.bjj-2018-0092.r2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims Osteolysis, secondary to local and systemic physiological effects, is a major challenge in total hip arthroplasty (THA). While osteolytic defects are commonly observed in long-term follow-up, how such lesions alter the distribution of stress is unclear. The aim of this study was to quantitatively describe the biomechanical implication of such lesions by performing subject-specific finite-element (FE) analysis on patients with osteolysis after THA. Patients and Methods A total of 22 hemipelvis FE models were constructed in order to assess the transfer of load in 11 patients with osteolysis around the acetabular component of a THA during slow walking and a fall onto the side. There were nine men and two women. Their mean age was 69 years (55 to 81) at final follow-up. Changes in peak stress values and loads to fracture in the presence of the osteolytic defects were measured. Results The von Mises stresses were increased in models of those with and those without defects for both loading scenarios. Although some regions showed increases in stress values of up to 100%, there was only a moderate 11.2% increase in von Mises stress in the series as a whole. The site of fracture changed in some models with lowering of the load to fracture by 500 N. The most common site of fracture was the pubic ramus. This was more frequent in models with larger defects. Conclusion We conclude that cancellous defects cause increases in stress within cortical structures. However, these are likely to lead to a modest decrease in the load to fracture if the defect is large (> 20cm3) or if the patient is small with thin cortical structures and low bone mineral density. Cite this article: Bone Joint J 2018;100-B:1455–62.
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Affiliation(s)
- J. T. Munro
- Auckland City Hospital, Department of Surgery and University of Auckland, Auckland, New Zealand
| | - J. S. Millar
- Auckland City Hospital, Department of Surgery and University of Auckland, Auckland, New Zealand
| | - J. W. Fernandez
- Auckland Bioengineering Institute and Department of Engineering Science, University of Auckland, Auckland, New Zealand
| | - C. G. Walker
- Department of Engineering Science, University of Auckland, Auckland, New Zealand
| | - D. W. Howie
- Orthopaedic and Trauma Service, Royal Adelaide Hospital, Adelaide, Australia; Professor and Head of Discipline of Orthopaedics and Trauma, University of Adelaide, Adelaide, Australia
| | - V. B. Shim
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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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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Alarkawi D, Ali MS, Bliuc D, Center JR, Prieto‐Alhambra D. The Challenges and Opportunities of Pharmacoepidemiology in Bone Diseases. JBMR Plus 2018; 2:187-194. [PMID: 30283902 PMCID: PMC6124176 DOI: 10.1002/jbm4.10051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 03/21/2018] [Accepted: 03/27/2018] [Indexed: 11/29/2022] Open
Abstract
Pharmacoepidemiology is used extensively in osteoporosis research and involves the study of the use and effects of drugs in large numbers of people. Randomized controlled trials are considered the gold standard in assessing treatment efficacy and safety. However, their results can have limited external validity when applied to day-to-day patients. Pharmacoepidemiological studies aim to assess the effect/s of treatments in actual practice conditions, but they are limited by the quality, completeness, and inherent bias due to confounding. Sources of information include prospectively collected (primary) as well as readily available routinely collected (secondary) (eg, electronic medical records, administrative/claims databases) data. Although the former enable the collection of ad hoc measurements, the latter provide a unique opportunity for the study of large representative populations and for the assessment of rare events at relatively low cost. Observational cohort and case-control studies, the most commonly implemented study designs in pharmacoepidemiology, each have their strengths and limitations. However, the choice of the study design depends on the research question that needs to be answered. Despite the many advantages of observational studies, they also have limitations. First, missing data is a common issue in routine data, frequently dealt with using multiple imputation. Second, confounding by indication arises because of the lack of randomization; multivariable regression and more specific techniques such as propensity scores (adjustment, matching, stratification, trimming, or weighting) are used to minimize such biases. In addition, immortal time bias (time period during which a subject is artefactually event-free by study design) and time-varying confounding (patient characteristics changing over time) are other types of biases usually accounted for using time-dependent modeling. Finally, residual "uncontrolled" confounding is difficult to assess, and hence to account for it, sensitivity analyses and specific methods (eg, instrumental variables) should be considered.
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Affiliation(s)
- Dunia Alarkawi
- Bone Biology DivisionGarvan Institute of Medical ResearchSchool of MedicineUniversity of New South WalesSydneyAustralia
| | - M Sanni Ali
- Centre for Statistics in Medicine and Nuffield Department of OrthopaedicsRheumatologyand Musculoskeletal Sciences (NDORMS)University of OxfordOxfordUK
| | - Dana Bliuc
- Bone Biology DivisionGarvan Institute of Medical ResearchSchool of MedicineUniversity of New South WalesSydneyAustralia
| | - Jacqueline R Center
- Bone Biology DivisionGarvan Institute of Medical ResearchSchool of MedicineUniversity of New South WalesSydneyAustralia
- Clinical SchoolSt Vincent's HospitalSydneyAustralia
| | - Daniel Prieto‐Alhambra
- Centre for Statistics in Medicine and Nuffield Department of OrthopaedicsRheumatologyand Musculoskeletal Sciences (NDORMS)University of OxfordOxfordUK
- MRC Lifecourse Epidemiology UnitSouthamptonUK
- GREMPAL Research Group (Idiap Jordi Gol Primary Care Research Institute) and CIBERFesUniversitat Autonoma de BarcelonaBarcelonaSpain
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Fatigue as the missing link between bone fragility and fracture. Nat Biomed Eng 2018; 2:62-71. [DOI: 10.1038/s41551-017-0183-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 12/07/2017] [Indexed: 02/07/2023]
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Yeh WL, Su CY, Chang CW, Chen CH, Fu TS, Chen LH, Lin TY. Surgical outcome of atypical subtrochanteric and femoral fracture related to bisphosphonates use in osteoporotic patients with or without teriparatide treatment. BMC Musculoskelet Disord 2017; 18:527. [PMID: 29237448 PMCID: PMC5729282 DOI: 10.1186/s12891-017-1878-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 11/28/2017] [Indexed: 11/19/2022] Open
Abstract
Background Atypical subtrochanteric fracture and femoral fracture have been considered to be rare complications related to long-term bisphosphonates use. A reduced bone turnover rate may lead to delayed bone healing. Limited data have revealed that teriparatide treatment may reverse the effect of bisphosphonates and be effective in bone healing. Methods We reviewed patients with atypical subtrochanteric and femoral fracture related to bisphosphonates use between January 2008 and December 2014. Thirteen female patients were enrolled. Radiographic findings were compatible with the characteristics of atypical fracture. Surgical intervention was performed for all, and teriparatide use was advised postoperatively. Outcome measures included perioperative results, and clinical and radiographic outcome. Results Of the 13 female patients enrolled, 10 had subtrochanteric and 6 had proximal femoral fracture; 3 had bilateral fractures. The mean age of the patients at surgery was 70.15±6.36 years. Most fractures (68.8%) presented prodromal thigh pain. All patients were treated with an intramedullary fixation system without severe complications. The patients were divided into 2 groups based on whether they had received treatment with teriparatide or not. The mean time to bone union was 4.4 months in the teriparatide-treated group, and 6.2 months in the non-teriparatide-treated group (p=0.116). Six patients (75%) in the teriparatide-treated group and 4 (50%) in the non-teriparatide-treated group (p= 0.3) achieved bone union within 6 months. The means of the modified Harris Hip Score and Numerical Rating Scale were significantly better in the teriparatide-treated group at postoperative 6 months. Seven patients had the same ability to walk at the 1-year follow-up as they did before the atypical fracture. Conclusions Teriparatide treatment in patients with atypical fracture may help in fracture healing, hip function recovery, and pain relief in this reduced bone turnover patient group.
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Affiliation(s)
| | | | - Chia-Wei Chang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Bone and Joint Research Center, and Chang Gung University,, Taiwan, F7, No 222 Mai-King Road, Keelung, Taiwan
| | - Chien-Hao Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Bone and Joint Research Center, and Chang Gung University,, Taiwan, F7, No 222 Mai-King Road, Keelung, Taiwan
| | - Tsai-Sheng Fu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Bone and Joint Research Center, and Chang Gung University,, Taiwan, F7, No 222 Mai-King Road, Keelung, Taiwan
| | - Lih-Huei Chen
- Department of Orthopedic Surgery, Division of Trauma, Chang Gung Memorial Hospital, Linkou branch, Bone and Joint Research Center and Chang Gung University, Taoyuan, Taiwan
| | - Tung-Yi Lin
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Bone and Joint Research Center, and Chang Gung University,, Taiwan, F7, No 222 Mai-King Road, Keelung, Taiwan.
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Pedrazzoni M, Giusti A, Girasole G, Abbate B, Verzicco I, Cervellin G. Atypical femoral fractures in Italy: a retrospective analysis in a large urban emergency department during a 7-year period (2007-2013). J Bone Miner Metab 2017; 35:562-570. [PMID: 27830385 DOI: 10.1007/s00774-016-0790-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 09/20/2016] [Indexed: 10/20/2022]
Abstract
The aim of this study was to determine the incidence of atypical femoral fractures (AFFs) seen in a large emergency department in Italy. It was a retrospective study of all men and women aged 40 years or older admitted to the Emergency Department of Parma University Hospital for a femoral fracture. Cases were identified in the hospital database with use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 820 or 821 or text strings. All the radiographic images of fractures not clearly identified as proximal or condylar were retrieved and evaluated by three independent reviewers. Fractures were considered as atypical if all three reviewers agreed on at least four of five major features defined by the 2013 American Society for Bone and Mineral Research criteria. In the 7-year period (2007-2013), with a total follow-up of 1,383,154 patient-years, we found 22 AFFs in 21 patients, accounting for 7.1% of low-trauma subtrochanteric/femoral shaft fractures and 0.6% of all femoral fractures. The incidence was very low (1.6 in 100,000 patient-years in both sexes combined). In contrast, the incidence of classic fractures of the proximal end of the femur was at least two orders of magnitude higher (typical/atypical rate ratio 152). Bisphosphonate use was reported in 13 patients (62%; mean treatment duration 9 years; range 5-14 years). Among 286 patients with typical subtrochanteric/femoral shaft fractures, 20 were being treated with bisphosphonate (7%; odds ratio 22; 95% confidence interval 8-58; p < 0.001). This study confirms the very low incidence of AFFs in the largest Italian cohort of patients to date. Even though the risk is higher in patients treated with bisphosphonates, AFFs are very rare, and typical femoral fractures are at least 100-fold more frequent.
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Affiliation(s)
- Mario Pedrazzoni
- Department of Clinical and Experimental Medicine, University of Parma, Via Gramsci 14, 43126, Parma, Italy.
| | - Andrea Giusti
- Bone Clinic, Department of Geriatric Care, Ortho-Geriatrics and Rehabilitation, Galliera Hospital, Genoa, Italy
| | | | - Barbara Abbate
- Department of Clinical and Experimental Medicine, University of Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Ignazio Verzicco
- Department of Clinical and Experimental Medicine, University of Parma, Via Gramsci 14, 43126, Parma, Italy
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Lateral Cortical Thickening and Bone Heterogeneity of the Subtrochanteric Femur Measured With Quantitative CT as Indicators for Early Detection of Atypical Femoral Fractures in Long-Term Bisphosphonate Users. AJR Am J Roentgenol 2017; 209:867-873. [PMID: 28796551 DOI: 10.2214/ajr.17.17938] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of our study was to compare subtrochanteric femur bone mineral density (BMD) and bone quality of long-term bisphosphonate (BP) users who sustained an atypical femoral fracture (AFF) with BP users who did not sustain a femoral fracture and BP-naïve patients with no history of femoral fracture using quantitative CT (QCT). MATERIALS AND METHODS Fourteen female BP users with an AFF (mean age, 72.6 years; mean duration of BP use, 6.2 years; mean body mass index, 21.9) who had undergone QCT before fracture events were sex-, age-, BP use duration-, and body mass index-matched to 14 BP users who did not sustain a fracture and 14 BP-naïve patients. The lateral cortical thickness index (CTI) and the mean BMD (BMDmean) and SD of the BMD (BMDSD) within the lateral cortex and within the entire cross-sectional area of the subtrochanteric femur were measured on axial QCT. Femoral neck-shaft angles were measured on the QCT scout image. Parameters were analyzed using the Kruskal-Wallis test. RESULTS Lateral CTIs were greater in the BP users with an AFF (median, 0.28) than in the BP users without a femoral fracture (median, 0.21) (p = 0.038) and the BP-naïve group (median, 0.21) (p = 0.009). The lateral cortex BMDSD was significantly higher in the BP users with an AFF (median, 59.59 mg/cm3) than the BP users without a femoral fracture (median, 39.27 mg/cm3; p = 0.049) and the BP-naïve group (median, 31.02 mg/cm3; p = 0.037). There was no significant difference among groups in lateral cortex BMDmean, BMDmean and BMDSD of the entire cross-sectional area, and femoral neck-shaft angle. CONCLUSION Long-term BP users with a subsequent AFF had a thicker lateral cortex and higher lateral cortex BMDSD at the subtrochanteric area before the fracture on QCT than BP users who did not sustain a femoral fracture and BP-naïve patients.
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Wright NC, Foster PJ, Mudano AS, Melnick JA, Lewiecki EM, Shergy WJ, Curtis JR, Cutter GR, Danila MI, Kilgore ML, Lewis EC, Morgan SL, Redden DT, Warriner AH, Saag KG. Assessing the feasibility of the Effectiveness of Discontinuing Bisphosphonates trial: a pilot study. Osteoporos Int 2017; 28:2495-2503. [PMID: 28540506 PMCID: PMC5734645 DOI: 10.1007/s00198-017-4073-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 05/01/2017] [Indexed: 10/19/2022]
Abstract
UNLABELLED The Effectiveness of Discontinuing Bisphosphonates (EDGE) study is a planned pragmatic clinical trial to guide "drug holiday" clinical decision making. This pilot study assessed work flow and feasibility of such a study. While participant recruitment and treatment adherence were suboptimal, administrative procedures were generally feasible and minimally disrupted clinic flow. INTRODUCTION The comparative effectiveness of continuing or discontinuing long-term alendronate (ALN) on fractures is unknown. A large pragmatic ALN discontinuation study has potential to answer this question. METHODS We conducted a 6-month pilot study of the planned the EDGE study among current long-term ALN users (women aged ≥65 with ≥3 years of ALN use) to determine study work flow and feasibility including evaluating the administrative aspects of trial conduct (e.g., time to contract, institutional review board (IRB) approval), assessing rates of site and participant recruitment, and evaluating post-randomization outcomes, including adherence, bisphosphonate-associated adverse events, and participant and site satisfaction. We assessed outcomes 1 and 6 months after randomization. RESULTS Nine sites participated, including seven community-based medical practices and two academic medical centers. On average (SD), contract execution took 3.4 (2.3) months and IRB approval took 13.9 (4.1) days. Sites recruited 27 participants (13 to continue ALN and 14 to discontinue ALN). Over follow-up, 22% of participants did not adhere to their randomization assignment: 30.8% in the continuation arm and 14.3% in the discontinuation arm. No fractures or adverse events were reported. Sites reported no issues regarding work flow, and participants were highly satisfied with the study. CONCLUSIONS Administrative procedures of the EDGE study were generally feasible, with minimal disruption to clinic flow. In this convenience sample, participant recruitment was suboptimal across most practice sites. Accounting for low treatment arm adherence, a comprehensive recruitment approach will be needed to effectively achieve the scientific goals of the EDGE study.
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Affiliation(s)
- N C Wright
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - P J Foster
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - A S Mudano
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J A Melnick
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - E M Lewiecki
- New Mexico Clinical Research and Osteoporosis Center, Albuquerque, NM, USA
| | - W J Shergy
- Rheumatology Associates of North Alabama, Huntsville, AL, USA
| | - J R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - G R Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - M I Danila
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - M L Kilgore
- Deparment of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, AL, USA
| | - E C Lewis
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - S L Morgan
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - D T Redden
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - A H Warriner
- Division of Endocrinology, Diabetes and Metabolism, University of Alabama at Birmingham, Birmingham, AL, USA
| | - K G Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
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Watts NB, Aggers D, McCarthy EF, Savage T, Martinez S, Patterson R, Carrithers E, Miller PD. Responses to Treatment With Teriparatide in Patients With Atypical Femur Fractures Previously Treated With Bisphosphonates. J Bone Miner Res 2017; 32:1027-1033. [PMID: 28071822 DOI: 10.1002/jbmr.3081] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 01/05/2017] [Accepted: 01/08/2017] [Indexed: 11/07/2022]
Abstract
If oversuppression of bone turnover explained the association between bisphosphonate use and atypical subtrochanteric femur fractures (AFF), this could be reversed with anabolic treatment such as teriparatide. We conducted a prospective, open-label study in patients previously treated with bisphosphonates who sustained AFF, examining the response to 24-month treatment with teriparatide on bone mineral density (BMD), trabecular bone score (TBS), bone turnover markers (BTM), and fracture healing as well as quantitative histomorphometry. We studied 14 patients. Baseline BMD, BTM, and TBS varied widely. On initial bone biopsies, 12 of 14 patients showed tetracycline labels, but mineralizing surface/bone surface was below published normal values in all but 2. Lumbar spine BMD increased significantly at month 24 (6.1% ± 4.3%, p < 0.05 versus baseline), whereas total hip BMD and TBS did not change significantly. Changes in BTM occurred as reported previously for patients without AFF treated with teriparatide after prior bisphosphonate treatment. At month 24, fractures were healed in 6 patients, showed partial healing in 3, were unchanged in 2, and showed nonunion in 1. In a patient with two fractures, the fracture that occurred before teriparatide treatment was reported as healed, but the fracture that occurred while on treatment showed only partial healing. Bisphosphonate-treated patients who sustain AFF show heterogeneity of bone turnover. Treatment with teriparatide resulted in increases in BTM and lumbar spine BMD, as has been reported for patients without AFF. There was no significant effect of teriparatide on hip BMD, mineralizing surface to bone surface (MS/BS), or TBS and no consistent effect on fracture healing. In the context of a patient who has experienced an AFF after receiving bisphosphonate treatment, therapy with teriparatide for 24 months would be expected to increase BMD and BTM (and probably reduce the risk of fractures resulting from osteoporosis) but should not be relied on to aid in healing of the AFF. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
- Nelson B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA
| | - Deborah Aggers
- Colorado Center for Bone Research at Centura Health, Lakewood, CO, USA
| | - Edward F McCarthy
- Department of Orthopedic Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tina Savage
- Colorado Center for Bone Research at Centura Health, Lakewood, CO, USA
| | | | - Rachel Patterson
- Colorado Center for Bone Research at Centura Health, Lakewood, CO, USA
| | - Erin Carrithers
- Colorado Center for Bone Research at Centura Health, Lakewood, CO, USA
| | - Paul D Miller
- Colorado Center for Bone Research at Centura Health, Lakewood, CO, USA
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Koh A, Guerado E, Giannoudis PV. Atypical femoral fractures related to bisphosphonate treatment: issues and controversies related to their surgical management. Bone Joint J 2017; 99-B:295-302. [PMID: 28249967 DOI: 10.1302/0301-620x.99b3.bjj-2016-0276.r2] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 11/21/2016] [Indexed: 12/12/2022]
Abstract
AIMS Treatment guidelines for atypical femoral fractures associated with bisphosphonates have not been established. We conducted a systematic review of the treatment of atypical femoral fractures first, to evaluate the outcomes of surgical fixation of complete atypical fractures and secondly, to assess whether prophylactic surgery is necessary for incomplete atypical fractures. MATERIALS AND METHODS Case reports and series were identified from the PubMed database and were included if they described the treatment of atypical femoral fractures. In total, 77 publications met our inclusion criteria and 733 patients with 834 atypical complete or incomplete femoral fractures were identified. RESULTS For complete fractures, internal fixation was predominantly achieved by intramedullary nailing. The mean time to healing post-operatively was 7.3 months (2 to 31). Revision surgery for nonunion or implant failure was needed in 77 fractures (12.6%). A greater percentage of fractures treated with plate fixation (31.3%) required revision surgery than those treated with intramedullary nailing (12.9%) (p < 0.01). Non-operative treatment of incomplete fractures failed and surgery was eventually needed in nearly half of the patients (47%), whereas prophylactic surgery was successful and achieved a 97% rate of healing. CONCLUSION Intramedullary nailing is the first-line treatment for a complete fracture, although the risk of delayed healing and revision surgery seems to be higher than with a typical femoral fracture. Non-operative treatment does not appear to be a reliable way of treating an incomplete fracture: prophylactic intramedullary nailing should be considered if the patient is in intractable pain. Radiographs of the opposite side should be obtained routinely looking for an asymptomatic fracture. Bisphosphonates must be discontinued but ongoing metabolic management in the form of calcium and/or vitamin D supplements is advisable. Teriparatide therapy can be considered as an alternative treatment. Cite this article: Bone Joint J 2017;99-B:295-302.
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Affiliation(s)
- A Koh
- Kobe Rosai Hospital, 4-1-23 Kagoike-dori, Chuo-ku, Kobe, 651-0053, Japan
| | - E Guerado
- University of Malaga, Autovia A-7 K, 187 29603, Marbella, Malaga, Spain
| | - P V Giannoudis
- NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, Leeds, UK
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Lee KJ, Yoo JJ, Oh KJ, Yoo JH, Rhyu KH, Nam KW, Suh DH. Surgical outcome of intramedullary nailing in patients with complete atypical femoral fracture: A multicenter retrospective study. Injury 2017; 48:941-945. [PMID: 28274470 DOI: 10.1016/j.injury.2017.02.036] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 02/28/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Management of atypical femoral fracture on bisphosphonate therapy still remains controversy and is reported high rate of complications. The aim of this study was to evaluate the outcome of intramedullary nailing in patients with atypical femoral fracture who took bisphosphonate more than one year through the multicenter retrospective study. METHODS We gathered 75 atypical femoral fractures from seven institutions between 2009 and 2014. Among them 46 atypical femoral fractures which met the inclusion criteria was evaluated in this study. The average age was 70.1 years (53-80) and the average duration of bisphosphonate use was 5.1 years (1-15 years). Medical records and radiographs were reviewed to determine time to union, union rate, need for revision surgery, restoration of ambulatory function, and complications. RESULTS Twenty-nine (63%) fractures healed within 6 months without complications. The average time to union except two non-union was 24.9 weeks (11-48 weeks). Two patients (4.3%) underwent revision surgery for non-union and there was no implant failure. Thirty-seven (80.4%) patients achieved their pre-fracture ambulatory function at the final follow up. CONCLUSIONS Although the incidence of delayed bone healing is high in atypical femoral fracture on bisphosphonate therapy even treated with intramedullary nailing, the incidence of revision surgery and implant failure was relatively lower than those of extramedullary devices.
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Affiliation(s)
- Kyung-Jae Lee
- Department of Orthopaedic Surgery, Keimyung University Dongsan Medical Center, Daegu, South Korea.
| | - Jeong Joon Yoo
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, South Korea.
| | - Kwang-Jun Oh
- Department of Orthopaedic Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, South Korea.
| | - Je-Hyun Yoo
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Anyang, South Korea.
| | - Kee Hyung Rhyu
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, South Korea.
| | - Kwang Woo Nam
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju, South Korea.
| | - Dong-Hoon Suh
- Department of Orthopaedic Surgery, Korea University Ansan Hospital, Ansan, South Korea.
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Çiftçi S, Terlemez R, Duman Z, Doğu B, Öncü J, Yılmaz F, Kuran B. Femur shaft complete fractures associated with misdiagnosed stress fractures due to bisphosphonates. Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Atypical Femoral Shaft Fractures in Female Bisphosphonate Users Were Associated with an Increased Anterolateral Femoral Bow and a Thicker Lateral Cortex: A Case-Control Study. BIOMED RESEARCH INTERNATIONAL 2017; 2017:5932496. [PMID: 28459066 PMCID: PMC5387805 DOI: 10.1155/2017/5932496] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 03/14/2017] [Accepted: 03/15/2017] [Indexed: 12/27/2022]
Abstract
The purpose of our study was to investigate the radiographic characteristics of atypical femoral shaft fractures (AFSFs) in females with a particular focus on femoral bow and cortical thickness. We performed a fracture location-, age-, gender-, and ethnicity-matched case-control study. Forty-two AFSFs in 29 patients and 22 typical osteoporotic femoral shaft fractures in 22 patients were enrolled in AFSF group and control group, respectively. With comparing demographics between two groups, radiographically measured femoral bow and cortical thicknesses of AFSF group were compared with control group. All AFSF patients were females with a mean age of 74.4 years (range, 58–85 years). All had a history of bisphosphonate (BP) use with a mean duration of 7.3 years (range 1–17 years). Femoral bow of AFSF group was significantly higher than control group on both anteroposterior (AP) and lateral radiographs after age correction. Mean femoral bow on an AP radiograph was 12.39° ± 5.38° in AFSF group and 3.97 ± 3.62° in control group (P < 0.0001). Mean femoral bow on the lateral radiograph was 15.71° ± 5.62° in AFSF group and 10.72° ± 4.61° in control group (after age correction P = 0.003). And cortical thicknesses of AFSF group demonstrated marked disparity between tensile and compressive side of bowed femurs in this study. An adjusted lateral cortical thickness was 10.5 ± 1.4 mm in AFSF group and 8.1 ± 1.3 mm in control group (after age correction P < 0.0001) while medial cortical thickness of AFSF group was not statistically different from control group. Correlation analysis showed that the lateral femoral bow on the AP radiograph was solely related to lateral CTI (R = 0.378, P = 0.002). AFSFs in female BP users were associated with an increased anterolateral femoral bow and a thicker lateral cortex of femurs.
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Ma S, Goh EL, Jin A, Bhattacharya R, Boughton OR, Patel B, Karunaratne A, Vo NT, Atwood R, Cobb JP, Hansen U, Abel RL. Long-term effects of bisphosphonate therapy: perforations, microcracks and mechanical properties. Sci Rep 2017; 7:43399. [PMID: 28262693 PMCID: PMC5338252 DOI: 10.1038/srep43399] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 01/20/2017] [Indexed: 12/11/2022] Open
Abstract
Osteoporosis is characterised by trabecular bone loss resulting from increased osteoclast activation and unbalanced coupling between resorption and formation, which induces a thinning of trabeculae and trabecular perforations. Bisphosphonates are the frontline therapy for osteoporosis, which act by reducing bone remodelling, and are thought to prevent perforations and maintain microstructure. However, bisphosphonates may oversuppress remodelling resulting in accumulation of microcracks. This paper aims to investigate the effect of bisphosphonate treatment on microstructure and mechanical strength. Assessment of microdamage within the trabecular bone core was performed using synchrotron X-ray micro-CT linked to image analysis software. Bone from bisphosphonate-treated fracture patients exhibited fewer perforations but more numerous and larger microcracks than both fracture and non-fracture controls. Furthermore, bisphosphonate-treated bone demonstrated reduced tensile strength and Young's Modulus. These findings suggest that bisphosphonate therapy is effective at reducing perforations but may also cause microcrack accumulation, leading to a loss of microstructural integrity and consequently, reduced mechanical strength.
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Affiliation(s)
- Shaocheng Ma
- Department of Mechanical Engineering, Faculty of Engineering, Imperial College London, London, SW7 2AZ, United Kingdom
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, United Kingdom
| | - En Lin Goh
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, United Kingdom
| | - Andi Jin
- Department of Mechanical Engineering, Faculty of Engineering, Imperial College London, London, SW7 2AZ, United Kingdom
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, United Kingdom
| | - Rajarshi Bhattacharya
- St. Mary’s Hospital, North West London Major Trauma Centre, Imperial College, London, W2 1NY, United Kingdom
| | - Oliver R. Boughton
- Department of Mechanical Engineering, Faculty of Engineering, Imperial College London, London, SW7 2AZ, United Kingdom
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, United Kingdom
| | - Bhavi Patel
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, United Kingdom
| | - Angelo Karunaratne
- Department of Mechanical Engineering, Faculty of Engineering, University of Moratuwa, Moratuwa, 10400, Sri Lanka
| | - Nghia T. Vo
- Diamond Light Source Ltd, Harwell Science and Innovation Campus, Didcot, OX11 0DE, United Kingdom
| | - Robert Atwood
- Diamond Light Source Ltd, Harwell Science and Innovation Campus, Didcot, OX11 0DE, United Kingdom
| | - Justin P. Cobb
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, United Kingdom
| | - Ulrich Hansen
- Department of Mechanical Engineering, Faculty of Engineering, Imperial College London, London, SW7 2AZ, United Kingdom
| | - Richard L. Abel
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, United Kingdom
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Abstract
OBJECTIVES Bisphosphonates are widely used as first-line treatment for primary and secondary prevention of fragility fractures. Whilst they have proved effective in this role, there is growing concern over their long-term use, with much evidence linking bisphosphonate-related suppression of bone remodelling to an increased risk of atypical subtrochanteric fractures of the femur (AFFs). The objective of this article is to review this evidence, while presenting the current available strategies for the management of AFFs. METHODS We present an evaluation of current literature relating to the pathogenesis and treatment of AFFs in the context of bisphosphonate use. RESULTS Six broad themes relating to the pathogenesis and management of bisphosphonate-related AFFs are presented. The key themes in fracture pathogenesis are: bone microdamage accumulation; altered bone mineralisation and altered collagen formation. The key themes in fracture management are: medical therapy and surgical therapy. In addition, primary prevention strategies for AFFs are discussed. CONCLUSIONS This article presents current knowledge about the relationship between bisphosphonates and the development of AFFs, and highlights key areas for future research. In particular, studies aimed at identifying at-risk subpopulations and organising surveillance for those on long-term therapy will be crucial in both increasing our understanding of the condition, and improving population outcomes.Cite this article: N. Kharwadkar, B. Mayne, J. E. Lawrence, V. Khanduja. Bisphosphonates and atypical subtrochanteric fractures of the femur. Bone Joint Res 2017;6:144-153. DOI: 10.1302/2046-3758.63.BJR-2016-0125.R1.
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Affiliation(s)
- N Kharwadkar
- The Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, UK
| | - B Mayne
- F2, James Cook University Hospital, Marton Rd, Middlesbrough TS4 3BW, UK
| | - J E Lawrence
- Junior Clinical Fellow, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - V Khanduja
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Box 37, Hills Road, Cambridge CB2 0QQ, UK
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Shah K, Ubale T, Abdul R, Kasodekar V, Assudani A, Makwana K. Fracture Diaphyseal Femur in a Case of Ipsilateral Excision Arthroplasty of Hip: Report of Two Cases with Description of an Unusual Injury Pattern, Mechanism, and Clinical Decision-making in Management. J Orthop Case Rep 2017; 6:111-113. [PMID: 28164068 PMCID: PMC5288612 DOI: 10.13107/jocr.2250-0685.598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Although fracture diaphyseal femur is commonly seen in orthopedic practice, its association with ipsilateral resection arthroplasty of hip/pseudarthrosis of neck is rare. The technique of excision arthroplasty has undergone modification with emphasis on preserving as much bone as possible. However, it is not always possible to preserve bone while removing the earlier prosthesis and cement. This often leads to extensive proximal bone loss. Associated ipsilateral fracture femur presents a unique scenario. Till date, only one case report is published highlighting its surgical management. CASE REPORT We report two cases of diaphyseal fracture femur associated with resection arthroplasty of hip at subtrochanteric level with greater trochanter as a separate fragment (Case 1) and other with pseudarthrosis of the neck of femur with intact greater trochanter (Case 2). The first case was operated with surface fixation, whereas the second was operated with closed antegrade intramedullary nail. CONCLUSION Decision-making and formulating treatment plan includes taking various factors into account such as level of resection arthroplasty of hip/pseudarthrosis of neck, status of greater trochanter (intact or separate fragment), osteoporosis, and post-operative ambulation and rehabilitation. In this report, we highlight the unusual occurrence, probable mechanism of injury, risk factors for fracture, and decision-making in the surgical management of such a condition.
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Affiliation(s)
- Kunal Shah
- Department of Orthopaedics, R. N. Cooper Hospital, Mumbai, Maharashtra, India
| | - Tushar Ubale
- Department of Orthopaedics, R. N. Cooper Hospital, Mumbai, Maharashtra, India
| | - Rahematullah Abdul
- Department of Orthopaedics, R. N. Cooper Hospital, Mumbai, Maharashtra, India
| | - Vaibhav Kasodekar
- Department of Orthopaedics, Sushrut Hospital, Mumbai, Maharashtra, India
| | - Ashish Assudani
- Department of Orthopaedics, R. N. Cooper Hospital, Mumbai, Maharashtra, India
| | - Kiran Makwana
- Department of Orthopaedics, R. N. Cooper Hospital, Mumbai, Maharashtra, India
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Kayali C, Altay T, Ozan F, Sozkesen S, Yamak K. Atypical femoral shaft fractures secondary to long-term bisphosphonate therapy. J Orthop 2017; 14:226-230. [PMID: 28203048 DOI: 10.1016/j.jor.2017.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 01/06/2017] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Bisphosphonates (BPs) are one of the most commonly used agents in the treatment of post-menopausal osteoporosis and other metabolic bone diseases. METHODS Between 2010 and 2015, data of 22 osteoporotic women with femoral fractures due to low-energy trauma who received BPs previously were analysed. RESULTS The mean duration of BP therapy was 7.6 years. The mean duration of union was 7.4 months. Five patients had non-union. Stress reaction was observed in the contralateral femur in 11 patients. CONCLUSION Radiographic studies should be performed on a regular basis to prevent atypical femoral fractures in patients on long-term BP therapy.
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Affiliation(s)
- Cemil Kayali
- Department of Orthopedics and Traumatology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Taskin Altay
- Department of Orthopedics and Traumatology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Firat Ozan
- Department of Orthopedics and Traumatology, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Serkan Sozkesen
- Department of Orthopedics and Traumatology, Ağrı State Hospital, Ağrı, Turkey
| | - Kamil Yamak
- Department of Orthopedics and Traumatology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
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Adams AL, Xue F, Chantra JQ, Dell RM, Ott SM, Silverman S, Giaconi JC, Critchlow C. Sensitivity and specificity of radiographic characteristics in atypical femoral fractures. Osteoporos Int 2017; 28:413-417. [PMID: 27766369 DOI: 10.1007/s00198-016-3809-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/11/2016] [Indexed: 12/30/2022]
Abstract
UNLABELLED Using the American Society for Bone and Mineral Research Task Force case definition for atypical femoral fractures, sensitivity and specificity of radiographic fracture characteristics were calculated. Fracture pattern was the most sensitive and specific characteristic. This suggests that some characteristics should be weighted more heavily when identifying these fractures. INTRODUCTION To estimate the sensitivity and specificity of each radiographic criterion in the 2013 ASBMR atypical femoral fracture (AFF) case definition for distinguishing AFF from other subtrochanteric/diaphyseal fractures (non-AFF) among women enrolled in a large integrated health care organization. METHODS Radiographs from 55 physician-confirmed AFFs and a sample of 39 non-AFFs were reviewed by four independent expert reviewers representing four medical specialties. One image per fracture was selected for review. Using a standardized data collection tool, based on the 2013 AFF case definition, reviewers indicated the presence or absence of the following characteristics viewable on radiograph: fracture pattern, comminution, periosteal and/or endosteal thickening, and cortical thickening. Sensitivity and specificity for each characteristic was calculated for each reviewer and summarized across reviewers with the mean and range. Agreement across reviewers was quantified using Fleiss's kappa (FK) statistic. RESULTS The most sensitive factors distinguishing AFF from non-AFF were lateral cortex transverse fracture pattern (mean 93.6 %, range 85.5-98.2 %), medial cortex transverse or oblique fracture pattern (mean 84.1 %, range 72.7-98.2 %), and minimal/non-comminution (mean 93.2 %, range 89.1-98.2 %). Specificity was the greatest for lateral cortex transverse fracture pattern (mean 95.5 %, range 92.3-97.4 %). Agreement across reviewers was the highest for lateral cortex transverse fracture pattern (FK 0.83) and incomplete fracture through the lateral cortex only (FK 0.80). CONCLUSION Lateral cortex transverse fracture pattern was the most sensitive and specific characteristic and the most highly agreed upon across reviewers. Other characteristics were less readily agreed upon across reviewers. Measurement of discrete combinations of individual characteristics may enhance sensitivity and/or specificity.
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Affiliation(s)
- A L Adams
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA.
| | - F Xue
- Center for Observational Research, Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA, 91320, USA
| | - J Q Chantra
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA
| | - R M Dell
- Department of Orthopedic Surgery, Kaiser Permanente Southern California, 9333 Imperial Hwy, Downey, CA, 90242, USA
| | - S M Ott
- Department of Medicine, University of Washington, 1959 NE Pacific Street, UW Mailbox 356426, Seattle, WA, 98195, USA
| | - S Silverman
- Department of Rheumatology, Cedars-Sinai/UCLA, 200 UCLA Medical Plaza, Los Angeles, CA, 90095, USA
| | - J C Giaconi
- Cedars Sinai Imaging Medical Group, Cedars Sinai Medical Center, 8700 Beverly Blvd.,, Los Angeles, CA, 90048, USA
| | - C Critchlow
- Center for Observational Research, Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA, 91320, USA
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