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Lo JC, Yang W, Park-Sigal JJ, Ott SM. Osteoporosis and Fracture Risk among Older US Asian Adults. Curr Osteoporos Rep 2023; 21:592-608. [PMID: 37542683 PMCID: PMC10858302 DOI: 10.1007/s11914-023-00805-7] [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] [Accepted: 06/06/2023] [Indexed: 08/07/2023]
Abstract
PURPOSE OF REVIEW This review summarizes the current knowledge regarding osteoporosis and fracture among older US Asian adults. RECENT FINDINGS Asian adults have lower (areal) bone density than non-Hispanic White adults and thus are more likely to be diagnosed and treated for osteoporosis, despite their lower risk of hip fracture. The latter may relate to favorable characteristics in hip geometry, volumetric bone density, and bone microarchitecture; lower risk of falls; and other clinical factors. The fracture risk calculator FRAX accounts for the lower risk of hip fracture among US Asian adults. However, data on major osteoporotic fracture risk remain limited. Fracture rates also vary by Asian subgroup, which may have implications for fracture risk assessment. Furthermore, among women receiving bisphosphonate drugs, Asian race is a risk factor for atypical femur fracture, an uncommon complication associated with treatment duration. Recent clinical trial efficacy data pertaining to lower bisphosphonate doses and longer dosing intervals may be relevant for Asian adults. More research is needed to inform osteoporosis care of US Asian adults, including risk-benefit considerations and the optimal duration of bisphosphonate treatment. Greater evidence-based guidance for primary fracture prevention among US Asian adults will ensure health equity in the prevention of osteoporotic fractures.
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Affiliation(s)
- Joan C Lo
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
- The Permanente Medical Group, Oakland, CA, USA.
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
| | - Wei Yang
- The Permanente Medical Group, Oakland, CA, USA
- Department of Endocrinology, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Jennifer J Park-Sigal
- The Permanente Medical Group, Oakland, CA, USA
- Department of Endocrinology, Kaiser Permanente South San Francisco Medical Center, South San Francisco, CA, USA
| | - Susan M Ott
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
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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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West TA, Pollard JD, Chandra M, Hui RL, Weintraub MR, King CM, Grimsrud CD, Lo JC. The Epidemiology of Metatarsal Fractures Among Older Females With Bisphosphonate Exposure. J Foot Ankle Surg 2020; 59:269-273. [PMID: 32130989 PMCID: PMC7831749 DOI: 10.1053/j.jfas.2019.02.008] [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: 11/11/2018] [Revised: 02/08/2019] [Accepted: 02/18/2019] [Indexed: 02/03/2023]
Abstract
Bisphosphonates (BP) are used to treat osteoporosis, although rare atypical femur fractures have occurred with long-term exposure, especially among Asians. Metatarsal fractures have also been reported with atypical femur fracture. We examined the epidemiology of metatarsal fractures among 48,390 females aged ≥50 years who initiated oral BP and were followed for a median 7.7 years, including 68 females who experienced an atypical femur fracture. Incident metatarsal fractures after BP initiation were identified by clinical diagnoses and validated by record review. The association of BP, clinical risk factors, race/ethnicity, and metatarsal fracture was examined by using Cox proportional hazard analyses. Among 1123 females with incident metatarsal fracture, 61.0% had an isolated fifth metatarsal fracture. The incidence of metatarsal fracture was 312 per 100,000 person-years of follow-up and was substantially lower for Asians. The adjusted relative rate for metatarsal fractures was 0.5 (95% confidence interval 0.4 to 0.6) for Asians compared with whites. Younger age, prior fracture, other risk factors, and current BP were associated with an increased relative rate of metatarsal fracture, but BP duration was not. Females with atypical femur fracture were not more likely to experience metatarsal fracture (2.9% versus 2.3%, p = .7), but only 68 females had an atypical fracture and stress fracture of the metatarsals was not examined. Except for age, the demographic profile for metatarsal fracture after initiating BP was similar to that for osteoporotic fracture, with Asians at a much lower risk. Although metatarsal fractures were not associated with BP duration or atypical femur fracture, the subset of metatarsal stress fractures was not specifically examined.
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Affiliation(s)
- Tenaya A West
- Surgeon, Department of Podiatric Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Jason D Pollard
- Surgeon, Department of Podiatric Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Malini Chandra
- Senior Data Consultant, Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Rita L Hui
- Pharmacy Research Scientist, Pharmacy Outcomes Research Group, Kaiser Permanente California, Oakland, CA
| | - Miranda Ritterman Weintraub
- Senior Research Manager, Department of Graduate Medical Education, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Christy M King
- Surgeon, Department of Podiatric Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Christopher D Grimsrud
- Chief, Department of Orthopedic Surgery, Kaiser Permanente Oakland Medical Center; Oakland, CA
| | - Joan C Lo
- Research Scientist, Division of Research, Kaiser Permanente Northern California, Oakland, CA.
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Akgun U, Canbek U, Aydogan NH. Reliability and diagnostic utility of radiographs in patients with incomplete atypical femoral fractures. Skeletal Radiol 2019; 48:1427-1434. [PMID: 30972429 DOI: 10.1007/s00256-019-03212-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 03/13/2019] [Accepted: 03/21/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the sensitivity and specificity of radiographs in identifying incomplete atypical femoral fractures and to determine interobserver and intra-observer reliability. MATERIALS AND METHODS Anterior-posterior and lateral radiographs of 10 femurs with incomplete atypical femoral fractures confirmed using bone scintigraphy and magnetic resonance imaging, and 40 femurs without incomplete atypical femoral fractures confirmed using bone scintigraphy, were reviewed by 4 orthopedic surgeons and 4 radiology specialists. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated to determine a diagnosis of incomplete atypical femoral fractures. Interobserver reliability was measured using Fleiss' kappa value, and intra-observer reliability was ascertained using Cohen's kappa statistic. RESULTS Mean sensitivity, specificity, accuracy, and the positive and negative predictive values were found to be 89, 89, 89, 67, and 97% respectively, in diagnosing incomplete atypical femoral fractures using radiographs. Interobserver reliability was found to be at a good level (Fleiss' kappa = 0.66, standard error = 0.03, 95% confidence interval = 0.61-0.71). Intra-observer Cohen's kappa values ranged from 0.53 to 0.91. CONCLUSION The use of radiography was satisfactory in identifying incomplete atypical femoral fractures, and the level of interobserver agreement was found to be good. As radiographs are associated with low positive predictive values, an advanced imaging method should be used when an increase in femoral cortical thickness is the only contributory factor to suspicion of an incomplete atypical femoral fracture.
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Affiliation(s)
- Ulas Akgun
- Faculty of Medicine, Department of Orthopaedics and Traumatology, Mugla Sitki Kocman University, 48000, Mentese, Mugla, Turkey.
| | - Umut Canbek
- Faculty of Medicine, Department of Orthopaedics and Traumatology, Mugla Sitki Kocman University, 48000, Mentese, Mugla, Turkey
| | - Nevres Hurriyet Aydogan
- Faculty of Medicine, Department of Orthopaedics and Traumatology, Mugla Sitki Kocman University, 48000, Mentese, Mugla, Turkey
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Dell R, Greene D. A proposal for an atypical femur fracture treatment and prevention clinical practice guideline. Osteoporos Int 2018; 29:1277-1283. [PMID: 29675745 DOI: 10.1007/s00198-018-4506-9] [Citation(s) in RCA: 18] [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: 08/29/2017] [Accepted: 03/23/2018] [Indexed: 01/27/2023]
Abstract
UNLABELLED The prevention as well as the treatment of atypical femur fractures (AFFs) remains controversial but there have been many clinical recommendations suggested. We have summarized these recommendations as well as expanded upon them in this paper. INTRODUCTION The purpose of the paper was to develop a clinical practice guideline that both treats AFF and decreases the risk of AFF in patients requiring antiresorptive medications. Examples of these medications include bisphosphonates and denosumab for the treatment of osteoporosis. METHODS A literature review looking for recommendations on AFF identification, management, and prevention was done. We also performed an updated review of clinical guidelines on AFF prevention and treatment that were developed for the Kaiser Permanente osteoporosis/fracture prevention team. RESULTS Concise clinical practice guidelines are presented that can be applied in treatment of AFF as well as help reduce the risk of developing an AFF in patients requiring antiresorptive medications. These guidelines are based on using both typical fracture and AFF risk assessment to determine duration of antiresorptive of 3 to 5 years before consideration if a drug holiday is needed. Specific groups such as younger Asian women should be reassessed at 3 years with DXA and FRAX to see if a drug holiday is needed whereas patients at higher risk for typical fractures may be reassessed at 5 years of treatment. The DXA rescreening can now be accessed if focal or generalized lateral cortex changes are present that may indicate incomplete AFFs are present. If an incomplete AFF is discovered either by DXA or by other imaging studies, it is imperative to stop antiresorptive medications and to take additional measures to lower the risk of progression to a complete AFF. If complete AFF does occur, then antiresorptive medications should be stopped and additional measures should be taken to decrease the risk of developing an AFF on the contralateral femur. CONCLUSIONS Clinical practice guidelines for the treatment and prevention of AFF will benefit clinicians who are frequently faced with having to make clinical decisions in patients requiring antiresorptive medications.
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Affiliation(s)
- R Dell
- Kaiser Downey Southern California, 9353 Imperial Hwy, Downey, CA, 90242, USA.
| | - D Greene
- Kaiser Downey Southern California, 9353 Imperial Hwy, Downey, CA, 90242, USA
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Shin WC, Moon NH, Jang JH, Park KY, Suh KT. Anterolateral femoral bowing and loss of thigh muscle are associated with occurrence of atypical femoral fracture: Effect of failed tension band mechanism in mid-thigh. J Orthop Sci 2017; 22:99-104. [PMID: 27720510 DOI: 10.1016/j.jos.2016.09.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 08/23/2016] [Accepted: 09/10/2016] [Indexed: 02/09/2023]
Abstract
BACKGROUND The purpose of this study was to characterize anterolateral bowing of the femur using X-rays and muscular atrophy in the mid-thigh using computed tomography (CT) in patients with atypical femoral fractures (AFFs). We then compared the results with those of an intertrochanteric fracture to understand whether these measures act as causative factors of AFFs. METHODS From January 2009 to December 2015, 37 patients with complete AFF and 12 patients with incomplete AFF were enrolled in this study. Lateral femoral bowing, anterior femoral bowing, cross-sectional area (CSA), and attenuation coefficient of thigh muscles in the AFF group are measured and compare with those in the intertrochanteric fracture group. RESULTS Lateral and anterior femoral bowing in the AFF group were significantly higher than those in the intertrochanteric fracture group. The level of fracture was found to be significantly associated with lateral and anterior femoral bowing (r = 0.569, r2 = 0.324, p < 0.001; r = -0.530, r2 = 0.281, p < 0.001, respectively). Total CSA and CSA of anterior and medial compartments were significantly lower in the AFF group (p < 0.05). The attenuation coefficient of the total thigh muscle and all three compartments in the AFF group were significantly lower than those in the intertrochanteric fracture group (p < 0.05). CONCLUSIONS This study demonstrated that anterolateral femoral bowing and loss of thigh muscle were highly associated with the occurrence of AFFs.
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Affiliation(s)
- W C Shin
- Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, South Korea
| | - N H Moon
- Department of Orthopaedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Hospital, South Korea.
| | - J H Jang
- Department of Orthopaedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Hospital, South Korea
| | - K Y Park
- Department of Orthopaedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Hospital, South Korea
| | - K T Suh
- Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, South Korea
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Lo JC, Hui RL, Grimsrud CD, Chandra M, Neugebauer RS, Gonzalez JR, Budayr A, Lau G, Ettinger B. The association of race/ethnicity and risk of atypical femur fracture among older women receiving oral bisphosphonate therapy. Bone 2016; 85:142-7. [PMID: 26769007 PMCID: PMC5108728 DOI: 10.1016/j.bone.2016.01.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 11/09/2015] [Accepted: 01/04/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE Several epidemiologic studies suggest that compared to white women, Asians have a greater propensity to suffer an atypical femur fracture (AFF) while taking bisphosphonate therapy. This study examines the relative risk of AFF following bisphosphonate initiation for Asian compared to white women. METHODS Using data from a large integrated northern California healthcare delivery system, we examined diaphyseal femur fracture outcomes among women age≥50years old who initiated oral bisphosphonate therapy during 2002-2007. An AFF was defined by the 2013 American Society of Bone and Mineral Research Task Force criteria. The risk of radiographically-confirmed AFF was examined for Asian compared to white women, adjusting for differences in bisphosphonate exposure and other potential risk factors. RESULTS Among 48,390 women (65.3% white, 17.1% Asian) who newly initiated bisphosphonate therapy and were followed for a median of 7.7years, 68 women experienced an AFF. The rate of AFF was 18.7 per 100,000 person-years overall and eight-fold higher among Asian compared to white women (64.2 versus 7.6 per 100,000 person-years). Asians were also more likely to have longer bisphosphonate treatment duration compared to whites (median 3.8 versus 2.7years). The age-adjusted relative hazard for AFF was 8.5 (95% confidence interval 4.9-14.9) comparing Asian to white women, and was only modestly reduced to 6.6 (3.7-11.5) after adjusting for bisphosphonate duration and current use. CONCLUSIONS Our study confirms marked racial disparity in AFF risk that should be further investigated, particularly the mechanisms accounting for this difference. These findings also underscore the need to further examine the association of bisphosphonate duration and AFF in women of Asian race, as well as differential risk across Asian subgroups. In the interim, counseling of Asian women about osteoporosis drug continuation should include consideration of their potentially higher AFF risk.
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Affiliation(s)
- Joan C Lo
- Division of Research, Kaiser Permanente Northern California, USA; Department of Medicine, Kaiser Permanente Oakland Medical Center, USA.
| | - Rita L Hui
- Pharmacy Outcomes Research Group, Kaiser Permanente California, USA
| | | | - Malini Chandra
- Division of Research, Kaiser Permanente Northern California, USA
| | | | - Joel R Gonzalez
- Division of Research, Kaiser Permanente Northern California, USA
| | - Amer Budayr
- Department of Medicine, Kaiser Permanente Oakland Medical Center, USA
| | - Gene Lau
- Department of Medicine, Kaiser Permanente San Francisco Medical Center, USA
| | - Bruce Ettinger
- Division of Research, Kaiser Permanente Northern California, USA; Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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Temponi EF, de Carvalho Junior LH, Costa LP. Atypical femoral fracture due to chronic use of bisphosphonates: case report. Rev Bras Ortop 2015; 50:482-5. [PMID: 26401508 PMCID: PMC4563046 DOI: 10.1016/j.rboe.2015.06.016] [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: 07/13/2014] [Accepted: 08/26/2014] [Indexed: 11/02/2022] Open
Abstract
The causal relationship between chronic use of bisphosphonates and occurrences of atypical femoral fractures has not yet been established. Nonetheless, it is known that their chronic use is more related to fractures with a pattern differing from that of classical osteoporotic fractures. Atypical fractures are still rare events and the benefit from using bisphosphonates remains greater for prevention and treatment of osteoporosis. There are few studies guiding the diagnosis and management of these fractures, thus making it difficult to achieve better results. In this report, we present the case of an elderly patient with an atypical femoral fracture that was managed in accordance with guidance from the American Society for Bone and Mineral Research.
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Temponi EF, Carvalho Júnior LHD, Costa LP. Fratura femoral atípica devida a uso crônico de bifosfonato. Relato de caso. Rev Bras Ortop 2015. [DOI: 10.1016/j.rbo.2014.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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