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Hashimoto J, Oh Y, Yamamoto K, Yoshii T, Fukushima K, Kitagawa M, Okawa A. Frequency and pathogenesis of periprosthetic atypical femoral fractures associated with total knee arthroplasty: A multicenter prospective study with complementary histopathological and biomechanical analysis. Injury 2024; 55:111136. [PMID: 37867026 DOI: 10.1016/j.injury.2023.111136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/04/2023] [Accepted: 10/14/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Although the diagnostic criteria for atypical femoral fracture (AFF) exclude periprosthetic fractures, reports of periprosthetic femoral fractures with characteristics of AFF are rapidly increasing. In this study, we investigated the frequency and pathogenesis of periprosthetic AFF associated with total knee arthroplasty (TKA) based on a theory of AFF subtypes that divides AFFs into two main types: fragility stress fractures of the bowed femoral shaft in the mid-shaft and "typical" subtrochanteric AFFs due to suppression of bone turnover (e.g., by bisphosphonates). PATIENTS AND METHODS This multicenter prospective study of AFFs was conducted from 2015 through 2022. Clinical, pathological, and morphological characteristics were investigated in patients with periprosthetic AFFs associated only with non-stem TKA. Then, biomechanical investigation of the periprosthetic AFF was performed by computer tomography-based finite element analysis (CT/FEA) using two models with different load axes to examine how the correction of lower limb alignment by TKA influences the tensile stress distribution of the femur and the location of the AFF. RESULTS Four of 61 AFFs (6.6%) were identified to be periprosthetic AFF (1 mid-shaft; 3 subtrochanteric). Periprosthetic AFFs had characteristics including mechanical stress due to bowing deformity and potentially suppressed bone turnover due to long-term exposure to specific drugs (e.g., bisphosphonates and glucocorticoids). Although 2 periprosthetic AFFs appeared to involve a bowed femur, one with both of the aforementioned characteristics occurred in the subtrochanteric region, which would be an unusual site for a bowed AFF, and it was demonstrated histologically to have biological activity at the fracture site, suggesting a stress fracture. Furthermore, CT/FEA revealed that tensile stress distribution changed proximally as load axis was shifted laterally according to correction of lower limb alignment by TKA. CONCLUSION Orthopedic surgeons should recognize the presence of TKA-associated periprosthetic AFF caused by various factors including specific drugs, bowing deformity, and lower limb alignment. X-rays of the full-length femurs should be checked regularly after TKA, especially in patients with bowed femurs or long-term exposure to specific drugs.
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Affiliation(s)
- Jun Hashimoto
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoto Oh
- Department of Orthopaedic and Trauma Research, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Kouhei Yamamoto
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Masanobu Kitagawa
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Okawa
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Shih JT, Tan TL, Shen PH, Yeh TT, Wu CC, Pan RY, Chien WC, Chung CH, Wang SH. Postoperative Bisphosphonates Use is Associated with Reduced Adverse Outcomes After Primary Total Joint Arthroplasty of Hip and Knee: A Nationwide Population-Based Cohort Study. Calcif Tissue Int 2024; 114:451-460. [PMID: 38492035 DOI: 10.1007/s00223-024-01192-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 02/06/2024] [Indexed: 03/18/2024]
Abstract
Bisphosphonates have been associated with a decreased risk of revision surgery after total joint arthroplasty of the hip or knee (TJA) because of their effects on decreased periprosthetic bone loss and prosthetic migration. However, the results in the early literature are inconsistent, and the influence of bisphosphonates on associated complications and subsequent TJA remains unknown. This study investigated the association between the use of bisphosphonates and the risk of adverse outcomes after primary TJA. This matched cohort study utilized the National Health Insurance Research Database in Taiwan to identify patients who underwent primary TJA over a 15-year period (January 2000-December 2015 inclusive). Study participants were further categorized into two groups, bisphosphonate users and nonusers, using propensity score matching. The Kaplan-Meier curve analysis and adjusted hazard ratios (aHRs) of revision surgery, adverse outcomes of primary surgery and subsequent TJA were calculated using Cox regression analysis. This study analyzed data from 6485 patients who underwent total hip arthroplasty (THA) and 20,920 patients who underwent total knee arthroplasty (TKA). The risk of revision hip and knee arthroplasty was significantly lower in the bisphosphonate users than in the nonusers (aHR, 0.54 and 0.53, respectively). Furthermore, the risk of a subsequent total joint arthroplasty, adverse events and all-cause mortality were also significantly reduced in the bisphosphonate users. This study, involving a large cohort of patients who underwent primary arthroplasties, revealed that bisphosphonate treatment may potentially reduce the risk of revision surgery and associated adverse outcomes. Furthermore, the use of bisphosphonates after TJA is also associated with a reduced need for subsequent arthroplasty.Research Registration Unique Identifying Number (UIN): ClinicalTrials.gov Identifier-NCT05623540 ( https://clinicaltrials.gov/show/NCT05623540 ).
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Affiliation(s)
- Jen-Ta Shih
- Department of Orthopedics, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist., Taipei City, 11472, Taiwan
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei City, Taiwan
| | - Timothy L Tan
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Pei-Hung Shen
- Department of Orthopedics, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist., Taipei City, 11472, Taiwan
| | - Tsu-Te Yeh
- Department of Orthopedics, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist., Taipei City, 11472, Taiwan
| | - Chia-Chun Wu
- Department of Orthopedics, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist., Taipei City, 11472, Taiwan
| | - Ru-Yu Pan
- Department of Orthopedics, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist., Taipei City, 11472, Taiwan
| | - Wu-Chien Chien
- School of Public Health, National Defense Medical Center, Taipei City, Taiwan
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei City, Taiwan
- Taiwanese Injury Prevention and Safety Promotion Association, Taipei City, Taiwan
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei City, Taiwan
| | - Chi-Hsiang Chung
- School of Public Health, National Defense Medical Center, Taipei City, Taiwan
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei City, Taiwan
- Taiwanese Injury Prevention and Safety Promotion Association, Taipei City, Taiwan
| | - Sheng-Hao Wang
- Department of Orthopedics, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist., Taipei City, 11472, Taiwan.
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Scott CEH, Jain S, Moran M, Haddad FS. Which Unified Classification System type B periprosthetic fractures around cemented polished tapered stems should not be fixed? Bone Joint J 2023; 105-B:481-486. [PMID: 37121589 DOI: 10.1302/0301-620x.105b5.bjj-2022-1395.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
The Unified Classification System (UCS), or Vancouver system, is a validated and widely used classification system to guide the management of periprosthetic femoral fractures. It suggests that well-fixed stems (type B1) can be treated with fixation but that loose stems (types B2 and B3) should be revised. Determining whether a stem is loose can be difficult and some authors have questioned how to apply this classification system to polished taper slip stems which are, by definition, loose within their cement mantle. Recent evidence has challenged the common perception that revision surgery is preferable to fixation surgery for UCS-B periprosthetic fractures around cemented polished taper slip stems. Indications for fixation include an anatomically reducible fracture and cement mantle, a well-fixed femoral bone-cement interface, and a well-functioning acetabular component. However, not all type B fractures can or should be managed with fixation due to the risk of early failure. This annotation details specific fracture patterns that should not be managed with fixation alone.
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Affiliation(s)
- Chloe E H Scott
- Department of Orthopaedics, The University of Edinburgh, Edinburgh, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Matt Moran
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London, UK
- The Princess Grace Hospital, London, UK
- The Bone & Joint Journal , London, UK
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Cohen JS, Agarwal AR, Kinnard MJ, Thakkar SC, Golladay GJ. The Association of Postoperative Osteoporosis Therapy With Periprosthetic Fracture Risk in Patients Undergoing Arthroplasty for Femoral Neck Fractures. J Arthroplasty 2023; 38:726-731. [PMID: 36328102 DOI: 10.1016/j.arth.2022.10.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/23/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Displaced femoral neck fractures in older adults are generally treated with hip arthroplasty. One concern following hip arthroplasty is the risk for periprosthetic fractures (PPFs). Most patients who have hip fractures are candidates for antiosteoporotic therapy, but the impact of this treatment on PPFs is unknown. Therefore, the primary objective of this study was to evaluate whether patients treated with antiosteoporotic medical therapy had lower odds of PPFs following arthroplasty for hip fracture. METHODS Patients at least 65 years old who underwent hip arthroplasty for femoral neck fractures from 2010 to 2020 were identified in a national database. Patients were stratified based on whether they initiated antiosteoporotic therapy within 1 year of hip arthroplasty. Minimum follow-up was 1 year, and maximum follow-up was 10.6 years. The primary endpoint was cumulative incidence of PPF as determined using Kaplan-Meier and Cox proportional hazards regression analyses. Overall, 2,026 patients who underwent arthroplasty for femoral neck fracture received antiosteoporotic medications within 1 year following surgery (mean follow up 4.8 years; range 1.0 to 10.6 years) and 33,639 patients did not (mean follow up 4.1 years; range 1.1 to 10.3 years). RESULTS The 10-year cumulative incidence of PPF for patients treated for osteoporosis was 3.88% compared to 5.92% for those who were untreated (P < .001). Adjusting for covariates, patients who received osteoporosis treatment had a significantly lower risk for PPF than those who were untreated (hazard ratio (HR): 0.663; 95% confidence interval (CI): 0.465-0.861; P = .038). CONCLUSION The present study suggests that osteoporosis treatment is associated with lower incidence of PPF following hip arthroplasty for femoral neck fractures. Treatment of osteoporosis should be initiated in eligible patients who sustain a femoral neck fracture, especially those who undergo hip arthroplasty.
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Affiliation(s)
- Jordan S Cohen
- University of Pennsylvania, Department of Orthopaedic Surgery, Philadelphia, Pennsylvania
| | - Amil R Agarwal
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Matthew J Kinnard
- Walter Reed National Military Medical Center, Department of Orthopaedic Surgery, Bethesda, Maryland
| | - Savyasachi C Thakkar
- Johns Hopkins University, Department of Orthopaedic Surgery, Baltimore, Maryland
| | - Gregory J Golladay
- Virginia Commonwealth University, Department of Orthopaedic Surgery, Richmond, Virginia
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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.
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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
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Powell-Bowns MF, Oag E, Martin DH, Clement ND, Moran M, Scott CE. Factors associated with failure of fixation of Vancouver B fractures around a cemented polished tapered stem: A 5 to 14 year follow up study. Injury 2023:S0020-1383(23)00196-1. [PMID: 36964036 DOI: 10.1016/j.injury.2023.03.003] [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: 12/12/2022] [Revised: 02/04/2023] [Accepted: 03/04/2023] [Indexed: 03/26/2023]
Abstract
AIMS There is increasing evidence for fixation as opposed to revision for Vancouver B fractures around polished taper slip stems, however it is remains unclear whether fixation is associated with stem loosening in the longer term. This study aims to assess survival of plate-fixation of Vancouver-B-fractures around a polished-taper- slip cemented stem and identify factors associated with failure. METHODS Retrospective cohort study assessed 129 consecutive unilateral Vancouver-B-fractures around cemented Exeter stems at a minimum of 5 years following open-reduction-internal-fixation (ORIF) with unilateral non-locked unilateral plating+/-cerclage cables. The primary outcome measure was reoperation for any reason. Kaplan Meier survival analysis was performed. RESULTS Fractures (B1 n = 31 (24%); B2 n = 91 (71%); and B3 n = 7 (5%)) occurred at median of 6 years (IQR 1.2-9.2) after primary surgery. Mean patient age was 78.2 (SD10.56, range 46-96) and 54 (42.9%) were female. Mean follow up was 8.7 years (SD 2.48, 5.7 to 14.4). Symptomatic femoral stem loosening requiring revision occurred in two B2 fractures of metaphyseal split and short spiral patterns. The most common mode of failure was non-union (n = 7, 5%). Both fixation failure (n = 6/31 Vs n = 3/91 vs n = 0/7, p = 0.008) and reoperation (n = 8/31 vs n = 6/91 vs n = 0/7, p = 0.008) were significantly higher following fixation of B1 fractures compared to B2 and B3 fractures. Overall 5year survival free from reoperation was 88.8% (82.0-94.7 95%CI). B1 fracture types were associated with an increase risk of failure (endpoints fixation failure p = 0.010; and reoperation p = 0.016). Transverse fractures (B1) were associated with a relative risk of reoperation of 4.22 (1.63-10.9 95% CI, p = 0.008). CONCLUSION Fixation of Vancouver-B fractures around cemented Exeter stems, when the bone-cement interface is intact and the fracture is anatomically reducible, had an excellent 5-year survival. Only 2 (1.6%) cases of late femoral stem loosening occurred, however, B1 type transverse fractures were associated with a higher rate of reoperation.
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Affiliation(s)
| | - Erlend Oag
- Royal Infirmary of Edinburgh, Little France Cres, Edinburgh EH164SA, United Kingdom
| | - Damien H Martin
- Royal Infirmary of Edinburgh, Little France Cres, Edinburgh EH164SA, United Kingdom
| | - Nicholas D Clement
- Royal Infirmary of Edinburgh, Little France Cres, Edinburgh EH164SA, United Kingdom
| | - Matthew Moran
- Royal Infirmary of Edinburgh, Little France Cres, Edinburgh EH164SA, United Kingdom
| | - Chloe Eh Scott
- Royal Infirmary of Edinburgh, Little France Cres, Edinburgh EH164SA, United Kingdom; University of Edinburgh, Edinburgh, United Kingdom
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Increased Risk of Hospital Readmissions and Implant-Related Complications in Patients Who Had a Recent History of Fragility Fracture: A Matched Cohort Analysis. J Arthroplasty 2023; 38:266-273. [PMID: 36055439 DOI: 10.1016/j.arth.2022.08.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND With the increasing utilization of total knee arthroplasty (TKA) in a continually aging US population, the number of patients who have low bone mineral density who undergo TKA may concomitantly increase. This study aimed to assess the rates of short-term complications following TKA in patients who did and did not have a recent history of a prior fragility fracture. METHODS A matched retrospective cohort study analyzing 48,796 patients was performed using a national database to determine the impact of a preceding fragility fracture on rates of short-term complications following TKA. The rates of complications at 1 and 2 years post-TKA were analyzed using multivariate logistic regressions. RESULTS Prior fragility fracture was associated with increased rates of 1-year hospital readmissions (hazard ratio = 1.30, 95% CI, 1.22-1.38), periprosthetic fractures (odds ratio [OR] = 2.72, 95% CI, 1.89-3.99), non-infection-related revisions (OR = 1.32, 95% CI, 1.09-1.60), secondary fragility fractures (OR = 4.62, 95% CI, 4.19-5.12), prosthesis dislocations (OR = 1.76, 95% CI, 1.22-2.56), prosthesis instabilities (OR = 1.64, 95% CI, 1.25-2.15), and periprosthetic infections (OR = 1.49, 95% CI, 1.29-1.71), with similar trends in implant-related complications also seen at the 2-year mark. Patients who filled a prescription for osteoporosis pharmacotherapy had clinically similar rates of these complications compared to those who did not. CONCLUSION Sustaining a fragility fracture prior to TKA is associated with an increased risk of hospital readmission and significant implant-related postoperative complications, potentially increasing the morbidity and mortality of TKA in these patients.
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Kim JW, Oh CW, Park KH, Oh JK, Yoon YC, Kim JK. Peri-implant atypical femoral fracture after nail or plate osteosynthesis. J Orthop Sci 2022; 27:866-875. [PMID: 34052080 DOI: 10.1016/j.jos.2021.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 03/23/2021] [Accepted: 04/12/2021] [Indexed: 02/09/2023]
Abstract
BACKGROUND A lack of scientific information regarding the risk factors and diagnosis of peri-implant atypical femoral fracture (PI-AFF) exists. We report a case series of developed PI-AFF with a nail or plate construct wherein prior femoral fractures were already healed after osteosynthesis. This study aimed to identify the cause and risk factors of PI-AFF and to devise a preventive method based on this. METHODS We identified 11 PI-AFFs displaying features of AFFs. All patients were ambulant females (mean age, 74.9 years). The mean T-score of the femur measured by DEXA (Dual Energy X-ray Absorptiometry) scan was 3.5. Osteosynthesis was performed with a plate and an intramedullary nail in six and five patients, respectively. Possible risk factors were investigated, including the used implant, the medication of bisphosphonate, the characteristics of previous fracture (AFF or non-AFF), and the co-existence of AFF on the contralateral side. RESULTS The PI-AFFs developed at an average of 6.6 years from the time of prior fracture. All fractures were located at the screw through the plate or nail. Regarding anatomic locations, seven and four fractures were at the subtrochanteric area and diaphysis, respectively. Diaphyseal PI-AFFs occurred in plating cases, all of which were associated with excessive femoral bowing. Subtrochanteric PI-AFFs included all five patients with nail fixation, which occurred near a proximal interlocking screw. Six of the 11 patients were on bisphosphonate treatment before or at the time of fracture. The duration of bisphosphonate treatment was 6 years on average. Concerning the previous femoral fractures, seven and four patients were AFF and non-AFF, respectively. Considering the pathology on the contralateral leg, eight had suffered diaphyseal AFF. Four patients were treated nonoperatively. Seven patients needed an operation; 6 of them healed after reconstruction nailing, and one needed hip arthroplasty because of the associated displaced femoral neck fracture. CONCLUSIONS PI-AFFs may develop through the screw hole at the subtrochanteric or diaphyseal area due to femoral fragility and stress riser effect of the implant. An improved osteosynthesis strategy may be necessary to avoid PI-AFFs when fixing osteoporotic femoral fractures.
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Affiliation(s)
- Joon-Woo Kim
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, 41944, Republic of Korea
| | - Chang-Wug Oh
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, 41944, Republic of Korea.
| | - Kyeong-Hyeon Park
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, 41944, Republic of Korea
| | - Jong-Keon Oh
- Department of Orthopaedic Surgery, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Yong-Cheol Yoon
- Orthopedic Trauma Division, Trauma Center, Gachon University College of Medicine, 21, Namdong-daero 774 Beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea
| | - June-Kyu Kim
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, 41944, Republic of Korea
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Contemporaneous Insufficiency Fractures of Bilateral Femoral Necks in an Older Patient Taking Bisphosphonate: A Case Report and Literature Review. Case Rep Orthop 2022; 2022:9294289. [PMID: 35528280 PMCID: PMC9076345 DOI: 10.1155/2022/9294289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/18/2022] [Indexed: 12/04/2022] Open
Abstract
We report, to the best of our knowledge, the first case of simultaneous insufficiency fracture of the bilateral femoral neck in an older patient taking bisphosphonate. Femoral neck fractures frequently occur in older individuals because of traumatic incidents, such as a fall. A 74-year-old woman with osteoporosis was taking raloxifene hydrochloride and bisphosphonate for approximately 5 and 3 years, respectively. Despite no history of falls or any other traumatic incidence, the patient reported cooccurrence of pain on both sides of the hip. Imaging revealed bilateral femoral neck fractures. Bipolar hemiarthroplasty and internal fixation were conducted on the right and left hips, respectively. At 6 months postoperatively, the patient reported gradual disappearance of left hip pain, and a radiograph revealed that the fracture had healed. Overall, clinical and histological findings suggested an atypical fracture, thereby proving that this type of fracture can occur in areas other than the femoral shaft.
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Sabsuantang K, Chotanaphuti T, Wongsak S, Sa-Ngasoongsong P, Khuangsirikul S, Chulsomlee K, Kulachote N. Atypical Periprosthetic Femoral Fracture Associated With Prolonged Bisphosphonate Therapy: A Two-Centered Retrospective Case Series and Literature Review. Cureus 2022; 14:e24514. [PMID: 35497080 PMCID: PMC9043311 DOI: 10.7759/cureus.24514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2022] [Indexed: 12/03/2022] Open
Abstract
To date, atypical periprosthetic femoral fractures (APFFs) are not well-understood due to a relatively small number of studies on the topic. Moreover, there is a paucity of guidance regarding the appropriate treatment strategy. We would therefore like to present and analyze a series of five APFF cases (one incomplete APFF and four complete APFFs) that were treated in two university hospitals; a review of the literature is also provided. The results provide additional and useful information regarding the treatment strategy for APFFs.
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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.
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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
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12
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Shen G, Liu X, Lei W, Duan R, Yao Z. Plumbagin is a NF-κB-inducing kinase inhibitor with dual anabolic and antiresorptive effects that prevents menopausal-related osteoporosis in mice. J Biol Chem 2022; 298:101767. [PMID: 35235833 PMCID: PMC8958545 DOI: 10.1016/j.jbc.2022.101767] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 12/03/2022] Open
Abstract
Osteoporosis is caused by enhanced bone resorption and relatively reduced bone formation. There is an unmet need to develop new agents with both antiresorptive and anabolic effects to treat osteoporosis, although drugs with either effect alone are available. A small molecular compound, plumbagin, was reported to inhibit receptor activator of nuclear factor kappa-B ligand-induced osteoclast (OC) differentiation by inhibiting IκBα phosphorylation-mediated canonical NF-κB activation. However, the key transcriptional factor RelA/p65 in canonical NF-κB pathway functions to promote OC precursor survival but not terminal OC differentiation. Here, we found that plumbagin inhibited the activity of NF-κB inducing kinase, the key molecule that controls noncanonical NF-κB signaling, in an ATP/ADP-based kinase assay. Consistent with this, plumbagin inhibited processing of NF-κB2 p100 to p52 in the progenitor cells of both OCs and osteoblasts (OBs). Interestingly, plumbagin not only inhibited OC but also stimulated OB differentiation in vitro. Importantly, plumbagin prevented trabecular bone loss in ovariectomized mice. This was associated with decreased OC surfaces on trabecular surface and increased parameters of OBs, including OB surface on trabecular surface, bone formation rate, and level of serum osteocalcin, compared to vehicle-treated mice. In summary, we conclude that plumbagin is a NF-κB-inducing kinase inhibitor with dual anabolic and antiresorptive effects on bone and could represent a new class of agent for the prevention and treatment of osteoporosis.
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Affiliation(s)
- Gengyang Shen
- Department of Pathology and Laboratory Medicine, and Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, New York, USA
| | - Xin Liu
- Department of Pathology and Laboratory Medicine, and Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, New York, USA
| | - Wei Lei
- Department of Pathology and Laboratory Medicine, and Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, New York, USA
| | - Rong Duan
- Department of Pathology and Laboratory Medicine, and Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, New York, USA
| | - Zhenqiang Yao
- Department of Pathology and Laboratory Medicine, and Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, New York, USA.
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13
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Park J, Won S, Kim H, Won SJ, Lee Y, Koo K. Current Incidence and Future Projection of Periprosthetic Fractures in South Korea: A Study Based on National Claim Database. Orthop Surg 2022; 14:530-535. [PMID: 35098681 PMCID: PMC8927022 DOI: 10.1111/os.13219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 12/10/2021] [Accepted: 12/20/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Jung‐Wee Park
- Department of Orthopaedic Surgery Seoul National University Bundang Hospital Seongnam South Korea
| | - Seok‐Hyung Won
- Department of Orthopaedic Surgery Seoul National University Bundang Hospital Seongnam South Korea
| | - Hong‐Seok Kim
- Department of Orthopaedic Surgery Seoul National University Bundang Hospital Seongnam South Korea
| | - Samuel Jaeyoon Won
- Department of Orthopaedic Surgery Seoul National University Bundang Hospital Seongnam South Korea
| | - Young‐Kyun Lee
- Department of Orthopaedic Surgery Seoul National University Bundang Hospital Seongnam South Korea
| | - Kyung‐Hoi Koo
- Department of Orthopaedic Surgery Seoul National University Bundang Hospital Seongnam South Korea
- Department of Orthopaedic Surgery Seoul National University College of Medicine Seoul South Korea
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14
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Bégin MJ, Audet MC, Chevalley T, Portela M, Padlina I, Hannouche D, Ing Lorenzini K, Meier R, Peter R, Uebelhart B, Rizzoli R, Ferrari S, Biver E. Fracture Risk Following an Atypical Femoral Fracture. J Bone Miner Res 2022; 37:87-94. [PMID: 34668223 PMCID: PMC9298806 DOI: 10.1002/jbmr.4461] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/05/2021] [Accepted: 10/14/2021] [Indexed: 12/11/2022]
Abstract
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).
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Affiliation(s)
- Marie-Josée Bégin
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marie-Claude Audet
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Thierry Chevalley
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marina Portela
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Ivan Padlina
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Didier Hannouche
- Division of Orthopedic Surgery, Department of Surgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Kuntheavy Ing Lorenzini
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Raphaël Meier
- Department of Surgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Robin Peter
- Division of Orthopedic Surgery, Department of Surgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Brigitte Uebelhart
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - René Rizzoli
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Serge Ferrari
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Emmanuel Biver
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
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15
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The Olympia anatomic polished cemented stem is associated with a high survivorship, excellent hip-specific functional outcome, and high satisfaction levels: follow-up of 239 consecutive patients beyond 15 years. Arch Orthop Trauma Surg 2022; 142:2361-2370. [PMID: 34304278 PMCID: PMC9381461 DOI: 10.1007/s00402-021-03992-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 06/09/2021] [Indexed: 10/29/2022]
Abstract
INTRODUCTION The Olympia femoral stem is a stainless steel, anatomically shaped, polished and three-dimensionally tapered implant designed for use in cemented total hip arthroplasty (THA). The primary aim of this study was to determine the long-term survivorship, radiographic outcome, and patient-reported outcome measures (PROMs) of the Olympia stem. PATIENTS AND METHODS Between May 2003 and December 2005, 239 patients (264 THAs) underwent a THA with an Olympia stem in our institution. Patient-reported outcome measures were assessed using the Oxford Hip Score (OHS), EuroQol-5 dimensions (EQ-5D) score, and patient satisfaction at mean 10 years following THA. Patient records and radiographs were then reviewed at a mean of 16.5 years (SD 0.7, 15.3-17.8) following THA to identify occurrence of complications or revision surgery for any cause following surgery. Radiographs were assessed for lucent lines and lysis according to Gruen's zones RESULTS: Mean patient age at surgery was 68.0 years (SD 10.9, 31-93 years). There were 156 women (65%, 176 THAs). Osteoarthritis was the indication for THA in 204 patients (85%). All cause stem survivorship at 10 years was 99.2% (95% confidence interval [CI], 97.9%-100%) and at 15 years was 97.5% (94.6%-100%). The 15-year stem survival for aseptic loosening was 100%. Analysis of all-cause THA failure demonstrated a survivorship of 98.5% (96.3%-100%) at 10 years and 95.9% (92.4%-99.4%) at 15 years. There were 9 THAs with non-progressive lucent lines in a single Gruen zone and 3 had lines in two zones, and no patient demonstrated signs for lysis. At a mean of 10-year (SD 0.8, 8.7-11.3) follow-up, mean OHS was 39 (SD 10.3, range 7-48) and 94% of patients reported being very satisfied or satisfied with their THA. CONCLUSIONS The Olympia stem demonstrated excellent 10-year PROMs and very high rates of stem survivorship at final follow-up beyond 15 years.
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16
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Jeong SY, Hwang KT, Oh CW, Kim JW, Sohn OJ, Kim JW, Cho YH, Park KC. Infographic: Mid-term outcomes after the surgical treatment of atypical femoral fractures : minimum three-year follow-up. Bone Joint J 2021; 103-B:1646-1647. [PMID: 34719273 DOI: 10.1302/0301-620x.103b11.bjj-2021-1428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- S-Y Jeong
- Department of Orthopaedic Surgery, Hanyang University Guri Hospital, Guri, South Korea
| | - K-T Hwang
- Hanyang University College of Medicine, Seoul, South Korea
| | - C-W Oh
- Department of Orthopedic Surgery, Kyungpook National University Hospital, Daegu, South Korea
| | - J-W Kim
- Department of Orthopedic Surgery, Kyungpook National University Hospital, Daegu, South Korea
| | - O J Sohn
- Yeungnam University, Gyeongsan, South Korea
| | - J W Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Y-H Cho
- Daegu Fatima Hospital, Daegu, South Korea
| | - K C Park
- Department of Orthopaedic Surgery, Hanyang University Guri Hospital, Guri, South Korea
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17
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Jeong SY, Hwang KT, Oh CW, Kim JW, Sohn OJ, Kim JW, Cho YH, Park KC. Mid-term outcomes after the surgical treatment of atypical femoral fractures : minimum three-year follow-up. Bone Joint J 2021; 103-B:1648-1655. [PMID: 34719278 DOI: 10.1302/0301-620x.103b11.bjj-2021-0416.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AIMS The incidence of atypical femoral fractures (AFFs) continues to increase. However, there are currently few long-term studies on the complications of AFFs and factors affecting them. Therefore, we attempted to investigate the outcomes, complications, and risk factors for complication through mid-term follow-up of more than three years. METHODS From January 2003 to January 2016, 305 patients who underwent surgery for AFFs at six hospitals were enrolled. After exclusion, a total of 147 patients were included with a mean age of 71.6 years (48 to 89) and 146 of whom were female. We retrospectively evaluated medical records, and reviewed radiographs to investigate the fracture site, femur bowing angle, presence of delayed union or nonunion, contralateral AFFs, and peri-implant fracture. A statistical analysis was performed to identify the significance of associated factors. RESULTS The mean follow-up period was 70.2 months (36 to 191). There were 146 AFFs (99.3%) in female patients and the mean age was 71.6 years (48 to 89). The AFFs were located in the subtrochanter and shaft in 52 cases (35.4%) and 95 (64.6%), respectively. The preoperative mean anterior/lateral femoral bowing angles were 10.5° (SD 5.7°)/6.1° (SD 6.2°). The postoperative mean anterior/lateral bowing values were changed by 8.7° (SD 5.4°)/4.6° (SD 5.9°). Bisphosphonates had been used contemporarily in 115 AFFs (78.2%) for a mean of 52.4 months (1 to 204; SD 45.5) preoperatively. Nailing was performed in 133 AFFs (90.5%), and union was obtained at a mean of 23.6 weeks (7 to 85). Delayed union occurred in 41 (27.9%), and nonunion occurred in 13 (8.8%). Contralateral AFF occurred in 79 patients (53.7%), and the use of a bisphosphonate significantly influenced the occurrence of contralateral AFFs (p = 0.019). Peri-implant fractures occurred in a total of 13 patients (8.8%), and a significant increase was observed in cases with plating (p = 0.021) and high grade of postoperative anterolateral bowing (p = 0.044). CONCLUSION The use of a bisphosphonate was found to be a risk factor for contralateral AFF, and high-grade postoperative anterolateral bowing and plate fixation significantly increased the occurrence of peri-implant fractures. Long-term follow-up studies on the bilaterality of AFFs and peri-implant fractures are warranted. Cite this article: Bone Joint J 2021;103-B(11):1648-1655.
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Affiliation(s)
- Soo-Young Jeong
- Department of Orthopedic Surgery, Hanyang University Guri Hospital, Guri, South Korea
| | - Kyu-Tae Hwang
- Orthopedic Surgery, Hanyang University College of Medicine, Seoul, South Korea
| | - Chang-Wug Oh
- Department of Orthopedic Surgery, Kyungpook National University Hospital, Daegu, South Korea
| | - Joon-Woo Kim
- Department of Orthopedic Surgery, Kyungpook National University Hospital, Daegu, South Korea
| | | | - Ji Wan Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | - Ki Chul Park
- Department of Orthopedic Surgery, Hanyang University Guri Hospital, Guri, South Korea
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18
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Atypical periprosthetic femoral fractures after arthroplasty for fracture are at high risk of complications. Sci Rep 2021; 11:14378. [PMID: 34257322 PMCID: PMC8277775 DOI: 10.1038/s41598-021-93574-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 06/28/2021] [Indexed: 12/23/2022] Open
Abstract
It is difficult to investigate clinical features in a single-center study because atypical periprosthetic femoral fracture (APFF) is rare. This study aims to perform a nationwide survey of APFF to investigate the characteristics of this fracture and compare the clinical outcome with that of typical periprosthetic femoral fracture (typical PFF). A nationwide survey was performed asking for cooperation from 183 councilors of the Japanese Society for Fracture Repair. The subjects were patients with APFF injured between 2008 and 2017. The control group was comprised of patients with typical PFF of our facility injured in the same period. A total of 43 patients met the APFF definition. The control group was comprised of 75 patients with typical PFF. The rate of bisphosphonate use was significantly higher in the APFFs group than in the typical PFF group (62.8% and 32%, p < 0.02). The rate of cemented stem was significantly higher in the APFFs group than in the typical PFF group (30.2% and 6.7%, p < 0.001). In the patients with arthroplasty for hip fracture, multivariable logistic regression analyses showed that APFF was an independent risk factor of complications following the initial management (Odds ratio 11.1, 95% confidence interval 1.05–117.2, p = 0.045). However, no significant association between PFF and APFF was observed in the patients with arthroplasty for other hip diseases. The risk of complications was higher in the APFF group than in the typical PFF group in the patients with arthroplasty for fracture. When AFPP after arthroplasty for the fracture is suspected, it may be necessary to add not only internal fixation with a normal plate but also some additional treatment.
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19
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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.
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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
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20
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Aro HT. The potential use of denosumab in patients with arthroplasty. THE LANCET. RHEUMATOLOGY 2021; 3:e165-e166. [PMID: 38279378 DOI: 10.1016/s2665-9913(20)30447-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 12/17/2020] [Indexed: 01/28/2024]
Affiliation(s)
- Hannu T Aro
- Department of Orthopaedic Surgery and Traumatology, University of Turku and Turku University Hospital, 20521 Turku, Finland.
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21
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Powell-Bowns MFR, Oag E, Ng N, Pandit H, Moran M, Patton JT, Clement ND, Scott CEH. Vancouver B periprosthetic fractures involving the Exeter cemented stem. Bone Joint J 2021; 103-B:309-320. [PMID: 33517729 DOI: 10.1302/0301-620x.103b2.bjj-2020-0695.r1] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIMS The aim of this study was to determine whether fixation, as opposed to revision arthroplasty, can be safely used to treat reducible Vancouver B type fractures in association with a cemented collarless polished tapered femoral stem (the Exeter). METHODS This retrospective cohort study assessed 152 operatively managed consecutive unilateral Vancouver B fractures involving Exeter stems; 130 were managed with open reduction and internal fixation (ORIF) and 22 with revision arthroplasty. Mean follow-up was 6.5 years (SD 2.6; 3.2 to 12.1). The primary outcome measure was revision of at least one component. Kaplan-Meier survival analysis was performed. Regression analysis was used to identify risk factors for revision following ORIF. Secondary outcomes included any reoperation, complications, blood transfusion, length of hospital stay, and mortality. RESULTS Fractures (B1 n = 74 (49%); B2 n = 50 (33%); and B3 n = 28 (18%)) occurred at median of 4.2 years (interquartile range (IQR) 1.2 to 9.2) after primary total hip arthroplasty (THA) (n = 138) or hemiarthroplasty (n = 14). Rates of revision and reoperation were significantly higher following revision arthroplasty compared to ORIF for B2 (p = 0.001) and B3 fractures (p = 0.050). Five-year survival was significantly better following ORIF: 92% (95% confidence interval (CI) 86.4% to 97.4%) versus 63% (95% CI 41.7% to 83.3%), p < 0.001. ORIF was associated with reduced blood transfusion requirement and reoperations, but there were no differences in medical complications, hospital stay, or mortality between surgical groups. No independent predictors of revision following ORIF were identified: where the bone-cement interface was intact, fixation of B2 or B3 fractures was not associated with an increased risk of revision. CONCLUSION When the bone-cement interface was intact and the fracture was anatomically reducible, all Vancouver B fractures around Exeter stems could be managed with fixation as opposed to revision arthroplasty. Fixation was associated with reduced need for blood transfusion and lower risk of revision surgery compared with revision arthroplasty. Cite this article: Bone Joint J 2021;103-B(2):309-320.
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Affiliation(s)
| | - Erlend Oag
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nathan Ng
- Department of Orthopaedics, The University of Edinburgh, Edinburgh, UK
| | - Hemant Pandit
- Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Matthew Moran
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - James T Patton
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nick D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Chloe E H Scott
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Orthopaedics, The University of Edinburgh, Edinburgh, UK
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22
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Evaluation and management of atypical femoral fractures: an update of current knowledge. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:825-840. [PMID: 33590316 DOI: 10.1007/s00590-021-02896-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 01/29/2021] [Indexed: 12/12/2022]
Abstract
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.
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Caruso G, Corradi N, Amoroso T, Martini I, Lorusso V, Massari L. Atypical periprosthetic femur fracture on an underestimated atypical femoral pattern. A case report. Trauma Case Rep 2021; 32:100407. [PMID: 33665304 PMCID: PMC7900765 DOI: 10.1016/j.tcr.2021.100407] [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] [Accepted: 02/06/2021] [Indexed: 12/12/2022] Open
Abstract
Case Atypical fracture patterns, especially to the femur midshaft, have begun emerging since long-term bisphosphonate use was introduced. The same fracture pattern could arise around prosthetic hip implant, but the literature reports few cases regarding atypical periprosthetic femur fracture on previous total hip arthroplasty implant in patients on long-term bisphosphonate therapy. To our knowledge we report here the first case of atypical periprosthetic femur fracture arising after total hip arthroplasty implant on a previously identified but underestimated atypical femur pattern. Conclusion Surgeons should never underestimate an atypical femur pattern on x-rays and always relate groin and thigh pain to hip pathology before performing total hip arthroplasty.
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Affiliation(s)
- Gaetano Caruso
- Orthopedic and Traumatology Unit, Sant'Anna University Hospital of Ferrara, Via Aldo Moro 8, 44124 Cona, Ferrara, Italy.,Department of Neurosciences and Rehabilitation, University of Ferrara, Via Luigi Borsari 46, 44121, Ferrara, Italy
| | - Nicola Corradi
- Orthopedic and Traumatology Unit, Sant'Anna University Hospital of Ferrara, Via Aldo Moro 8, 44124 Cona, Ferrara, Italy
| | - Tommaso Amoroso
- Orthopedic and Traumatology Unit, Sant'Anna University Hospital of Ferrara, Via Aldo Moro 8, 44124 Cona, Ferrara, Italy
| | - Ilaria Martini
- Orthopedic and Traumatology Unit, Sant'Anna University Hospital of Ferrara, Via Aldo Moro 8, 44124 Cona, Ferrara, Italy
| | - Vincenzo Lorusso
- Orthopedic and Traumatology Unit, Sant'Anna University Hospital of Ferrara, Via Aldo Moro 8, 44124 Cona, Ferrara, Italy
| | - Leo Massari
- Orthopedic and Traumatology Unit, Sant'Anna University Hospital of Ferrara, Via Aldo Moro 8, 44124 Cona, Ferrara, Italy.,Department of Neurosciences and Rehabilitation, University of Ferrara, Via Luigi Borsari 46, 44121, Ferrara, Italy
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Oh Y, Yamamoto K, Yoshii T, Kitagawa M, Okawa A. Current concept of stress fractures with an additional category of atypical fractures: a perspective review with representative images. Ther Adv Endocrinol Metab 2021; 12:20420188211049619. [PMID: 34671453 PMCID: PMC8521412 DOI: 10.1177/20420188211049619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 09/12/2021] [Indexed: 11/16/2022] Open
Abstract
Stress fractures have traditionally been classified into three categories: fatigue fractures due to overuse of bone with normal elastic resistance; insufficiency fractures due to everyday physiological stress on fragile bone with poor elastic resistance; and pathologic fractures due to bone weakness involving tumors. The concept of atypical fractures has emerged and is considered a type of stress fracture. However, there has been some inconsistency in interpretation when using the traditional classification of stress fractures, and atypical femoral fractures (AFFs) can potentially be classified into subtypes: "typical" AFFs involving bone turnover suppression due to specific drugs (e.g. bisphosphonates) and fragility fractures of the bowed femoral shaft. In this article, the classification of stress fractures is redefined with the addition of atypical fractures as a fourth category, in which biological activity for fracture healing is absent, to promote consistent understanding and interpretation of clinical conditions involving stress fractures.
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Affiliation(s)
| | - Kouhei Yamamoto
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masanobu Kitagawa
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Okawa
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Valgus osteotomy for atypical interprosthetic femoral fracture with lateral bowing of the femur. Trauma Case Rep 2020; 31:100381. [PMID: 33426258 PMCID: PMC7776954 DOI: 10.1016/j.tcr.2020.100381] [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] [Accepted: 12/06/2020] [Indexed: 01/29/2023] Open
Abstract
Introduction In recent years, it has been reported that periprosthetic femoral fractures in the form of atypical femoral fractures (AFFs) are found occasionally as difficult-to-treat conditions. To date, there have been no reports of interprosthetic femoral fractures (IPFFs) having the form of AFFs. We report a case of an atypical IPFF with breakage of the plate due to abnormal femoral alignment. Case report A 70-year-old woman was admitted. She underwent left knee replacement and left hemi-arthroplasty at ages 61 and 60. And she had been taking bisphosphonate for 5 years. A plain X-ray revealed IPFF. The fracture was a complete transverse fracture with circumscribed thickening of the lateral cortical bone ("beak sign") at the fracture site. She underwent surgery. A reversed condylar locking compression plate (LCP) was used for internal fixation. Subsequently, she could walk without particular pain. Five months after the operation, she heard the snap of a bone breaking, and had difficulty walking. Plain X-ray revealed a re-fracture of the fracture site and breakage of the plate at the same high position. She underwent re-operation. A valgus osteotomy was performed at an angle of 15°. A reversed condylar LCP was used on the lateral side of the femur. A bone grafting was performed focusing on the fracture site. In addition, a short-LCP was fixed anteriorly to the femur. The bone union 1 year and 6 months postoperatively. She could walk, with no impairment being noted regarding ADL. Conclusions We performed osteosynthesis for an IPFF having the characteristics of AFF, but the patient suffered breakage of the plate and re-fracture. Bone union was achieved as a result of re-operation that consisted of valgus osteotomy of the fracture site in combination with autologous bone grafting and double orthogonal plating.
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Vicenti G, Bizzoca D, Solarino G, Carrozzo M, Belluati A, D'Arienzo A, De Carolis O, Moretti B. Periprosthetic femoral re-fractures pathogenesis, classification, and surgical implications. Injury 2020; 54 Suppl 1:S24-S30. [PMID: 33218615 DOI: 10.1016/j.injury.2020.11.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 11/10/2020] [Indexed: 02/02/2023]
Abstract
Periprosthetic femoral re-fractures (PFRFs) represent an emerging challenge for orthopaedic surgeons, since their incidence is growing in the last years, but very few experiences about their management have been currently published. The present study aims to (1) introduce, for the first time, an etiologic classification for PRFRs and (2) to provide surgical and pharmacological tips for the correct management of these injuries. Periprosthetic femoral re-fractures (PFRFs) could be classified into traumatic-PFRFs (T-PFRFs) and pathological-PFRFs (P-PFRFs). T-PFRFs, i.e. the "true" periprosthetic re-fractures, present as new fracture lines occurring proximally or distally to a previous periprosthetic fracture, that has correctly healed. They are generally unpredictable injuries but, in selected cases, it is possible to predict them by analyzing the construct used in the treatment of the previous periprosthetic fracture. P-PFRFs, on the other hand, define re-fractures occurring on a previous periprosthetic non-union or delayed union: the new fracture line appears in the same district of the old one. According to the etiologic factors influencing the P-PFRFs pathogenesis, it is possible to define re-fractures caused by mechanical failures, biological failures, septic failures and multifactorial failures, i.e., a combination of the previously mentioned concerns. A successful postoperative outcome, following the surgical management of PFRFs, requires the correct identification of all the underlying causes, which should be promptly and appropriately managed.
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Affiliation(s)
- Giovanni Vicenti
- School of Medicine, University of Bari Aldo Moro, AOU Consorziale "Policlinico", Department of Basic Medical Sciences, Neuroscience and Sense Organs, Orthopaedic & Trauma Unit, Bari, Italy.
| | - Davide Bizzoca
- School of Medicine, University of Bari Aldo Moro, AOU Consorziale "Policlinico", Department of Basic Medical Sciences, Neuroscience and Sense Organs, Orthopaedic & Trauma Unit, Bari, Italy
| | - Giuseppe Solarino
- School of Medicine, University of Bari Aldo Moro, AOU Consorziale "Policlinico", Department of Basic Medical Sciences, Neuroscience and Sense Organs, Orthopaedic & Trauma Unit, Bari, Italy
| | - Massimiliano Carrozzo
- School of Medicine, University of Bari Aldo Moro, AOU Consorziale "Policlinico", Department of Basic Medical Sciences, Neuroscience and Sense Organs, Orthopaedic & Trauma Unit, Bari, Italy
| | - Alberto Belluati
- Ospedale "Santa Maria delle Croci", Ravenna, AUSL Romagna, Italy
| | | | - Oronzo De Carolis
- Orthopaedic and Traumatology Unit, "Di Venere" Hospital, Bari, Italy
| | - Biagio Moretti
- School of Medicine, University of Bari Aldo Moro, AOU Consorziale "Policlinico", Department of Basic Medical Sciences, Neuroscience and Sense Organs, Orthopaedic & Trauma Unit, Bari, Italy
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Ramavath A, Lamb JN, Palan J, Pandit HG, Jain S. Postoperative periprosthetic femoral fracture around total hip replacements: current concepts and clinical outcomes. EFORT Open Rev 2020; 5:558-567. [PMID: 33072408 PMCID: PMC7528669 DOI: 10.1302/2058-5241.5.200003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The rising incidence of postoperative periprosthetic femoral fracture (PFF) presents a significant clinical and economic burden. A detailed understanding of risk factors is required in order to guide preventative strategies. Different femoral stems have unique characteristics and management strategies must be tailored appropriately. Consensus regarding treatment of PFFs around well-fixed stems is lacking, but revision surgery may provide more predictable outcomes for unstable fracture patterns and fractures around polished taper-slip stems. Future research should focus on implant-related risk factors, treatment of concurrent metabolic bone disease and the use of large endoprostheses.
Cite this article: EFORT Open Rev 2020;5:558-567. DOI: 10.1302/2058-5241.5.200003
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Affiliation(s)
- Ashoklal Ramavath
- Department of Orthopaedic Surgery, Chapel Allerton Hospital, Leeds, UK
| | - Jonathan N Lamb
- Department of Orthopaedic Surgery, Chapel Allerton Hospital, Leeds, UK.,University of Leeds, Leeds, UK
| | - Jeya Palan
- Department of Orthopaedic Surgery, Chapel Allerton Hospital, Leeds, UK
| | - Hemant G Pandit
- Department of Orthopaedic Surgery, Chapel Allerton Hospital, Leeds, UK.,University of Leeds, Leeds, UK
| | - Sameer Jain
- Department of Orthopaedic Surgery, Chapel Allerton Hospital, Leeds, UK
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Affiliation(s)
- Mengnai Li
- The Ohio State University Wexner Medical Center, Columbus, Ohio
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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.
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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.
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30
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Affiliation(s)
- Fares S. Haddad
- The Bone & Joint Journal, Professor of Orthopaedic Surgery, University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK
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