Bilateral sequential femoral neck stress fractures in young adult with HIV infection on antiretroviral therapy: A case report

Bilateral femoral neck stress fractures in elderly individuals: A case report and literature review

RATIONALE

Bilateral femoral neck stress fractures are relatively rare injuries that occur frequently in military recruits, athletes and patients with osteoporosis, renal bone disease, metabolic bone disease, and chronic steroid use. Herein, a case of an elderly patient with bilateral femoral neck stress fractures is reported.

PATIENT CONCERNS

A 65-year-old man presented to the author's hospital with right hip pain for over a month. The patient was a farmer, had a long history of field labor before the onset of pain, denied any history of trauma.

DIAGNOSIS

The patient was diagnosed with a right subcapital fracture of the femoral neck after examination. The patient complained of only right hip symptoms, and hip computed tomography showed no abnormalities in the left hip. A tension fracture of the left femoral neck was missed due to unawareness of the abnormal signal of the left femoral neck seen on right hip magnetic resonance imaging.

INTERVENTIONS

During the first hospitalization, the patient underwent total hip arthroplasty (THA) on the right hip. Two months after the operation, the patient started to have pain in the left hip and underwent left THA again for a displaced left femoral neck fracture.

OUTCOMES

The patient eventually underwent bilateral THA surgery and had a satisfactory functional recovery. But the oversight in the diagnostic process led to the patient undergoing left THA that could have been avoided.

LESSONS

For patients who complain of hip pain but deny a history of trauma, we should be concerned about the presence of a hip fracture even if the patient's radiograph does not report a positive result. The most sensitive method is bilateral magnetic resonance imaging examination of the hip. Femoral neck stress fractures require early diagnosis and treatment to prevent complications.

Femoral neck stress fracture return to activity and the effect of metabolic dysfunction on recovery: A systematic review

Background

Femoral neck stress fractures are rare fractures traditionally found in athletes and military personnel. There is limited literature on return to activity.

Objectives

To report return to activity rates and times, and long-term outcomes for femoral neck stress fractures reported in the literature. To examine the effects of bone metabolic dysfunction and surgical management on return to activity following FNSF.

Research design & methods

A systematic literature review of case reports and case series on adults with femoral neck stress fracture that were diagnosed by gross fracture line on X-ray or gold-standard diagnosis with MRI was conducted. Initial search was limited to articles published from January 1997 to Jan 2023 listed in Medline, Embase, and Scopus. Additional articles were manually added via search of retained paper sources. Patient demographics, fracture type, return to activity time, and surgical vs non-surgical treatment modality were collected. In addition, long-term outcomes and metabolic effects, if reported, were abstracted.

Results

A total of 40 case reports or case series were retained. 123 stress fractures of the femoral neck from 103 patients were compiled. Of the 103 patients, data on return to activity at least one year following treatment was available for 53 patients. 71% (37/53) of those with long-term follow-up information returned to full pre-injury activity. 24% (13/53) at long-term follow-up had functional recovery but did not return to pre-injury activity due to residual pain. 4% (3/53) had disabling pain. Metabolic workup information was available for 36 patients.

Conclusion

Long-term follow-up and return to activity information following FNSF treatment are not commonly reported. Based on the available data, outcomes appear benign with most returning to full activity. There is a clear need for standardization of follow-up periods and hip function measure after FNSF treatment. Additionally, a sizable proportion of FNSF occurred in a new population of low-activity individuals with abnormal bone metabolism, which warrants further exploration.

Bilateral symmetrical stress fractures of femoral Neck in HIV patient: Case report and brief review of literature

Osseous changes in HIV(Human immunodeficiency virus) positive patients receiving ART (antiretroviral therapy) are three times greater than in normal individuals.These changes include osteopenia/osteoporosis,stress fractures,fragility fractures and osteonecrosis.On an average,bone mineral density reduces by 2 to 6% in the first two years after commencement of antiretroviral therapy. High risk for stress fractures is observed in these patients.In present article,we report a case of bilateral femoral neck stress fractures in a known HIV patient.

Bilateral subtrochanteric stress riser fractures following percutaneous screw fixation of femoral neck stress fractures: a literature review and case report

Hip and groin pain in patients at-risk for femoral neck stress fracture demand a careful workup including advanced imaging in the setting of normal radiographs. A delay in diagnosis can lead to fracture displacement, which negatively impacts outcomes. Non-displaced tension-sided fractures and displaced fractures warrant operative fixation, while non-displaced compression-side fractures can be managed conservatively. Fixation with a sliding hip screw or cephalomedullary nail is recommended over cannulated screws. In addition, all patients should undergo a metabolic workup to identify correctable parameters. We present a rare case of bilateral compression-sided basicervical femoral neck stress fractures in a non-compliant osteoporotic patient who was treated with cannulated screws. The postoperative course was complicated by bilateral subtrochanteric stress riser fractures requiring revision fixation, which could have been prevented with use of a different implant.

Bilateral sub-trochanteric femur fragility fractures in a patient on antiretroviral therapy: a case based discussion and review of literature

BACKGROUND

The burden of HIV/AIDS is ever increasing, affecting populations all over the world. Along with the disease, its effects and consequences on bone health are also on a rise. A commonly used drug in managing HIV, "Tenofovir" has been shown to affect bone health, specifically on prolonged usage. Osteomalacia and osteoporosis secondary to drug induced Fanconi syndrome and the disease itself, could lead to pathological/fragility fractures with trivial trauma.

CASE DESCRIPTION

A 45 year old female on antiretroviral drugs (ART) for HIV, presented with right hip pain and inability to bear weight. She has had similar symptoms previously in the left hip which resolved after 6 weeks of limited weight bearing. Anteroposterior and lateral radiographs of pelvis with hips showed bilateral sub-trochanteric fractures; healed on the left side and displaced on the right side. The patient was managed with cessation of tenofovir and right side proximal femoral nail anti-rotation (PFNA). Patient was lost to follow up but had started to ambulate independently with a cane, by the end of 6 weeks, before she succumbed to systemic complications.

CONCLUSION

Patients receiving antiretrovirals especially tenofovir should be regularly investigated for their renal impairment and bone health. Fixation of pathological fractures and early mobilization are important to prevent prolonged bed immobilization and associated complications in these immunocompromised patients.

Low-velocity simultaneous bilateral femoral neck fracture following long-term antiepileptic therapy: A case report

BACKGROUND

Simultaneous bilateral femoral neck fractures are relatively rare injuries. They are usually associated with underlying metabolic bone disorders or systemic diseases. Long-term use of narcotics and bisphosphonates can also result in similar fracture patterns; however, association of this fracture type with long-term use of antiepileptic drugs is not very common. Only one such case has been reported in the literature. This article describes the second.

CASE REPORT

We report a case of simultaneous displaced bilateral femoral neck fractures in a 50-year-old epileptic patient, who had taken phenytoin for the past 3 years. The fractures were a result of low-velocity injury following a fall from the bed. The fractures were managed with a bilateral hemi-replacement arthroplasty. Oral bisphosphonates were given to improve the bone quality in the post-operative period. The patient had a good post-operative outcome, that was sustained throughout the entire follow-up period of 1 year.

CONCLUSION

Antiepileptic drugs should be supplemented with bisphosphonates and vitamin D to improve bone quality and prevent fractures in epileptic patients.