Effect of Teriparatide on Healing of Atypical Femoral Fractures: A Systemic Review

Osteoporotic osseointegration: therapeutic hallmarks and engineering strategies

Osteoporosis is a systemic skeletal disease caused by an imbalance between bone resorption and formation. Current treatments primarily involve systemic medication and hormone therapy. However, these systemic treatments lack directionality and are often ineffective for locally severe osteoporosis, with the potential for complex adverse reactions. Consequently, treatment strategies using bioactive materials or external interventions have emerged as the most promising approaches. This review proposes twelve microenvironmental treatment targets for osteoporosis-related pathological changes, including local accumulation of inflammatory factors and reactive oxygen species (ROS), imbalance of mitochondrial dynamics, insulin resistance, disruption of bone cell autophagy, imbalance of bone cell apoptosis, changes in neural secretions, aging of bone cells, increased local bone tissue vascular destruction, and decreased regeneration. Additionally, this review examines the current research status of effective or potential biophysical and biochemical stimuli based on these microenvironmental treatment targets and summarizes the advantages and optimal parameters of different bioengineering stimuli to support preclinical and clinical research on osteoporosis treatment and bone regeneration. Finally, the review addresses ongoing challenges and future research prospects.

Bisphosphonate-induced atypical femoral shaft fracture: A case report

Osteoporosis is an important cause of fractures in postmenopausal women. Bisphosphonates are the first line of treatment for osteoporosis. However, long-term use of these medications has been related to atypical femoral fractures (AFF). We present a case of a 71-year-old postmenopausal woman, with a history of osteoporosis being treated with bisphosphonates for 6 years. The patient developed pain in her left hip and thigh over a period of 3-4 months. Radiographic studies showed an AFF and she was managed conservatively. Stopping bisphosphonate therapy should be an initial step in managing or limiting the progression of AFF. A drug holiday should be considered in patients who have been treated for more than 3-5 years to prevent AFFs. The risk of developing AFFs should never be ignored in this subset of patients.

Position Statement: Atypical Femoral Fracture from the Korean Society for Bone and Mineral Research in 2023

As the aging population increases, the number of patients with osteoporosis is gradually rising. Osteoporosis is a metabolic bone disease characterized by low bone mass and the microarchitectural deterioration of bone tissue, resulting in reduced bone strength and an increased risk of low-energy or fragility fractures. Thus, the use of anti-resorptive agents, such as bisphosphonates (BPs), to prevent osteoporotic fractures is growing annually. BPs are effective in reducing hip and other fractures. However, the longer a patient takes BPs, the higher the risk of an atypical femoral fracture (AFF). The exact mechanism by which long-term BP use affects the development of AFFs has not yet been clarified. However, several theories have been suggested to explain the pathogenesis of AFFs, such as suppressed bone remodeling, impaired bone healing, altered bone quality, and femoral morphology. The management of AFFs requires both medical and surgical approaches. BPs therapy should be discontinued immediately, and calcium and vitamin D levels should be evaluated and supplemented if insufficient. Teriparatide can be used for AFFs. Intramedullary nailing is the primary treatment for complete AFFs, and prophylactic femoral nailing is recommended if signs of an impending fracture are detected.

Surgical strategy of the treatment of atypical femoral fractures

The atypical femoral fracture (AFF) has been attracting significant attention because of its increasing incidence; additionally, its treatment is challenging from biological and mechanical aspects. Although surgery is often required to manage complete AFFs, clear guidelines for the surgical treatment of AFFs are currently sparse. We reviewed and described the surgical treatment of AFFs and the surveillance of the contralateral femur. For complete AFFs, cephalomedullary intramedullary nailing spanning the entire length of the femur can be used. Various surgical techniques to overcome the femoral bowing common in AFFs include a lateral entry point, external rotation of the nail, and the use of a nail with a small radius of curvature, or a contralateral nail. In the case of a narrow medullary canal, severe femoral bowing, or pre-existing implants, plate fixation may be considered as an alternative. For incomplete AFFs, prophylactic fixation depends on several risk factors, such as a subtrochanteric location, presence of a radiolucent line, functional pain, and condition of the contralateral femur; the same surgical principles as those in complete AFFs can be applied. Finally, once AFF is diagnosed, clinicians should recognize the increased risk of contralateral AFFs, and close surveillance of the contralateral femur is recommended.

The effect of teriparatide on fracture healing after atypical femoral fracture: A systematic review and meta-analysis

This meta-analysis demonstrated that a greater prevalence of delayed union and nonunion and a longer time to fracture healing in the group that did not receive TPTD treatment after AFFs than in the group that received TPTD treatment.

PURPOSE

To date, there is no hard evidence for medical management after atypical femoral fracture (AFF), even though weak data indicate faster healing with teriparatide (TPTD). Herein, we aimed to investigate the effect of postfracture TPTD treatment on AFF healing using a pairwise meta-analysis focusing on delayed union, nonunion, and fracture healing time.

METHODS

A systematic search of the MEDLINE (PUBMED), Embase, and Cochrane Library databases was performed for studies investigating the effect of TPTD after AFF up to October 11, 2022. We compared the incidence of delayed union and nonunion and the time of fracture healing between the TPTD ( +) and TPTD (-) groups.

RESULTS

The 6 studies analyzed a total of 214 AFF patients, including 93 who received TPTD therapy after AFF and 121 who did not. The pooled analysis showed a significantly higher rate of delayed union in the TPTD (-) group than in the TPTD ( +) group (OR, 0.24; 95% CI, 0.11-0.52; P < 0.01; I² = 0%), and a higher nonunion rate was observed in the TPTD (-) group than in the TPTD ( +) group with low heterogeneity (OR, 0.21; 95% CI, 0.06-0.78; P = 0.02; I² = 0%). The TPTD (-) group required 1.69 months longer to achieve fracture union than the TPTD ( +) group, with statistical significance (MD =  - 1.69, 95% CI: - 2.44 to - 0.95, P < 0.01; I² = 13%). Subgroup analysis for patients with complete AFF showed that the TPTD (-) group had a higher rate of delayed union with low heterogeneity (OR, 0.22; 95% CI, 0.10-0.51; P < 0.01; I² = 0%), but there was no significant difference in the nonunion rate between TPTD ( +) and TPTD (-) groups (OR, 0.35; 95% CI, 0.06-2.21; P = 0.25; I² = 0%). Fracture healing took significantly longer in the TPTD (-) group (MD =  - 1.81, 95% CI: - 2.55 to - 1.08; P < 0.01; I² = 48%). The reoperation rate showed no significant difference between the two groups (OR, 0.29; 95% CI, 0.07-1.20; P = 0.09; I² = 0%).

CONCLUSIONS

The current meta-analysis supported the hypothesis that TPTD treatment following AFF might benefit fracture healing, lowering the rate of delayed union and nonunion and shortening the fracture healing time.

Is bisphosphonate use a risk factor for atypical periprosthetic/peri-implant fractures? - A metanalysis of retrospective cohort studies and systematic review of the current evidence

INTRODUCTION

Atypical periprosthetic/peri-implant fractures are not recognised in any widely used classification and therefore little focus is given to them. Multiple case reports and case series demonstrate these fractures exist and are related to bisphosphonate (BP) use.

HYPOTHESIS

Are patients taking long-term BPs at an increased risk of developing an atypical periprosthetic/peri-implant fracture? Is a particular BP drug causing an increased risk of fracture? Is there a correlation between the time of BP use and the incidence of fractures? Do vitamin D analogues or parathyroid hormones reduce the time to union?

MATERIAL AND METHODS

Systematic review of all available evidence on the existence of periprosthetic/peri-implant atypical fractures in patients taking long-term BPs and metanalysis of available retrospective cohort studies. Selected 1 systematic review, 7 retrospective cohort studies (5 used for metanalysis) and 32 case reports.

RESULTS

Metanalysis reported a risk ratio of 14.1, p=0.25, suggesting bisphosphonates are a risk factor in the development of periprosthetic/peri-implant atypical fractures. The secondary outcomes couldn't be reliably identified due to the small size of available studies and risk of significant bias.

DISCUSSION

Atypical periprosthetic/peri-implant fractures are an entity and seem to be associated with the use of bisphosphonates. The benefits of bisphosphonates use outweigh the risks, but clinicians should be aware of atypical fractures and actively search for them when patients on long-term bisphosphonates attend with non-specific pain close to the implant/prosthesis or reduced mobility.

LEVEL OF EVIDENCE

II, Systematic review and metanalysis.

Bilateral Atypical Femoral Fractures after Bisphosphonate Treatment for Osteoporosis: A Literature Review

INTRODUCTION

This literature review aimed to investigate the incidence, anatomical concerns, etiology, symptoms, diagnostic tools, management, and prognosis of bisphosphonate (BP)-associated bilateral atypical femoral fractures (AFFs).

METHODS

The PubMed, Cochrane Library, Web of Sciences, and CINAHL databases were searched up to 20 March 2022. All cases of bilateral AFFs were included, excluding those without any bisphosphonate treatment information and those in which the femoral fracture did not precisely fit into the diagnostic criteria for AFF.

RESULTS

We identified 43 patients with bilateral AFFs associated with BP use and conducted a comprehensive analysis. Among 43 patients, 29 (67%) had prodromal symptoms. Regarding the simultaneity of fracture, 21 cases (49%) occurred simultaneously, and 22 cases (51%) occurred sequentially. Alendronate was the most commonly used BP treatment (59%). Regardless of the medication type, BP intake duration was more than 5 years in 77%. The initial diagnosis was performed using X-rays in all cases. A total of 53% of patients had complete fractures, and all patients underwent surgical treatment. Among the remaining patients with incomplete fractures, 18% and 29% received surgical and medical treatments, respectively. After BP discontinuation, teriparatide was most commonly used (63%).

CONCLUSIONS

The careful evaluation of relevant imaging findings in patients with thigh/groin pain allows the identification of early incomplete fractures and timely management. Since the rate of contralateral side fractures is also high, imaging studies should be performed on the asymptomatic contralateral side.

Factors affecting healing and progression of conservatively treated incomplete atypical femoral fractures: retrospective observational study

INTRODUCTION

Incomplete atypical femoral fractures (iAFF) may occur with prolonged bisphosphonate usage. Factors influencing iAFF healing and progression are not well understood. This study of conservatively managed iAFF assessed factors influencing iAFF healing and progression including the effects of bisphosphonates and teriparatide use.

MATERIALS AND METHODS

Single-center retrospective observational study of 69 consecutive patients with 78 radiographically confirmed iAFF from 2002 to 2017. Serial radiographs assessed for focal cortical thickening, dreaded black line (DBL) and complete fracture. Chief outcome measures were DBL healing and complete fracture.

RESULTS

DBL had a significant association (p < 0.05) with fracture progression by multivariable logistic regression (55.8% versus 25.7%, odds ratio [OR] 26.57 (95% CI 1.40-504.78)) and shorter fracture-free survival (mean 3.21 versus 6.27 years). Presence of symptoms was associated with shorter fracture-free survival (mean 2.68 versus 5.98 years). Discontinuing bisphosphonates had significant associations (p < 0.001) by multivariable logistic regression with decreased fracture rate (11.6% versus 92.0%; OR 0.00, 95% CI 0.00-0.08) and longer fracture-free survival (mean 7.52 versus 1.99 years). DBL healing occurred in 36.4%, only when bisphosphonates were discontinued. Age, sex, race, fracture site, glucocorticoid use, teriparatide supplementation and duration of bisphosphonate use showed no statistically significant effect although teriparatide use appeared to improve DBL healing (50% versus 17.9%, p = 0.188).

CONCLUSIONS

In conservatively managed iAFF, DBL healing occurred in 36.4% if bisphosphonates were discontinued. Bisphosphonates and DBL were significantly associated with fracture progression and together with symptoms with fracture survival.

Bisphosphonate-induced atypical femoral fracture in tandem: long-term follow-up is warranted

Summary

Although bisphosphonates (BPs) are mainly used for the treatment of osteoporosis and are generally safe, long-term use and more dosage as utilised in malignant conditions may be associated with the rare adverse event of an atypical femoral fracture (AFF). Occasionally, the risk of developing an AFF persists long after BPs are withdrawn. A 39-year-old woman who underwent chemotherapy and an autologous stem cell transplantation for multiple myeloma presented to us with history of pain in the left thigh. She had received multiple doses of oral and parenteral BPs for about 10 years in view of the underlying myeloma with osteoporosis. Her investigations showed a suppressed CTX of 192 pg/mL, and radiograph of pelvis displayed thickened cortices with beaking of the left femoral shaft, which was suggestive of an AFF. Following discontinuation of BPs, she underwent prophylactic intra-medullary nailing with which her symptoms improved. Five years later, she presented with similar complaints on the right side. Investigations showed that her bone turnover continued to be suppressed with Cross linked C- Telopeptide of type 1 collagen (CTX) of 165 pg/mL and an X-ray done showed AFF on the right side despite being off BPs. A second intra-medullary nailing was done and on follow-up, she has been symptom-free and independent in her daily activities. Discontinuation of BPs may not prevent the incident second AFF and, therefore, thus warranting long-term follow-up.

Learning points

Regular screening and follow-up of patients who receive long-term bisphosphonate (BP) therapy should be done. Discontinuation of BPs does not preclude the possibility of repeated occurrence of a second AFF. Long-term BP therapy warrants regular monitoring and follow-up should an AFF occur.

Preventive bilateral femoral nailing in atypical femoral fracture non responder to anabolic therapy: case report and mini-review

Currently bisphosphonates are the main antiresorptive medications used in osteoporosis. However, a prolonged use of these drugs is associated to an increased risk of atypical femoral fractures, especially in patients suffering from others predisposing clinical conditions. This report describes a case of a woman presenting bilateral impending femoral fracture initially treated with bisphosphonates suspension and intramedullary nailing of right femur. Despite anabolic therapy, the patient presented progression of incomplete contralateral femoral fracture which required a second surgical treatment.

Fracture Risk Following an Atypical Femoral Fracture

Atypical femoral fractures (AFFs) occurring during the course of osteoporosis treatment usually lead to discontinuation of anti-resorptive (AR) drugs. However, the risk of fracture after an AFF is unknown. We conducted a follow-up study of patients with AFF matched 1:3 for age and gender with patients with a peripheral major osteoporotic fracture (pMOF), in the setting of a fracture liaison service, to investigate the incidence of subsequent low-trauma fractures. Fifty-five patients with AFF (95% women, age [mean ± standard deviation] 75 ± 10 years, 89% exposed to AR drugs), followed for 6.2 ± 3.7 years, were compared to 165 matched controls with a pMOF (hip 85%) followed for 4.3 ± 2.6 years. During the follow-up, 38% of patients in the AFF group and 16% in the pMOF group received AR therapies. Continuation of AR drugs after an AFF was associated with contralateral AFF in 27% of subjects. The risks of new low-trauma, major osteoporotic and imminent (within 2 years) fractures, were similar between the two groups: incidence rate ratio (95% confidence interval [CI]) of subsequent fracture following AFF relative to pMOF, 1.30 (95% CI, 0.82-2.04), 1.28 (95% CI, 0.74-2.15), and 1.11 (95% CI, 0.54-2.15), respectively. Moreover, the risk of sustaining multiple fractures per participant was significantly increased among patients with AFF compared to pMOF (hazard ratio 1.48 [95% CI, 1.00-2.19]; p = 0.049). When taking mortality into account, the risk of subsequent fractures tended to be higher in the AFF group (sub-hazard ratio 1.42 [95% CI, 0.95-2.12]). In conclusion, patients who sustained an AFF are at high risk of subsequent fragility fractures, at least equal or even greater to the risk observed after a pMOF. However, continuation of AR drugs increases the risk of contralateral AFF. Therefore, optimal modalities for secondary fracture prevention after AFF require further evaluation. © 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).

Combined Surgical and Medical Treatment for Vancouver B1 and C Periprosthetic Femoral Fractures: A Proposal of a Therapeutic Algorithm While Retaining the Original Stable Stem

INTRODUCTION

There is lack of consensus regarding best operative fixation strategy for periprosthetic femoral fractures (PFFs) around a stable stem. Evidence exists that some patterns of fracture around a stable stem are better treated with revision surgery than with standard fixation. Anyway, a more aggressive surgical procedure together with medical treatment could allow for stem retention, and reduced risk of nonunion/hardware failure, even in these cases.

SIGNIFICANCE

This paper is placed in a broader context of lack of studies on the matter, and its aim is to shed some light on the management of PFFs around a stable stem, when peculiar mechanical and biological aspects are present.

RESULTS

Based on our casuistry in the treatment of nonunions after PFF successfully treated with original stem retention, and on review of Literature about risk factors for fixation failure, an algorithm is proposed that can guide in choosing the ideal surgical technique even for first-time PFFs with a stable stem, without resorting to revision. Mechanical (major and minor) and biological (local and systemic) factors that may influence fracture healing, leading to nonunion and hardware failure, and subsequent need for re-operation, are considered. The proposed surgical technique consists of rigid fixation with absolute stability (using a plate and structural allograft) plus local biological support (structural allograft and autologous bone marrow concentrate over a platelet-rich plasma-based scaffold) at fracture site. Systemic anabolic treatment (Teriparatide) is also administered in the post-operative period.

CONCLUSION

Mechanical factors are not the only issues to be considered when choosing the surgical approach to PFFs over a stable stem. Systemic and local biological conditions should be taken into account, as well. A therapeutic algorithm is proposed, given the prosthetic stem to be stable, considering mechanical and biological criteria.

Current concepts in the management of bisphosphonate associated atypical femoral fractures

Bisphosphonates are a class of drugs used as the mainstay of treatment for osteoporosis. Bisphosphonates function by binding to hydroxyapatite, and subsequently targeting osteoclasts by altering their ability to resorb and remodel bone. Whilst aiming to reduce the risk of fragility fractures, bisphosphonates have been associated with atypical insufficiency fractures, specifically in the femur. Atypical femoral fractures occur distal to the lesser trochanter, until the supracondylar flare. There are a number of the differing clinical and radiological features between atypical femoral fractures and osteoporotic femoral fractures, indicating that there is a distinct difference in the respective underlying pathophysiology. At the point of presentation of an atypical femoral fracture, bisphosphonate should be discontinued. This is due to the proposed inhibition of osteoclasts and apoptosis, resulting in impaired callus healing. Conservative management consists primarily of cessation of bisphosphonate therapy and partial weightbearing activity. Nutritional deficiencies should be investigated and appropriately corrected, most notably dietary calcium and vitamin D. Currently there is no established treatment guidelines for either complete or incomplete fractures. There is agreement in the literature that nonoperative management of bisphosphonate-associated femoral fractures conveys poor outcomes. Currently, the favoured methods of surgical fixation are cephalomedullary nailing and plate fixation. Newer techniques advocate the use of both modalities as it gives the plate advantage of best reducing the fracture and compressing the lateral cortex, with the support of the intramedullary nail to stabilise an atypical fracture with increased ability to load-share, and a reduced bending moment across the fracture site. The evidence suggests that cephalomedullary nailing of the fracture has lower revision rates. However, it is important to appreciate that the anatomical location and patient factors may not always allow for this. Although causation between bisphosphonates and atypical fractures is yet to be demonstrated, there is a growing evidence base to suggest a higher incidence to atypical femoral fractures in patients who take bisphosphonates. As we encounter a growing co-morbid elderly population, the prevalence of this fracture-type will likely increase. Therefore, it is imperative clinicians continue to be attentive of atypical femoral fractures and treat them effectively.

Effectiveness of parathyroid hormone (PTH) analogues on fracture healing: a meta-analysis

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.

Atypical periprosthetic femoral fractures of the hip: A PRISMA compliant systematic review

INTRODUCTION

Long-term use of bisphosphonates (BPs) is associated with Atypical Femoral Fracture (AFF). Theoretically, periprosthetic femoral fractures (PFF) should be excluded from the diagnosis of AFF. However, recently several studies reported the occurrence of PPFs around a hip arthroplasty presenting features of an AFF. The present study describes the characteristics of Atypical Periprosthetic Femoral Fracture (APFF) and evaluates the effectiveness of their management through a PRISMA compliant systematic review of the published case reports and series.

MATERIALS AND METHODS

A literature search was performed using "periprosthetic fracture" and "atypical femoral fracture" as keywords. Patients demographics, drug use, clinical and imaging characteristics, stem fixation and classification, management strategies for APFF and patients' outcomes, were also collected.

RESULTS

The present review included and analysed 17 patients from 12 studies. All APFFs occurred in females with a mean age of 75.9 years of age (range 43-87). In 11 patients, APFFs occurred around an uncemented stem, and in 6 around a cemented stem. Ten fractures were incomplete, and 7 complete. Conservative management was effective in 4 of 10 patients with incomplete fracture, while all patients with complete fractures underwent open reduction and internal fixation. A fracture non-union was observed in 5 patients and further surgery was required.

DISCUSSIONS

APFFs share several clinical and imaging characteristics with AFF. An appropriate and early diagnosis may allow to improve the outcome of these fractures, the management of which should be based on the same principles of that of AFFs.

CONCLUSIONS

Considering the low quality of published articles and the heterogeneity of the treatment used, a clear recommendation of the most appropriate treatment cannot be formulated.

Drug-induced Hyperprolactinemia Results in Atypical Atypical Fracture

We report a case of bilateral femur fracture which may have resulted in part from long-term administration of antipsychotic agents. A 43-year-old female patient with pain in both thighs visited our clinic. We conducted X-ray and magnetic resonance imaging (MRI) examinations which revealed bilateral femur fractures. The right proximal femur had a complete fracture, and the left proximal femur had an incomplete fracture, both of which were in the subtrochanteric area. The patient was treated by intramedullary nailing in the right femur. Laboratory analysis showed hyperprolactinemia and hypogonadism. Bone mineral density analysis showed osteoporosis. Antipsychotic drug-induced hyperprolactinemia is a well-known phenomenon. Despite concerns about hyperprolactinemia induced osteoporotic fracture in patients treated with only prolactin-elevating medications, the issue has not been extensively studied. If hyperprolactinemia patients suffer from uncontrolled pain, we recommend MRI examination as surgeons should be aware of the possibility of osteoporotic fracture induced by hyperprolactinemia.

Roles of Parathyroid Hormone-Related Protein (PTHrP) and Its Receptor (PTHR1) in Normal and Tumor Tissues: Focus on Their Roles in Osteosarcoma

Osteosarcoma (OS) is the most common primary bone tumor and originates from bone forming mesenchymal cells and primarily affects children and adolescents. The 5-year survival rate for OS is 60 to 65%, with little improvement in prognosis during the last four decades. Studies have demonstrated the evolving roles of parathyroid hormone-related protein (PTHrP) and its receptor (PTHR1) in bone formation, bone remodeling, regulation of calcium transport from blood to milk, regulation of maternal calcium transport to the fetus and reabsorption of calcium in kidneys. These two molecules also play critical roles in the development, progression and metastasis of several tumors such as breast cancer, lung carcinoma, chondrosarcoma, squamous cell carcinoma, melanoma and OS. The protein expression of both PTHrP and PTHR1 have been demonstrated in OS, and their functions and proposed signaling pathways have been investigated yet their roles in OS have not been fully elucidated. This review aims to discuss the latest research with PTHrP and PTHR1 in OS tumorigenesis and possible mechanistic pathways.

This review is dedicated to Professor Michael Day who died in May 2020 and was a very generous collaborator.

More Evidence for Teriparatide after Fixation of Atypical Femoral Fractures: Report of Four Cases

Atypical femoral fractures (AFF) have low union rates. The use of teriparatide has been advocated for the post-operative healing of AFF, but the evidence is limited to case reports and some series due to its low incidence.

We present a case series of four female patients to support the use of teriparatide after the surgical fixation of their AFF. Three of the patients had a complete AFF and one had an incomplete fracture. Their mean age was 70 (52 - 87) years, mean body mass index 24.6 (18.3 - 29.3), mean bone mineral density T-score of -2.3 (-4.8/-1.0), with a prior history of anti-resorptive therapy with bisphosphonates and denosumab.

Teriparatide was started at an average of 8 (2-18) days post-fixation, with 20mcg daily for six months. Immediate full weight-bearing was permitted in three patients, while one was non-weight bearing for two months. The mean time to union was 12 (10 - 14) weeks. No side effects were observed over a mean follow-up of 58 (50 – 72) weeks.

The use of teriparatide facilitated the quick union of AFF after surgical fixation. It appeared to be safe and promoted fracture healing in AFF.

Outcome of intramedullary nail for fixation of osteoporotic femoral shaft fractures in the elderly above 60

INTRODUCTION

Intramedullary nailing is an acceptable treatment option for femoral shaft fracture in young patients but not extensively studied in the elderly with osteoporotic fractures. Plate fixation for osteoporotic femoral shaft fractures have a high rate of complications and delayed healing time, and the most acceptable treatment is intramedullary nailing. This study evaluated the healing time and incidence of complications in osteoporotic femoral shaft fractures after intramedullary nailing.

PATIENTS &METHODS

This was a retrospective study that included 16 patients above 60 years old with osteoporotic femoral shaft fractures operated between January 2015 and December 2018. Patients with metastatic fractures or with atypical fractures were excluded. Thirteen patients had low-energy injuries such as a simple fall from standing height or lower and twisting injuries. The remaining 3 patients sustained high-energy-mechanism of injury. No patient received bisphosphonate except 2 patients received oral bisphosphonate for a period of 6 and 8 months, respectively.

RESULTS

Sixteen patients (12 females and 4 males) with mean age 69.5 ± 3.7 presented with femoral shaft fracture were operated with intramedullary nail, 10 patients were fixed with trochanteric entry nails with proximal neck screws, and 6 patients were fixed with piriformis entry nails. In 9 patients, closed reduction of fracture was achieved while 7 patients required open reduction, of which 5 fracture required cerclage wire addition. The mean bone healing time was 5.35±1.2 months. Intraoperative extension of femoral fractures during intramedullary nail insertion was observed in two cases that required open reduction and addition of cerclage wires around the fracture. The overall incidence of complications was 18.7%.

CONCLUSIONS

Intramedullary nailing for osteoporotic femoral shaft fracture is a good acceptable option in elderly patients with reasonable healing time with no major complications.

Evaluation and management of atypical femoral fractures: an update of current knowledge

Atypical femoral fractures are often attributed to the use of anti-resorptive medications such as bisphosphonates (BP). Whilst they have proven effects on fragility fracture prevention, clinical and laboratory evidence is evolving linking BP-related suppression of bone remodelling to the development of atypical stress-related sub-trochanteric fractures (Shane et al. in JBMR 29:1-23, 2014; Odvina et al. in JCEM 90:1294-301, 2005; Durchschlag et al. in JBMR 21(10):1581-1590, 2006; Donnelly et al. in JBMR 27:672-678, 2012; Mashiba et al. in Bone 28(5):524-531, 2001; Dell et al. in JBMR 27(12):2544-2550, 2012; Black et al. in Lancet 348:1535-1541, 1996; Black et al. in NEJM 356:1809-1822, 2007; Black et al. in JAMA 296:2927-2938, 2006; Schwartz et al. in JBMR 25:976-82, 2010). Injuries may present asymptomatically or with prodromal thigh pain and most can be successfully managed with cephalomedullary nailing and discontinuation of BP therapy. Such injuries exhibit a prolonged time to fracture union with high rates of non-union and metal-work failure when compared to typical subtrochanteric osteoporotic femoral fractures. Despite emerging literature on AFFs, their management continues to pose a challenge to the orthopaedic and extended multi-disciplinary team. The purpose of this review includes evaluation of the current evidence supporting the management of AFFs, clinical and radiological features associated with their presentation and a review of reported surgical strategies to treat and prevent these devastating injures.

Does Teriparatide Improve Fracture Union?: A Systematic Review

We conducted an updated review of the evidence of teriparatide (TPTD) for fracture healing for the following questions. (1) Does it decrease fracture healing time?; (2) Can it be an alternative treatment for nonunion?; (3) Does it aid the union of atypical femoral fracture (AFF)? We searched PubMed, EMBASE, and Cochrane Library including “Fracture” AND “nonunion” AND “Teriparatide”. In total, 57 publications met our inclusion criteria were summarized. This systemic review of the available literature revealed that TPTD works positively with regard to enhancing fracture healing time and union of AFF. There are also many case studies on the use of TPTD could be a potential new safe treatment for nonunion with no side effects. However, level 1 studies on the evidence of TPTD are still lacking so far. Over the last decade, a growing body of evidence has accumulated suggesting that TPTD can be an adjunct to enhance fracture healing or a therapeutic option to treat nonunion, but greater evidences from large volume prospective trials are needed.

The limitations of today’s clinical guidance: Atypical femoral fracture and long-term bone-modifying agents in the oncology setting

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.

The Treatment of Acute Diaphyseal Long-bones Fractures with Orthobiologics and Pharmacological Interventions for Bone Healing Enhancement: A Systematic Review of Clinical Evidence

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.

Teriparatide may accelerate the growth of a pre-existing malignant tumor in an elderly patient with osteoporosis: A case report

The present report describes a case in which teriparatide, which is widely used to treat osteoporosis, may have accelerated the growth of an undiagnosed pre-existing bone tumor of the femur. A 76-year-old woman visited hospital with pain in the right thigh after falling from a ladder. A non-pathological femoral shaft fracture was diagnosed by plain radiography. There were no findings of pathological fracture on the examination. In addition, the patient underwent intramedullary femoral nail fixation and started teriparatide treatment for osteoporosis. The teriparatide was discontinued after 2 months due to nausea. A total of 6 months after surgery, the woman visited Hirosaki University Hospital with abnormal swelling of the right thigh. Following a diagnosis of high-grade malignant mesenchymal bone tumor by needle biopsy, the patient underwent right hip disarticulation. Pathological examination provided a definitive diagnosis of osteoblastic osteosarcoma. The present case is a reminder that teriparatide may accelerate the growth of a pre-existing malignant tumor and that fractures, particularly in elderly patients, should be screened for pathological fracture prior to administering teriparatide.

Diaphyseal femoral fracture due to severe vitamin D3 deficiency and low parathyroid hormone levels on long-term hemodialysis: a case report

INTRODUCTION

Currently, there are no reports of diaphyseal femoral fracture equivalent to atypical femoral fractures (AFFs) in patients receiving long-term hemodialysis (HD).

CASE REPORT

A 56-year-old Japanese man receiving long-term HD for 34 years was admitted to our hospital due to a delay in postoperative healing. The patient began maintenance hemodialysis at 22 years of age. The patient then underwent surgical parathyroidectomy (PTX) for secondary hyperparathyroidism at 43 years of age, which resulted in decreased levels of parathyroid hormone (PTH). Thereafter, this patient's serum 1,25(OH)₂ D₃ level was very low because active vitamin D₃ derivative was not administered. At 54 years of age, a transverse fracture of the femoral shaft equivalent to AFF occurred. Surgery with open reduction and internal fixation using intramedullary nailing was performed; however, the delay of postoperative healing continued for 16 months. A left iliac crest bone biopsy was performed and showed osteoid-like lesion and an increase of woven bone. The patient received active vitamin D₃ derivative and recombinant human PTH (1-34) derivative. Twenty-nine months after the first surgery, a reoperation was performed. Simultaneously, a right iliac crest bone biopsy was performed. Bone morphometrical improvement was confirmed. Six months after resurgery, the bone union was achieved. Severe vitamin D₃ deficiency and decreased levels of PTH may induce a higher osteoid state and an increase of woven bone, which may then attribute to the development of diaphyseal femoral fracture and impairment of postoperative bone healing. It is hypothesized that treatment with active vitamin D₃ and teriparatide acetate may be a therapeutic option via the accelerated formation of lamellar bone for refractory diaphyseal femoral fracture of long-term dialysis.

Detection and management of atypical femur fractures

PURPOSE OF REVIEW

This article summarizes the risk factors for atypical femur fractures (AFF), discusses current and emerging imaging modalities for early identification of AFF, and offers recommendations for prevention and management of AFFs based on the current concepts.

RECENT FINDINGS

Antiresorptive therapies are widely recommended for prevention and treatment of osteoporosis. Despite their well established effectiveness to reduce fracture risk, emerging concerns related to potential adverse effects have led to a substantial decline in the use of bisphosphonates. Although, the pathogenesis of AFF has not yet been elucidated, the bulk of evidence supports that the well known therapeutic benefits of bisphosphonate far outweigh the relatively low risk of AFFs. Recommendations for early identification of patients at risk for AFF using radiographic imaging have been established. Consensus on the management of AFF and osteoporosis in patients with AFF needs to be formulated.

SUMMARY

AFF is a rare event associated with long-term bisphosphonate therapy, which represents an apparent paradox in the management of osteoporosis. Improved understanding of pathogenetic mechanisms will be helpful in further refining of screening guidelines and standardization of management and treatment strategies.

Teriparatide as nonoperative treatment for femoral shaft atrophic nonunion: A case report

BACKGROUND

Femoral shaft fractures are a common type of fracture among adults and have high union rates. However, clinical decisions are difficult to make because of the different types of nonunions. Atrophic nonunion usually requires revision surgery combined with bone grafting. Furthermore, no study of teriparatide administration for femoral atrophic nonunion have been previously reported.

CASE SUMMARY

A 60-year-old woman had a right femoral shaft fracture due to a traffic accident, and she immediately underwent closed reduction and internal fixation surgery with an intramedullary nailing. However, after 6 mo of rehabilitation, the fracture site showed no signs of healing, and her condition was diagnosed as atrophic nonunion. Subsequently, teriparatide was administered for 6 mo. Complete union was observed at the fracture site 6 mo after teriparatide discontinued.

CONCLUSION

The use of teriparatide can be a promising treatment to improve the healing of nonunion fractures.

Atypical femoral fractures from bisphosphonate in cancer patients - Review

Bisphosphonates are commonly used in patients with metastatic bone disease to prevent skeletal related events. Atypical femur fracture is a known complication of long-term bisphosphonate use but the incidence in cancer patients and pathogenesis are not well known. Several mechanisms of pathogenesis have been proposed including altered angiogenesis, altered bone mechanical properties, micro damage and bone remodeling suppression. Atypical femur fractures are atraumatic or minimally traumatic fractures in the sub trochanteric region or the femoral shaft. Awareness of atypical femur fractures is critical to diagnose and treat them in a timely manner. There is a paucity of data regarding the management of atypical femur fracture in patients with malignancy. Management options of atypical femur fractures include stopping bisphosphonates, initiating calcium/vitamin D supplementation and either surgery with internal fixation or conservative management. In the future, it will be important to explore the effect of continuous vs. intermittent exposure, cumulative dose and length of exposure on the incidence of this complication. Herein, we review the epidemiology, risk factors, management options and proposed mechanisms of pathogenesis of atypical femur fractures.

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

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.

Antiresorptive-associated spontaneous fractures of both tibiae, followed by an atypical femur fracture during the sequential treatment with alendronate, denosumab then teriparatide

A 35-year-old man with juvenile idiopathic arthritis since childhood presented with bilateral atypical tibial fractures, followed by a later, single atypical fracture of the femur. The fractures were associated with 6 years of oral alendronate treatment immediately followed by subcutaneous denosumab therapy and later teriparatide therapy for osteoporosis. Atypical fractures are known to occur in the femur following bisphosphonate therapy; however, there are only a few documented cases of atypical fractures in the tibia. Our case highlights a rare but serious complication of a commonly prescribed antiresorptive agent. It also shows that teriparatide, while helpful in increasing bone mass, does not fully prevent the development of atypical fractures. Careful investigation should be considered in patients on long-term antiresorptive therapy presenting with bony tenderness to exclude an atypical fracture.

Two Cases of Periprosthetic Atypical Femoral Fractures in Patients on Long-Term Bisphosphonate Treatment

The current definition of atypical femoral fractures (AFFs) excludes periprosthetic fractures. However, a few cases of bisphosphonates (BPs) -associated periprosthetic atypical femoral fractures (PAFFs) have been reported in the literature. Here, we report two rare cases of PAFFs that fulfilled the major criteria for AFFs in patients with prolonged use of BPs. Both cases progressed to a complete fracture with minor trauma from an incomplete fracture at the distal tip of the well-fixed femoral stem. The femoral stem effect on lateral femoral cortical bone, together with the decreased bone elastic resistance induced by BPs, was considered the cause of onset. In each case, we performed open reduction and internal fixation using a locking plate with cable grip and postoperatively prescribed teriparatide and low-intensity pulsed ultrasound (LIPUS). Both cases had a good clinical course. However, as conservative treatment was not effective in these cases, treatment such as non-weight-bearing exercises during hospitalization or prophylactic surgery may be necessary. Further studies are needed to determine the optimal treatment strategy.

Salvage of failed osteosynthesis for an atypical subtrochanteric femoral fracture associated with long-term bisphosphonate treatment using a 95° angled blade plate

AIMS

The aim of this study was to evaluate the outcomes of a salvage procedure using a 95° angled blade plate for failed osteosynthesis of atypical subtrochanteric femoral fractures associated with the long-term use of bisphosphonates. These were compared with those for failed osteosynthesis of subtrochanteric fractures not associated with bisphosphonate treatment.

PATIENTS AND METHODS

Between October 2008 and July 2016, 14 patients with failed osteosynthesis of an atypical subtrochanteric femoral fracture were treated with a blade plate (atypical group). Their mean age was 67.8 years (60 to 74); all were female. During the same period, 21 patients with failed osteosynthesis of a typical subtrochanteric fracture underwent restabilization using a blade plate (typical group). Outcome variables included the time of union, postoperative complications, Harris Hip Score, and Sanders functional rating scale.

RESULTS

In the atypical group, union was achieved in 12 patients (85.7%) at a mean of 8.4 months (4 to 12). The mean follow-up was 31.2 months (12 to 92) The plate broke in one patient requiring further stabilization with a longer plate and strut-allograft. Another patient with failure of fixation and varus angulation at the fracture site declined further surgery. In the typical group, union was achieved in 18 patients (85.7%) at a mean of 7.9 months (4 to 12). There was no difference in the mean Harris Hip Score between the two groups (83.1 points vs 86.8 points; p = 0.522) at the time of final follow-up. Sanders functional rating scores were good or excellent in 78.6% of the atypical group and in 81.0% of the typical group.

CONCLUSION

The 95° angled blade plate was shown to be an effective fixation modality for nonunion of atypical subtrochanteric fractures with a high rate of union and functional improvement, comparable to those after fractures not associated with bisphosphonate treatment. Cite this article: Bone Joint J 2018;100-B:1511-17.

The enigma of atypical femoral fractures: A summary of current knowledge

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.

Update on the Comprehensive Approach to Fragility Fractures

The prevention and treatment of fragility fractures continuously evolve. Adequate fracture care should involve treating the fracture itself and the underlying bone disease. Although effective treatments of osteoporosis are available, a large proportion of patients with fragility fractures are not prescribed antiosteoporotic medications after their injury. Recent advances in diagnostic tools, medications, and implementation of Fracture Liaison Services allow for more effective and comprehensive treatment or fragility fractures. In the Fracture Liaison Service model, a physician and physician extenders coordinate care. This includes a thorough medical and surgical history, metabolic bone disease laboratory testing, dual-energy x-ray absorptiometry screening, treatment, and long-term follow-up. Treatment options include nonpharmacologic treatment with calcium and vitamin D and antiresorptive and anabolic agents. Antiresorptive agents such as bisphosphonates and denosumab are first-line treatments for osteoporosis and anabolic agents such as teriparatide are effective in reducing bone density loss and have implications in fracture healing. In addition, new anabolic agents including antisclerostin antibodies and parathyroid hormone-related protein show promise as potential treatments to increase bone density.

A proposal for an atypical femur fracture treatment and prevention clinical practice guideline

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.

Comparison of Atypical and Osteoporotic Femoral Shaft Fractures in the Elderly: A Multicenter Study

BACKGROUND

In atypical femoral fractures, owing to the high rates of complications and delayed healing that accompany the plate fixation, the most favorable treatment is intramedullary nailing. Although there is insufficient evidence, plate fixation is chosen due to anterolateral bowing of the femur. This study compared the bone healing time and rates of complications in atypical femoral shaft fractures and osteoporotic femoral shaft fractures.

METHODS

We searched the medical records of 3 institutions in Japan for patients with femoral shaft fractures who visited between 1 January 2010 and 31 December 2015. We identified 65 patients and excluded 37 among these due to high-energy injuries or being younger than 65 years. Among the remaining patients, we identified 17 and 11 women with atypical (AFF group) and osteoporotic femoral shaft fractures (OP group), respectively.

RESULTS

In surgical method, there were differences in intramedullary nailing (94.1% versus 27.2%) (p < 0.01). The mean bone healing time was 11.1 months versus 6.7 months in 2 groups (p < 0.01). Iatrogenic femoral fractures during intramedullary nail insertion were observed in both groups, and reoperation was only seen in atypical femoral fractures treated with a plate fixation, but there was no difference in the rate of complications (23.5% versus 9.1%).

CONCLUSIONS

In the atypical femoral fracture group, intramedullary nailing was more chosen, but the bone healing time was delayed and plate fixation cases needed reoperation. There was no significant difference in the rate of complications between the 2 groups.

Long-term use of bisphosphonates in osteoporosis

Objectives:

To report and describe the management and response to treatment of patients referred to the osteoporosis clinic after prolonged use of bisphosphonate BPs) (4 years and more) with and without new fracture (any site) or any other new skeletal symptoms.

Methods:

This is a single center observational retrospective cohort study conducted from January 2009 to May 2016 in a tertiary center. We describe cause of referral, X-rays findings, management, and response to treatment.

Results:

Thirty-four patients, aged 46-89 years, were collected. Reason for referral included review of therapy (11 patients), recent low trauma fracture (21 patients), or chronic severe thigh pain (2 patients) of unknown etiology. All patients with fracture or thigh pain (23/34 patients) were treated with teriparatide 20 mcg daily. Sixteen of them (16/23) completed teriparatide course (18-24 months), 11 patients had complete healing of fracture at the end of the course, and 5 remained with nonunion of fracture, the remaining 5 patients were lost to follow up.

Conclusion:

Prolonged use of bisphosphonates can lead to atypical femoral fracture that may involve sites other than femoral shaft or rarely chronic thigh pain without fracture. Teriparatide may facilitates fracture healing and improve thigh pain.

Atypical fractures: An issue of concern or a myth?

Atypical Femoral Fractures (AFF) represent fractures located between the lesser trochanter and the supracondylar flare of a femur. An increasing pool of evidence supports their association with the prolonged use of bisphosphonates, even though a direct correlation is yet to be proved. The purpose of this review is to encapsulate the current evidence associating bisphosphonate use and the development of AFFs, the clinical features related to their presentation, as well as to report the armamentarium of strategies available in the prevention and treatment of AFFs. Based on these evidence, we propose a management algorithm for AFFs, that can serve as a guide for patients presenting with this condition.

Teriparatide for treatment of patients with bisphosphonate-associated atypical fracture of the femur

The Fracture Improvement with Teriparatide (Fix-IT) study randomized 13 women with an atypical femur fracture to immediate vs delayed teriparatide therapy; all were followed for 12 months. Results suggested a trend for superior healing and lesser bone mineral density declines in the immediate vs delayed group with no differences in adverse events.

PURPOSE

Little clinical data are available on the use of teriparatide for the treatment of bisphosphonate-associated atypical femur fractures (AFF). The goal of the Fix-IT study was to determine if immediate therapy with teriparatide was superior for fracture healing after an AFF compared to a 6-month delay in teriparatide therapy.

METHODS

This randomized pilot clinical trial included 13 women with an AFF who were randomized to immediate teriparatide vs a delay of 6 months. All were followed for 12 months on teriparatide. The primary outcomes included individual and composite measures of radiologic bone healing (scored 1 point [no healing] to 4 points [complete healing]) at 6 and 12 months. Secondary outcomes included bone mineral density of the unfractured contralateral hip, spine, 1/3 distal radius, and adverse events.

RESULTS

We found there was a trend for superior healing with the composite score (12.6 vs 11.2 at 6 months and 15.4 vs 13.2 at 12 months), and lesser bone mineral density declines at the 1/3 distal radius (12-month change - 1.9 vs - 6.1%) in the immediate vs the delayed group. There were no differences in adverse events. There was one implant failure in the delayed group.

CONCLUSIONS

There is a preliminary signal for greater improvements with immediate teriparatide therapy vs delayed therapy. However, because an AFF is a rare event, and only a small number of patients were included, the results must be interpreted with caution.

Mortality following benign sacral insufficiency fracture and associated risk factors

This study demonstrated increased mortality following sacral insufficiency fractures as with other major osteoporotic fractures. The 6-month mortality rate was 9.8%, the 1-year mortality rate was 17.5%, and the 3-year mortality rate was 25.5%. Sex- and age-adjusted standardized mortality ratio increased after fractures.

INTRODUCTION

There are no data about mortality after sacral insufficiency fractures. The purposes of this study were to investigate the mortality rate among sacral insufficiency fracture patients and to identify risk factors associated with mortality.

METHODS

This is a retrospective cohort study of patients diagnosed with sacral insufficiency fracture via radiological exam in a single institute from 2001 to 2014, excluding patients with pathological sacral fracture due to metastasis or primary tumor. Mortality and its predisposing factors were analyzed based on a review of electronic medical records and mortality data provided by the Korean Statistical Information Service. Kaplan-Meier survival analysis and Cox regression analysis were used for statistical analysis.

RESULTS

A total of 325 patients were included (275 women and 50 men). The mean age at the time of diagnosis was 69.4 years. One hundred and forty patients (43.1%) had a history of malignancy, and 71 patients (21.8%) had undergone pelvic radiation therapy before fracture diagnosis. Twenty-one patients (6.5%) underwent sacroplasty, and the others underwent conservative management after fracture diagnosis. The mean follow-up was 51.5 months, and a total of 101 patients died at the final follow-up. The 6-month mortality rate was 9.8%, the 1-year mortality rate was 17.5%, and the 3-year mortality rate was 25.5%. Sex- and age-adjusted standardized mortality ratio (SMR) increased after fractures. The overall SMR is 8.9 at 3 months decreasing to 4.5 at 2 years. Multivariable Cox regression analysis showed that significant factors associated with increased mortality were male gender, malignancy history, lumbosacral fusion with distal fusion level S1, stroke history, low total femur bone mineral density score, and low body mass index.

CONCLUSIONS

Like other types of osteoporotic fractures, sacral insufficiency fractures are associated with increased mortality.

Responses to Treatment With Teriparatide in Patients With Atypical Femur Fractures Previously Treated With Bisphosphonates

If oversuppression of bone turnover explained the association between bisphosphonate use and atypical subtrochanteric femur fractures (AFF), this could be reversed with anabolic treatment such as teriparatide. We conducted a prospective, open-label study in patients previously treated with bisphosphonates who sustained AFF, examining the response to 24-month treatment with teriparatide on bone mineral density (BMD), trabecular bone score (TBS), bone turnover markers (BTM), and fracture healing as well as quantitative histomorphometry. We studied 14 patients. Baseline BMD, BTM, and TBS varied widely. On initial bone biopsies, 12 of 14 patients showed tetracycline labels, but mineralizing surface/bone surface was below published normal values in all but 2. Lumbar spine BMD increased significantly at month 24 (6.1% ± 4.3%, p < 0.05 versus baseline), whereas total hip BMD and TBS did not change significantly. Changes in BTM occurred as reported previously for patients without AFF treated with teriparatide after prior bisphosphonate treatment. At month 24, fractures were healed in 6 patients, showed partial healing in 3, were unchanged in 2, and showed nonunion in 1. In a patient with two fractures, the fracture that occurred before teriparatide treatment was reported as healed, but the fracture that occurred while on treatment showed only partial healing. Bisphosphonate-treated patients who sustain AFF show heterogeneity of bone turnover. Treatment with teriparatide resulted in increases in BTM and lumbar spine BMD, as has been reported for patients without AFF. There was no significant effect of teriparatide on hip BMD, mineralizing surface to bone surface (MS/BS), or TBS and no consistent effect on fracture healing. In the context of a patient who has experienced an AFF after receiving bisphosphonate treatment, therapy with teriparatide for 24 months would be expected to increase BMD and BTM (and probably reduce the risk of fractures resulting from osteoporosis) but should not be relied on to aid in healing of the AFF. © 2017 American Society for Bone and Mineral Research.

Osteoporosis: a discussion on the past 5 years

PURPOSE OF THE REVIEW

The purposes of this study are to examine the literature within the past 5 years regarding osteoporosis and offer a discussion on new topics and controversies.

RECENT FINDINGS

Patient compliance with therapy remains an issue. The effectiveness of Vitamin D and calcium are being called into question Atypical femur fractures have been associated with bisphosphonate and denosumab use. Treatment is both surgical and pharmaceutical. A multidisciplinary approach to osteoporotic fractures is important and having some form of fracture liaison service (FLS) improves the efficacy of osteoporotic care and decreases secondary fractures. Screening for osteoporosis remains low. Ultrasound may be cost-effective for diagnosis. Understanding of osteoporosis has come a long way in the medical community, but the translation to the lay community has lagged behind. Patients often take a laissez-faire attitude toward osteoporosis that can affect compliance. Information read by patients often focuses on complications, such as atypical femur fractures and myocardial infarctions. It is essential for providers to be able to discuss these issues with patients. Newer medications and more cost-effective diagnostic tests exist, but availability may be limited. FLS are effective, but the most cost-effective model for therapy still eludes us. Areas for further investigation include FLS models, the effectiveness of vitamin supplementation, and more ubiquitous and cost-effective diagnostic tools.

The Efficacy of Bisphosphonates for Prevention of Osteoporotic Fracture: An Update Meta-analysis

BACKGROUND

The efficacy of bisphosphonates for osteoporotic fracture has been consistently reported in recent randomized controlled trials (RCTs) enrolling hundreds of patients. The objective of this study was to update knowledge on the efficacy of available bisphosphonates in the prevention of vertebral and non-vertebral fractures.

METHODS

An approach "using systematic reviews" on PubMed and Cochrane Library was taken. Twenty-four RCTs investigating the effects of bisphosphonates for the prevention of osteoporotic fracture were included in final analysis. A pairwise meta-analysis was conducted with a random effects model. Subgroup analysis was performed according to the type of bisphosphonate.

RESULTS

The use of bisphosphonate decrease the risk of overall osteoporotic fracture (odds ratio [OR] 0.62; P<0.001), vertebral fracture (OR 0.55; P<0.001) and non-vertebral fracture (OR 0.73; P<0.001). Subgroup analysis indicated that zoledronic acid showed the lowest risk reduction (OR 0.61; P<0.001) for overall osteoporotic fractures but no significance was observed for etidronate (OR 0.34; P=0.127).

CONCLUSIONS

This update meta-analysis re-confirmed that bisphosphonate use can effectively reduce the risk of osteoporotic fracture. However, there is a lack of evidence regarding etidronate for the prevention of osteoporotic fracture.

Bisphosphonates and atypical femoral fractures

PURPOSE OF REVIEW

Bisphosphonates are used widely for the treatment of osteoporosis and prevention of fractures. Although generally well tolerated and effective, bisphosphonates (and denosumab, a newer antiresorptive agent) have been associated with unusual fractures of the femoral shaft.

RECENT FINDINGS

New information about the incidence, pathophysiology, and management of atypical femoral fractures (AFFs) are reviewed. Histomorphometric studies have shown variable amounts of bone turnover suppression, but new studies suggest that healing near bone cracks may not occur in patients with AFF. Some studies suggest that hip and femur geometry make certain people more at risk for AFF. In some but not all studies, the risk of AFF appears to be related to duration of treatment. Thus, the benefit/risk ratio needs to be reassessed as bisphosphonate therapy is prolonged.

SUMMARY

If we can better understand the pathogenesis of AFF, it may be possible to identify those patients at highest risk. In the meantime, clinicians must periodically assess risk for osteoporotic fracture versus risk for AFF in managing patients with osteoporosis.

Total Hip Arthroplasty for Implant Rupture after Surgery for Atypical Subtrochanteric Femoral Fracture

Treatment methods for delayed union and nonunion of atypical femoral fracture are still controversial. Moreover, no treatment method has been established for implant rupture caused by delayed union and nonunion. We encountered a 74-year-old female in whom nonunion-induced implant rupture occurred after treatment of atypical subtrochanteric femoral fracture with internal fixation using a long femoral nail. It was unlikely that sufficient fixation could be obtained by repeating osteosynthesis alone. Moreover, the patient was elderly and early weight-bearing activity was essential for early recovery of ADL. Based on these reasons, we selected one-stage surgery with total hip arthroplasty and osteosynthesis with inverted condylar locking plate as salvage procedures. Bone union was achieved at 6 months after surgery. This case illustrated that osteosynthesis-combined one-staged total hip arthroplasty could be considered as one of the options for nonunion-induced implant rupture of atypical femoral subtrochanteric fracture.

Atypical Femur Fractures in Patients Treated with Bisphosphonates: Identification, Management, and Prevention

Osteoporosis is a common condition with significant health care costs. First-line therapy is with bisphosphonates, which have proven anti-fracture efficacy. Around 10 years after the introduction of bisphosphonates reports began to be published of atypical femoral fractures (AFFs) that may be associated with this therapy. These fractures are associated with significant morbidity although lower mortality than the more common osteoporotic neck-of-femur fractures. A case definition has been described to allow identification of this class of fracture. Further work has established a high relative risk of AFFs in patients treated with bisphosphonates, but a low absolute risk in comparison to that of osteoporotic fractures. Proposed pathological mechanisms include low bone turnover states leading to stress/insufficiency fractures. Clinicians should be aware of the risk of AFFs and in particular the high rate of prodromal thigh/groin pain that warrants investigation in a patient receiving a bisphosphonate. If an incomplete fracture is diagnosed then bisphosphonate therapy needs to be stopped and prophylactic surgery may be considered. Due to these rare side effects patients on bisphosphonates require regular review, and this is particularly advised after 5 years of oral or 3 years of intravenous therapy.

Atypical periprosthetic acetabular fracture in long-term alendronate therapy

Bisphosphonates have been commonly used in the treatment of osteoporosis, demonstrating its efficacy in fracture risk reduction. However, even if are generally safe and well tolerated, concerns have emerged about atypical fractures related to its prolonged use. Although atypical femoral fracture are more common, case reports demonstrated that even other skeletal areas can be involved by unusual pattern of fracture. We report a atypical acetabular periprosthetic fracture in a 83-year-old female patient after prolonged alendronate treatment for osteoporosis and isolated acetabular revision surgery. The patient underwent to clinical, bioumoral and radiological evaluation and all the history cases were fully reported. We believe this periprosthetic fracture, according to the available data, may have similar underlying pathology to atypical femoral fractures. Awareness of symptoms, in addition to a regular radiographic survey may facilitate early diagnosis and possible prevention of spontaneous periprosthetic fractures, in patients receiving bisphosphonate therapy beyond 5 years. The treatment of this atypical periprosthetic fracture should include both surgical than pharmacological therapy to obtained bone healing.

The Effect of Teriparatide on Fracture Healing of Osteoporotic Patients: A Meta-Analysis of Randomized Controlled Trials

Purpose. This meta-analysis is to assess the effectiveness of teriparatide in fracture healing and clinical function improvement of the osteoporotic patients. Methods. We searched PubMed, Embase, Web of Science, and the Cochrane databases for randomized and quasi-randomized controlled trials comparing teriparatide to placebo, no treatment, or comparator interventions in the osteoporotic patients. Results. Five studies with 251 patients were included. Patients treated with teriparatide therapy had a significant shorter radiological fracture healing time compared with those in the control group (mean difference [MD] −4.54 days, 95% confidence interval [CI] −8.80 to −0.28). Stratified analysis showed that lower limb group had significant shorter healing time (MD −6.24 days, 95% CI −7.20 to −5.29), but upper limb group did not (MD −1 days, 95% CI −2.02 to 0.2). Patients treated with teriparatide therapy showed better functional outcome than those in the control group (standardized mean difference [SMD] −1.02, 95% CI −1.81 to −0.22). Patients with therapy duration over 4 weeks would have better functional outcome (SMD −1.68, 95% CI −2.07 to −1.29). Conclusions. Teriparatide is effective in accelerating fracture healing and improving functional outcome of osteoporotic women. However, more clinical studies are warranted in order to determine whether the results are applicable to males and the clinical indications for teriparatide after osteoporotic fractures.