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Auger K, Lee J, Hong IS, Jankowski JM, Liporace FA, Yoon RS. Bilateral Atypical Femoral Fracture in a Bisphosphonate-Naïve Patient with Prior Long-Term Denosumab Therapy: A Case Report of the Management Strategy and a Literature Review. J Clin Med 2024; 13:2785. [PMID: 38792327 PMCID: PMC11122202 DOI: 10.3390/jcm13102785] [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: 04/01/2024] [Revised: 05/04/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
The benefits of denosumab as an antiresorptive therapy and in reducing fragility fractures are well documented. However, its association with atypical femur fractures (AFFs), especially in the absence of prior bisphosphonate use, remains poorly understood and warrants further investigation. This case report presents a rare instance of bilateral AFFs in a 78-year-old bisphosphonate-naïve patient with a history of long-term denosumab therapy for previous metastatic breast cancer. Management involved intramedullary nail fixation after initial presentation with a unilateral AFF and a recommendation to cease denosumab therapy. However, the patient subsequently experienced a contralateral periprosthetic AFF below a total hip implant 5 months thereafter and was treated with open reduction internal fixation. This case report highlights the critical need for orthopedic surgeons to maintain a high level of suspicion and vigilance in screening for impending AFFs, especially in patients with a prolonged history of denosumab therapy without prior bisphosphonate use. Furthermore, the growing report of such cases emphasizes the urgent need for comprehensive research aimed at refining treatment protocols that balance the therapeutic benefits of denosumab and its associated risks of AFFs.
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Affiliation(s)
- Kyle Auger
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center—RWJBarnabas Health, Livingston, NJ 07039, USA; (K.A.); (J.L.); (I.S.H.); (J.M.J.); (F.A.L.)
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center—RWJBarnabas Health, Jersey City, NJ 07302, USA
| | - Jason Lee
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center—RWJBarnabas Health, Livingston, NJ 07039, USA; (K.A.); (J.L.); (I.S.H.); (J.M.J.); (F.A.L.)
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center—RWJBarnabas Health, Jersey City, NJ 07302, USA
| | - Ian S. Hong
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center—RWJBarnabas Health, Livingston, NJ 07039, USA; (K.A.); (J.L.); (I.S.H.); (J.M.J.); (F.A.L.)
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center—RWJBarnabas Health, Jersey City, NJ 07302, USA
| | - Jaclyn M. Jankowski
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center—RWJBarnabas Health, Livingston, NJ 07039, USA; (K.A.); (J.L.); (I.S.H.); (J.M.J.); (F.A.L.)
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center—RWJBarnabas Health, Jersey City, NJ 07302, USA
| | - Frank A. Liporace
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center—RWJBarnabas Health, Livingston, NJ 07039, USA; (K.A.); (J.L.); (I.S.H.); (J.M.J.); (F.A.L.)
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center—RWJBarnabas Health, Jersey City, NJ 07302, USA
| | - Richard S. Yoon
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center—RWJBarnabas Health, Livingston, NJ 07039, USA; (K.A.); (J.L.); (I.S.H.); (J.M.J.); (F.A.L.)
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center—RWJBarnabas Health, Jersey City, NJ 07302, USA
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Fukui T, Oe K, Kawamoto T, Morishita M, Fujita I, Takahara S, Sakurai A, Iwakura T, Yoshida K, Ito K, Shoda E, Hiranaka T, Tsunoda M, Kuroda R, Niikura T. Multicenter study on atypical femoral fractures in patients with bone metastases taking bone- modifying agents. J Bone Oncol 2023; 40:100478. [PMID: 37180736 PMCID: PMC10173009 DOI: 10.1016/j.jbo.2023.100478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/02/2023] [Accepted: 04/08/2023] [Indexed: 05/16/2023] Open
Abstract
Bone-modifying agents (BMAs), with bone-resorptive inhibitory effects, such as zoledronic acid and denosumab, are widely used at higher doses for bone-related events caused by bone metastasis of malignant tumors. These drugs have been suggested to be associated with atypical femoral fractures (AFFs), and the relationship between BMAs and AFFs has attracted attention. To investigate the clinical features including bone union time of AFFs in patients administered BMA for bone metastasis, we conducted a retrospective multicenter study. Thirty AFFs from 19 patients were enrolled in this study. Thirteen patients had bilateral AFFs, and nineteen AFFs had prodromal symptoms. Eighteen AFFs underwent surgery after complete fracture, three failed to achieve bone union and required nonunion surgery, and 11 AFFs that achieved bone union had an average period until bone union of 16.2 months, which was much longer than that previously reported for ordinary AFFs. Seven patients discontinued the BMAs, but not due to AFFs. Stopping BMAs in patients with bone metastasis would make it difficult to secure their performance of activities of daily living, and AFF with BMA administration might require a longer time for union. Therefore, it would be important to prevent incomplete AFF from becoming complete AFF via prophylactic internal fixation.
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Affiliation(s)
- Tomoaki Fukui
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Keisuke Oe
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Teruya Kawamoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | | | - Ikuo Fujita
- Department of Orthopaedic Surgery, Hyogo Cancer Center, Japan
| | | | - Atsushi Sakurai
- Department of Orthopaedic Surgery, Awaji Medical Center, Japan
| | - Takashi Iwakura
- Department of Orthopaedic Surgery, Awaji Medical Center, Japan
- Department of Orthopaedic Surgery, Sanda City Hospital, Japan
| | - Keiji Yoshida
- Department of Orthopaedic Surgery, Kobe City Nishi-Kobe Medical Center, Japan
| | - Kenjiro Ito
- Department of Orthopaedic Surgery, Akashi Medical Center, Japan
| | - Etsuo Shoda
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, Japan
| | | | - Masaya Tsunoda
- Department of Orthopaedic Surgery, Sanda City Hospital, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Takahiro Niikura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, Japan
- Corresponding author at: Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan.
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Sharma A, Sharma C, Shah OP, Chigurupati S, Ashokan B, Meerasa SS, Rashid S, Behl T, Bungau SG. Understanding the mechanistic potential of plant based phytochemicals in management of postmenopausal osteoporosis. Biomed Pharmacother 2023; 163:114850. [PMID: 37172332 DOI: 10.1016/j.biopha.2023.114850] [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: 03/23/2023] [Revised: 04/29/2023] [Accepted: 05/04/2023] [Indexed: 05/14/2023] Open
Abstract
Postmenopausal osteoporosis, an epidemic disorder is defined as a loss in bone mineral density and a greater possibility of fractures in older women. It is a multifactorial disease under the control of various genetic, hormonal, and environmental factors. Insufficiency of estrogen hormone, leads to postmenopausal osteoporosis. Hormone replacement therapy (HRT), despite being the most effective treatment, it is associated with the risk of breast cancer and cardiovascular disorders. This review seeks to compile the most recent information on medicinal plants and natural compounds used to treat and prevent postmenopausal osteoporosis. Furthermore, the origin, chemical constituents and the molecular mechanisms responsible for this therapeutic and preventive effect are also discussed. Literature research was conducted using PubMed, Science direct, Scopus, Web of Science, and Google Scholar. Different plant extracts and pure compounds exerts their antiosteoporotic activity by inhibition of RANKL and upregulation of OPG. RANKL signaling regulates osteoclast formation, characterized by increased bone turnover and osteoprotegrin is a decoy receptor for RANKL thereby preventing bone loss from excessive resorption. In addition, this review also includes the chemical structure of bioactive compounds acting on NFκB, TNF α, RUNX2. In conclusion, we propose that postmenopausal osteoporosis could be prevented or treated with herbal products.
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Affiliation(s)
- Aditi Sharma
- Department of Pharmacology, School of Pharmaceutical Sceinces, Shoolini University, Solan, Himachal Pradesh 173229, India
| | - Chakshu Sharma
- Department of Pharmacology, School of Pharmaceutical Sceinces, Shoolini University, Solan, Himachal Pradesh 173229, India
| | - Om Praksah Shah
- Department of Pharmacology, School of Pharmaceutical Sceinces, Shoolini University, Solan, Himachal Pradesh 173229, India
| | - Sridevi Chigurupati
- Department of Medicinal Chemistry and Pharmacognosy, College of Pharmacy, Qassim University, Buraydah 52571, Saudi Arabia; Department of Biotechnology, Saveetha School of Engineering, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Saveetha Nagar, Thandalam, Chennai, 602105 India
| | - Bhaskaran Ashokan
- Department of Surgery, College of Medicine, Shaqra University, Shaqra 15526, Saudi Arabia
| | - Semmal Syed Meerasa
- Department of Physiology, College of Medicine, Shaqra University, Shaqra 15526, Saudi Arabia
| | - Summya Rashid
- Department of Pharmacology & Toxicology, College of Pharmacy, Prince Sattam Bin Abdulaziz University, PO Box 173, Al-Kharj 11942, Saudi Arabia
| | - Tapan Behl
- School of Health Sciences and Technology, University of Petroleum and Energy Studies, Bidholi, Dehradun 248007, Uttarakhand, India.
| | - Simona Gabriela Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania; Doctoral School of Biomedical Sciences, University of Oradea, Oradea 410028, Romania.
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Goh JKM, Koh JSB, Ng ACM, Png MA, Howe TS. Bilateral Atypical Femur Fractures After Denosumab in a Bisphosphonate Naive Patient: A Case Report. Calcif Tissue Int 2022; 111:96-101. [PMID: 35132455 DOI: 10.1007/s00223-022-00952-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/24/2022] [Indexed: 11/26/2022]
Abstract
A case report of bilateral atypical femur fractures (AFF) in a bisphosphonate naive patient. A 62-year-old female bisphosphonate naive patient was started on denosumab for osteoporosis. Approximately 3 years later she complained of right hip pain and was found to have a bilateral incomplete AFFs. She was asymptomatic on the left lower limb. Patient was managed conservatively and placed on protected weight bearing on both legs. Symptoms subsequently resolved over a period of 3 months, although radiographic findings remained at approximately 1 year. AFFs may be associated with patients on denosumab therapy even without a prior history of bisphosphonate use. Patients should be counselled appropriately and monitored for such complications.
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Affiliation(s)
- Jeremy Keng Meng Goh
- Department of Orthopaedic Surgery, Singapore General Hospital, Outram Road Academia Building Level 4, Singapore, 119228, Singapore.
| | - Joyce Suang Bee Koh
- Department of Orthopaedic Surgery, Singapore General Hospital, Outram Road Academia Building Level 4, Singapore, 119228, Singapore
| | - Alvin Choong Meng Ng
- Mount Elizabeth Medical Centre, The Endocrine Clinic, 3 Mount Elizabeth #15-04, Singapore, 228510, Singapore
| | - Meng Ai Png
- Department of Diagnostic Radiology, Singapore General Hospital, Block 2, Level 1, Outram Road, Singapore, 169608, Singapore
| | - Tet Sen Howe
- Department of Orthopaedic Surgery, Singapore General Hospital, Outram Road Academia Building Level 4, Singapore, 119228, Singapore
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Skibicki HE, Ponzio DY, Brustein JA, Post ZD, Ong AC, Orozco FR. A cautionary case: osteoporotic femur fracture after robotic-assisted total knee arthroplasty. Osteoporos Int 2021; 32:2125-2129. [PMID: 33928403 DOI: 10.1007/s00198-021-05977-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/25/2021] [Indexed: 10/21/2022]
Abstract
Osteoporosis is a disease of low bone mass which leads to an increased risk of fracture. The prevalence of osteoporosis is greatest amongst postmenopausal women who also form a large portion of patients with osteoarthritis presenting for total knee arthroplasty. We present a case of a 77-year-old female with knee osteoarthritis and osteoporosis on denosumab who underwent robotic-assisted total knee arthroplasty. Postoperatively, she suffered an atraumatic midshaft femur fracture at the pin site associated with the use of intraoperative robotic technology. This is a unique complication related to the use of robotics which requires additional skeletal fixation versus standard arthroplasty surgical technique. We recommend caution and further study regarding the use of robotics in total knee arthroplasty in the setting of osteoporosis and denosumab use.
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Affiliation(s)
- H E Skibicki
- Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - D Y Ponzio
- Rothman Orthopaedic Institute, Egg Harbor Township, NJ, USA
| | - J A Brustein
- Rothman Orthopaedic Institute, Egg Harbor Township, NJ, USA
| | - Z D Post
- Rothman Orthopaedic Institute, Egg Harbor Township, NJ, USA
| | - A C Ong
- Rothman Orthopaedic Institute, Egg Harbor Township, NJ, USA
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Goodloe JB, Toner S, Althoff A, Herzog L, Rothwell S, Reid K. Bilateral Atypical Femur Fractures Complicated by Carbon Fiber Cephalomedullary Nail Fracture: A Case Report. JBJS Case Connect 2020; 10:e2000182. [PMID: 32960020 DOI: 10.2106/jbjs.cc.20.00182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 69-year-old woman with a history of breast cancer, on long-term antiresorptive medications, was treated with carbon fiber cephalomedullary nails for bilateral atypical femur fractures. Her thigh pain was presumed to be from metastatic lesions and was treated with radiation without standard imaging. The index procedure was complicated by a left nail fracture. The patient underwent exchange cephalomedullary nail fixation with plate augmentation. At 1 year, the patient was asymptomatic with radiographs demonstrating healing. CONCLUSION This case highlights the importance of appropriate imaging in all patients with thigh pain on antiresorptive therapy and features an uncommon complication of carbon fiber cephalomedullary nail fixation.
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Affiliation(s)
- J Brett Goodloe
- 1Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, South Carolina 2Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
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Seong YJ, Shin JK, Park WR. Early detected femoral neck insufficiency fracture in a patient treated with long-term bisphosphonate therapy for osteoporosis: A need for MRI. Int J Surg Case Rep 2020; 70:213-215. [PMID: 32417741 PMCID: PMC7229416 DOI: 10.1016/j.ijscr.2020.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/23/2020] [Accepted: 04/01/2020] [Indexed: 12/03/2022] Open
Abstract
If long term bisphosphonate users complain of non-traumatic hip pain, medical examination should be taken with care. Even though no fractures are identified in their radiographs, it is recommended to check an MRI. If the fracture can be identified before cortical breakage, the treatment success rate for the fracture will be high.
Introduction Atypical femoral fracture is an uncommon complication of prolonged use of bisphosphonates, mainly occurring in the femoral shaft. We report a case of an atraumatic insufficiency fracture of femoral neck after four years of treatment with a bisphosphonate. Presentation of case A 71-year-old female presented with history of pain on Lt. hip and difficulty in walking. Although there was no fracture on the radiographs, diagnosis could be made early using magnetic resonance imaging (MRI) scans. She was treated by internal fixation using cannulated screws. Discussion Because bisphosphonate prevents bone healing and remodeling, it is difficult to accomplish the bony union despite of proper treatment in patients who have fractured after long-term use of bisphosphonate. Conclusion A high suspicion index and early diagnosis through the use of MRI are essential for the successful treatment of these fractures.
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Affiliation(s)
- Yoon Jae Seong
- Department of Orthopaedic Surgery, Dongeui Medical Center, 62 Yangjung-ro, Jin-gu, Busan, 47227, South Korea
| | - Jong Ki Shin
- Department of Orthopaedic Surgery, Dongeui Medical Center, 62 Yangjung-ro, Jin-gu, Busan, 47227, South Korea
| | - Won Ro Park
- Department of Orthopaedic Surgery, Dongeui Medical Center, 62 Yangjung-ro, Jin-gu, Busan, 47227, South Korea.
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van de Laarschot DM, McKenna MJ, Abrahamsen B, Langdahl B, Cohen-Solal M, Guañabens N, Eastell R, Ralston SH, Zillikens MC. Medical Management of Patients After Atypical Femur Fractures: a Systematic Review and Recommendations From the European Calcified Tissue Society. J Clin Endocrinol Metab 2020; 105:5684909. [PMID: 31867670 PMCID: PMC7121199 DOI: 10.1210/clinem/dgz295] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/27/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT Atypical femur fractures (AFFs) are serious adverse events associated with bisphosphonates and often show poor healing. EVIDENCE ACQUISITION We performed a systematic review to evaluate effects of teriparatide, raloxifene, and denosumab on healing and occurrence of AFF. EVIDENCE SYNTHESIS We retrieved 910 references and reviewed 67 papers, including 31 case reports, 9 retrospective and 3 prospective studies on teriparatide. There were no RCTs. We pooled data on fracture union (n = 98 AFFs on teriparatide) and found that radiological healing occurred within 6 months of teriparatide in 13 of 30 (43%) conservatively managed incomplete AFFs, 9 of 10 (90%) incomplete AFFs with surgical intervention, and 44 of 58 (75%) complete AFFs. In 9 of 30 (30%) nonoperated incomplete AFFs, no union was achieved after 12 months and 4 (13%) fractures became complete on teriparatide. Eight patients had new AFFs during or after teriparatide. AFF on denosumab was reported in 22 patients, including 11 patients treated for bone metastases and 8 without bisphosphonate exposure. Denosumab after AFF was associated with recurrent incomplete AFFs in 1 patient and 2 patients of contralateral complete AFF. Eight patients had used raloxifene before AFF occurred, including 1 bisphosphonate-naïve patient. CONCLUSIONS There is no evidence-based indication in patients with AFF for teriparatide apart from reducing the risk of typical fragility fractures, although observational data suggest that teriparatide might result in faster healing of surgically treated AFFs. Awaiting further evidence, we formulate recommendations for treatment after an AFF based on expert opinion.
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Affiliation(s)
- Denise M van de Laarschot
- Bone Centre, Department of Internal Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Malachi J McKenna
- DXA Unit, St. Vincent’s University Hospital, University College Dublin, Dublin, Ireland
| | - Bo Abrahamsen
- OPEN, University of Southern Denmark, Odense, Denmark
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Bente Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Martine Cohen-Solal
- Department of Rheumatology, Université de Paris and Inserm U1132, Hôpital Lariboisière, Paris, France
| | - Núria Guañabens
- Department of Rheumatology, Hospital Clinic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Richard Eastell
- Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - Stuart H Ralston
- Centre for Genomic & Experimental Medicine MRC Institute of Genetics & Molecular Medicine, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - M Carola Zillikens
- Bone Centre, Department of Internal Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Correspondence: Prof M. Carola Zillikens, MD, PhD, Erasmus University Medical Centre, PO Box 2040, 3000 CA Rotterdam, The Netherlands. E-mail:
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Cheung AM, McKenna MJ, van de Laarschot DM, Zillikens MC, Peck V, Srighanthan J, Lewiecki EM. Detection of Atypical Femur Fractures. J Clin Densitom 2019; 22:506-516. [PMID: 31377055 DOI: 10.1016/j.jocd.2019.07.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/08/2019] [Indexed: 12/14/2022]
Abstract
The 2019 International Society for Clinical Densitometry (ISCD) Position Development Conference Task Force for monitoring with dual-energy X-ray absorptiometry (DXA) identified detection of atypical femur fractures (AFFs) as an important topic and established this working group to answer key questions in this area. The authors conducted a systematic review of the literature and deliberated on proposed ISCD positions, which were then reviewed by an external expert panel and vetted at the 2019 ISCD Position Development Conference in Kuala Lumpur on March 23, 2019. This paper summarizes the final ISCD positions and the rationale for supporting these positions. Default-length femur imaging or extended-length femur imaging as well as full-length femur imaging (FFI), both single-energy and dual-energy scans, by DXA can detect abnormalities in the spectrum of AFF. It is important to visually inspect all DXA scans of the hip and femur, and report on findings of focal periosteal and endosteal thickening at the lateral cortex (grade: Good, A, W). FFI is the preferred DXA scan mode for detecting abnormalities in the spectrum of AFF. The FFI report should state the absence or presence of abnormalities in the spectrum of AFF. If focal thickening is present on the lateral cortex, the report should state whether a lucent line is seen (grade: Fair, C, W). The ISCD recommends considering the use of bilateral FFI in patients who are currently or have been in the past year on potent antiresorptive therapy (ie, oral or intravenous bisphosphonate or subcutaneous denosumab therapy) for a cumulative period of 3 or more years, especially those on long-term glucocorticoid therapy (grade: Fair, B, W). More research is needed to determine the role of repeat testing and the optimal time interval for follow-up DXA scans, whether an automated measuring tool would perform better than visual inspection, whether FFI would change patient management and outcomes, and the cost-effectiveness of FFI.
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Affiliation(s)
- Angela M Cheung
- Centre of Excellence in Skeletal Health Assessment, University of Toronto, Toronto, Ontario, Canada; Osteoporosis Program, University Health Network and Sinai Health System, Toronto, Ontario, Canada.
| | - Malachi J McKenna
- DXA Unit, St. Vincent's University Hospital, Dublin, Ireland; School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Denise M van de Laarschot
- Bone Centre, Department of Internal Medicine, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - M Carola Zillikens
- Bone Centre, Department of Internal Medicine, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Valerie Peck
- Osteoporosis and Metabolic Bone Disease Program, Department of Medicine, NYU Langone Health, New York, NY, USA
| | - Jeevitha Srighanthan
- Centre of Excellence in Skeletal Health Assessment, University of Toronto, Toronto, Ontario, Canada; Osteoporosis Program, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
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10
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Atypical femoral fractures from bisphosphonate in cancer patients - Review. J Bone Oncol 2019; 18:100259. [PMID: 31497503 PMCID: PMC6722257 DOI: 10.1016/j.jbo.2019.100259] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/13/2019] [Accepted: 08/21/2019] [Indexed: 02/08/2023] Open
Abstract
Bisphosphonates are commonly used in patients with metastatic bone disease to prevent skeletal related events. Atypical femur fracture is a known complication of long-term bisphosphonate use but the incidence in cancer patients and pathogenesis are not well known. Several mechanisms of pathogenesis have been proposed including altered angiogenesis, altered bone mechanical properties, micro damage and bone remodeling suppression. Atypical femur fractures are atraumatic or minimally traumatic fractures in the sub trochanteric region or the femoral shaft. Awareness of atypical femur fractures is critical to diagnose and treat them in a timely manner. There is a paucity of data regarding the management of atypical femur fracture in patients with malignancy. Management options of atypical femur fractures include stopping bisphosphonates, initiating calcium/vitamin D supplementation and either surgery with internal fixation or conservative management. In the future, it will be important to explore the effect of continuous vs. intermittent exposure, cumulative dose and length of exposure on the incidence of this complication. Herein, we review the epidemiology, risk factors, management options and proposed mechanisms of pathogenesis of atypical femur fractures.
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Key Words
- AFF, atypical femur fracture
- AGE, advanced glycation end products
- ASBMR, American Society of Bone and Mineral Research
- Atypical femur fracture
- BP, bisphosphonate
- Bisphosphonates
- Bone metastasis
- Bone remodeling
- CI, confidence interval
- CT, computed tomography
- Denosumab
- GGPPS, geranyl geranyl pyrophosphate synthase Her2, human epidermal growth factor receptor
- IM, intramedullary
- IV, intravenous
- MGUS, monoclonal gammopathy of unknown significance
- MRI, magnetic resonance imaging
- ONJ, osteonecrosis of the jaw
- OR, odds ratio
- ORIF, open reduction internal fixation
- RCT, randomized clinical trial
- VEGF, vascular endothelial growth factor
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Schimpf R, Siekmann H, Bauer C, Radetzki F. [Atypical distal tibial shaft fractures in a patient with bilateral TKA and antiresorptive treatment]. DER ORTHOPADE 2018; 47:688-691. [PMID: 29974163 DOI: 10.1007/s00132-018-3596-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
There are many cases in the literature that describe atypical femur fractures under antiresorptive therapy. Other localizations of fractures of this genesis, especially if occurring bilaterally, are rare. This case reports about the diagnosis, treatment and process of a 76-year old patient, who within a 4‑month period suffered from bilateral distal tibial shaft fractures, after years of treatment with bisphosphonates, strontium ranelate and denosumab.
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Affiliation(s)
- R Schimpf
- Department für Orthopädie, Unfall- und Wiederherstellungschirurgie, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland.
| | - H Siekmann
- Abteilung für Unfall- und Wiederherstellungschirurgie, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - C Bauer
- Department für Orthopädie, Unfall- und Wiederherstellungschirurgie, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - F Radetzki
- Klinik für Orthopädie und Unfallchirurgie, Städtisches Klinikum Dessau, Dessau, Deutschland
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12
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Impending Atypical Femoral Fracture in a Patient of Breast Cancer With Bone Metastases Receiving Long-term Denosumab. Clin Nucl Med 2018. [DOI: 10.1097/rlu.0000000000002058] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Abstract
Atypical Femoral Fractures (AFF) represent fractures located between the lesser trochanter and the supracondylar flare of a femur. An increasing pool of evidence supports their association with the prolonged use of bisphosphonates, even though a direct correlation is yet to be proved. The purpose of this review is to encapsulate the current evidence associating bisphosphonate use and the development of AFFs, the clinical features related to their presentation, as well as to report the armamentarium of strategies available in the prevention and treatment of AFFs. Based on these evidence, we propose a management algorithm for AFFs, that can serve as a guide for patients presenting with this condition.
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14
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Tan JY, Seow CJ. Management of atypical femoral fracture in a patient with osteogenesis imperfecta. BMJ Case Rep 2017; 2017:bcr-2017-221835. [PMID: 29269360 DOI: 10.1136/bcr-2017-221835] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Osteogenesis imperfecta (OI) is a generalised connective tissue disorder associated with low bone mass, bone fragility and increased susceptibility to fractures. First-line treatment to improve bone mineral density (BMD) is usually with bisphosphonates but long-term usage has been associated with uncommon complications such as atypical femoral fractures (AFF). Treatment with teriparatide in this situation has been reported with positive outcomes. However, choice of treatment after 2 years of teriparatide has not been well studied or reported. We describe a patient with OI treated with bisphosphonates for 9 years, who then suffered a spontaneous AFF, was subsequently started on teriparatide for 2 years followed by 6 monthly Denosumab. 1 year post-treatment with Denosumab, there was significant improvement in BMD, good fracture healing and no new fractures. This case highlights the potential use of denosumab following 2 years of teriparatide treatment in patients with OI with AFF.
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Affiliation(s)
- Jing Yuan Tan
- Endocrinology, National University Singapore Yong Loo Lin School of Medicine, Singapore, Singapore
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15
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van de Laarschot DM, Smits AA, Buitendijk SK, Stegenga MT, Zillikens MC. Screening for Atypical Femur Fractures Using Extended Femur Scans by DXA. J Bone Miner Res 2017; 32:1632-1639. [PMID: 28467663 DOI: 10.1002/jbmr.3164] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 04/19/2017] [Accepted: 05/02/2017] [Indexed: 01/18/2023]
Abstract
Atypical femur fractures (AFFs) are a rare but serious complication associated with the use of antiresorptive drugs such as bisphosphonates. Assessment of incomplete AFFs on extended femur scans by dual-energy X-ray absorptiometry (DXA) may prevent the development of complete fractures. The aim of this study was to evaluate the potential of extended femur scans by DXA as a screening tool for incomplete AFFs. From June 2014 until September 2016, extended femur scans were routinely performed in all consecutive patients undergoing DXA scanning who had used bisphosphonates or denosumab at any given moment in the previous year. When "beaking" was found, defined as a localized periosteal or endosteal thickening of the lateral cortex, a radiograph of the femur was performed to confirm incomplete AFF. Beaking was detected in 12 of 282 patients (4.3%) with extended scans of both femora. In 9 patients (3.2%), beaking corresponded with the radiological presence of incomplete AFFs, of whom 4 already had an X-ray made because of a previous complete AFF of the other leg. Five patients (1.8%) were newly diagnosed with 6 yet unknown incomplete AFFs. No additional X-ray was performed in 2 patients because of loss of follow-up. Beaking was explained by known soft tissue calcifications in 1 patient. The positive predictive value of beaking on extended femur scan was 83.3% in our study. Three cases in whom the new diagnosis of incomplete AFF has affected medical and surgical treatment are further discussed to illustrate the relevance of early detection. We conclude that extended femur scans by DXA can detect incomplete AFFs in patients on antiresorptive treatment and should therefore be considered a clinically relevant screening tool because early identification of AFFs has therapeutic consequences. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
| | - Alexandra Aa Smits
- Bone Centre, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Sanne Kc Buitendijk
- Bone Centre, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Merel T Stegenga
- Bone Centre, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - M Carola Zillikens
- Bone Centre, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
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16
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Hanley DA, McClung MR, Davison KS, Dian L, Harris ST, Miller PD, Lewiecki EM, Kendler DL. Western Osteoporosis Alliance Clinical Practice Series: Evaluating the Balance of Benefits and Risks of Long-Term Osteoporosis Therapies. Am J Med 2017; 130:862.e1-862.e7. [PMID: 28359721 DOI: 10.1016/j.amjmed.2017.03.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/01/2017] [Accepted: 03/01/2017] [Indexed: 01/22/2023]
Abstract
Osteoporosis is a chronic disease that requires life-long strategies to reduce fracture risk. Few trials have investigated the balance of benefits and risk with long-term use of osteoporosis therapies, and fewer still have investigated the consequences of treatment discontinuation. The best available evidence suggests that up to 10 years of treatment with an oral bisphosphonate maintains the degree of fracture risk reduction observed in the 3-year registration trials. With denosumab, 10 years of therapy appears to provide fracture risk reduction similar to or better than that observed in the 3-year registration trial. Available data suggest an increasing but low risk of fractures with atypical features with increasing duration of bisphosphonate therapy. Published data linking duration of therapy to osteonecrosis of the jaw are lacking for bisphosphonates and denosumab. Other side effects associated with denosumab or bisphosphonates do not appear to be related to therapy duration. The antifracture benefits of long-term therapy with bisphosphonates and denosumab in appropriately selected patients outweigh the low risk of serious side effects.
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Affiliation(s)
- David A Hanley
- Departments of Medicine, Oncology, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada.
| | - Michael R McClung
- Oregon Osteoporosis Center, Portland; Institute of Health and Ageing, Australian Catholic University, Melbourne, Australia
| | | | - Larry Dian
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Steve T Harris
- Department of Medicine, University of California, San Francisco
| | | | | | - David L Kendler
- Department of Medicine, University of British Columbia, Vancouver
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17
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Austin DC, Torchia MT, Klare CM, Cantu RV. Atypical femoral fractures mimicking metastatic lesions in 2 patients taking denosumab. Acta Orthop 2017; 88:351-353. [PMID: 28077015 PMCID: PMC5434608 DOI: 10.1080/17453674.2016.1277412] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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18
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Xuan W, Feng X, Qian C, Peng L, Shi Y, Xu L, Wang F, Tan W. Osteoclast differentiation gene expression profiling reveals chemokine CCL4 mediates RANKL-induced osteoclast migration and invasion via PI3K pathway. Cell Biochem Funct 2017; 35:171-177. [PMID: 28370169 DOI: 10.1002/cbf.3260] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 02/26/2017] [Accepted: 02/27/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Wenhua Xuan
- Department of Rheumatology; The First Affiliated Hospital of Nanjing Medical University; Nanjing China
| | - Xiaoke Feng
- Department of Traditional Chinese Medicine; The First Affiliated Hospital of Nanjing Medical University; Nanjing China
| | - Chen Qian
- Department of Rheumatology; The First Affiliated Hospital of Nanjing Medical University; Nanjing China
| | - Liuying Peng
- Department of Rheumatology; The First Affiliated Hospital of Nanjing Medical University; Nanjing China
| | - Yumeng Shi
- Department of Rheumatology; The First Affiliated Hospital of Nanjing Medical University; Nanjing China
| | - Lingxiao Xu
- Department of Rheumatology; The First Affiliated Hospital of Nanjing Medical University; Nanjing China
| | - Fang Wang
- Department of Cardiology; The First Affiliated Hospital of Nanjing Medical University; Nanjing China
| | - Wenfeng Tan
- Department of Rheumatology; The First Affiliated Hospital of Nanjing Medical University; Nanjing China
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19
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Yang SP, Kim TWB, Boland PJ, Farooki A. Retrospective Review of Atypical Femoral Fracture in Metastatic Bone Disease Patients Receiving Denosumab Therapy. Oncologist 2017; 22:438-444. [PMID: 28275116 DOI: 10.1634/theoncologist.2016-0192] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 12/02/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Denosumab therapy is used to reduce skeletal-related events in metastatic bone disease (MBD). There have been reports of atypical femoral fracture (AFF) in osteoporotic patients treated with denosumab but none in the context of higher dose and more frequent denosumab therapy for MBD. The goal of this study was to assess the incidence of AFF in MBD. PATIENTS AND METHODS We conducted a retrospective review of 253 patients who received a minimum of 12 doses of denosumab at 120 mg each for MBD. To identify patients with asymptomatic atypical stress reactions in the lateral subtrochanteric femur (which precede fractures), we reviewed the skeletal images of 66 patients who had received at least 21 doses of denosumab for AFF features. RESULTS These patients received a median of 17 doses, with a median treatment duration of 23 months. There was 1 case of undiagnosed clinical AFF detected after chart review and 2 cases of subclinical atypical femoral stress reaction observed on imaging review after 23 doses of denosumab over 33 months, 28 doses over 27 months, and 21 doses over 21 months, respectively. Scout computed tomography films showed diffuse cortical thickening of diaphysis with localized periosteal reaction of lateral femoral cortex. Bone scan and magnetic resonance imaging scan of 2 patients with stress reactions confirmed the diagnosis. CONCLUSION The incidence of clinical AFF in this context is 0.4% (1/253; 95% confidence interval [CI] 0.1%-2.2%), and the incidence of atypical femoral stress reaction based on imaging review is 4.5% (3/66; 95% CI 1.6%-12.5%). Clinicians should be aware of the clinical prodrome (which may or may not be present) and antecedent imaging changes associated with AFF. The Oncologist 2017;22:438-444Implications for Practice: Among patients with metastatic bone disease treated with denosumab, cases of clinical and subclinical atypical femoral fracture (AFF) are rare. The one detected case of clinical fracture went unrecognized despite prodromic symptoms. Clinicians should be aware of (a) the potential prodrome of anterior thigh/groin pain and (b) subclinical imaging changes in the lateral femur, both of which may precede clinical AFF.
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Affiliation(s)
- Samantha Peiling Yang
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Endocrinology Division, Department of Medicine, National University Hospital, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tae Won B Kim
- Department of Orthopedic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Orthopedic Oncology Division, Department of Orthopedic Surgery, Cooper University Hospital, Camden, New Jersey, USA
| | - Patrick J Boland
- Department of Orthopedic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Azeez Farooki
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
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20
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21
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van de Laarschot DM, Somford MP, Jager A, Oei EH, Bos PK, Zillikens MC. "Atypical" atypical femur fractures and use of bisphosphonates. CLINICAL CASES IN MINERAL AND BONE METABOLISM 2017; 13:204-208. [PMID: 28228783 DOI: 10.11138/ccmbm/2016.13.3.204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Atypical femur fractures (AFFs) present a rare but serious condition associated with use of bisphosphonates. Underlying mechanisms and clinical risk factors remain unclear. According to the diagnostic criteria formulated by the ASBMR, a lateral localization of an AFF is required. CASE HISTORY We present a patient who developed bilateral leg pain while using an oral bisphosphonate and aromatase inhibitor in the course of adjuvant treatment for breast cancer. Initially she was diagnosed with bone metastases and received radiotherapy on the right femur. However, the bilateral periosteal reactions of the subtrochanteric femur are highly suggestive of AFFs. Our case meets all criteria for AFF except that she presented with lesions at the medial side of the femur. Therefore they could be best described as "atypical" atypical femur fractures. DISCUSSION Since the pathogenesis of AFFs is not fully understood, we cannot rule out that AFFs also occur in the medial femur or in other weight-baring bones. Hence we propose that medial stress reactions belong to a spectrum of atypical fractures associated with use of antiresorptive drugs. The localization may depend on yet unknown biomechanical factors. CONCLUSION We propose that these periosteal reactions of the subtrochanteric femur are in fact AFFs with uncommon medial localization and could hence be considered "atypical" AFFs. We recommend being alert of AFFs in patients with bone pain and medial subtrochanteric lesions. More epidemiological studies are needed to investigate the occurrence of both medial and lateral AFFs and to gain more insight into its frequency and pathogenesis.
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Affiliation(s)
| | - Matthijs P Somford
- Department of Orthopedic Surgery, Rijnstate Hospital, Arnhem, The Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Edwin H Oei
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - P Koen Bos
- Department of Orthopedics, Erasmus MC, Rotterdam, The Netherlands
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22
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Bubbear JS. Atypical Femur Fractures in Patients Treated with Bisphosphonates: Identification, Management, and Prevention. Rambam Maimonides Med J 2016; 7:RMMJ.10259. [PMID: 27824547 PMCID: PMC5101006 DOI: 10.5041/rmmj.10259] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Osteoporosis is a common condition with significant health care costs. First-line therapy is with bisphosphonates, which have proven anti-fracture efficacy. Around 10 years after the introduction of bisphosphonates reports began to be published of atypical femoral fractures (AFFs) that may be associated with this therapy. These fractures are associated with significant morbidity although lower mortality than the more common osteoporotic neck-of-femur fractures. A case definition has been described to allow identification of this class of fracture. Further work has established a high relative risk of AFFs in patients treated with bisphosphonates, but a low absolute risk in comparison to that of osteoporotic fractures. Proposed pathological mechanisms include low bone turnover states leading to stress/insufficiency fractures. Clinicians should be aware of the risk of AFFs and in particular the high rate of prodromal thigh/groin pain that warrants investigation in a patient receiving a bisphosphonate. If an incomplete fracture is diagnosed then bisphosphonate therapy needs to be stopped and prophylactic surgery may be considered. Due to these rare side effects patients on bisphosphonates require regular review, and this is particularly advised after 5 years of oral or 3 years of intravenous therapy.
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Affiliation(s)
- Judith Sarah Bubbear
- Department of Rheumatology, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
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23
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Toro G, Ojeda-Thies C, Calabrò G, Toro G, Moretti A, Guerra GMD, Caba-Doussoux P, Iolascon G. Management of atypical femoral fracture: a scoping review and comprehensive algorithm. BMC Musculoskelet Disord 2016; 17:227. [PMID: 27215972 PMCID: PMC4878072 DOI: 10.1186/s12891-016-1086-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 05/17/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Atypical femoral fractures (AFF) are a rare type of femoral stress fracture recently described, potentially associated with prolonged bisphosphonate therapy. Evidence-based recommendations regarding diagnosis and management of these fractures are scarce. The purpose of this study is to propose an algorithm for the diagnosis and management of AFF. METHODS We performed a PubMed search of the last ten years using the keywords "atypical femoral fractures" and identified further articles through an evaluation of the publications cited in these articles. Relevant studies were included by agreement between researchers, depending on their specialization. Pertinent points of debate were discussed based on the available literature, allowing for consensus regarding the proposed management algorithm. RESULTS Using a systematic approach we performed a scoping review that included a total of 137 articles. CONCLUSIONS A practical guide for diagnosis and management of AFF based on the current concepts is proposed. In spite of the impressive large volume of published literature available since AFF were initially identified, the level of evidence is mostly poor, in particular regarding treatment choice. Therefore, further studies are required.
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Affiliation(s)
- Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, Second University of Naples, Via De Crecchio, 4, 80138 Naples, Italy
| | - Cristina Ojeda-Thies
- Trauma Unit, Department of Orthopaedic Surgery and Traumatology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Giampiero Calabrò
- Unit of Orthopaedics and Traumatology, Villa Malta Hospital, Sarno, Italy
| | - Gabriella Toro
- Unit of Radiology, Santa Maria della Speranza Hospital, Battipaglia, Italy
| | - Antimo Moretti
- Department of Medical and Surgical Specialties and Dentistry, Second University of Naples, Via De Crecchio, 4, 80138 Naples, Italy
| | | | - Pedro Caba-Doussoux
- Trauma Unit, Department of Orthopaedic Surgery and Traumatology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, Second University of Naples, Via De Crecchio, 4, 80138 Naples, Italy
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24
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Selga J, Nuñez JH, Minguell J, Lalanza M, Garrido M. Simultaneous bilateral atypical femoral fracture in a patient receiving denosumab: case report and literature review. Osteoporos Int 2016; 27:827-32. [PMID: 26501556 DOI: 10.1007/s00198-015-3355-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 09/29/2015] [Indexed: 11/26/2022]
Abstract
Osteoporosis remains a chronic and common disease associated with high medical costs. Pharmacological therapy has shown to be a good strategy to significantly reduce fracture risk. While literary evidence for bone protection in the short and medium term is strongly in it's favor, there are concerns about long-term treatment with antiresorptive drugs. Increased risk of atypical femoral fractures (AFFs) have been demonstrated in several studies following the long-term use of bisphosphonate. Denosumab offers an alternative approach to the treatment of osteoporosis, however, it is also an antiresorptive drug. We present a case of simultaneous bilateral atypical femoral fractures in a patient with denosumab treatment. These findings highlight the need to reevaluate the optimal antiresorptive therapy duration, as well as the safety of transition from bisphosphonates to denosumab and the need for continued monitoring in the prevention of AFFs.
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25
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Adler RA, El-Hajj Fuleihan G, Bauer DC, Camacho PM, Clarke BL, Clines GA, Compston JE, Drake MT, Edwards BJ, Favus MJ, Greenspan SL, McKinney R, Pignolo RJ, Sellmeyer DE. Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment: Report of a Task Force of the American Society for Bone and Mineral Research. J Bone Miner Res 2016; 31:16-35. [PMID: 26350171 PMCID: PMC4906542 DOI: 10.1002/jbmr.2708] [Citation(s) in RCA: 373] [Impact Index Per Article: 46.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 09/04/2015] [Accepted: 09/07/2015] [Indexed: 12/19/2022]
Abstract
Bisphosphonates (BPs) are the most commonly used medications for osteoporosis. This ASBMR report provides guidance on BP therapy duration with a risk-benefit perspective. Two trials provided evidence for long-term BP use. In the Fracture Intervention Trial Long-term Extension (FLEX), postmenopausal women receiving alendronate for 10 years had fewer clinical vertebral fractures than those switched to placebo after 5 years. In the HORIZON extension, women who received 6 annual infusions of zoledronic acid had fewer morphometric vertebral fractures compared with those switched to placebo after 3 years. Low hip T-score, between -2 and -2.5 in FLEX and below -2.5 in HORIZON extension, predicted a beneficial response to continued therapy. Hence, the Task Force suggests that after 5 years of oral BP or 3 years of intravenous BP, reassessment of risk should be considered. In women at high risk, for example, older women, those with a low hip T-score or high fracture risk score, those with previous major osteoporotic fracture, or who fracture on therapy, continuation of treatment for up to 10 years (oral) or 6 years (intravenous), with periodic evaluation, should be considered. The risk of atypical femoral fracture, but not osteonecrosis of the jaw, clearly increases with BP therapy duration, but such rare events are outweighed by vertebral fracture risk reduction in high-risk patients. For women not at high fracture risk after 3 to 5 years of BP treatment, a drug holiday of 2 to 3 years can be considered. The suggested approach for long-term BP use is based on limited evidence, only for vertebral fracture reduction, in mostly white postmenopausal women, and does not replace the need for clinical judgment. It may be applicable to men and patients with glucocorticoid-induced osteoporosis, with some adaptations. It is unlikely that future trials will provide data for formulating definitive recommendations. © 2015 American Society for Bone and Mineral Research.
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Affiliation(s)
- Robert A Adler
- McGuire Veterans Affairs Medical Center and Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | | | - Douglas C Bauer
- University of California, San Francisco, San Francisco, CA, USA
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26
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Lim SY, Rastalsky N, Choy E, Bolster MB. Tibial stress reaction presenting as bilateral shin pain in a man taking denosumab for giant cell tumor of the bone. Bone 2015; 81:31-35. [PMID: 26117225 DOI: 10.1016/j.bone.2015.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 06/09/2015] [Accepted: 06/18/2015] [Indexed: 10/23/2022]
Abstract
Prolonged bisphosphonate use has been associated with increased risk of atypical femoral fractures. Very few cases of atypical femoral fractures have been reported with denosumab. We report a case of bilateral tibial stress reactions in a 60-year-old man with no history of osteoporosis who was on prolonged high-dose denosumab for the treatment of giant cell tumor of bone. He presented with a 3-month history of pain in his bilateral shins worsening with activity and improving with rest. Although initial radiographs were unremarkable, he was found to have changes consistent with a stress reaction on magnetic resonance imaging of the distal tibia. To our knowledge, bilateral tibial stress reactions have not been previously reported with anti-resorptive therapies (neither bisphosphonates nor denosumab). Our case is intriguing in terms of the development of stress reactions as a precursor to stress fractures which may also relate to atypical fractures. Our case suggests a possible association between denosumab use and stress reactions. Of note the indication for denosumab in our case was for the treatment of giant cell tumor of bone where the Food and Drug Administration (FDA) approved dose is substantially higher than the FDA approved dose for osteoporosis treatment. Although rare, clinicians should consider the possibility of stress fractures in patients on anti-resorptive medications such as denosumab, especially when a patient presents with new onset thigh pain, hip pain or pain over an area affecting the long bones. Evaluation by imaging of affected areas should be pursued to enable early detection and intervention, as well as prevention of morbidity and associated ongoing risk to the patient.
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Affiliation(s)
- Sian Yik Lim
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Address-55 Fruit Street Bulfinch 165, Boston, MA 02114, United States.
| | - Naina Rastalsky
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Address-55 Fruit Street Bulfinch 165, Boston, MA 02114, United States
| | - Edwin Choy
- Center for Sarcoma and Connective Tissue Oncology, Massachusetts General Hospital Cancer Center, Address-55 Fruit Street, Yawkey 2, Boston, MA 02114, United States
| | - Marcy B Bolster
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Address-55 Fruit Street Bulfinch 165, Boston, MA 02114, United States
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27
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Stopeck AT, Fizazi K, Body JJ, Brown JE, Carducci M, Diel I, Fujiwara Y, Martín M, Paterson A, Tonkin K, Shore N, Sieber P, Kueppers F, Karsh L, Yardley D, Wang H, Maniar T, Arellano J, Braun A. Safety of long-term denosumab therapy: results from the open label extension phase of two phase 3 studies in patients with metastatic breast and prostate cancer. Support Care Cancer 2015; 24:447-455. [PMID: 26335402 PMCID: PMC4669370 DOI: 10.1007/s00520-015-2904-5] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 08/16/2015] [Indexed: 11/28/2022]
Abstract
Purpose Zoledronic acid (ZA) or denosumab treatment reduces skeletal-related events; however, the safety of prolonged therapy has not been adequately studied. Here, we describe safety results of extended denosumab therapy in patients with bone metastases from the open-label extension phase of two phase 3 trials. Methods Patients with metastatic breast or prostate cancer received subcutaneous denosumab 120 mg Q4W or intravenous ZA 4 mg Q4W in a double-blinded fashion. Denosumab demonstrated superior efficacy in the blinded treatment phase; thus, patients were offered open-label denosumab for up to an additional 2 years. Results Cumulative median (Q1, Q3) denosumab exposure was 19.1 (9.2, 32.2) months in the breast cancer trial (n = 1019) and 12.0 (5.6, 21.3) months in the prostate cancer trial (n = 942); 295 patients received denosumab for >3 years. No new safety signals were identified during the open-label phase, or among patients who switched from ZA to denosumab. During the blinded treatment phase, exposure-adjusted subject incidences of osteonecrosis of the jaw (ONJ) were 49 (1.9 %) and 31 (1.2 %) in the denosumab and ZA groups, respectively. In total, 32 (6.9 %) and 25 (5.5 %) new cases of ONJ (not adjusted for exposure) were reported for patients continuing and switching to denosumab, respectively. The incidences of hypocalcemia were 4.3 and 3.1 %, in patients continuing and switching to denosumab, respectively. Conclusion These results describe the safety profile of denosumab after long-term exposure, or after switching to denosumab from ZA. No new safety signals were identified. Hypocalcemia rates were similar in the blinded treatment and open-label phases. ONJ rates increased with increasing exposure to antiresorptives, consistent with previous reports.
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Affiliation(s)
| | - Karim Fizazi
- Institut Gustave Roussy, University of Paris Sud, Villejuif, France
| | - Jean-Jacques Body
- Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Janet E Brown
- Cancer Research UK Experimental Cancer Medicine Centres, St James's University Hospital, Leeds, UK.,Weston Park Hospital, University of Sheffield, Sheffield, UK
| | - Michael Carducci
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Ingo Diel
- Center for Comprehensive Gynecology Clinic, Mannheim, Germany
| | | | - Miguel Martín
- Instituto de Investigación Sanitaria General Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | | | | | - Neal Shore
- Carolina Urologic Research Center, Myrtle Beach, SC, USA
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28
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Abstract
There is an increasing number of effective therapies for fracture prevention in adults at risk of osteoporosis. However, shortcomings in the evidence underpinning our management of osteoporosis still exist. Evidence of antifracture efficacy in the groups of patients who most commonly use calcium and vitamin D supplements is lacking, the safety of calcium supplements is in doubt, and the safety and efficacy of high doses of vitamin D give cause for concern. Alendronate, risedronate, zoledronate and denosumab have been shown to prevent spine, nonspine and hip fractures; in addition, teriparatide and strontium ranelate prevent both spine and nonspine fractures, and raloxifene and ibandronate prevent spine fractures. However, most trials provide little information regarding long-term efficacy or safety. A particular concern at present is the possibility that oral bisphosphonates might cause atypical femoral fractures. Observational data suggest that the incidence of this type of fracture increases steeply with duration of bisphosphonate use, resulting in concern that the benefit-risk balance may become negative in the long term, particularly in patients in whom the osteoporotic fracture risk is not high. Therefore, reappraisal of ongoing use of bisphosphonates after about 5 years is endorsed by expert consensus, and 'drug holidays' should be considered at this time. Further studies are needed to guide clinical practice in this area.
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Affiliation(s)
- I R Reid
- University of Auckland, Auckland, New Zealand.,the Department of Endocrinology, Auckland District Health Board, Auckland, New Zealand
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29
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Khow KSF, Yong TY. Atypical femoral fracture in a patient treated with denosumab. J Bone Miner Metab 2015; 33:355-8. [PMID: 24996528 DOI: 10.1007/s00774-014-0606-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 05/18/2014] [Indexed: 10/25/2022]
Abstract
Atypical fractures of the femur (AFF) have been reported in the literature at an increasing rate over the past decade, especially in patients who have been on prolonged courses of bisphosphonates. However, there have only been a few reported cases of AFF in those treated with other antiresorptive medications. In this case report, a 72-year-old woman with chronic obstructive pulmonary disease and osteoporosis presented with an atraumatic right femoral fracture in the setting of denosumab use. In contrast with other reports, this patient had received bisphosphonate therapy for a short duration before the switch to denosumab. While causality between the fracture and denosumab use cannot be established in this case, there is a growing number of reports of a similar association. Ongoing vigilance is required to determine whether denosumab is associated with or potentially a cause of AFF.
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Affiliation(s)
- Kareeann Sok Fun Khow
- Department of Aged and Extended Care, The Queen Elizabeth Hospital and University of Adelaide, Adelaide, SA, Australia
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30
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Frakturprävention bei der älteren Frau. GYNAKOLOGISCHE ENDOKRINOLOGIE 2015. [DOI: 10.1007/s10304-014-0647-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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31
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Antiresorptive drugs beyond bisphosphonates and selective oestrogen receptor modulators for the management of postmenopausal osteoporosis. Drugs Aging 2015; 31:413-24. [PMID: 24797286 PMCID: PMC4033814 DOI: 10.1007/s40266-014-0179-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Osteoporotic fractures are a major cause of morbidity in the elderly population. Since postmenopausal osteoporosis is related to an increase in osteoclastic activity at the time of menopause, inhibitors of bone resorption have genuinely been considered an adequate strategy for prevention and treatment of osteoporosis. Bisphosphonates and selective oestrogen receptor modulators are widely prescribed to treat osteoporosis. However, other antiresorptive drugs have been developed for the management of osteoporosis, with the objective of providing a substantial reduction in osteoporotic fractures at all skeletal sites, combined with an acceptable long-term skeletal and systemic safety profile. Denosumab, a human monoclonal antibody to receptor activator for nuclear factor kappa B ligand, has shown efficacy against vertebral, nonvertebral and hip fractures. Its administration every 6 months as a subcutaneous formulation might significantly influence compliance and persistence to therapy. Additional results regarding long-term skeletal safety (i.e. osteonecrosis of the jaw and atypical diaphyseal femoral fracture) are needed. Odanacatib, a selective cathepsin K inhibitor, is a promising new approach to the inhibition of osteoclastic resorption, with the potential to uncouple bone formation from bone resorption. Results regarding its anti-fracture efficacy are expected in the coming months.
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32
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Hamrick I, Schrager S, Nye AM. Treatment of osteoporosis: current state of the art. Wien Med Wochenschr 2014; 165:54-64. [DOI: 10.1007/s10354-014-0335-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 11/11/2014] [Indexed: 01/21/2023]
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33
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Reginster JY, Neuprez A, Dardenne N, Beaudart C, Emonts P, Bruyere O. Efficacy and safety of currently marketed anti-osteoporosis medications. Best Pract Res Clin Endocrinol Metab 2014; 28:809-34. [PMID: 25432354 DOI: 10.1016/j.beem.2014.09.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
During the past 2 decades, many interventions were proven effective in the management of postmenopausal osteoporosis. The objective of an anti-osteoporosis treatment is to reduce fracture rates, ideally at all skeletal sites (i.e. spine, hip, and other non-spine). The armamentarium against osteoporosis includes anti-resorptive agents (i.e. bisphosphonates, selective estrogen receptor modulators and denosumab), bone-forming agents (i.e. peptides from the parathyroid hormone family) and one agent with a dual mechanism of action (i.e. strontium ranelate). All these medications combine antifracture efficacy with a reasonable benefit/risk profile. However, the choice of a particular chemical entity, in one individual patient is based on the knowledge and expertise of the physician. Prioritization of drugs should be based on the individual profile of the patient, the severity of osteoporosis and the specific contraindications, warnings and precautions of use of the various available medications.
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Affiliation(s)
- J Y Reginster
- Department of Public Health, Epidemiology and Health Economics, CHU Sart Tilman, University of Liège, Avenue de l'Hôpital, 1, B23 Sart Tilman, 4020 Liège, Belgium; Bone and Cartilage Metabolism Unit, CHU Centre Ville, University of Liège, Liège, Belgium.
| | - A Neuprez
- Department of Public Health, Epidemiology and Health Economics, CHU Sart Tilman, University of Liège, Avenue de l'Hôpital, 1, B23 Sart Tilman, 4020 Liège, Belgium; Bone and Cartilage Metabolism Unit, CHU Centre Ville, University of Liège, Liège, Belgium.
| | - N Dardenne
- Department of Public Health, Epidemiology and Health Economics, CHU Sart Tilman, University of Liège, Avenue de l'Hôpital, 1, B23 Sart Tilman, 4020 Liège, Belgium; Bone and Cartilage Metabolism Unit, CHU Centre Ville, University of Liège, Liège, Belgium.
| | - C Beaudart
- Department of Public Health, Epidemiology and Health Economics, CHU Sart Tilman, University of Liège, Avenue de l'Hôpital, 1, B23 Sart Tilman, 4020 Liège, Belgium; Bone and Cartilage Metabolism Unit, CHU Centre Ville, University of Liège, Liège, Belgium.
| | - P Emonts
- Department of Public Health, Epidemiology and Health Economics, CHU Sart Tilman, University of Liège, Avenue de l'Hôpital, 1, B23 Sart Tilman, 4020 Liège, Belgium
| | - O Bruyere
- Department of Public Health, Epidemiology and Health Economics, CHU Sart Tilman, University of Liège, Avenue de l'Hôpital, 1, B23 Sart Tilman, 4020 Liège, Belgium; Bone and Cartilage Metabolism Unit, CHU Centre Ville, University of Liège, Liège, Belgium.
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34
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Juby AG, Crowther S, Cree M. Identifying atypical femoral fractures--a retrospective review. Calcif Tissue Int 2014; 95:405-12. [PMID: 25209972 DOI: 10.1007/s00223-014-9908-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 08/11/2014] [Indexed: 10/24/2022]
Abstract
Subtrochanteric atypical femoral fractures (AFFs) have been reported in patients on osteoporosis therapy (bisphosphonates and denosumab). In 2010, and again in 2013, the ASBMR AFF Task Force developed strict diagnostic criteria for AFFs. This is the first study using these criteria to define the prevalence of AFFs in Canada. This study is a retrospective review of all adult patients (April 2002-March 2013) with an ICD 10 code for hip, femoral or subtrochanteric fracture, from two referral hospitals in Alberta, Canada. All identified as isolated subtrochanteric fractures were further evaluated by chart review, prescription review and examination of radiographs. Of 349 subjects, 79 had isolated subtrochanteric fractures. Of the 70 cases of subtrochanteric fractures that were radiographically assessed (9 films unavailable), 41 fulfilled ASBMR 2013 AFF criteria. The remaining subjects had subtrochanteric fractures but did not meet the ASBMR criteria to qualify as AFFs. There were 11 AFFs in 2012/2013, giving a rate of AFFs of 1.42 per 100,000 50 + year adults, compared to a rate of 103.47 per 100,000 50+ year adults for typical hip fractures. Isolated subtrochanteric fractures are rare. They cannot reliably be identified by ICD coding alone. In this study, only 59 % of all isolated subtrochanteric/femoral shaft fractures fulfilled the ASBMR task force criteria for true AFFs. The rate of typical hip fractures was substantially higher than the rate of AFFs, defined by ASBMR diagnostic criteria.
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Affiliation(s)
- Angela G Juby
- Department of Medicine, University of Alberta, 1-108 Clinical Sciences Building, 11350 83rd Avenue, Edmonton, AB, T6G 2P4, Canada,
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35
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Ng VY, Davidson DJ, Kim EY, Pollack SM, Conrad Iii EU, Jones RL. The multidisciplinary management of giant cell tumor of bone. Expert Rev Anticancer Ther 2014; 14:783-90. [PMID: 24666240 DOI: 10.1586/14737140.2014.901891] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Giant cell tumor of bone is a locally aggressive lesion with a predilection for local recurrence, and in a small proportion of patients, metastatic disease can develop. Surgery is the mainstay of management for extremity-based lesions. For tumors located in challenging anatomical locations such as the sacrum and spine however, surgery may be associated with unacceptable functional morbidity. There are limited data regarding other treatment modalities such as radiation therapy, cytotoxic chemotherapy, interferon and bisphosphonates. Serial arterial embolization can be effective in some cases. Recent evidence has demonstrated denosumab to be a promising agent in the treatment of unresectable or metastatic disease.
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Affiliation(s)
- Vincent Y Ng
- University of Washington/Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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36
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Rothman MS, West SG, McDermott MT. Osteoporosis for the practicing neurologist. Neurol Clin Pract 2014; 4:34-43. [PMID: 29473600 PMCID: PMC5765589 DOI: 10.1212/01.cpj.0000437349.39987.fa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Osteoporosis is a common condition of impaired bone strength leading to fractures. A targeted history, physical exam, and blood work can help elucidate potentially reversible causes of low bone mass. In the neurology office, particular attention should be paid to the patient on glucocorticoids or antiepileptic medications, as these have distinct detrimental effects on bone. Patients can be risk-stratified by using the FRAX calculator, a tool that can help determine whether the patient is at sufficient risk of fracture to warrant pharmacologic therapy. Nonpharmacologic treatments such as calcium, vitamin D, and exercise should be discussed with the patient. The cornerstone of pharmacologic therapy has been treatment with bisphosphonates, but newer medications are available as well for the high-risk patient.
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Affiliation(s)
- Micol S Rothman
- Department of Medicine-Endocrinology (MSR, MTM) and Department of Medicine-Rheumatology (SGW), University of Colorado School of Medicine, Denver, CO
| | - Sterling G West
- Department of Medicine-Endocrinology (MSR, MTM) and Department of Medicine-Rheumatology (SGW), University of Colorado School of Medicine, Denver, CO
| | - Michael T McDermott
- Department of Medicine-Endocrinology (MSR, MTM) and Department of Medicine-Rheumatology (SGW), University of Colorado School of Medicine, Denver, CO
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37
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Affiliation(s)
- Jörg Schilcher
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköping University, Sweden
| | - Per Aspenberg
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköping University, Sweden
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38
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Drampalos E, Skarpas G, Barbounakis N, Michos I. Atypical femoral fractures bilaterally in a patient receiving denosumab. Acta Orthop 2014; 85:3-5. [PMID: 24171686 PMCID: PMC3940982 DOI: 10.3109/17453674.2013.854668] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
| | - George Skarpas
- Orthopedic Department, Asklipieion Voulas Hospital, Athens, Greece
| | | | - Ioannis Michos
- Orthopedic Department, Asklipieion Voulas Hospital, Athens, Greece
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39
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Rementer CW, Wu M, Buranaphatthana W, Yang HYL, Scatena M, Giachelli CM. An inducible, ligand-independent receptor activator of NF-κB gene to control osteoclast differentiation from monocytic precursors. PLoS One 2013; 8:e84465. [PMID: 24386387 PMCID: PMC3874012 DOI: 10.1371/journal.pone.0084465] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 11/22/2013] [Indexed: 12/28/2022] Open
Abstract
Osteoclasts are bone-resorbing cells that are critical for the normal formation and maintenance of teeth and skeleton. Osteoclast deficiency can contribute to heterotopic ossification (HO), a pathology that is particularly detrimental to the mechanical functions of joints, valves and blood vessels. On the other hand, osteoclast over-activity is a major cause of osteoporosis. A reliable method for controlled generation of osteoclasts would be useful as a potential autologous cell therapy for HO, as well as high-throughput drug screening for anti-osteoporotic drugs. In this report, we describe the development of a cell engineering approach to control monocytic precursor cell differentiation to osteoclasts. Oligomerization of receptor activator of nuclear factor κB (RANK) is known to be essential for osteoclast differentiation from monocyte/macrophage precursors. We engineered a murine monocytic cell line, RAW264.7 to express a fusion protein comprising the intracellular RANK signaling domain and FK506-derived dimerization domains that bind to a small molecule chemical inducer of dimerization (CID). Virally infected cells expressing this fusion protein were treated with CID and dose-dependent induction of tartrate-resistant acid phosphatase activity, as well as multinucleated osteoclast formation were observed. Furthermore, NF-κB signaling was upregulated in a CID-dependent fashion, demonstrating effective RANK intracellular signaling. Functionally CID-induced osteoclasts had robust mineral resorptive activity in both two-dimensional and three-dimensional in vitro resorption assays. In addition, the CID-induced osteoclasts have the same life span as native RANKL-induced osteoclasts. Most importantly and crucially, the engineered cells differentiated into osteoclasts that were resistant to the potent osteoclast inhibitor, osteoprotegerin. Taken together, these studies are the first to describe a method for inducible control of monocytic precursor differentiation to osteoclasts that may be useful for future development of an engineered autologous cell therapy as well as high-throughput drug testing systems to treat diseases of osteoclast over-activity that are independent of osteoprotegerin.
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Affiliation(s)
- Cameron W. Rementer
- Department of Bioengineering, University of Washington, Seattle, Washington, United States of America
| | - Meiting Wu
- Department of Bioengineering, University of Washington, Seattle, Washington, United States of America
| | - Worakanya Buranaphatthana
- Department of Oral Health Sciences, University of Washington, Seattle, Washington, United States of America
| | - Hsueh-Ying L. Yang
- Department of Bioengineering, University of Washington, Seattle, Washington, United States of America
| | - Marta Scatena
- Department of Bioengineering, University of Washington, Seattle, Washington, United States of America
| | - Cecilia M. Giachelli
- Department of Bioengineering, University of Washington, Seattle, Washington, United States of America
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40
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An atraumatic femoral fracture in a patient with rheumatoid arthritis and osteoporosis treated with denosumab. Case Rep Rheumatol 2013; 2013:249872. [PMID: 24490096 PMCID: PMC3893843 DOI: 10.1155/2013/249872] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 11/11/2013] [Indexed: 11/17/2022] Open
Abstract
Osteoporosis is responsible for a significant burden both individually and socially, but is readily treated with antiresorptive agents and mineral supplementation. However, long-term usage of these agents, notably bisphosphonates, is rarely associated with atypical fractures. Denosumab is a monoclonal antibody that reduces osteoclast activity and thus increases bone mineral density. In this case report, we present a 78-year-old woman with a background of rheumatoid arthritis and osteoporosis who presented with an atypical diaphyseal femoral fracture.
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41
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Abstract
INTRODUCTION Denosumab is a fully human monoclonal antibody against the receptor activator of nuclear factor kappa-B ligand. It is an antiresorptive agent that reduces osteoclastogenesis. AREAS COVERED This drug evaluation reviews denosumab for use in osteoporosis. Denosumab has been shown to improve bone mineral density (BMD) and to reduce the incidence of new vertebral, hip and nonvertebral fractures in postmenopausal women. It prevents bone loss and reduces vertebral fracture risk in men with nonmetastatic prostate cancer who are receiving androgen deprivation therapy. It has also been shown to improve BMD in men with osteoporosis unrelated to androgen deprivation therapy. Safety concerns include infections, cancer, skin reactions, cardiovascular disease, hypocalcemia, osteonecrosis of the jaw and atypical femur fractures. EXPERT OPINION Although bisphosphonates are typically preferred as initial therapy for osteoporosis, denosumab could be used as initial therapy in select patients at high risk for fracture, including older patients who have difficulty with the dosing requirements of oral bisphosphonates, patients who are intolerant of or unresponsive to other therapies, and in those with impaired renal function. Additional data is needed to address issues regarding treatment duration and discontinuation, as well as to provide more information regarding denosumab's efficacy and safety.
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Affiliation(s)
- Dima L Diab
- University of Cincinnati Bone Health and Osteoporosis Center, Cincinnati VA Medical Center, Division of Endocrinology/Metabolism, Department of Internal Medicine , 260 Stetson St, Suite 4200, Cincinnati, OH 45219 , USA +1 513 558 4444 ; +1 513 558 8581 ;
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42
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Abstract
PURPOSE OF REVIEW The aim of this study is to provide a thorough updated review of the diagnosis and treatment of postmenopausal osteoporosis. RECENT FINDINGS There have been several important findings in the field of postmenopausal osteoporosis over the past 1-2 years. Fewer morphometric vertebral fractures were found in women treated for 6 years with zoledronic acid compared with those who stopped treatment after 3 years. Longer duration of bisphosphonate therapy is associated with a higher risk of atypical femur fractures. Combination therapy with teriparatide and denosumab appears to increase bone mineral density to a greater extent than either therapy alone in postmenopausal women at high risk for fracture. There are several novel therapies under investigation for the treatment of osteoporosis, which are in various stages of development. Nonadherence to osteoporosis therapies continues to be a major problem in clinical practice. SUMMARY There are numerous effective pharmacologic treatment options for postmenopausal osteoporosis. Bisphosphonate drug holidays continue to be an area of significant debate.
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Affiliation(s)
- Dima L Diab
- aDepartment of Internal Medicine, Division of Endocrinology/Metabolism bMercy Health Osteoporosis and Bone Health Services, Cincinnati, Ohio, USA
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43
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Abstract
Cancer therapy-induced bone loss (CTIBL) is a form of secondary osteoporosis associated with systemic chemotherapy and hormonal ablation therapy. The monitoring and treatment of CTIBL is an important component of comprehensive cancer care, especially for patients with curable disease and long life expectancies. Whereas oral bisphosphonates remain the most commonly used therapeutic option for CTIBL, additional treatment options may be required for patients who do not respond adequately or are intolerant to bisphosphonates, have renal insufficiency, or are receiving treatment with nephrotoxic medications. For these patients, denosumab, a monoclonal antibody targeting the receptor activator of nuclear factor-κB ligand (RANKL), offers an effective and well-tolerated alternative. Several recent randomized trials have examined the use of denosumab as treatment for CTIBL associated with hormone ablation therapy for breast and prostate cancer. Recent data suggest a possible role for RANKL inhibitors in both chemoprevention and the prevention of cancer recurrence through direct effects on breast tissue and breast cancer stem cells. The outcomes of several international Phase III clinical trials currently underway will help clarify the role of denosumab in patients undergoing cancer therapy.
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