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Jeon I, Park SB, Moon BJ, Choi M, Kuh SU, Kim J. Comparison of the Clinical Efficacy of Anabolic Agents and Bisphosphonates in the Patients With Osteoporotic Vertebral Fracture: Systematic Review and Meta-analysis of Randomized Controlled Trials. Neurospine 2024; 21:416-429. [PMID: 38697911 PMCID: PMC11224729 DOI: 10.14245/ns.2347256.628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/03/2024] [Accepted: 02/04/2024] [Indexed: 05/05/2024] Open
Abstract
OBJECTIVE We investigated the clinical efficacy of anabolic agents compared with bisphosphonates (BPs) for the incidence of new osteoporotic vertebral fracture (OVF) and fracture healing of OVF in the patients with OVF via meta-analyses of randomized controlled trials (RCTs). METHODS Electronic databases, including PubMed, Embase, and Cochrane Library were searched for published RCTs till December 2022. The RCTs that recruited participants with osteoporosis at high-/very high-risk of fracture (a history of osteoporotic vertebral or hip fracture) or fresh OVF were included in this study. We assessed the risk of bias on every included RCTs, estimated relative risk (RR) for the incidence of new OVF and fracture healing of OVF, and overall certainty of evidence. Meta-analyses were performed by Cochrane review manager (RevMan) ver. 5.3. Cochrane risk of bias 2.0 and GRADEpro/GDT were applied for evaluating methodological quality and overall certainty of evidence, respectively. RESULTS Five hundred eighteen studies were screened, and finally 6 eligible RCTs were included in the analysis. In the patients with prevalent OVF, anabolic agents significantly reduced the incidence of new OVF (teriparatide and romosozumab vs. alendronate and risedronate [RR, 0.57; 95% confidence interval, 0.45-0.71; p < 0.00001; high-certainty of evidence]; teriparatide vs. risedronate [RR, 0.50; 95% confidence interval, 0.37-0.68; p < 0.0001; high-certainty of evidence]). However, there was no evidence of teriparatide compared to alendronate in fracture healing of OVF (RR, 1.23; 95% confidence interval, 0.95-1.60; p = 0.12; low-certainty of evidence). CONCLUSION In the patients with prevalent OVF, anabolic agents showed a significant superiority for preventing new OVF than BPs, with no significant evidence for promoting fracture healing of OVF. However, considering small number of RCTs in this study, additional studies with large-scale data are required to obtain more robust evidences.
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Affiliation(s)
- Ikchan Jeon
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, Daegu, Korea
| | - Sung Bae Park
- Department of Neurosurgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Bong Ju Moon
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Miyoung Choi
- Clinical Evidence Research, Division of Health Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Sung Uk Kuh
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jongtae Kim
- Department of Neurosurgery, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
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Al-Ajlouni YA, Lee JL, Lee JL, Samuels B. Atypical femur fracture in a male without history of bisphosphonate use: a case report. J Med Case Rep 2024; 18:2. [PMID: 38172929 PMCID: PMC10765697 DOI: 10.1186/s13256-023-04308-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Atypical femur fractures are a rare occurrence, especially in bisphosphonate-naïve men, and merit reporting owing to their unusual presentation and clinical implications. This case report highlights a unique instance of atypical femur fractures in a 73-year-old male with no prior bisphosphonate exposure. CASE PRESENTATION The patient, a 73-year-old Indian male with no history of bisphosphonate use, presented with left thigh pain and swelling following a minor fall. Radiographic assessment unveiled a closed left mid diaphyseal femoral shaft fracture. Subsequent imaging revealed an impending fracture in the contralateral femur. A comprehensive diagnostic evaluation, encompassing radiographic analysis, laboratory tests, and clinical assessment confirmed the diagnosis. Surgical management via intramedullary nailing was pursued for both fractures. Notably, the patient's medical history was characterized by radiographic manifestations, the infrequent occurrence of atypical femur fractures in men, and associated risk factors. Treatment encompassed anabolic bone therapy employing teriparatide, alongside discontinuation of antiresorptive agents. CONCLUSIONS This case underscores the significance of considering atypical femur fractures in older individuals with limited trauma history. It accentuates the role of anabolic agents in the therapeutic regimen and contributes to the evolving understanding of atypical femur fractures. The report underscores the need for vigilant monitoring and tailored management strategies in similar cases, thereby enhancing clinical practice and patient care.
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Affiliation(s)
| | - Justin Lin Lee
- School of Medicine, New York Medical College, Valhalla, NY, 10595, USA
| | - Jessica Lin Lee
- School of Medicine, New York Medical College, Valhalla, NY, 10595, USA
| | - Blossom Samuels
- School of Medicine, New York Medical College, Valhalla, NY, 10595, USA
- Westchester Medical Center, Valhalla, NY, 10595, USA
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Liu Z, Wang Q, Zhang J, Qi S, Duan Y, Li C. The Mechanotransduction Signaling Pathways in the Regulation of Osteogenesis. Int J Mol Sci 2023; 24:14326. [PMID: 37762629 PMCID: PMC10532275 DOI: 10.3390/ijms241814326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
Bones are constantly exposed to mechanical forces from both muscles and Earth's gravity to maintain bone homeostasis by stimulating bone formation. Mechanotransduction transforms external mechanical signals such as force, fluid flow shear, and gravity into intracellular responses to achieve force adaptation. However, the underlying molecular mechanisms on the conversion from mechanical signals into bone formation has not been completely defined yet. In the present review, we provide a comprehensive and systematic description of the mechanotransduction signaling pathways induced by mechanical stimuli during osteogenesis and address the different layers of interconnections between different signaling pathways. Further exploration of mechanotransduction would benefit patients with osteoporosis, including the aging population and postmenopausal women.
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Affiliation(s)
- Zhaoshuo Liu
- School of Engineering Medicine, Beihang University, Beijing 100191, China
- School of Biological Science and Medical Engineering, Beihang University, Beijing 100191, China
| | - Qilin Wang
- School of Engineering Medicine, Beihang University, Beijing 100191, China
- School of Biological Science and Medical Engineering, Beihang University, Beijing 100191, China
| | - Junyou Zhang
- School of Engineering Medicine, Beihang University, Beijing 100191, China
- School of Biological Science and Medical Engineering, Beihang University, Beijing 100191, China
| | - Sihan Qi
- School of Engineering Medicine, Beihang University, Beijing 100191, China
- School of Biological Science and Medical Engineering, Beihang University, Beijing 100191, China
| | - Yingying Duan
- School of Engineering Medicine, Beihang University, Beijing 100191, China
- School of Biological Science and Medical Engineering, Beihang University, Beijing 100191, China
| | - Chunyan Li
- School of Engineering Medicine, Beihang University, Beijing 100191, China
- School of Biological Science and Medical Engineering, Beihang University, Beijing 100191, China
- Key Laboratory of Big Data-Based Precision Medicine (Ministry of Industry and Information Technology), Beihang University, Beijing 100191, China
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Beihang University, Beijing 100191, China
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Xiao Y, Chen Y, Huang Y, Xiao Y. Atypical femur fracture associated with common anti-osteoporosis drugs in FDA adverse event reporting system. Sci Rep 2023; 13:10892. [PMID: 37407650 DOI: 10.1038/s41598-023-37944-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 06/30/2023] [Indexed: 07/07/2023] Open
Abstract
Atypical femur fracture (AFF) is a rare but catastrophic adverse event first reported in the long-term use of alendronate, one of the most commonly used drugs for osteoporosis currently. However, further evidence is needed to learn more regarding other common anti-osteoporosis drugs and the risk for AFF. In this study, reports of AFF were identified from Food and Drug Administration Adverse Event Reporting System database. Disproportionality analyses were performed to examine the reporting odds ratio (ROR), information component (IC) and adjusted ROR (adj. ROR) signals for AFF for common anti-osteoporosis drugs. A total of 1692 unique AFF reports were identified. The disproportionality signals (the lower bound of 95% confidence interval > 1 for ROR and adjusted ROR, and > 0 for IC) were detected for alendronate, denosumab, pamidronate, risedronate, zoledronate, ibandronate, and teriparatide while no signal was detected for raloxifene, abaloparatide, and romosozumab. When restricted in patients with osteoporosis, the disproportionality signals were still detected for alendronate, pamidronate, risedronate, denosumab, and ibandronate. Our results suggest that alendronate has the largest risk signal, while the risks varied among different bisphosphonates. In addition, denosumab was found statistically associated with AFF in both the entire database and patients with osteoporosis.
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Affiliation(s)
- Yao Xiao
- Department of Endocrinology, Endocrinology Research Center, Xiangya Hospital of Central South University, Changsha, 410008, Hunan, China
| | - Yiqian Chen
- Department of Gastroenterology, Xiangya Hospital of Central South University, Changsha, 410008, Hunan, China
| | - Yan Huang
- Department of Endocrinology, Endocrinology Research Center, Xiangya Hospital of Central South University, Changsha, 410008, Hunan, China
| | - Yuan Xiao
- Department of Endocrinology, Endocrinology Research Center, Xiangya Hospital of Central South University, Changsha, 410008, Hunan, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, 410008, Hunan, China.
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Migliorini F, Cocconi F, Vecchio G, Schäefer L, Koettnitz J, Maffulli N. Pharmacological agents for bone fracture healing: talking points from recent clinical trials. Expert Opin Investig Drugs 2023; 32:855-865. [PMID: 37740660 DOI: 10.1080/13543784.2023.2263352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 09/22/2023] [Indexed: 09/24/2023]
Abstract
INTRODUCTION Pharmacological strategies might influence bone healing in terms of time to union or quality of mature bone. This expert opinion discussed the current level I evidence on the experimental pharmacological agents used to favor bone fracture healing. AREAS COVERED This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement. In April 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, Embase. All the randomized clinical trials investigating pharmacological agents for bone fracture healing were accessed. No time constraint was set for the search. The search was restricted to RCTs. No additional filters were used in the database search. Data from 19 RCTs (4067 patients) were collected. 78% (3160 of 4067) were women. The mean length of the follow-up was 9.3 months (range, 1-26 months). The mean age of the patients was 64.4 years (range, 8-84 years). EXPERT OPINION Calcitonin could favor bone fracture healing. Bisphosphonates (alendronate, zoledronate, clodronate), monoclonal antibodies (denosumab, romosozumab), statins, vitamin D and calcium supplementation, strontium ranelate, and ibuprofen did not influence bony healing. Concerning the effect of parathormone, current level I evidence is controversial, and additional studies are required. LEVEL OF EVIDENCE Level I, systematic review of RCTs.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Aachen, Germany
| | - Federico Cocconi
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University, Bolzano, Italy
| | - Gianluca Vecchio
- Department of Trauma and Orthopaedic Surgery, University Hospital Sant' Andrea, University La Sapienza, Rome, Italy
| | - Luise Schäefer
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Aachen, Germany
| | - Julian Koettnitz
- Department of Orthopedics, Auguste-Viktoria Clinic, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, University Hospital Sant' Andrea, University La Sapienza, Rome, Italy
- School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Stoke on Trent, UK
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London, UK
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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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Treatment of Osteoporosis With Anabolic Agents and the Risk of Primary Bone Cancers: A Study of 44,728 Patients Treated With Teriparatide and Abaloparatide. J Am Acad Orthop Surg 2023; 31:520-528. [PMID: 36913523 DOI: 10.5435/jaaos-d-22-01094] [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] [Received: 11/18/2022] [Accepted: 02/06/2023] [Indexed: 03/15/2023] Open
Abstract
INTRODUCTION Bone anabolic agents can benefit orthopaedic patients perioperatively and improve outcomes after fragility fractures. However, preliminary animal data raised concern for the potential development of primary bony malignancies after treatment with these medications. METHODS This investigation examined 44,728 patients older than 50 years who were prescribed teriparatide or abaloparatide and compared them with a matched control group to evaluate risk of primary bone cancer development. Patients younger than 50 years with a history of cancer or other risk factors of bony malignancy were excluded. A separate cohort of 1,241 patients prescribed an anabolic agent with risk factors of primary bone malignancy, along with 6,199 matched control subjects, was created to evaluate the effect of anabolic agents. Cumulative incidence and incidence rate per 100,000 person-years were calculated as were risk ratios and incidence rate ratios. RESULTS The overall risk of primary bone malignancy development for risk factor-excluded patients in the anabolic agent-exposed group was 0.02%, compared with 0.05% in the nonexposed group. The incidence rate per 100,000 person-years was calculated at 3.61 for the anabolic-exposed patients and 6.46 for control subjects. A risk ratio of 0.47 (P = 0.03) and incidence rate ratio of 0.56 (P = 0.052) were observed for the development of primary bone malignancies in patients undergoing treatment with bone anabolic agents. Among high-risk patients, 5.96% of the anabolic-exposed cohort developed primary bone malignancies and 8.13% of nonexposed patients developed primary bone malignancy. The risk ratio was 0.73 (P = 0.01), and the incidence rate ratio was 0.95 (P = 0.67). CONCLUSION Teriparatide and abaloparatide can safely be used for osteoporosis and orthopaedic perioperative management without increased risk of development of primary bone malignancy.
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Gao J, Liu X, Wu X, Li X, Liu J, Li M. A brief review and clinical evidences of teriparatide therapy for atypical femoral fractures associated with long-term bisphosphonate treatment. Front Surg 2023; 9:1063170. [PMID: 36684309 PMCID: PMC9852062 DOI: 10.3389/fsurg.2022.1063170] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/07/2022] [Indexed: 01/07/2023] Open
Abstract
The risk of bisphosphonate (BP)-associated atypical femur fracture (AFF) has markedly increased over recent decades due to suppression of bone turnover, accumulation of structural micro-damage and reduction of bone remodeling consequent to long-term BP treatment. These medications further delay bone union and result in challenging clinical management. Teriparatide (TPTD), a synthetic human parathyroid hormone, exhibits unique anabolic effects and can increase bone remodeling and improve bone microarchitecture, further promoting fracture healing and reducing the rate of bone non-union. In this study, we briefly define AFF as well as the effects of BPs on AFFs, detailed the role of TPTD in AFF management and the latest clinical therapeutic findings. We have confirmed that TPTD positively promotes the healing of AFFs by reducing the time to bone union and likelihood of non-union. Thus, teriparatide therapy could be considered as an alternative treatment for AFFs, however, further research is required for the establishment of effective clinical guidelines of TPTD use in the management of AFF.
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Affiliation(s)
- Jianpeng Gao
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
| | - Xiao Liu
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
| | - Xiaoyong Wu
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China
| | - Xiaoya Li
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China
| | - Jianheng Liu
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China,Correspondence: Ming Li Jianheng Liu
| | - Ming Li
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China,Correspondence: Ming Li Jianheng Liu
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LeBoff MS, Greenspan SL, Insogna KL, Lewiecki EM, Saag KG, Singer AJ, Siris ES. The clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int 2022; 33:2049-2102. [PMID: 35478046 PMCID: PMC9546973 DOI: 10.1007/s00198-021-05900-y] [Citation(s) in RCA: 279] [Impact Index Per Article: 139.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 02/19/2021] [Indexed: 12/16/2022]
Abstract
Osteoporosis is the most common metabolic bone disease in the USA and the world. It is a subclinical condition until complicated by fracture(s). These fractures place an enormous medical and personal burden on individuals who suffer from them and take a significant economic toll. Any new fracture in an adult aged 50 years or older signifies imminent elevated risk for subsequent fractures, particularly in the year following the initial fracture. What a patient perceives as an unfortunate accident may be seen as a sentinel event indicative of bone fragility and increased future fracture risk even when the result of considerable trauma. Clinical or subclinical vertebral fractures, the most common type of osteoporotic fractures, are associated with a 5-fold increased risk for additional vertebral fractures and a 2- to 3-fold increased risk for fractures at other sites. Untreated osteoporosis can lead to a vicious cycle of recurrent fracture(s), often resulting in disability and premature death. In appropriate patients, treatment with effective antifracture medication prevents fractures and improves outcomes. Primary care providers and medical specialists are critical gatekeepers who can identify fractures and initiate proven osteoporosis interventions. Osteoporosis detection, diagnosis, and treatment should be routine practice in all adult healthcare settings. The Bone Health and Osteoporosis Foundation (BHOF) - formerly the National Osteoporosis Foundation - first published the Clinician's Guide in 1999 to provide accurate information on osteoporosis prevention and treatment. Since that time, significant improvements have been made in diagnostic technologies and treatments for osteoporosis. Despite these advances, a disturbing gap persists in patient care. At-risk patients are often not screened to establish fracture probability and not educated about fracture prevention. Most concerning, the majority of highest risk women and men who have a fracture(s) are not diagnosed and do not receive effective, FDA-approved therapies. Even those prescribed appropriate therapy are unlikely to take the medication as prescribed. The Clinician's Guide offers concise recommendations regarding prevention, risk assessment, diagnosis, and treatment of osteoporosis in postmenopausal women and men aged 50 years and older. It includes indications for bone densitometry as well as fracture risk thresholds for pharmacologic intervention. Current medications build bone and/or decrease bone breakdown and dramatically reduce incident fractures. All antifracture therapeutics treat but do not cure the disease. Skeletal deterioration resumes sooner or later when a medication is discontinued-sooner for nonbisphosphonates and later for bisphosphonates. Even if normal BMD is achieved, osteoporosis and elevated risk for fracture are still present. The diagnosis of osteoporosis persists even if subsequent DXA T-scores are above - 2.5. Ongoing monitoring and strategic interventions will be necessary if fractures are to be avoided. In addition to pharmacotherapy, adequate intake of calcium and vitamin D, avoidance of smoking and excessive alcohol intake, weight-bearing and resistance-training exercise, and fall prevention are included in the fracture prevention armamentarium. Where possible, recommendations in this guide are based on evidence from RCTs; however, relevant published data and guidance from expert clinical experience provides the basis for recommendations in those areas where RCT evidence is currently deficient or not applicable to the many osteoporosis patients not considered for RCT participation due to age and morbidity.
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Affiliation(s)
- M. S. LeBoff
- Brigham and Women’s Hospital, Harvard Medical School, 221 Longwood Ave, Boston, MA 02115 USA
| | - S. L. Greenspan
- University of Pittsburgh Medical Center, 1110 Kaufmann Building, 3471 Fifth Ave, Pittsburgh, PA 15213 USA
| | - K. L. Insogna
- Yale School of Medicine, 333 Cedar St, New Haven, CT 06520 USA
| | - E. M. Lewiecki
- University of New Mexico Health Sciences Center, 300 Oak St NE, Albuquerque, NM 87106 USA
| | - K. G. Saag
- University of Alabama at Birmingham, 1720 2nd Avenue South, FOT 820, Birmingham, AL 35294 USA
| | - A. J. Singer
- MedStar Georgetown University Hospital and Georgetown University Medical Center, 3800 Reservoir Road NW, 3rd Floor, Washington, DC 20007 USA
| | - E. S. Siris
- Columbia University Irving Medical Center, 180 Fort Washington Ave, Suite 9-903, New York, NY 10032 USA
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Cha SM, Shin HD, Lee SH, Shin JW. Radiological Reversibility of Incomplete Atypical Femoral Fracture with Cessation of Bisphosphonate: Including an Early Stage of Incomplete Fracture. Indian J Orthop 2022; 56:1023-1032. [PMID: 35669026 PMCID: PMC9123112 DOI: 10.1007/s43465-022-00639-y] [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: 09/07/2021] [Accepted: 04/02/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND We found some important early findings in simple radiographs under the bisphosphonate (BP) treatment through a retrospective study. Here, we report the degree of reversibility of the early findings before overt fracture and analyze the factors affecting the differences through a retrospective case-control study. METHODS We retrospectively inspected the clinical charts of patients diagnosed with atypical femoral fracture (AFF) at our institute between March 2006 and September 2018. Among the 209 screened patients, 102 patients were ultimately divided into 3 categories: Category 1 was described as endosteal diffuse flaring (EDF, early IAFF); category 2 was typical IAFF, with a tiny/partial crack that was limited to less than half of the thickness of the cortex; and category 3 was IAFF with a crack through the entire cortex. Demographics, clinical factors, and three categories of incomplete atypical femoral fracture (IAFF) were analyzed to determine whether their radiological condition "improved" or "progressed" after cessation of BP via univariate and multivariate analyses. RESULTS Thirty-three, 53, and 16 were classified as categories 1, 2, and 3, respectively. Groups 1 and 2 consisted of 79 patients whose IAFF on the side of interest improved and 23 patients whose IAFF progressed, respectively. The uni/multivariate analyses of the groups demonstrated that the total period of BP (odds ratio [OR] = 1.49) and period of cessation of BP (OR = 0.24) were significant variables. In addition, prophylactic treatment for a contralateral IAFF was a strong factor for progression of the incomplete lesion on the side of interest (OR = 25.99). The rate of progression was significantly higher in patients with a mean treatment period of 43 months or longer, and in those with a mean cessation period shorter than 1.2 months. CONCLUSION Early-stage IAFF was found to be a unique finding in simple radiographs before the typical features of AFF. This EDF (category 1) was definitively reversible to normal bone when administration of BP was stopped. In addition, a long period of BP treatment and recent cessation of BP adversely affected IAFF with respect to spontaneous healing. LEVEL OF EVIDENCE Level III, a retrospective case-control study.
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Affiliation(s)
- Soo Min Cha
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, 266 Munwha-ro, Jung-Gu, Daejeon, Korea
| | - Hyun Dae Shin
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, 266 Munwha-ro, Jung-Gu, Daejeon, Korea
| | - Seung Hoo Lee
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, 266 Munwha-ro, Jung-Gu, Daejeon, Korea
| | - Jae Woo Shin
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, 266 Munwha-ro, Jung-Gu, Daejeon, Korea
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Lewiecki EM, Anderson PA, Bilezikian JP, Binkley N, Cheung AM, Imel EA, Krueger D, McClung MR, Miller PD, Rothman MS. Proceedings of the 2021 Santa Fe Bone Symposium: Advances in the Management of Osteoporosis and Metabolic Bone Diseases. J Clin Densitom 2022; 25:3-19. [PMID: 34785102 DOI: 10.1016/j.jocd.2021.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/05/2021] [Indexed: 12/29/2022]
Abstract
The 2021 Virtual Santa Fe Bone Symposium was held August 5-8, with over 300 registered attendees from throughout the USA, and at least 18 other countries. This annual meeting focuses on applying advances in basic science and clinical research to the care of patients with osteoporosis and those with inherited and acquired disorders of bone metabolism. Participants represented a broad range of medical disciplines with an interest in skeletal diseases. These included physicians of many specialties and practice settings, fellows, advanced practice providers, fracture liaison service (FLS) coordinators, clinical researchers, and bone density technologists. There were lectures, case presentations, and panel discussions, all followed by interactive discussions. Breakout sessions included an FLS workshop, Bone Health TeleECHO workshop, special interest groups, meet-and-greet the faculty, and satellite symposia. The agenda covered topics of interest such as strategies for the use of osteoanabolic therapy, prevention of periprosthetic fractures, management of atypical femur fractures, what we know and don't know about vitamin D, advances in the use of dual-energy X-ray absorptiometry in the assessment of skeletal health, controversies and conundrums in osteoporosis care, skeletal health in transgender patients, management of patients with hypophosphatasia and hypophosphatemia, and treat-to-target approaches for managing patients with osteoporosis. The Proceedings of the 2021 Virtual Santa Fe Bone Symposium consists of highlights of each presentation with current strategies for optimizing the care of patients with skeletal disorders.
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Affiliation(s)
- E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA.
| | - Paul A Anderson
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - John P Bilezikian
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Neil Binkley
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Erik A Imel
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Diane Krueger
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Michael R McClung
- Oregon Osteoporosis Center, Portland, OR, USA, and Mary MacKillop Center for Health Research, Australian Catholic University, Melbourne, Australia
| | | | - Micol S Rothman
- University of Colorado Health School of Medicine, Aurora, CO, USA
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Gu KD, Ettinger B, Grimsrud CD, Lo JC. Progression of atypical femur stress fracture after discontinuation of bisphosphonate therapy. Osteoporos Int 2021; 32:2119-2123. [PMID: 33914104 DOI: 10.1007/s00198-021-05948-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 04/01/2021] [Indexed: 01/16/2023]
Abstract
Atypical femur fracture (AFF) is an uncommon complication of long-term bisphosphonate use, but the risk declines substantially after treatment cessation. We report a case of a 70-year-old woman with osteopenia treated with alendronate for 9 years who presented with right mid-thigh pain and radiographic findings of focal lateral cortical thickening in the right mid-femur and lateral cortex irregularity in the proximal-mid left femur. Alendronate was discontinued, but she remained on estrogen for menopausal symptoms. Four years later, a horizontal linear translucent defect was seen in the right mid-femur area of cortical hypertrophy, consistent with an incomplete AFF. The patient underwent prophylactic intramedullary rodding of the right femur and estrogen was discontinued. Three years later (7 years after initial presentation), the cortical irregularities in the left femur were more prominent and three small horizontal linear translucent defects were now evident, consistent with early incomplete atypical fracture development. The patient also suffered a wrist fracture. She was treated with teriparatide for 1.5 years with resolution of the translucent defects in the left but not the right femur, although abnormal thickening of the lateral cortex persisted in both femurs. Our case demonstrates incomplete atypical femur fracture progression in a patient with long-term bisphosphonate exposure, even after treatment cessation. These findings highlight the importance of follow-up for patients who develop diaphyseal femur stress fractures and the potential for early healing with anabolic therapy. This case also demonstrates the challenge in managing older patients with incomplete AFF at risk for progression to complete AFF and osteoporotic fracture.
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Affiliation(s)
- K D Gu
- Department of Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, 94611, USA
| | - B Ettinger
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - C D Grimsrud
- Department of Orthopedic Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
- The Permanente Medical Group, Oakland, CA, 94612, USA
| | - J C Lo
- Department of Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, 94611, USA.
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
- The Permanente Medical Group, Oakland, CA, 94612, USA.
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The effect of osteoporosis and its treatment on fracture healing a systematic review of animal and clinical studies. Bone Rep 2021; 15:101117. [PMID: 34458509 PMCID: PMC8379440 DOI: 10.1016/j.bonr.2021.101117] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/25/2021] [Accepted: 08/10/2021] [Indexed: 01/08/2023] Open
Abstract
Introduction Osteoporosis is characterised by low bone mass and micro-architectural deterioration of bone structure. Its treatment is directed at the processes of bone formation or resorption, that are of utmost importance in fracture healing. We provide a comprehensive review of the literature aiming to summarize and clarify the effects of osteoporosis and its treatment on fracture healing. Material and methods A literature search was conducted in PubMed and Embase (OVID version). In vivo animal and human studies on long bone fractures were included. A total of 93 articles were included for this review; 23 studies on the effect of osteoporosis (18 animal and 5 clinical studies) and 70 studies on the effect of osteoporosis treatment (41 animal, 26 clinical studies and 3 meta-analyses) on fracture healing. Results In animal fracture models osteoporosis was associated with decreased callus formation and bone growth, bone mineral density, biomechanical strength and delayed cellular and differentiation processes during fracture healing. Two large databases identified osteoporosis as a risk factor for non-union whereas three other studies did not. One of those three studies however found a prolonged healing time in patients with osteoporosis. Anti-osteoporosis medication showed inconsistent effects on fracture healing in both non-osteoporotic and osteoporotic animal models. Only the parathyroid hormone and anti-resorption medication were related to improved fracture healing and delayed remodelling respectively. Clinical studies performed in predominantly hip and distal radius fracture patients showed no effect of bisphosphonates on fracture healing. Parathyroid hormone reduced time to union in several clinical trials performed in mainly hip fracture patients, but this did not result in decreased delayed or non-union rates. Conclusion Evidence that substantiates the negative influence of osteoporosis on fracture healing is predominantly from animal studies and to a lesser extent from clinical studies, since convincing clinical evidence lacks. Bisphosphonates and parathyroid hormone may be used during fracture healing, since no clear negative effect has been shown. Parathyroid hormone might even decrease time to fracture union, without decreasing union rate. Osteoporosis negatively influences fracture healing in animal models. There is no convincing evidence for a similar effect in humans. In animals, bisphosphonates delay bone remodelling In animals, parathyroid hormone improves fracture healing In humans, anti-osteoporotic drugs do not interfere with fracture healing.
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Eastman K, Gerlach M, Piec I, Greeves J, Fraser W. Effectiveness of parathyroid hormone (PTH) analogues on fracture healing: a meta-analysis. Osteoporos Int 2021; 32:1531-1546. [PMID: 33559713 DOI: 10.1007/s00198-021-05847-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 01/12/2021] [Indexed: 12/21/2022]
Abstract
UNLABELLED This meta-analysis evaluated the evidence for the use of parathyroid hormone (PTH) analogues to improve fracture healing. Eligible studies were prospective randomised controlled trials of adults with acute fractures treated with a PTH analogue. PTH improved functional outcomes but did not affect fracture healing rate or reduce pain. PURPOSE This meta-analysis evaluated the evidence of parathyroid hormone (PTH) analogues in fracture healing. The use of PTH analogues to prevent osteoporotic fractures is well investigated, and studies are emerging on extended indications. One such indication receiving increasing attention is the effect of PTH in fracture healing; however, the overall degree of efficacy remains inconclusive. METHODS A systematic electronic database search of MEDLINE, EMBASE and the Cochrane Library was conducted for relevant articles in August 2019 with no date restrictions. Randomised controlled trials of adults with acute fractures treated with a PTH analogue were included. PTH was compared with a comparator intervention, placebo or no treatment. RESULTS PTH analogue treatment improved functional outcomes in a range of fracture types but did not affect the fracture healing rate or reduce pain. Most trials included in this review were in elderly patients with osteoporosis. There was no evidence that PTH treatment caused harm or impeded fracture healing. CONCLUSIONS Meta-analysis of published data supports the use of PTH analogues to improve functional outcomes but not fracture healing rate or pain for different fracture types. The evidence for PTH analogue use in fracture healing is less clear in younger, non-osteoporotic patient populations. Trial design was heterogeneous and of limited quality, justifying further original trials.
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Affiliation(s)
- K Eastman
- Norwich Medical School, University of East Anglia, Norwich, UK.
| | - M Gerlach
- Norfolk and Norwich University Hospital, Norwich, UK
| | - I Piec
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - J Greeves
- Norwich Medical School, University of East Anglia, Norwich, UK
- Department of Army Health and Performance Research, Andover, Hampshire, UK
| | - W Fraser
- Norwich Medical School, University of East Anglia, Norwich, UK
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Kim K, Won YY, Lee SW, Seo KD. The Effect of Teriparatide on the Hip: A Literature Review. Hip Pelvis 2021; 33:45-52. [PMID: 34141690 PMCID: PMC8190496 DOI: 10.5371/hp.2021.33.2.45] [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: 11/10/2020] [Revised: 12/09/2020] [Accepted: 12/14/2020] [Indexed: 12/04/2022] Open
Abstract
Teriparatide (TPTD) is a bone-forming agent used to treat postmenopausal osteoporosis. Since hip fractures are related to higher morbidity and mortality rates than other fractures, efficacious osteoporosis drugs for the hip are critical. We reviewed research articles reporting the efficacy of TPTD in terms of bone mineral density (BMD), fractures prevention, changes in the outer diameter, cortical thickness and porosity, post-operative periprosthetic BMD loss, and healing of typical and atypical fractures of the hip. Data meta-analyses indicated that TPTD not only increased the BMD of the proximal femur but also decreased the risk of hip fractures. Even though TPTD increases the cortical bone porosity of the proximal femur, the bone strength does not decrease as the majority of the porosity is located at the endocortex; further, it increases the outer diameter and thickens the cortical bone. TPTD stimulates bone remodeling and facilitates callus maturity and fracture healing. There have been many reports on improving the effect of TPTD on the healing of atypical fractures; therefore it is advisable to use TPTD considering the increase benefit compared to the risk.
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Affiliation(s)
- Kwangkyoun Kim
- Department of Orthopaedic Surgery, Konyang University College of Medicine, Daejeon, Korea
| | - Ye-Yeon Won
- Department of Orthopedic Surgery, Ajou University College of Medicine, Suwon, Korea
| | - Seok-Won Lee
- Department of Orthopaedic Surgery, Konyang University College of Medicine, Daejeon, Korea
| | - Kyung-Deok Seo
- Department of Orthopaedic Surgery, Konyang University College of Medicine, Daejeon, Korea
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Marmor MT, Matz J, McClellan RT, Medam R, Miclau T. Use of Osteobiologics for Fracture Management: The When, What, and How. Injury 2021; 52 Suppl 2:S35-S43. [PMID: 33549314 DOI: 10.1016/j.injury.2021.01.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/17/2021] [Accepted: 01/18/2021] [Indexed: 02/02/2023]
Abstract
Osteobiologics are defined as a group of natural and synthetic materials used to augment bone healing. The selection of the most appropriate osteobiologic from the growing list of available options can be a challenging task. In selecting a material, surgeons should weigh a variety of considerations, including the indication for their use (the when), the most suitable substance (the what), and the correct mode of application (the how). This summary reviews these considerations and seeks to provide the surgeon with a basis for informed clinical evidence-based decision-making in their choice of a successful option.
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Affiliation(s)
- Meir T Marmor
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Jacob Matz
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Robert Trigg McClellan
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Ramapaada Medam
- University of Central Florida College of Medicine, Orlando, FL, USA
| | - Theodore Miclau
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.
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Papaioannou I, Pantazidou G, Baikousis A, Korovessis P. Femoral Bowing and Femoral Neck-Shaft Angle Evaluation Can Reduce Atypical Femoral Fractures in Osteoporotic Patients: A Scientific Report. Cureus 2020; 12:e10771. [PMID: 33154843 PMCID: PMC7606192 DOI: 10.7759/cureus.10771] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Bisphosphonates (BPs) are the mainstay of osteoporosis treatment due to their safety and efficacy. There is evidence that BPs medication may be complicated by atypical femoral fractures (AFFs). Prolonged administration of BPs is even more strongly associated with AFFs. AFF is a relatively rare complication of BPs when taking into account the huge population worldwide that benefits from this pharmacotherapy. AFF is, however, a serious complication of BPs treatment, which includes prolonged healing time and high revision rate when operative treatment is required. Less frequently, AFFs occur even without BPs administration, while these fractures have all the characteristics of “stress” or “insufficiency” fractures. The critical point of view in AFFs pathogenesis seems to be not only the biology of cortical bone, but also the mechanical issue. It has been proven that BPs, glucocorticoids and proton pump inhibitors (PPIs) can cause bone turnover suppression and affect the biological parameter of AFFs pathogenesis. Specific mechanical femoral bone properties predispose to AFFs pathogenesis. Several studies have already reported that increased femoral bowing > 5.250 degrees or decreased femoral neck-shaft angle <125 degrees, are associated with increased risk for diaphyseal and subtrochanteric AFFs respectively, regardless of BPs uptake. If these two parameters are simultaneously present, the probability for AFFs occurrence increases dramatically. Our scientific report, which is based on the current evidence about AFFs, is that if both femoral bowing angle and femoral neck-shaft angle are evaluated before BPs administration, this intervention may reduce the incidence of AFFs. Thus, in cases with excessive lateral femoral shaft bowing or very small femoral neck-shaft angle, the prescription of another anti-osteoporotic treatment than BPs should be recommended. If, however, BPs can’t be avoided, clinicians should be aware of the fact that long-term administration may be implicated with AFFs occurrence. In these cases, short term BPs administration with timely drug holiday between three and five years may be reasonable. Finally, roentgenographic evaluation of both femurs every six months and medical reference in case of any emerging thigh pain are also logical interventions to prevent and reduce AFFs.
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Affiliation(s)
- Ioannis Papaioannou
- Orthopedics and Traumatology and Spine Surgery, General Hospital of Patras, Patras, GRC
| | - Georgia Pantazidou
- Otolaryngology - Head and Neck Surgery, General Hospital of Patras, Patras, GRC
| | - Andreas Baikousis
- Orthopedics and Traumatology and Spine Surgery, General Hospital of Patras, Patras, GRC
| | - Panagiotis Korovessis
- Orthopedics and Traumatology and Spine Surgery, General Hospital of Patras, Patras, GRC
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Tile L, Cheung AM. Atypical femur fractures: current understanding and approach to management. Ther Adv Musculoskelet Dis 2020; 12:1759720X20916983. [PMID: 32913448 PMCID: PMC7443989 DOI: 10.1177/1759720x20916983] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 02/24/2020] [Indexed: 01/19/2023] Open
Abstract
Osteoporosis and resulting osteoporotic fractures are responsible for
significant morbidity, excess mortality, and health care costs in the
developed world. Medical therapy for osteoporosis has been shown in
multiple randomized controlled trials to reduce the risk of vertebral
and non-vertebral fractures and hip fractures, and in some studies
bisphosphonate medications have been associated with improved
survival. Although the overall benefit to risk ratio of osteoporosis
medications remains favorable, there have been concerns raised about
the long-term safety of these treatments. Atypical femur fracture,
which is a rare type of fracture that has been associated with the
long-term use of potent antiresorptive bone medications, is a
potentially devastating consequence of osteoporosis treatment. This
paper reviews our current understanding of atypical femur fractures,
their relationship to antiresorptive osteoporosis medications, and
proposed strategies for management, in order to inform clinical
decision making about the optimal use and duration of medical therapy
for the treatment of patients with osteoporosis or at high risk for
osteoporotic fractures.
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Affiliation(s)
- Lianne Tile
- EN7-222 Toronto General Hospital, 200 Elizabeth St, Toronto, Ontario, Canada M5G 2C4
| | - Angela M Cheung
- Divisions of General Internal Medicine and Endocrinology and Metabolism, Osteoporosis Program, Department of Medicine; Centre of Excellence in Skeletal Health Assessment, Joint Department of Medical Imaging; University Health Network and University of Toronto. Toronto, ON, Canada
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Cheung E, Borno HT. The limitations of today’s clinical guidance: Atypical femoral fracture and long-term bone-modifying agents in the oncology setting. J Oncol Pharm Pract 2020; 26:1180-1189. [DOI: 10.1177/1078155220907965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
While bone-modifying agents such as bisphosphonates and denosumab are crucial to preventing skeletal-related events in patients with bone metastases, the optimal duration remains undefined. Extended duration may be associated with adverse effects such as osteonecrosis of the jaw and atypical femoral fracture. Although uncommon, atypical femoral fracture represents a serious consequence of prolonged bone-modifying agent use and are characterized by a prodrome and distinct radiographic findings. The oncology setting encompasses a unique set of atypical femoral fracture risk factors and considerations, with hormonal therapy in early stage disease, bone metastases in the advanced setting, and new targeted agents that may affect bone homeostasis. As outcomes in cancer treatment continue to improve, the questions of risks versus benefits of long-term bone-modifying agents and how to mitigate atypical femoral fracture risk become increasingly pertinent.
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Affiliation(s)
- Edna Cheung
- Department of Clinical Pharmacy and School of Pharmacy, University of California San Francisco, San Francisco, USA
| | - Hala T Borno
- Division of Hematology/Oncology, School of Medicine, University of California San Francisco, San Francisco, USA
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van de Laarschot DM, McKenna MJ, Abrahamsen B, Langdahl B, Cohen-Solal M, Guañabens N, Eastell R, Ralston SH, Zillikens MC. Medical Management of Patients After Atypical Femur Fractures: a Systematic Review and Recommendations From the European Calcified Tissue Society. J Clin Endocrinol Metab 2020; 105:5684909. [PMID: 31867670 PMCID: PMC7121199 DOI: 10.1210/clinem/dgz295] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/27/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT Atypical femur fractures (AFFs) are serious adverse events associated with bisphosphonates and often show poor healing. EVIDENCE ACQUISITION We performed a systematic review to evaluate effects of teriparatide, raloxifene, and denosumab on healing and occurrence of AFF. EVIDENCE SYNTHESIS We retrieved 910 references and reviewed 67 papers, including 31 case reports, 9 retrospective and 3 prospective studies on teriparatide. There were no RCTs. We pooled data on fracture union (n = 98 AFFs on teriparatide) and found that radiological healing occurred within 6 months of teriparatide in 13 of 30 (43%) conservatively managed incomplete AFFs, 9 of 10 (90%) incomplete AFFs with surgical intervention, and 44 of 58 (75%) complete AFFs. In 9 of 30 (30%) nonoperated incomplete AFFs, no union was achieved after 12 months and 4 (13%) fractures became complete on teriparatide. Eight patients had new AFFs during or after teriparatide. AFF on denosumab was reported in 22 patients, including 11 patients treated for bone metastases and 8 without bisphosphonate exposure. Denosumab after AFF was associated with recurrent incomplete AFFs in 1 patient and 2 patients of contralateral complete AFF. Eight patients had used raloxifene before AFF occurred, including 1 bisphosphonate-naïve patient. CONCLUSIONS There is no evidence-based indication in patients with AFF for teriparatide apart from reducing the risk of typical fragility fractures, although observational data suggest that teriparatide might result in faster healing of surgically treated AFFs. Awaiting further evidence, we formulate recommendations for treatment after an AFF based on expert opinion.
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Affiliation(s)
- Denise M van de Laarschot
- Bone Centre, Department of Internal Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Malachi J McKenna
- DXA Unit, St. Vincent’s University Hospital, University College Dublin, Dublin, Ireland
| | - Bo Abrahamsen
- OPEN, University of Southern Denmark, Odense, Denmark
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Bente Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Martine Cohen-Solal
- Department of Rheumatology, Université de Paris and Inserm U1132, Hôpital Lariboisière, Paris, France
| | - Núria Guañabens
- Department of Rheumatology, Hospital Clinic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Richard Eastell
- Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - Stuart H Ralston
- Centre for Genomic & Experimental Medicine MRC Institute of Genetics & Molecular Medicine, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - M Carola Zillikens
- Bone Centre, Department of Internal Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Correspondence: Prof M. Carola Zillikens, MD, PhD, Erasmus University Medical Centre, PO Box 2040, 3000 CA Rotterdam, The Netherlands. E-mail:
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Marongiu G, Contini A, Cozzi Lepri A, Donadu M, Verona M, Capone A. The Treatment of Acute Diaphyseal Long-bones Fractures with Orthobiologics and Pharmacological Interventions for Bone Healing Enhancement: A Systematic Review of Clinical Evidence. Bioengineering (Basel) 2020; 7:bioengineering7010022. [PMID: 32102398 PMCID: PMC7148449 DOI: 10.3390/bioengineering7010022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 02/17/2020] [Accepted: 02/20/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The healing of long bones diaphyseal fractures can be often impaired and eventually end into delayed union and non-union. A number of therapeutic strategies have been proposed in combination with surgical treatment in order to enhance the healing process, such as scaffolds, growth factors, cell therapies and systemic pharmacological treatments. Our aim was to investigate the current evidence of bone healing enhancement of acute long bone diaphyseal fractures. METHODS A systematic review was conducted by using Pubmed/MEDLINE; Embase and Ovid databases. The combination of the search terms "long-bones; diaphyseal fracture; bone healing; growth factors; cell therapies; scaffolds; graft; bone substitutes; orthobiologics; teriparatide". RESULTS The initial search resulted in 4156 articles of which 37 papers fulfilled the inclusion criteria and were the subject of this review. The studies included 1350 patients (837 males and 513 females) with a mean age of 65.3 years old. CONCLUSIONS General lack of high-quality studies exists on the use of adjuvant strategies for bone healing enhancement in acute shaft fractures. Strong evidence supports the use of bone grafts, while only moderate evidence demineralized bone matrix and synthetic ceramics. Conflicting results partially supported the use of growth factors and cell therapies in acute fractures. Teriparatide showed promising results, particularly for atypical femoral fractures and periprosthetic femoral fractures.
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Affiliation(s)
- Giuseppe Marongiu
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
- Correspondence: or ; Tel.: +39-070-6094368
| | - Andrea Contini
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
| | - Andrea Cozzi Lepri
- Orthopaedic Traumatologic Center, University of Florence, 50121 Florence, Italy;
| | - Matthew Donadu
- Dipartimento di Chimica e Farmacia, University of Sassari, 07100 Sassari, Italy;
| | - Marco Verona
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
| | - Antonio Capone
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
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Yamashita J, McCauley LK. Effects of Intermittent Administration of Parathyroid Hormone and Parathyroid Hormone-Related Protein on Fracture Healing: A Narrative Review of Animal and Human Studies. JBMR Plus 2019; 3:e10250. [PMID: 31844831 PMCID: PMC6894727 DOI: 10.1002/jbm4.10250] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 10/08/2019] [Accepted: 10/30/2019] [Indexed: 12/17/2022] Open
Abstract
Intermittent administration of parathyroid hormone (PTH) stimulates skeletal remodeling and is a potent anabolic agent in bone. PTH‐related protein (PTHrP) is anabolic acting on the same PTH1 receptor and is in therapeutic use for osteoporosis. The body of literature for PTH actions in fracture healing is emerging with promising yet not entirely consistent results. The objective of this review was to perform a literature analysis to extract up‐to‐date knowledge on the effects of intermittent PTH and PTHrP therapy in bone fracture healing. A literature search of the PubMed database was performed. Clinical case studies and articles related to “regeneration,” “implant,” and “distraction osteogenesis” were excluded. A narrative review was performed to deliberate the therapeutic potential of intermittent PTH administration on fracture healing. A smaller number of studies centered on the use of PTHrP or a PTHrP analog were also reviewed. Animal studies clearly show that intermittent PTH therapy promotes fracture healing and revealed the strong therapeutic potential of PTH. Human subject studies were fewer and not as consistent as the animal studies yet provide insight into the potential of intermittent PTH administration on fracture healing. Differences in outcomes for animal and human studies appear to be attributed partly to variable doses, fracture sites, age, remodeling patterns, and bone architectures, although other factors are involved. Future studies to examine the dose, timing, and duration of PTH administration will be necessary to further delineate the therapeutic potential of PTH for fracture healing in humans. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Junro Yamashita
- Center for Regenerative Medicine, Fukuoka Dental College Fukuoka Japan
| | - Laurie K McCauley
- Department of Periodontics and Oral Medicine, School of Dentistry University of Michigan Ann Arbor MI USA.,Department of Pathology, Medical School University of Michigan Ann Arbor MI USA
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23
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Shin WC, Moon NH, Jang JH, Seo HU, Suh KT. A retrospective bicenter comparative study of surgical outcomes of atypical femoral fracture: Potential effect of teriparatide on fracture healing and callus formation. Bone 2019; 128:115033. [PMID: 31398503 DOI: 10.1016/j.bone.2019.08.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/22/2019] [Accepted: 08/05/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND The main purpose of the present study was to assess the radiologic effect of teriparatide on fracture healing, including union rate, union time, and callus formation, by quantitative measurements using serial follow-up X-ray imaging examinations in patients with complete atypical femoral fractures (AFFs) treated using closed intramedullary nailing. METHODS From January 2010 to October 2017, 58 consecutive patients with complete AFF who were treated with intramedullary nailing at two institutions were enrolled. Patients were classified into two groups: those who received teriparatide therapy (group A) and those who did not (group B). Teriparatide (Forsteo®; Eli Lily Co., Indianapolis, IN, USA) at a once-daily 20 μg dose was prescribed as continuous treatment of osteoporosis or with the expectation of better bone healing. Surgical outcomes, including union rate, union time, modified radiologic union score (mRUS), and callus formation at 3, 6, and 12 months postoperatively, were assessed to evaluate the effect of teriparatide on fracture healing. Quantitative measurement of callus formation was performed using the region of interest (ROI) tool in the picture archiving communication system (PACS). RESULTS Non-union was not observed in group A, whereas two patients had non-union in group B. Union time was 18.3 ± 4.8 (range, 12-28) weeks in group A and 23.6 ± 9.5 (range, 12-64) weeks in group B and was significantly shorter in group A than group B (p = 0.010). The average mRUSs during periods A (3-4 months postoperatively), B (6-8 months postoperatively), and C (12-14 months postoperatively) were 10.0, 13.9, and 15.9 in group A, and 8.7, 12.0, and 14.9 in group B, respectively. The average mRUSs during periods A and B were significantly different (p = 0.027 and 0.011, respectively). The medial, posterior, and total callus areas during periods A and B were also significantly greater in group A than in group B. No difference was observed in the union rate between the two groups (p = 0.492). CONCLUSION Teriparatide may improve callus formation and shorten union time in patients with complete diaphyseal AFF who underwent closed intramedullary nailing. LEVEL OF EVIDENCE Level III retrospective comparative study.
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Affiliation(s)
- Won Chul Shin
- Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital
| | - Nam Hoon Moon
- Department of Orthopaedic Surgery, Bio-medical Research Institute, Pusan National University Hospital.
| | - Jae Hoon Jang
- Department of Orthopaedic Surgery, Bio-medical Research Institute, Pusan National University Hospital
| | - Han Ul Seo
- Department of Orthopaedic Surgery, Bio-medical Research Institute, Pusan National University Hospital
| | - Kuen Tak Suh
- Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital
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Kondo N, Miyasaka D, Watanabe Y, Sato H, Kanda T, Endo N. Atypical femoral fracture associated with delayed union for which the cessation of alendronate and daily administration of teriparatide contributed to fracture healing: histopathological evidence of the enhancement in bone formation parameters. Mod Rheumatol Case Rep 2019; 4:141-146. [PMID: 33086957 DOI: 10.1080/24725625.2019.1650992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
A female patient with systemic lupus erythematosus developed an atypical femoral fracture of the left femur after 5 years of glucocorticoid and alendronate therapy. We performed intramedullary nailing. However, 1 week later, we performed a revision surgery using a locking plate and an iliac bone graft because of displacement at the fracture site. At this stage, alendronate was discontinued and daily teriparatide was introduced and continued for 24 months. Twenty months after the revision surgery, a re-revision surgery was performed with an iliac bone graft because of breakage of the locking plate and fracture non-union. Fracture healing was eventually obtained 15 months after the re-revision surgery. Biopsies of the ilium before the treatment and 20 months after daily teriparatide treatment were evaluated. The histology revealed that proliferating osteoid and cuboidal osteoblasts were detected around the osteoid tissue after teriparatide treatment. Bone histomorphometry findings showed that bone volume parameters and osteoid parameters prominently increased with the teriparatide treatment, but not bone resorption parameters. Laboratory findings revealed the elevation of bone-specific alkaline phosphatase (24 U/L at 7 months) compared to its pre-teriparatide level (8.1 U/L) and increased bone mineral density of the hip (from -0.2 to 0.0 in T-score). These data indicated that the discontinuation of alendronate and initiation of teriparatide treatment activated bone-forming ability in our patient and may have contributed to fracture healing.
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Affiliation(s)
- Naoki Kondo
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Dai Miyasaka
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yo Watanabe
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hiroe Sato
- Health Administration Center, Niigata University, Niigata, Japan
| | - Toshihiro Kanda
- Division of Orthopedic Surgery, Seirei Hamamatsu Hospital, Hamamatsu, Japan
| | - Naoto Endo
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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25
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Guañabens N, Moro-Álvarez MJ, Casado E, Blanch-Rubió J, Gómez-Alonso C, Díaz-Guerra GM, Del Pino-Montes J, Valero Díaz de Lamadrid C, Peris P, Muñoz-Torres M. The next step after anti-osteoporotic drug discontinuation: an up-to-date review of sequential treatment. Endocrine 2019; 64:441-455. [PMID: 30963388 DOI: 10.1007/s12020-019-01919-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 03/29/2019] [Indexed: 12/16/2022]
Abstract
Several antiresorptive drugs, like bisphosphonates and denosumab, are currently available for the treatment of osteoporosis due to their evidenced efficacy in reducing fracture risk at mid-term. Osteoanabolic therapies, like teriparatide, whose treatment duration is limited to 2 years, have also shown efficacy in the reduction of fracture risk. However, depending on the severity of osteoporosis and the presence of other associated risk factors for fracture, some patients may require long-term treatment to preserve optimal bone strength and minimize bone fracture risk. Given the limited duration of some treatments, the fact that most of the antiresorptive drugs have not been assessed beyond 10 years, and the known long-term safety issues of these drugs, including atypical femoral fractures or osteonecrosis of the jaw, the long-term management of these patients may require an approach based on drug discontinuation and/or switching. In this regard, interest in sequential osteoporosis therapy, wherein drugs are initiated and discontinued over time, has grown in recent years, although the establishment of an optimal and individualized order of therapies remains controversial. This review reports the currently available clinical evidence on the discontinuation effects of different anti-osteoporotic drugs, as well as the clinical outcomes of the different sequential treatment regimens. The objective of this article is to present up-to-date practical knowledge on this area in order to provide guidance to the clinicians involved in the management of patients with osteoporosis.
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Affiliation(s)
- Núria Guañabens
- Metabolic Bone Diseases Unit, Department of Rheumatology, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Barcelona, Spain.
| | | | - Enrique Casado
- Rheumatology Department, Parc Taulí University Hospital, Autonomous University of Barcelona, Sabadell, Spain
| | | | - Carlos Gómez-Alonso
- Bone and Mineral Metabolism Unit, Central University Hospital of Asturias (HUCA), University of Oviedo, Oviedo, Spain
| | | | | | - Carmen Valero Díaz de Lamadrid
- University Hospital Marqués de Valdecilla, Research Institute Marqués de Valdecilla (IDIVAL), University of Cantabria, Santander, Spain
| | - Pilar Peris
- Metabolic Bone Diseases Unit, Department of Rheumatology, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Barcelona, Spain
| | - Manuel Muñoz-Torres
- Endocrinology and Nutrition Unit, Hospital Universitario San Cecilio de Granada, Department of Medicine, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria (Ibs.GRANADA), CIBERFES, Instituto de Salud Carlos III, Granada, Spain
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26
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Sølling ASK, Harsløf T, Langdahl B. Current Status of Bone-Forming Therapies for the Management of Osteoporosis. Drugs Aging 2019; 36:625-638. [DOI: 10.1007/s40266-019-00675-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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27
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Black DM, Abrahamsen B, Bouxsein ML, Einhorn T, Napoli N. Atypical Femur Fractures: Review of Epidemiology, Relationship to Bisphosphonates, Prevention, and Clinical Management. Endocr Rev 2019; 40:333-368. [PMID: 30169557 DOI: 10.1210/er.2018-00001] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 05/08/2018] [Indexed: 12/18/2022]
Abstract
Bisphosphonates (BPs) are highly effective in treating osteoporosis and reducing hip, vertebral, and other fractures by as much as 50% to 70%. However, since 2006, atypical femur fractures (AFFs) emerged as potential side effects of BPs and other treatments. These fractures have unusual radiologic features and occur with little trauma. Public concern has led to a >50% decrease in BP usage. AFFs are rare: for each AFF, >1200 fractures, including 135 hip fractures, are prevented. Case definition criteria were updated by the American Society of Bone and Mineral Research in 2014. Many epidemiologic studies have been reported, and although methodologically challenging, generally support a BP-AFF association. However, the magnitude of the association between BPs and AFFs is uncertain: estimates of relative risk for AFFs among BP users vs nonusers range from 1 to 65 with a meta-analysis estimate of 1.7. Although mechanistic studies have proposed several hypotheses explaining how BPs might decrease bone strength, AFF pathogenesis remains uncertain and cannot explain the paradox of efficacy of reduction of common fractures while increasing risk for rare fractures at one site. There are several consistent risk factors, including Asian race (in North America), femoral bowing, and glucocorticoid use, whereas others remain unclear. Consensus is emerging about strategies to prevent AFFs in BP users (including drug holidays after 5 years' use in some patients). In conclusion, AFFs can be devastating, but even under the most pessimistic assumptions, the benefit/risk ratio is highly positive for BPs, particularly during 3 to 5 years of use. As understanding of AFFs increases, it is becoming increasingly possible to maximize BP benefits while minimizing AFF risk.
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Affiliation(s)
- Dennis M Black
- University of California, San Francisco, San Francisco, California
| | | | | | | | - Nicola Napoli
- Università Campus Bio-Medico di Roma, Rome, Italy.,IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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28
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Babcock S, Kellam JF. Hip Fracture Nonunions: Diagnosis, Treatment, and Special Considerations in Elderly Patients. Adv Orthop 2018; 2018:1912762. [PMID: 30595922 PMCID: PMC6286768 DOI: 10.1155/2018/1912762] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 10/11/2018] [Accepted: 10/22/2018] [Indexed: 12/19/2022] Open
Abstract
In the United States, more than 300,000 hip fractures occur annually in the elderly population with associated significant morbidity and mortality. Both intracapsular and extracapsular hip fractures have inherent treatment challenges and therefore are at risk of nonunion complications. A systematic assessment including radiographic, metabolic, and infectious evaluations should be completed for all patients suspected of nonunion. Failed internal fixation of intracapsular hip fractures is typically treated with arthroplasty, while extracapsular proximal femur nonunions may be amenable to revision internal fixation or arthroplasty. While not a classic hip fracture, bisphosphate associated subtrochanteric femur fractures affect a similar patient population and are historically difficult to treat. Atypical subtrochanteric femur fractures are at increased risk of nonunion given the altered biologic environment secondary to bisphosphonate use; therefore adjuvant therapies may be beneficial in setting of revision fixation. Having a thorough understanding of nonunion risks, recognition, evaluation, and treatment is necessary for appropriate patient care.
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Affiliation(s)
- Sharon Babcock
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - James F. Kellam
- Department of Orthopaedic Surgery, UT Health Science Center at Houston, Houston, TX, USA
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29
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Pandey MK, Gupta SC, Karelia D, Gilhooley PJ, Shakibaei M, Aggarwal BB. Dietary nutraceuticals as backbone for bone health. Biotechnol Adv 2018; 36:1633-1648. [DOI: 10.1016/j.biotechadv.2018.03.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 03/13/2018] [Accepted: 03/21/2018] [Indexed: 12/11/2022]
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30
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Abstract
Atypical femoral fractures (AFF) are stress or ‘insufficiency’ fractures, often complicated by the use of bisphosphonates or other bone turnover inhibitors. While these drugs are beneficial for the intact osteoporotic bone, they probably prevent a stress fracture from healing which thus progresses to a complete fracture. Key features of atypical femoral fractures, essential for the diagnosis, are: location in the subtrochanteric region and diaphysis; lack of trauma history and comminution; and a transverse or short oblique configuration. The relative risk of patients developing an atypical femoral fracture when taking bisphosphonates is high; however, the absolute risk of these fractures in patients on bisphosphonates is low, ranging from 3.2 to 50 cases per 100,000 person-years. Treatment strategy in patients with AFF involves: radiograph of the contralateral side (computed tomography and magnetic resonance imaging should also be considered); dietary calcium and vitamin D supplementation should be prescribed following assessment; bisphosphonates or other potent antiresorptive agents should be discontinued; prophylactic surgical treatment of incomplete AFF with cephalomedullary nail, unless pain free; cephalomedullary nailing for surgical fixation of complete fractures; avoidance of gaps in the lateral and anterior cortex; avoidance of varus malreduction.
Cite this article: EFORT Open Rev 2018;3:494-500. DOI: 10.1302/2058-5241.3.170070.
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Affiliation(s)
| | - Hagen Schmal
- Department of Orthopaedics and Traumatology, Odense University Hospital, Denmark
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31
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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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