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Hart DA. Towards understanding how bisphosphonate-dependent alterations to nutrient canal integrity can contribute to risk for atypical femoral fractures: Biomechanical considerations and potential relationship to a real-world analogy. Bioessays 2024; 46:e2300117. [PMID: 38059881 DOI: 10.1002/bies.202300117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/08/2023]
Abstract
Bisphosphonates are a class of drugs which have shown good efficacy in the treatment of post-menopausal osteoporosis, as well as a good safety profile. However, side-effects such as risk for atypical femoral fractures (AFF) have appeared, leading to a decline in use of the drugs by many patients who would benefit from the treatment. While patient characteristics have contributed to improved understanding of risk factors, the mechanisms involved that explain AFF risk have not appeared. Recently, the possibility that the mechanism(s) involved drug-induced modification of cells of the nutrient canals of the femur and subsequent compromise in the bone matrix has been published. The present Hypothesis article builds on the concept presented earlier and expands into biomechanical considerations. An analogy of the mechanisms involved to a real-life scenario is also presented. While this analogy has limitations, consideration of the biomechanical implications of progressive alterations to defects presented by compromised nutrient canal-bone matrix also presents potential relationships with AFF risk.
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Affiliation(s)
- David A Hart
- Department of Surgery, Faculty of Kinesiology, McCaig Institute for Bone, & Joint Health, University of Calgary, Calgary, Alberta, Canada
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Tsuchie H, Kasukawa Y, Nozaka K, Kinoshita H, Sasaki K, Aizawa T, Mita M, Ouchi K, Yuasa Y, Miura T, Tomite T, Maekawa S, Abe H, Akagawa M, Shibata N, Fujii M, Takeshima M, Inoue J, Saito H, Miyakoshi N. Factors Affecting the Second Complete Atypical Femoral Fracture after the First Atypical Fracture. Med Princ Pract 2023; 33:10-20. [PMID: 38104544 PMCID: PMC10896619 DOI: 10.1159/000535759] [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: 04/22/2023] [Accepted: 12/10/2023] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVES Atypical femoral fracture (AFF) is an atypical low-energy subtrochanteric and diaphyseal femoral fracture. Even if bone fusion is achieved in patients with AFF, the risk of AFF in the contralateral femur must be considered. This study aimed to investigate the factors affecting complete AFF in the contralateral femur and conservatively treated incomplete AFF. SUBJECT AND METHODS Radiographs of 111 femurs in 104 AFF cases were examined, and the femurs were classified as follows: 85 contralateral femurs with complete AFF; 18 contralateral femurs with incomplete AFF; 8 femurs with incomplete AFF without surgical treatment. Various patients' clinical data were collected, and we investigated the factors affecting the second complete AFF. RESULTS Complete fractures occurred in 10 (9.7%) of 103 femurs without incomplete AFF at the first visit and in 3 (37.5%) of 8 femurs with incomplete AFF. The Kaplan-Meier curve revealed that lateral cortical bone thickening and thigh pain were associated with significantly poorer prognoses (p = 0.026 and p = 0.013, respectively). Multivariate analyses revealed that eldecalcitol usage after AFF onset (p = 0.0094) and previous use of bisphosphonate or denosumab (p = 0.0126) were protective factors for second complete AFF and that the presence of thigh pain (p = 0.0134) was a risk factor for second complete AFF. CONCLUSIONS Eldecalcitol administration after bone union of first AFF may prevent AFF recurrence. In addition, painful incomplete AFF has a high risk of developing a complete fracture.
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Affiliation(s)
- Hiroyuki Tsuchie
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Hondo, Akita, Japan
| | - Yuji Kasukawa
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Hondo, Akita, Japan
| | - Koji Nozaka
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Hondo, Akita, Japan
| | - Hayato Kinoshita
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Hondo, Akita, Japan
- Department of Orthopedic Surgery, Akita Kousei Medical Center, Iijima, Nishifukuro, Akita, Japan
| | - Ken Sasaki
- Department of Orthopedic Surgery, Hiraka General Hospital, Yatsuguchi, Maego, Yokote, Japan
| | - Toshiaki Aizawa
- Department of Orthopedic Surgery, Northern Akita Municipal Hospital, Shimosugi Aza Kamishimizusawa, Kitaakita, Japan
| | - Motoki Mita
- Department of Orthopedic Surgery, Yuri Kumiai General Hospital, Kawaguchi Aza Yaushiro, Yurihonjyo, Japan
| | - Kentaro Ouchi
- Department of Orthopedic Surgery, Yokote Municipal Hospital, Negishimachi, Yokote, Japan
| | - Yusuke Yuasa
- Department of Orthopedic Surgery, Nakadori General Hospital, Misono-Cho, Minami-Dori, Akita, Japan
| | - Takanori Miura
- Department of Orthopedic Surgery, Kakunodate General Hospital, Iwase, Kakunodate, Senboku, Japan
| | - Takenori Tomite
- Department of Orthopedic Surgery, Japanese Red Cross Akita Hospital, Saruta Aza Inawashirosawa, Kamikitate, Akita, Japan
| | - Shigeto Maekawa
- Department of Orthopedic Surgery, Ogachi Central Hospital, Yamada Aza Isamigaoka, Yuzawa, Japan
| | - Hidekazu Abe
- Department of Orthopedic Surgery, Ugo Municipal Hospital, Otomichi, Nishomonai, Ugo, Japan
| | - Manabu Akagawa
- Department of Orthopedic Surgery, Omagari Kousei Medical Center, Omagari Torimachi, Daisen, Japan
| | - Nobusuke Shibata
- Department of Orthopedic Surgery, Oga Minato Municipal Hospital, Funakawa Aza Kaigandori, Oga, Japan
| | - Masashi Fujii
- Department of Orthopedic Surgery, Akita City Hospital, Matsuokamachi, Kawamoto, Akita, Japan
| | - Masaaki Takeshima
- Department of Orthopedic Surgery, Honjyo Daiichi Hospital, Iwabuchishita, Yurihonjyo, Japan
| | - Jyunichi Inoue
- Department of Orthopedic Surgery, Omori Municipal Hospital, Omori Aza Sugouta, Yokote, Japan
| | - Hikaru Saito
- Department of Orthopedic Surgery, Akita Rosai Hospital, Karuizawa Aza Shimotai, Odate, Japan
| | - Naohisa Miyakoshi
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Hondo, Akita, Japan
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Marini F, Masi L, Giusti F, Cianferotti L, Cioppi F, Marcucci G, Ciuffi S, Biver E, Toro G, Iolascon G, Iantomasi T, Brandi ML. ALPL Genotypes in Patients With Atypical Femur Fractures or Other Biochemical and Clinical Signs of Hypophosphatasia. J Clin Endocrinol Metab 2022; 107:e2087-e2094. [PMID: 34935951 DOI: 10.1210/clinem/dgab914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Hypophosphatasia (HPP) is a rare metabolic disorder caused by deficiency of alkaline phosphatase (ALP) enzyme activity, leading to defective mineralization, due to pathogenic variants of the ALPL gene, encoding the tissue nonspecific alkaline phosphatase (TNSALP) enzyme. Inheritance can be autosomal recessive or autosomal dominant. An abnormal ALPL genetic test enables accurate diagnosis, avoiding the administration of contraindicated antiresorptive drugs that, in patients with HPP, substantially increase the risk of atypical femur fractures (AFFs) and worsen the fracture healing process that is usually already compromised in these patients. OBJECTIVE Performing ALPL genetic testing to identify rare variants in suspected adult patients with HPP. Comparing frequencies of ALPL common variants in individuals with biochemical and/or clinical signs suggestive of adult HPP and non-HPP controls, and among different clinical subgroups of patients with a clinical suspicion of adult HPP. METHODS Patients with suspected adult HPP were retrospectively selected for the genetic testing of the ALPL gene. Patients included were from 3 main European Bone Units (Florence, Naples, and Geneva); 106 patients with biochemical and/or clinical signs suggestive of a mild form of HPP were included. RESULTS Genetic testing led to the identification of a heterozygote rare variant in 2.8% of cases who were initially referred as suspected osteoporosis. The analysis of frequencies of ALPL common variants showed a high prevalence (30.8%) of homozygosity in subjects who developed an AFF, in association with normal serum total ALP activity. CONCLUSION The results suggest homozygosity of common ALPL variants as a possible genetic mark of risk for these fractures.
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Affiliation(s)
- Francesca Marini
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Florence, Italy
| | - Laura Masi
- University Hospital of Florence, Azienda Ospedaliero-Universitaria Careggi (AOUC), Florence, Italy
| | - Francesca Giusti
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Luisella Cianferotti
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
- University Hospital of Florence, Azienda Ospedaliero-Universitaria Careggi (AOUC), Florence, Italy
| | - Federica Cioppi
- University Hospital of Florence, Azienda Ospedaliero-Universitaria Careggi (AOUC), Florence, Italy
| | - Gemma Marcucci
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
- University Hospital of Florence, Azienda Ospedaliero-Universitaria Careggi (AOUC), Florence, Italy
| | - Simone Ciuffi
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Emmanuel Biver
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Teresa Iantomasi
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Maria Luisa Brandi
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Florence, Italy
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