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Hashimoto J, Oh Y, Yamamoto K, Yoshii T, Fukushima K, Kitagawa M, Okawa A. Frequency and pathogenesis of periprosthetic atypical femoral fractures associated with total knee arthroplasty: A multicenter prospective study with complementary histopathological and biomechanical analysis. Injury 2024; 55:111136. [PMID: 37867026 DOI: 10.1016/j.injury.2023.111136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/04/2023] [Accepted: 10/14/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Although the diagnostic criteria for atypical femoral fracture (AFF) exclude periprosthetic fractures, reports of periprosthetic femoral fractures with characteristics of AFF are rapidly increasing. In this study, we investigated the frequency and pathogenesis of periprosthetic AFF associated with total knee arthroplasty (TKA) based on a theory of AFF subtypes that divides AFFs into two main types: fragility stress fractures of the bowed femoral shaft in the mid-shaft and "typical" subtrochanteric AFFs due to suppression of bone turnover (e.g., by bisphosphonates). PATIENTS AND METHODS This multicenter prospective study of AFFs was conducted from 2015 through 2022. Clinical, pathological, and morphological characteristics were investigated in patients with periprosthetic AFFs associated only with non-stem TKA. Then, biomechanical investigation of the periprosthetic AFF was performed by computer tomography-based finite element analysis (CT/FEA) using two models with different load axes to examine how the correction of lower limb alignment by TKA influences the tensile stress distribution of the femur and the location of the AFF. RESULTS Four of 61 AFFs (6.6%) were identified to be periprosthetic AFF (1 mid-shaft; 3 subtrochanteric). Periprosthetic AFFs had characteristics including mechanical stress due to bowing deformity and potentially suppressed bone turnover due to long-term exposure to specific drugs (e.g., bisphosphonates and glucocorticoids). Although 2 periprosthetic AFFs appeared to involve a bowed femur, one with both of the aforementioned characteristics occurred in the subtrochanteric region, which would be an unusual site for a bowed AFF, and it was demonstrated histologically to have biological activity at the fracture site, suggesting a stress fracture. Furthermore, CT/FEA revealed that tensile stress distribution changed proximally as load axis was shifted laterally according to correction of lower limb alignment by TKA. CONCLUSION Orthopedic surgeons should recognize the presence of TKA-associated periprosthetic AFF caused by various factors including specific drugs, bowing deformity, and lower limb alignment. X-rays of the full-length femurs should be checked regularly after TKA, especially in patients with bowed femurs or long-term exposure to specific drugs.
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Affiliation(s)
- Jun Hashimoto
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoto Oh
- Department of Orthopaedic and Trauma Research, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Kouhei Yamamoto
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Masanobu Kitagawa
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Okawa
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Bliemel C, Birkelbach R, Knauf T, Pass B, Craiovan B, Schoeneberg C, Ruchholtz S, Bäumlein M. Surgical management and outcomes following atypical subtrochanteric femoral fractures - results from a matched-pair analysis of the registry for geriatric trauma of the German Trauma Society. Arch Orthop Trauma Surg 2024; 144:2561-2572. [PMID: 38642159 PMCID: PMC11211164 DOI: 10.1007/s00402-024-05297-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 03/24/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND AND OBJECTIVES The outcomes of patients with atypical subtrochanteric fractures (ASFs) remain unclear. Data from a large international geriatric trauma registry were analysed to examine the outcome of patients with ASFs compared to patients with typical osteoporotic subtrochanteric fractures (TSFs). MATERIALS AND METHODS Data from the Registry for Geriatric Trauma of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie [DGU]) (ATR-DGU) were analysed. All patients treated surgically for ASFs or TSFs were included in this analysis. Across both fracture types, a paired matching approach was conducted, where statistical twins were formed based on background characteristics sex, age, American Society of Anesthesiologists (ASA) score and walking ability. In-house mortality and mortality rates at the 120-day follow-up, as well as mobility at 7 and 120 days, the reoperation rate, hospital discharge management, the hospital readmission rate at the 120-day follow-up, health-related quality of life, type of surgical treatment and anti-osteoporotic therapy at 7 and 120 days, were assessed as outcome measures using a multivariate logistic regression analysis. RESULTS Amongst the 1,800 included patients, 1,781 had TSFs and 19 had ASFs. Logistic regression analysis revealed that patients with ASFs were more often treated with closed intramedullary nailing (RR = 3.59, p < 0.001) and had a higher probability of vitamin D supplementation as osteoporosis therapy at 120 days (RR = 0.88, p < 0.002). Patients with ASFs were also more likely to live at home after surgery (RR = 1.43, p < 0.001), and they also tended to continue living at home more often than patients with TSFs (RR = 1.33, p < 0.001). Accordingly, patients with TSFs had a higher relative risk of losing their self-sufficient living status, as indicated by increased rates of patients living at home preoperatively and being discharged to nursing homes (RR = 0.19, p < 0.001) or other hospitals (RR = 0.00, p < 0.001) postoperatively. CONCLUSIONS Surgical treatment of ASFs was marked by more frequent use of closed intramedullary fracture reduction. Furthermore, patients with ASFs were more likely to be discharged home and died significantly less often in the given timeframe. The rate of perioperative complications, as indicated by nonsignificant reoperation rates, as well as patient walking abilities during the follow-up period, remained unaffected.
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Affiliation(s)
- Christopher Bliemel
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, 35043, Baldingerstrasse, Marburg, Germany.
- Philipps University of Marburg, Marburg, Germany.
| | | | - Tom Knauf
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, 35043, Baldingerstrasse, Marburg, Germany
| | - Bastian Pass
- Department of Orthopedic and Emergency Surgery, Alfried Krupp Hospital, Essen, Germany
| | - Benjamin Craiovan
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, 35043, Baldingerstrasse, Marburg, Germany
| | - Carsten Schoeneberg
- Department of Orthopedic and Emergency Surgery, Alfried Krupp Hospital, Essen, Germany
| | - Steffen Ruchholtz
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, 35043, Baldingerstrasse, Marburg, Germany
- Philipps University of Marburg, Marburg, Germany
| | - Martin Bäumlein
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, 35043, Baldingerstrasse, Marburg, Germany
- Philipps University of Marburg, Marburg, Germany
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Guo J, Ma RY, Qian BZ. Macrophage heterogeneity in bone metastasis. J Bone Oncol 2024; 45:100598. [PMID: 38585688 PMCID: PMC10997910 DOI: 10.1016/j.jbo.2024.100598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/16/2024] [Accepted: 03/20/2024] [Indexed: 04/09/2024] Open
Abstract
Previous studies illustrated that macrophage, a type of innate immune cell, plays critical roles in tumour progression and metastasis. Bone is the most frequent site of metastasis for several cancer types including breast, prostate, and lung. In bone metastasis, osteoclast, a macrophage subset specialized in bone resorption, was heavily investigated in the past. Recent studies illustrated that other macrophage subsets, e.g. monocyte-derived macrophages, and bone resident macrophages, promoted bone metastasis independent of osteoclast function. These novel mechanisms further improved our understanding of macrophage heterogeneity in the context of bone metastasis and illustrated new opportunities for future studies.
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Affiliation(s)
| | | | - Bin-Zhi Qian
- Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, The Human Phenome Institute, Zhangjiang-Fudan International Innovation Center, Fudan University, Shanghai 200438, China
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Kaku T, Oh Y, Sato S, Koyanagi H, Funauchi Y, Hirai T, Yuasa M, Matsukura Y, Yoshii T, Nakagawa T, Miyake S, Okawa A. Prevalence of Precursory Signs of Atypical Femoral Fractures in Patients Receiving Bone-Modifying Agents for Bone Metastases: A Cross-Sectional Study. JBMR Plus 2023; 7:e10749. [PMID: 37457876 PMCID: PMC10339079 DOI: 10.1002/jbm4.10749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 03/23/2023] [Accepted: 04/01/2023] [Indexed: 07/18/2023] Open
Abstract
Patients on bone-modifying agents (BMAs) for bone metastases are at risk of atypical femoral fractures (AFFs), which can lead to a sudden deterioration in performance status. In this study, we sought to determine the prevalence of radiographic precursory signs of AFF in patients on oncologic BMAs. Forty-two patients (23 men, 19 women; mean age 68.8 ± 10.0 years) on oncologic BMAs (zoledronate for >3 years and/or denosumab for >1 year) and without clinical symptoms were enrolled between 2019 and 2021. All patients were receiving denosumab at enrollment and 5 had previously used zoledronate. The mean duration of BMA use was 31.2 ± 18.5 months. Radiographs of both femurs were screened for precursory signs of AFF (e.g., thickening of the lateral cortex). The patients were divided into two groups according to thickening status and compared by duration of BMA use. They were also divided into three groups by duration of BMA use (12-23 months, n = 18; 24-59 months, n = 19; ≥60 months, n = 5), and the prevalence of apparent thickenings was examined. As a result, 18 patients (42.9%) showed minute local or diffuse thickening and 10 (23.8%) showed apparent local thickening. The duration of BMA use was significantly longer in patients with apparent thickening than in those without (47.3 ± 23.6 months [n = 10] versus 26.2 ± 13.5 months [n = 32]; p < 0.05). The prevalence of apparent thickening increased with increasing duration of BMA use (12-23 months, 5.6%; 24-59 months, 31.6%; ≥60 months, 60.0%). In conclusion, radiographic precursory signs of AFF are common in patients on oncologic BMAs. Radiographic screening for AFF could be relevant in patients who have been on long-term oncologic BMAs, even if asymptomatic. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Takumi Kaku
- Department of Orthopaedic and Spinal SurgeryGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
| | - Yoto Oh
- Department of Orthopaedic and Trauma ResearchGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
| | - Shingo Sato
- Center for Innovative Cancer Treatment, Tokyo Medical and Dental University Medical HospitalTokyoJapan
| | - Hirotaka Koyanagi
- Department of Orthopaedic and Spinal SurgeryGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
| | - Yuki Funauchi
- Department of Orthopaedic and Spinal SurgeryGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
| | - Takashi Hirai
- Department of Orthopaedic and Spinal SurgeryGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
| | - Masato Yuasa
- Department of Orthopaedic and Spinal SurgeryGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
| | - Yu Matsukura
- Department of Orthopaedic and Spinal SurgeryGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
| | - Toshitaka Yoshii
- Department of Orthopaedic and Spinal SurgeryGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
| | - Tsuyoshi Nakagawa
- Department of Breast SurgeryTokyo Medical and Dental University Medical HospitalTokyoJapan
| | - Satoshi Miyake
- Department of Clinical OncologyGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
| | - Atsushi Okawa
- Department of Orthopaedic and Spinal SurgeryGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental UniversityTokyoJapan
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Leland CR, Pratilas CA, Gross JM, Levin AS. Diffuse Pulmonary Metastases at Presentation of Giant Cell Tumor of Bone: A Case Report and Synthesis of Literature. JBJS Case Connect 2023; 13:01709767-202303000-00004. [PMID: 36821126 DOI: 10.2106/jbjs.cc.22.00496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 10/27/2022] [Indexed: 02/24/2023]
Abstract
CASE We present a 23-year-old man with acute-on-chronic shoulder pain with an aggressive-appearing, destructive lesion of the left proximal humerus and diffuse lung metastases. Biopsy revealed conventional giant cell tumor of bone (GCTB) without sarcomatous differentiation, treated with resection and proximal humerus reconstruction. Without systemic treatment, his pulmonary metastases demonstrated modest spontaneous regression, with no impairment of pulmonary function. CONCLUSIONS Although GCTB is known to metastasize to lungs, these deposits most commonly follow local recurrence. We describe a young adult with diffuse pulmonary nodules at initial presentation, although still following an indolent clinical course without the need for additional systemic therapy.
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Affiliation(s)
- Christopher R Leland
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Christine A Pratilas
- Division of Pediatric Oncology, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
| | - John M Gross
- Division of Surgical Pathology, Department of Pathology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Adam S Levin
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
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Rachner TD, Coleman R, Hadji P, Hofbauer LC. Individualized Bone-Protective Management in Long-Term Cancer Survivors With Bone Metastases. J Bone Miner Res 2021; 36:1906-1913. [PMID: 34131949 DOI: 10.1002/jbmr.4391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/15/2021] [Accepted: 06/10/2021] [Indexed: 12/15/2022]
Abstract
Antiresorptive therapy is an important component of a multimodal approach to treating patients with advanced malignancies and metastatic bone disease. Over the past decade, overall survival of affected patients has improved in most cancer entities, and long-term disease control is a realistic goal in many cases. There are emerging clinical studies showing the benefits of an initial antiresorptive therapy using bisphosphonates or denosumab. However, some adverse events of these therapies, such as osteonecrosis of the jaw, correlate with the cumulative doses given, and there is an increasing clinical need for new antiresorptive concepts to treat long-term survivors. This review summarizes the clinical evidence of antiresorptive therapies across different cancers with bone involvement and presents concepts of dose-reduction protocols for long-term survivors with established metastatic bone disease. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Tilman D Rachner
- Division of Endocrinology, Diabetes and Bone Diseases & Center for Healthy Ageing, Department of Medicine III, Technische Universität Dresden, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Center for Healthy Aging, Technische Universität Dresden, Dresden, Germany
| | - Robert Coleman
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Peyman Hadji
- Frankfurt Center of Bone Health, Frankfurt, Germany.,Philips-University of Marburg, Marburg, Germany
| | - Lorenz C Hofbauer
- Division of Endocrinology, Diabetes and Bone Diseases & Center for Healthy Ageing, Department of Medicine III, Technische Universität Dresden, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Center for Healthy Aging, Technische Universität Dresden, Dresden, Germany
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Fuchioka Y, Suzuki K, Kimura H, Furuoka H, Tamura Y. Two cases of atypical femoral fracture in cancer patients administered with bone-modifying agents. J Rural Med 2021; 16:170-173. [PMID: 34239630 PMCID: PMC8249369 DOI: 10.2185/jrm.2020-061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/16/2021] [Indexed: 12/02/2022] Open
Abstract
Objective: We report two cases of atypical femoral fracture (AFF) in
patients with cancer. Patients: Two patients, a 53-year-old woman with breast cancer and a
77-year-old man with prostate cancer, could not walk after being injured in a fall. They
used bone-modifying agents (BMA) for the prevention of bone metastasis for three and four
years, respectively. Results: Intramedullary nails were placed to fix the femoral fractures in
each patient. Neither of them had pathological metastatic femoral fractures based on
fracture site specimens; however, severe suppression of bone turnover at the fracture site
was suspected. Both patients could ambulate with a T-cane and were free of hip pain after
surgery. Radiographs showed no callus formation at the fracture site. Conclusion: Based on the two cases of AFF in patients with cancer related to
BMA use, we should consider that the incidence of AFF may be associated with long-term BMA
use.
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Affiliation(s)
| | - Kohji Suzuki
- Department of Orthopaedic Surgery, JA Toride Medical Center
| | - Hiroaki Kimura
- Department of Orthopaedic Surgery, JA Toride Medical Center
| | - Hideto Furuoka
- Department of Orthopaedic Surgery, JA Toride Medical Center
| | - Yuri Tamura
- Department of Orthopaedic Surgery, JA Toride Medical Center
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Oh Y, Yamamoto K, Yoshii T, Kitagawa M, Okawa A. Current concept of stress fractures with an additional category of atypical fractures: a perspective review with representative images. Ther Adv Endocrinol Metab 2021; 12:20420188211049619. [PMID: 34671453 PMCID: PMC8521412 DOI: 10.1177/20420188211049619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 09/12/2021] [Indexed: 11/16/2022] Open
Abstract
Stress fractures have traditionally been classified into three categories: fatigue fractures due to overuse of bone with normal elastic resistance; insufficiency fractures due to everyday physiological stress on fragile bone with poor elastic resistance; and pathologic fractures due to bone weakness involving tumors. The concept of atypical fractures has emerged and is considered a type of stress fracture. However, there has been some inconsistency in interpretation when using the traditional classification of stress fractures, and atypical femoral fractures (AFFs) can potentially be classified into subtypes: "typical" AFFs involving bone turnover suppression due to specific drugs (e.g. bisphosphonates) and fragility fractures of the bowed femoral shaft. In this article, the classification of stress fractures is redefined with the addition of atypical fractures as a fourth category, in which biological activity for fracture healing is absent, to promote consistent understanding and interpretation of clinical conditions involving stress fractures.
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Affiliation(s)
| | - Kouhei Yamamoto
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masanobu Kitagawa
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Okawa
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Murai A, Tada K, Nakajima T, Akahane M, Matsuta M, Nakamura Y, Tsuchiya H. Case Report: Prophylactic Plate Fixation for Incomplete Atypical Ulnar Fractures Resulting From the Use of Denosumab for Bone Metastases. Front Endocrinol (Lausanne) 2021; 12:798653. [PMID: 35069445 PMCID: PMC8782234 DOI: 10.3389/fendo.2021.798653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/15/2021] [Indexed: 12/02/2022] Open
Abstract
Patients with bone metastases are treated with long-term bone resorption inhibitors such as bisphosphonates and denosumab. However, resorption inhibitors have been known to cause fractures, such as atypical femoral fractures (AFFs). In recent years, there have been an increasing number of reports of atypical ulna fractures (AUFs) caused by bone resorption inhibitor usage. Treatment of AUFs is complicated, especially when they occur in patients with bone metastases, because it is difficult to discontinue bone resorption inhibitor treatment without the risk of aggravating metastatic lesions. Prophylactic surgery is recommended in AFFs when fractures are predicted, but there are few reports of prophylactic surgery for AUFs. Here, we report a case of incomplete AUF in a 74-year-old woman which was surgically treated with prophylactic plate fixation. The patient had been using denosumab for 6 years to treat bone metastases due to thyroid cancer. After surgery, no fractures were observed for 2 years without discontinuing denosumab, and her forearm function was adequate. AUFs are rare and difficult to treat, so oncologists who treat bone metastases need to pay special attention to diagnose this incomplete AUF before the fracture worsens. We believe that detection of a possible fracture and prophylactic surgery can improve prognosis.
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