1
|
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.
Collapse
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
| |
Collapse
|
2
|
Ferreira P, Bates P, Daoub A, Dass D. 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. Orthop Traumatol Surg Res 2023; 109:103475. [PMID: 36347461 DOI: 10.1016/j.otsr.2022.103475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 07/05/2022] [Accepted: 07/18/2022] [Indexed: 11/07/2022]
Abstract
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.
Collapse
Affiliation(s)
- Pedro Ferreira
- Queen Mary University of London and Oswestry/Stoke Trauma and Orthopaedic Training Programme, Mile End Rd, Bethnal Green, London E1 4NS, United Kingdom.
| | - Peter Bates
- Orthopaedic Trauma Sciences - Queen Mary University of London, Lead for orthopaedic trauma, Barts Health, Mile End Rd, Bethnal Green, London E1 4NS, United Kingdom
| | - Ahmed Daoub
- Oswestry/Stoke Trauma and Orthopaedic Training Programme - Robert Jones and Agnes Hunt Hospital, Gobowen, Oswestry SY10 7AG, United Kingdom
| | - Debashis Dass
- Oswestry/Stoke Trauma and Orthopaedic Training Programme - Robert Jones and Agnes Hunt Hospital, Gobowen, Oswestry SY10 7AG, United Kingdom
| |
Collapse
|
3
|
Vicenti G, Solarino G, Ottaviani G, Carrozzo M, Simone F, Zavattini G, Zaccari D, Buono C, Bizzoca D, Maccagnano G, Moretti B. Atypical Vancouver B1 Periprosthetic Fractures: The Unsolved Problem. Geriatr Orthop Surg Rehabil 2023; 14:21514593221145884. [PMID: 36950184 PMCID: PMC10026097 DOI: 10.1177/21514593221145884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 11/17/2022] [Accepted: 11/21/2022] [Indexed: 03/24/2023] Open
Abstract
Atypical femoral fractures (AFF) are stress or insufficiency fractures induced by low energy trauma or no trauma, frequently correlated with prolonged bisphosphonate therapy. The diagnosis follows major and minor criteria, originally described by the Task Force of the American Society for Bone and Mineral Research in 2010 and updated in 2014. However, the definition of AFFs in the report excluded periprosthetic fractures. When atypical fractures occur close to a prosthetic implant the situation become critical, the surgical treatment is often demolitive and supported by medical treatment. Moreover, acute ORIF as a first line treatment is frequently burdened by a high failure rate , and often a stem revision is required as second line treatment. The healing process is long and difficult with poor functional results and impairing outcomes. We present a case treated at our institution of a 78 year old woman with a history of a femoral atypical periprosthetic fracture, complicated by multiple surgical revisions. Its arduous management reflects all the difficulties that these type of fractures could present to the surgeon, while its good final result may teach us how to approach them in a correct way.
Collapse
Affiliation(s)
- Giovanni Vicenti
- School of Medicine, University of Bari “Aldo Moro”- AOU
Policlinico Consorziale, Bari, Italy
- Giovanni Vicenti, School of Medicine,
University of Bari “Aldo Moro”- AOU Policlinico Consorziale, Piazza Giulio
Cesare 11, Bari 70124, Italy.
| | - Giuseppe Solarino
- School of Medicine, University of Bari “Aldo Moro”- AOU
Policlinico Consorziale, Bari, Italy
| | - Guglielmo Ottaviani
- School of Medicine, University of Bari “Aldo Moro”- AOU
Policlinico Consorziale, Bari, Italy
| | - Massimiliano Carrozzo
- School of Medicine, University of Bari “Aldo Moro”- AOU
Policlinico Consorziale, Bari, Italy
| | - Filippo Simone
- School of Medicine, University of Bari “Aldo Moro”- AOU
Policlinico Consorziale, Bari, Italy
| | - Giacomo Zavattini
- School of Medicine, University of Bari “Aldo Moro”- AOU
Policlinico Consorziale, Bari, Italy
| | - Domenico Zaccari
- School of Medicine, University of Bari “Aldo Moro”- AOU
Policlinico Consorziale, Bari, Italy
| | - Claudio Buono
- School of Medicine, University of Bari “Aldo Moro”- AOU
Policlinico Consorziale, Bari, Italy
| | - Davide Bizzoca
- School of Medicine, University of Bari “Aldo Moro”- AOU
Policlinico Consorziale, Bari, Italy
| | - Giuseppe Maccagnano
- Department of Basic Medical
Sciences, Neuroscience and Sense Organs, Foggia University
Hospital, Foggia, Italy
| | - Biagio Moretti
- School of Medicine, University of Bari “Aldo Moro”- AOU
Policlinico Consorziale, Bari, Italy
| |
Collapse
|
4
|
Lo LWT, Koh JSB, Howe TS, Png MA, Lo NN. Incomplete Periprosthetic Atypical Femoral Fracture With Concomitant Hip and Knee Arthroplasties: A Case Report. JBJS Case Connect 2023; 13:01709767-202303000-00016. [PMID: 36706214 DOI: 10.2106/jbjs.cc.22.00211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 10/14/2022] [Indexed: 01/29/2023]
Abstract
CASE We present a case of an incomplete periprosthetic femoral fracture at the mid-distal third of the femoral stem after 11 months of bisphosphonate use. It is 1 of 4 cases of mid-distal periprosthetic atypical femoral fractures (PAFFs) found in our literature review. She was treated with protected weight-bearing, cessation of bisphosphonates, and teriparatide. Eighteen months after diagnosis, follow-up radiographs showed a bridging callus and reduction of a transverse fracture line. CONCLUSION The incomplete PAFF was contributed by both decreased bone turnover from bisphosphonate use and increased mechanical stress at the lateral femoral cortex. Her previous left bipolar hemiarthroplasty and subsequent Total Knee Arthroplasty shifted the mechanical alignment medially, hence increasing tensile stress.
Collapse
|
5
|
Troiano E, Giacché T, Facchini A, Orlandi NC, Cacioppo M, Saviori M, Bottai V, Muratori F, Mondanelli N, Giannotti S. Surgical and Pharmacological Management of Periprosthetic Atypical Femoral Fractures: A Narrative Literature Review. Geriatr Orthop Surg Rehabil 2022; 13:21514593221090392. [PMID: 35433102 PMCID: PMC9006379 DOI: 10.1177/21514593221090392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 12/09/2021] [Accepted: 01/08/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction An increasing number of patients is annually undergoing total hip arthroplasty (THA), and a significant proportion of these patients are elderly and consequently at a higher risk of complications because of age, osteoporosis, and medical comorbidities. Periprosthetic femoral fractures (PFFs) are one of the worst complications of THA associated with high rates of unfavorable prognosis. Besides, in the last decade, a new independent disease entity called “atypical femoral fracture” (AFF) has been identified and defined by the American Society for Bone and Mineral Research (ASBMR) task force. Some PFFs present clinical history and radiographic aspect consistent with an AFF, meeting the ASBMR criteria for the diagnosis of AFF except that PFFs by themselves are an exclusion criterion for AFF. However, there is an increasing number of published studies suggesting that periprosthetic atypical femoral fractures (PAFFs) exist and should not be excluded by definition. Significance Nowadays, although there is an increasing interest in PAFFs, there are still very few studies published on the topic and a lack of consensus regarding their treatment. This narrative literature review aims to introduce this new emerging topic to a wider readership describing the characteristics of PAFFs and the state-of-the-art in their management. Conclusions Many authors agree that PAFFs should be considered as a subgroup of PFFs that have atypical characteristics; they also show a significant correlation with prolonged bisphosphonate use. A correct diagnosis is paramount for proper treatment of the disease that requires both surgical and medical actions to be taken.
Collapse
Affiliation(s)
- Elisa Troiano
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Tiziano Giacché
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Andrea Facchini
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Nicholas Crippa Orlandi
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Matteo Cacioppo
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Marco Saviori
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Vanna Bottai
- Second Clinic of Orthopedic and Traumatology, University of Pisa, Pisa, Italy
| | - Francesco Muratori
- Section of Orthopedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Nicola Mondanelli
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Stefano Giannotti
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| |
Collapse
|
6
|
De Cicco A, Toro G, Oliva F, Tarantino U, Schiavone Panni A, Maffulli N. Atypical periprosthetic femoral fractures of the hip: A PRISMA compliant systematic review. Injury 2021; 52:2407-2414. [PMID: 33810845 DOI: 10.1016/j.injury.2021.03.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/14/2021] [Accepted: 03/18/2021] [Indexed: 02/02/2023]
Abstract
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.
Collapse
Affiliation(s)
- Annalisa De Cicco
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", via L. De Crecchio 4, 80138, Naples, Italy
| | - Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", via L. De Crecchio 4, 80138, Naples, Italy; Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, viale Oxford, 00133, Rome, Italy
| | - Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Largo Città di Ippocrate 84131 Salerno, Italy.
| | - Umberto Tarantino
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, viale Oxford, 00133, Rome, Italy.
| | - Alfredo Schiavone Panni
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", via L. De Crecchio 4, 80138, Naples, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Largo Città di Ippocrate 84131 Salerno, Italy; Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Turner Street, Whitechapel, London, UK.
| |
Collapse
|
7
|
Takahashi Y, Hatashita S, Shinden Y, Ito M, Kaneuchi Y, Hakozaki M, Konno S. Periprosthetic Fracture Resembling Atypical Femoral Fracture After Fixation With Retrograde Intramedullary Nail in Elderly Women: A Report of Two Cases. In Vivo 2021; 35:1837-1842. [PMID: 33910870 DOI: 10.21873/invivo.12445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM The number of individuals diagnosed with and requiring medical treatment for osteoporosis continues to increase due to global population aging and the high awareness of osteoporosis. Bone-modifying agents (BMAs) including bisphosphonate and denosumab are widely used for osteoporosis, and atypical femoral fracture (AFF) is also gaining attention as a severe potential side effect of long-term BMA treatment. The definition of AFF excludes periprosthetic femoral fracture; here, we describe two cases of a periprosthetic femoral fracture that resembled AFF. CASE REPORT The fractures occurred at the proximal tip of the retrograde femoral nail after an internal fixation for a distal femoral shaft fracture in elderly Japanese women. Each woman had been treated with bisphosphonate therapy for >2 years and had continued the bisphosphonate after undergoing surgery for a distal femoral shaft fracture. Each patient had noticed thigh pain before falling down, and plain radiographs showed a short oblique or transverse fracture with medial spike and localized periosteal reaction of the lateral cortex in each case. The fractures were re-fixed with an antegrade intramedullary nail, and bone union was achieved at >1 year after the second operation. Although these two cases were classified as periprosthetic fractures, they fulfilled the characteristics of AFF. CONCLUSION Physicians should conduct a thorough interview of patients with a history of BMA treatment in order to correctly diagnose periprosthetic fractures that resemble AFFs, and they should be aware that symptomatic fractures can be prevented by prophylactic fixation. The discontinuance of BMA therapy and the introduction of another drug such as teriparatide may lead to faster healing of surgically treated AFFs.
Collapse
Affiliation(s)
- Yojiro Takahashi
- Aizu Traumatology and Reconstructive Surgery Center, Aizu Chuo Hospital, Fukushima, Japan.,Department of Traumatology and Reconstructive Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan.,Department of Orthopaedic Surgery Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Satoshi Hatashita
- Aizu Traumatology and Reconstructive Surgery Center, Aizu Chuo Hospital, Fukushima, Japan.,Department of Traumatology and Reconstructive Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yumetaka Shinden
- Aizu Traumatology and Reconstructive Surgery Center, Aizu Chuo Hospital, Fukushima, Japan.,Department of Traumatology and Reconstructive Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan.,Department of Orthopaedic Surgery Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Masayuki Ito
- Aizu Traumatology and Reconstructive Surgery Center, Aizu Chuo Hospital, Fukushima, Japan.,Department of Traumatology and Reconstructive Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yoichi Kaneuchi
- Department of Orthopaedic Surgery Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Michiyuki Hakozaki
- Department of Orthopaedic Surgery Fukushima Medical University School of Medicine, Fukushima, Japan; .,Higashi-Shirakawa Orthopaedic Academy, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Shinichi Konno
- Department of Orthopaedic Surgery Fukushima Medical University School of Medicine, Fukushima, Japan
| |
Collapse
|
8
|
Mondanelli N, Facchini A, Troiano E, Muratori F, Bottai V, Giannotti S. Periprosthetic Atypical Femoral Fractures Exist: A Retrospective Study at a Single Institution. Prevalence on 115 Periprosthetic Femoral Fractures Around a Primary Hip Stem. J Arthroplasty 2021; 36:2189-2196. [PMID: 33610412 DOI: 10.1016/j.arth.2021.01.066] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/19/2021] [Accepted: 01/23/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Some periprosthetic femoral fractures (PFFs) present history and radiographic aspect consistent with an atypical femoral fracture (AFF), fulfilling the criteria for AFF except that PFFs by themselves are excluded from the diagnosis of AFFs. The aim of this study is to evaluate in a single institution series of PFFs if any of them could be considered a periprosthetic atypical femoral fracture (PAFF), and their prevalence. METHODS Surgical records were searched for PFFs around a primary hip stem from January 2013 to December 2019. Cases were classified according to Vancouver classification. Demographic and medical history was extracted. Fisher's exact test was used for statistical analysis. RESULTS One hundred fifteen PFFs were identified, 59 of them were type B1 and 16 were type C. Radiographs and medical records were available for all patients. Twenty-four patients (32%) have been treated with bisphosphonates (BPs) for longer than 4 years. Four patients presented a fracture with characteristics of PAFF. When enlarged to all PFFs of the series, no other PAFF was found: prevalence of PAFFs was 5.3% for type B1 and C cases and 3.5% for all surgically treated PFFs. Statistical significative difference between PAFFs and PFFs was found for prolonged BP assumption and for the level of fracture clear of the stem. CONCLUSION Fracture with characteristics of AFFs can also happen over a prosthetic stem, configuring themselves as PAFFs, and they are related to prolonged BP use. As a correct diagnosis is mandatory for proper treatment, a revision of criteria for AFFs should be considered, accepting that PAFFs exist.
Collapse
Affiliation(s)
- Nicola Mondanelli
- Department of Medicine Surgery and Neurosciences, The Section of Orthopedics, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Andrea Facchini
- Department of Medicine Surgery and Neurosciences, The Section of Orthopedics, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Elisa Troiano
- Department of Medicine Surgery and Neurosciences, The Section of Orthopedics, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Francesco Muratori
- Department of Oncology, The Section of Orthopedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Vanna Bottai
- Department of Orthopedic and Trauma Surgery, Othopedic and Traumatology II, University of Pisa, Pisa, Italy
| | - Stefano Giannotti
- Department of Medicine Surgery and Neurosciences, The Section of Orthopedics, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Toro G, Di Fino C, De Cicco A, Toro G, Paoletta M, Toro A, Tarantino U, Iolascon G, Panni AS. Atypical periprosthetic femoral fractures of the hip: characterisation of three cases. Hip Int 2020; 30:77-85. [PMID: 33267685 DOI: 10.1177/1120700020971726] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Long-term use of bisphosphonates (BPs) has been associated with a specific type of tensile side femoral stress fracture known as Atypical Femoral Fracture (AFF). Theoretically periprosthetic femoral fractures (PFF) should be excluded from the diagnosis of AFF. However, emerging evidence correlates prolonged BPs use with the occurrence of a type of PFF with an atypical pattern (atypical PFF, APFF). The aim of the present study is to report 3 cases of APFF treated at a single centre. METHODS Clinical and radiographic records of PFF that occurred between January 2016 and August 2018 were retrospectively reviewed. All patients meeting the American Society for Bone and Mineral Research (ASBMR) criteria for definition of PFF were included. Management strategies for APFF and patient outcomes, including fracture healing and hip function (assessed by the Oxford Hip Score [OHS]) were collected. RESULTS 3 patients in the study period were identified as APFF (1 incomplete, 2 complete). All patients were females with a mean age of 83.3 years. All patients were treated with lateral plating. The application of a contralateral strut allograft resulted in fracture healing in cases of complete fractures. Mean OHS at final follow-up was 34.3. CONCLUSIONS Despite occurring around a hip stem like PFF, APFF had peculiar clinical and radiographic features, making them more similar to AFF. Therefore, the orthopaedic surgeon should also consider the natural history and healing problems associated with AFF prior in order to choose the most appropriate management for APFF.
Collapse
Affiliation(s)
- Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy.,Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Ciro Di Fino
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Annalisa De Cicco
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Marco Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonio Toro
- Unit of Orthopaedics and Traumatology, "Martiri del Villa Malta" Hospital, Sarno, Italy
| | - Umberto Tarantino
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Alfredo Schiavone Panni
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| |
Collapse
|
11
|
Dózsai D, Ecseri T, Csonka I, Gárgyán I, Doró P, Csonka Á. Atypical periprosthetic femoral fracture associated with long-term bisphosphonate therapy. J Orthop Surg Res 2020; 15:414. [PMID: 32933566 PMCID: PMC7493328 DOI: 10.1186/s13018-020-01941-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/01/2020] [Indexed: 12/18/2022] Open
Abstract
Background Atypical femoral fracture is one of the many complications after the long-term use of bisphosphonates. The American Society for Bone and Mineral Research has officially excluded periprosthetic femoral fractures (PFFs) from the definition of atypical femoral fractures (AFFs). Several case reports found that PFFs can occur with characteristics similar to those of AFFs. The purpose of our study was to evaluate the proportion of atypical fractures among Vancouver type B1 fractures, and to determine the association between the long-term use of bisphosphonates and the occurrence of atypical periprosthetic femoral fractures (APFFs). Methods In this retrospective study, we reviewed 41 patients with Vancouver type B1 periprosthetic fractures between January 1, 2011 and December 31, 2018. We classified them into two groups, namely atypical and typical PFFs, based on the fracture morphology. We noted the proportion of atypical periprosthetic fractures among B1 fractures and identified risk factors. Results Among the 41 PFFs, 5 (13%) fractures were classified as atypical PFF based on the radiological characteristics. The longer duration of bisphosphonate use was probably the only independent risk factor that significantly increases the occurrence of APFF (p = 0.03, 0.08 (CI 0.008 – 0.16)). There were no significant differences in age, gender, body mass index, comorbidities, corticosteroid use, positioning of the femoral stem, the method of fixation (cemented or cementless) and time lapse from before the primary prosthesis implantation to the PFF in the development of atypical fracture type. Conclusions There seems to be a correlation between the long-term intake of bisphosphonates and the atypical periprosthetic fracture. Atypical femoral fracture can also occur in the periprosthetic form. Trial registration Study number: 22/2019-SZTE, http://www.klinikaikutatas.hu/hu/kutatasetika/jovahagyott-vizsgalatok-koezerdeku-adatai/category/25-jovahagyott-vizsgalatok-kozerdeku-adatai-rkeb-2019.html?download=985:22-2019.
Collapse
Affiliation(s)
- Dávid Dózsai
- Traumatology Department, University of Szeged, Semmelweis u. 6, Szeged, 6725, Hungary
| | - Tamás Ecseri
- Traumatology Department, University of Szeged, Semmelweis u. 6, Szeged, 6725, Hungary
| | - István Csonka
- Traumatology Department, University of Szeged, Semmelweis u. 6, Szeged, 6725, Hungary
| | - István Gárgyán
- Traumatology Department, University of Szeged, Semmelweis u. 6, Szeged, 6725, Hungary
| | - Péter Doró
- Clinical Pharmacy Department, University of Szeged, Szikra utca 8, Szeged, 6725, Hungary
| | - Ákos Csonka
- Traumatology Department, University of Szeged, Semmelweis u. 6, Szeged, 6725, Hungary.
| |
Collapse
|
12
|
Nakamura S, Uezono S, Nagai Y, Kanetaka M, Wagatsuma K, Ishii K, Kumakawa T, Yasue K, Anamizu Y, Tokimura F, Miyazaki T. 18F-sodium fluoride positron emission tomography may help determine better treatment for thigh pain after hip arthroplasty-A case report. Clin Case Rep 2020; 8:1651-1658. [PMID: 32983470 PMCID: PMC7495866 DOI: 10.1002/ccr3.2920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/17/2020] [Accepted: 04/21/2020] [Indexed: 11/11/2022] Open
Abstract
Thigh pain after hip arthroplasty is multifactorial; uncovering its etiology is paramount for optimal treatment. This is the first case where 18F-sodium fluoride positron emission tomography substantially helped in diagnosing the post-hip arthroplasty persistent thigh pain and appropriate treatment selection. This imaging modality warrants further study and more widespread application.
Collapse
Affiliation(s)
- Shinya Nakamura
- Department of Orthopaedic SurgeryTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Shigehito Uezono
- Department of Orthopaedic SurgeryTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Yuko Nagai
- Department of Orthopaedic SurgeryTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Masakazu Kanetaka
- Department of Orthopaedic SurgeryTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Kei Wagatsuma
- Team for Neuroimaging ResearchTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Kenji Ishii
- Team for Neuroimaging ResearchTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Takeshi Kumakawa
- Department of Orthopaedic SurgeryTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Kensuke Yasue
- Department of Orthopaedic SurgeryTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Yorito Anamizu
- Department of Orthopaedic SurgeryTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Fumiaki Tokimura
- Department of Orthopaedic SurgeryTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Tsuyoshi Miyazaki
- Department of Orthopaedic SurgeryTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| |
Collapse
|
13
|
Zheng H, Gu H, Shao H, Huang Y, Yang D, Tang H, Zhou Y. Treatment and outcomes of Vancouver type B periprosthetic femoral fractures. Bone Joint J 2020; 102-B:293-300. [PMID: 32114805 DOI: 10.1302/0301-620x.102b3.bjj-2019-0935.r1] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims Vancouver type B periprosthetic femoral fractures (PFF) are challenging complications after total hip arthroplasty (THA), and some treatment controversies remain. The objectives of this study were: to evaluate the short-to-mid-term clinical outcomes after treatment of Vancouver type B PFF and to compare postoperative outcome in subgroups according to classifications and treatments; to report the clinical outcomes after conservative treatment; and to identify risk factors for postoperative complications in Vancouver type B PFF. Methods A total of 97 consecutive PPFs (49 males and 48 females) were included with a mean age of 66 years (standard deviation (SD) 14.9). Of these, 86 patients were treated with surgery and 11 were treated conservatively. All living patients had a minimum two-year follow-up. Patient demographics details, fracture healing, functional scores, and complications were assessed. Clinical outcomes between internal fixation and revisions in patients with or without a stable femoral component were compared. Conservatively treated PPFs were evaluated in terms of mortality and healing status. A logistic regression analysis was performed to identify risk factors for complications. Results In surgically treated patients, all fractures united and nine complications were identified. The mean postoperative Visual Analogue Scale (VAS) for pain was 1.5 (SD 1.3), mean Parker Mobility Score (PMS) was 6.5 (SD 2.4), and mean Harris Hip Score (HHS) was 79.4 (SD 16.2). Among type B2 and type B3 fractures, patients treated with internal fixation had significantly lower PMS (p = 0.032) and required a longer time to heal (p = 0.012). In conservatively treated patients, one-year mortality rate was 36.4% (4/11), and two patients ultimately progressed to surgery. Young age (p = 0.039) was found to be the only risk factor for complications. Conclusion The overall clinical outcome among Vancouver type B PFF was satisfactory. However, treatment with internal fixation in type B2 and B3 fractures had a significantly longer time to heal and lower mobility than revision cases. Conservative treatment was associated with high rates of early mortality and, in survivors, nonunion. This probably reflects our selection bias in undertaking surgical intervention. In our whole cohort, younger patient age was a risk factor for postoperative complications in Vancouver type B PFF. Cite this article: Bone Joint J 2020;102-B(3):293–300
Collapse
Affiliation(s)
- Hanlong Zheng
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China
| | - Hangyu Gu
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China
| | - Hongyi Shao
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China
| | - Yong Huang
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China
| | - Dejin Yang
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China
| | - Hao Tang
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China
| | - Yixin Zhou
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China
| |
Collapse
|
14
|
Marongiu G, Contini A, Cozzi Lepri A, Donadu M, Verona M, Capone A. The Treatment of Acute Diaphyseal Long-bones Fractures with Orthobiologics and Pharmacological Interventions for Bone Healing Enhancement: A Systematic Review of Clinical Evidence. Bioengineering (Basel) 2020; 7:bioengineering7010022. [PMID: 32102398 PMCID: PMC7148449 DOI: 10.3390/bioengineering7010022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 02/17/2020] [Accepted: 02/20/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The healing of long bones diaphyseal fractures can be often impaired and eventually end into delayed union and non-union. A number of therapeutic strategies have been proposed in combination with surgical treatment in order to enhance the healing process, such as scaffolds, growth factors, cell therapies and systemic pharmacological treatments. Our aim was to investigate the current evidence of bone healing enhancement of acute long bone diaphyseal fractures. METHODS A systematic review was conducted by using Pubmed/MEDLINE; Embase and Ovid databases. The combination of the search terms "long-bones; diaphyseal fracture; bone healing; growth factors; cell therapies; scaffolds; graft; bone substitutes; orthobiologics; teriparatide". RESULTS The initial search resulted in 4156 articles of which 37 papers fulfilled the inclusion criteria and were the subject of this review. The studies included 1350 patients (837 males and 513 females) with a mean age of 65.3 years old. CONCLUSIONS General lack of high-quality studies exists on the use of adjuvant strategies for bone healing enhancement in acute shaft fractures. Strong evidence supports the use of bone grafts, while only moderate evidence demineralized bone matrix and synthetic ceramics. Conflicting results partially supported the use of growth factors and cell therapies in acute fractures. Teriparatide showed promising results, particularly for atypical femoral fractures and periprosthetic femoral fractures.
Collapse
Affiliation(s)
- Giuseppe Marongiu
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
- Correspondence: or ; Tel.: +39-070-6094368
| | - Andrea Contini
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
| | - Andrea Cozzi Lepri
- Orthopaedic Traumatologic Center, University of Florence, 50121 Florence, Italy;
| | - Matthew Donadu
- Dipartimento di Chimica e Farmacia, University of Sassari, 07100 Sassari, Italy;
| | - Marco Verona
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
| | - Antonio Capone
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
| |
Collapse
|
15
|
Andrews KA, Wynkoop EI, Stokey PJ, Georgiadis GM. Impending Atypical Femur Fracture Presenting as Painful Total Knee Arthroplasty: A Report of 2 Cases. JBJS Case Connect 2020; 10:e0160. [PMID: 32224652 DOI: 10.2106/jbjs.cc.19.00160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
CASE We report on 2 patients with atypical femur fractures that initially presented as painful total knee arthroplasties. There was a history of long-term bisphosphonate use in each case. Knee radiographs and laboratory studies were normal, and the patients were managed conservatively. Both subsequently sustained atypical femur fractures and underwent surgical stabilization. CONCLUSIONS Referred pain from a bisphosphonate-related femoral stress fracture can masquerade as pain about a total knee arthroplasty. This should be included in the differential diagnosis in at-risk patients because it can result in an atypical femoral shaft fracture above the prosthesis if not properly treated.
Collapse
Affiliation(s)
- Kyle A Andrews
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Emily I Wynkoop
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Phillip J Stokey
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Gregory M Georgiadis
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
- Department of Orthopaedic Surgery, ProMedica Toledo Hospital, Toledo, Ohio
| |
Collapse
|
16
|
A Periprosthetic Femoral Fracture with Characteristics of Atypical Femoral Fracture. Case Rep Orthop 2019; 2019:1275369. [PMID: 31396425 PMCID: PMC6664512 DOI: 10.1155/2019/1275369] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 05/08/2019] [Indexed: 12/15/2022] Open
Abstract
Although the definition of atypical femoral fracture (AFF) excludes periprosthetic femoral fracture (PFF), the number of reports about PFF with characteristics of AFF is increasing. We present the case of such a fracture in this report. An 87-year-old woman who underwent bipolar hip arthroplasty for a femoral neck fracture 38 months prior reported left thigh pain with no history of trauma. Radiographs showed a simple transverse fracture at the level of the stem distal end with features of AFF: periosteal thickening of the lateral cortex, a medial spike, and a noncomminuted fracture. She presented other features resembling AFF: history of bisphosphonate use, prodromal symptoms, no associated trauma, and lateral bowing of the contralateral femur. The fracture showed nonunion after the initial osteosynthesis, and a revision surgery of the arthroplasty and osteosynthesis was performed. Nine months after the surgery, bony union was achieved and she regained the ability to walk. It is supposed that the fracture was influenced by a stress force related to implants and lateral bowing concentrating on the fracture site as a mechanical factor in addition to bisphosphonates as a biological factor. It would be important to recognize that AFF could occur at the peri-implant location, and early detection and treatment are essential.
Collapse
|
17
|
Two Cases of Periprosthetic Atypical Femoral Fractures in Patients on Long-Term Bisphosphonate Treatment. Case Rep Surg 2019; 2019:9845320. [PMID: 30944750 PMCID: PMC6421721 DOI: 10.1155/2019/9845320] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 01/17/2019] [Indexed: 02/07/2023] Open
Abstract
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.
Collapse
|
18
|
Kurinomaru N, Mori T, Tsukamoto M, Okada Y, Yumisashi K, Sakai A. Case Report and Literature Review of Periprosthetic Atypical Femoral Fractures After Total Hip Arthroplasty. J UOEH 2019; 41:409-416. [PMID: 31866658 DOI: 10.7888/juoeh.41.409] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
We describe a case of periprosthetic femoral fracture with 5 major features of an atypical femoral fracture (AFF) and localized cortical thickening at the fracture site, which is characteristic of an AFF. An 81-year-old female patient had undergone cementless total hip arthroplasty for a right femoral neck fracture at the age of 66, and had been taking oral alendronate since then. At the age of 79, she developed spontaneous right thigh pain. Radiographs showed lateral cortical thickening and pedestal formation around the end of the femoral component. She was advised to discontinue oral alendronate and change to eldecalcitol. At the age of 81, she developed sudden severe pain when standing up from a seated position and was not able to walk. Radiographs showed a periprosthetic femoral fracture with 5 major features of AFF at the site of localized cortical thickening. We diagnosed a Vancouver type B1 periprosthetic femoral fracture. She underwent open reduction and internal fixation (ORIF) with an NCB® Periprosthetic Femur Plate System with cable grips. Daily subcutaneous injection of teriparatide and low intensity pulsed ultrasound therapy were performed to stimulate bone healing. She was able to walk without assistance at 4 months after ORIF. Radiographs showed adequate bridging callus and a disappearing fracture line. This case was diagnosed as a periprosthetic atypical femoral fracture (PAFF), because a periprosthetic fracture is excluded from the definition of AFF. Similar to AFF, PAFF exhibits poor clinical outcomes. The approach to treating PAFF should be decided after considering the pathogenesis.
Collapse
Affiliation(s)
- Naoaki Kurinomaru
- Department of Orthopaedic Surgery, School of Medicine, University Hospital of Occupational and Environmental Health, Japan
| | - Toshiharu Mori
- Department of Orthopaedic Surgery, School of Medicine, University Hospital of Occupational and Environmental Health, Japan
| | - Manabu Tsukamoto
- Department of Orthopaedic Surgery, School of Medicine, University Hospital of Occupational and Environmental Health, Japan
| | - Yasuaki Okada
- Department of Orthopaedic Surgery, School of Medicine, University Hospital of Occupational and Environmental Health, Japan
| | - Keiichi Yumisashi
- Department of Orthopaedic Surgery, School of Medicine, University Hospital of Occupational and Environmental Health, Japan
| | - Akinori Sakai
- Department of Orthopaedic Surgery, School of Medicine, University Hospital of Occupational and Environmental Health, Japan
| |
Collapse
|
19
|
Leclerc JT, Michou L, Vaillancourt F, Pelet S, Simonyan D, Belzile EL. Prevalence and Characteristics of Atypical Periprosthetic Femoral Fractures. J Bone Miner Res 2019; 34:83-92. [PMID: 30280425 DOI: 10.1002/jbmr.3584] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/14/2018] [Accepted: 08/26/2018] [Indexed: 12/12/2022]
Abstract
Bisphosphonate use has been associated with atypical femoral fractures (AFFs), defined by the American Society of Bone and Mineral Research (ASBMR) Task Force criteria, which currently exclude periprosthetic fractures. The objectives of this study were to establish the prevalence of atypical periprosthetic femoral fractures (APFFs) in patients with hip and knee arthroplasties and to determine the clinical and radiological risk factors associated with these fractures. We performed a retrospective radiological review of all femoral fractures between January 1, 2006, and March 31, 2015, in Quebec City, Canada. Patients who sustained a periprosthetic femoral fracture (PFF) were identified and included in this study. We used the ASBMR Task Force criteria to identify atypical fractures and establish their prevalence. Data from medical records and radiological assessments of the femoral anatomy, the characteristics of the fracture, and the positioning of the prosthesis were collected. The prevalence of APFFs among PFFs was 8.3% (11/133). A strong association with bisphosphonates (p = 0.007) was observed, as well as an increased risk of APFFs among alendronate users compared to risedronate users (p = 0.04). A transverse fracture (p < 0.0001), a periosteal thickening of the lateral cortex at the fracture (p < 0.0001), a unicortical fracture (p = 0.02), and prodromal symptoms (p = 0.03) were associated with APFFs. The type of implant, its positioning, and the femoral geometry did not appear to be risk factors for APFFs compared to PFFs. © 2018 American Society for Bone and Mineral Research.
Collapse
Affiliation(s)
- Jean-Thomas Leclerc
- Department of Orthopedic Surgery, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Quebec, QC, Canada
| | - Laëtitia Michou
- Division of Rheumatology, Department of Medicine, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Quebec, QC, Canada.,Centre de recherche Fonds de la recherche du Québec en santé (FRQS) du Centre Hospitalier Universitaire (CHU) de Québec, Quebec, QC, Canada
| | | | - Stéphane Pelet
- Department of Orthopedic Surgery, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Quebec, QC, Canada.,Centre de recherche Fonds de la recherche du Québec en santé (FRQS) du Centre Hospitalier Universitaire (CHU) de Québec, Quebec, QC, Canada
| | - David Simonyan
- Clinical and Evaluative Research Platform, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval Research Centre, Quebec, QC, Canada
| | - Etienne L Belzile
- Department of Orthopedic Surgery, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Quebec, QC, Canada.,Centre de recherche Fonds de la recherche du Québec en santé (FRQS) du Centre Hospitalier Universitaire (CHU) de Québec, Quebec, QC, Canada
| |
Collapse
|
20
|
Frequency and associated factor of atypical periprosthetic femoral fracture after hip arthroplasty. Injury 2018; 49:2264-2268. [PMID: 30245278 DOI: 10.1016/j.injury.2018.09.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 08/20/2018] [Accepted: 09/07/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Atypical femoral fracture (AFF) is a serious complication after the use of bisphosphonates, and periprosthetic femoral fracture (PFF) appeared as a common complication after hip arthroplasty, especially in senile patients. Although American Society for Bone and Mineral Research has excluded PFFs from the definition of AFFs, several case reports found PFF patients undergoing bisphosphonate treatment, have fractures resembling AFF and the authors suggested that AFF can also occur in operated femurs after hip arthroplasty. To date, the frequency and risk factors of atypical PFF are unknown. The purpose of our study was (1) to evaluate the proportion of atypical PFF among Vancouver type B PFFs, and (2) to determine the association between occurrence of atypical PFF and use of bisphosphonate. METHODS We reviewed medical records and radiographs of 67 Vancouver type B PFFs (67 patients) due to low-energy trauma and classified them into atypical PFF group and ordinary PFF group. We calculated the proportion of atypical PFFs among PFFs and identified risk factors for atypical PFF. RESULTS Among the 67 PFFs, 7 fractures (10.4%) were classified as atypical PFF. Longer duration of bisphosphonate use was an independent risk factor of atypical PFF. (Odds ratio 2.600, 95% CI 1.184-5.709, p = 0.017). CONCLUSION In accordance with wide use of bisphosphonate, atypical PFFs after hip arthroplasty are not rare anymore. Physicians should suspect the atypical PFF, when they meet low-energy fracture in bisphosphonate users, and radiographs show features of AFF.
Collapse
|
21
|
Lateral fixation: an alternative surgical approach in the prevention of complete atypical femoral fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 28:299-304. [PMID: 28924690 PMCID: PMC5775348 DOI: 10.1007/s00590-017-2041-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 09/01/2017] [Indexed: 11/11/2022]
Abstract
Little evidence is available on how to treat incomplete atypical fractures of the femur. When surgery is chosen, intramedullary nailing is the most common invasive technique. However, this approach is adopted from the treatment of other types of ordinary femoral fracture and does not aim to prevent the impending complete fracture by interrupting the mechanism underlying the pathology. We suggest a different surgical approach that intends to counteract the underlying biomechanical conditions leading to a complete atypical fracture and thus could be better suited in selected cases. Here, we share an alternative surgical approach and present two cases treated accordingly.
Collapse
|
22
|
Yoon BH, Park SB. Insufficiency Fracture Occurring 3 Years After Union of an Intertrochanteric Hip Fracture: A Case Report. JBJS Case Connect 2017; 7:e1. [PMID: 29244683 DOI: 10.2106/jbjs.cc.16.00006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
CASE We present a rare case of insufficiency fracture at the level of the distal interlocking screw following union of an intertrochanteric hip fracture. A 74-year-old woman reported chronic thigh pain for 1 month. She had a history of an osteoporotic stable intertrochanteric fracture that was successfully treated with a short intramedullary nail 3.5 years prior. However, after union, the neck-shaft angle of the femur changed from 125° to 117°. She had been on alendronic acid therapy to prevent a secondary osteoporotic fracture. A recent radiograph and bone scan suggested an insufficiency fracture around the level of the distal interlocking screw. Revision surgery with a long intramedullary nail was performed, and complete union was observed 1 year postoperatively. CONCLUSION This case suggests that subsequent insufficiency fracture can occur after complete union of an intertrochanteric hip fracture. Physicians should be aware of the possibility of a stress fracture when a patient has thigh pain after an intertrochanteric fracture has healed following repair with a short intramedullary nail.
Collapse
Affiliation(s)
- Byung-Ho Yoon
- Department of Orthopaedic Surgery, Inje University College of Medicine, Seoul Paik Hospital, Seoul, South Korea
| | - Sung Bae Park
- Department of Orthopaedic Surgery, KEPCO Medical Foundation, KEPCO Medical Center, Seoul, South Korea
| |
Collapse
|
23
|
Marongiu G, Capone A. Atypical periprosthetic acetabular fracture in long-term alendronate therapy. CLINICAL CASES IN MINERAL AND BONE METABOLISM : THE OFFICIAL JOURNAL OF THE ITALIAN SOCIETY OF OSTEOPOROSIS, MINERAL METABOLISM, AND SKELETAL DISEASES 2016; 13:209-213. [PMID: 28228784 PMCID: PMC5318174 DOI: 10.11138/ccmbm/2016.13.3.209] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
Collapse
|
24
|
Ramani A, Wagner R. Periprosthetic Femoral Stress Fracture After Bisphosphonate Treatment Resulting in Nonunion Successfully Treated with Teriparatide: A Case Report. JBJS Case Connect 2016; 6:e37. [PMID: 29252670 DOI: 10.2106/jbjs.cc.15.00172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
CASE We present the case of a postmenopausal osteoporotic woman, treated with bisphosphonates, who developed a stress fracture at the tip of a revision femoral component, resulting in nonunion after several operative treatment attempts. The nonunion healed after 7 months of subcutaneous injections of 20 μg/day of teriparatide. CONCLUSION Teriparatide treatment should be considered for use in recalcitrant stress fractures after total hip arthroplasty.
Collapse
Affiliation(s)
- Azaan Ramani
- University of North Texas Health Science Center, Fort Worth, Texas
| | | |
Collapse
|
25
|
Maheshwari AV, Yarmis SJ, Tsai J, Jauregui JJ. Progression of bisphosphonate-associated impending atypical femoral fracture despite prophylactic cephalomedullary nailing: A case report and review of literature. J Clin Orthop Trauma 2016; 7:92-98. [PMID: 28018083 PMCID: PMC5167447 DOI: 10.1016/j.jcot.2016.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 05/01/2016] [Accepted: 06/08/2016] [Indexed: 01/29/2023] Open
Abstract
While bisphosphonates have been shown to be effective in reducing the incidence of typical osteoporotic fractures, long-term bisphosphonate may be associated with atypical femoral fractures. We report a case of a bisphosphonate-related impending atypical femoral fracture which progressed despite prophylactic cephalomedullary nailing. The fracture healed without further surgical intervention after correcting the patient's bone metabolic profile and stopping the possible offending factors. Although prophylactic fixation of these fractures is recommended, our case and relevant literature review demonstrate that a simple fixation without optimizing other possible predisposing factors may not prevent progression of these fractures.
Collapse
Affiliation(s)
| | | | | | - Julio J. Jauregui
- Corresponding author at: SUNY Downstate Medical Center, Department of Orthopaedics, 450 Clarkson Avenue, MSC 30, Brooklyn, NY 11203, United States. Tel.: +1 718 221 5270.SUNY Downstate Medical Center, Department of Orthopaedics450 Clarkson Avenue, MSC 30BrooklynNY11203United States
| |
Collapse
|
26
|
Lee KJ, Min BW, Jang HK, Ye HU, Lim KH. Periprosthetic Atypical Femoral Fracture-like Fracture after Hip Arthroplasty: A Report of Three Cases. Hip Pelvis 2015; 27:187-91. [PMID: 27536624 PMCID: PMC4972725 DOI: 10.5371/hp.2015.27.3.187] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 08/11/2015] [Accepted: 08/20/2015] [Indexed: 11/24/2022] Open
Abstract
Atypical femoral fractures are stress or insufficient fractures induced by low energy trauma or no trauma and have specific X-ray findings. Although the American Society for Bone and Mineral Research has excluded periprosthetic fractures from the definition of an atypical femoral fracture in 2013, this is still a matter of controversy because some authors report periprosthetic fractures showing specific features of atypical fractures around a well-fixed femoral stem. We report 3 cases of periprosthetic femur fractures that had specific radiographic features of atypical femoral fractures in patients with a history of prolonged bisphosphonate use; we also review relevant literature.
Collapse
Affiliation(s)
- Kyung-Jae Lee
- Department of Orthopedic Surgery, Keimyung University School of Medicine, Daegu, Korea
| | - Byung-Woo Min
- Department of Orthopedic Surgery, Keimyung University School of Medicine, Daegu, Korea
| | - Hyung-Kyu Jang
- Department of Orthopedic Surgery, Keimyung University School of Medicine, Daegu, Korea
| | - Hee-Uk Ye
- Department of Orthopedic Surgery, Keimyung University School of Medicine, Daegu, Korea
| | - Kyung-Hwan Lim
- Department of Orthopedic Surgery, Keimyung University School of Medicine, Daegu, Korea
| |
Collapse
|