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Ferreira P, Bates P, Daoub A, Dass D. Is bisphosphonate use a risk factor for atypical periprosthetic/peri-implant fractures? - A metanalysis of retrospective cohort studies and systematic review of the current evidence. Orthop Traumatol Surg Res 2023; 109:103475. [PMID: 36347461 DOI: 10.1016/j.otsr.2022.103475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 07/05/2022] [Accepted: 07/18/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Atypical periprosthetic/peri-implant fractures are not recognised in any widely used classification and therefore little focus is given to them. Multiple case reports and case series demonstrate these fractures exist and are related to bisphosphonate (BP) use. HYPOTHESIS Are patients taking long-term BPs at an increased risk of developing an atypical periprosthetic/peri-implant fracture? Is a particular BP drug causing an increased risk of fracture? Is there a correlation between the time of BP use and the incidence of fractures? Do vitamin D analogues or parathyroid hormones reduce the time to union? MATERIAL AND METHODS Systematic review of all available evidence on the existence of periprosthetic/peri-implant atypical fractures in patients taking long-term BPs and metanalysis of available retrospective cohort studies. Selected 1 systematic review, 7 retrospective cohort studies (5 used for metanalysis) and 32 case reports. RESULTS Metanalysis reported a risk ratio of 14.1, p=0.25, suggesting bisphosphonates are a risk factor in the development of periprosthetic/peri-implant atypical fractures. The secondary outcomes couldn't be reliably identified due to the small size of available studies and risk of significant bias. DISCUSSION Atypical periprosthetic/peri-implant fractures are an entity and seem to be associated with the use of bisphosphonates. The benefits of bisphosphonates use outweigh the risks, but clinicians should be aware of atypical fractures and actively search for them when patients on long-term bisphosphonates attend with non-specific pain close to the implant/prosthesis or reduced mobility. LEVEL OF EVIDENCE II, Systematic review and metanalysis.
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Affiliation(s)
- Pedro Ferreira
- Queen Mary University of London and Oswestry/Stoke Trauma and Orthopaedic Training Programme, Mile End Rd, Bethnal Green, London E1 4NS, United Kingdom.
| | - Peter Bates
- Orthopaedic Trauma Sciences - Queen Mary University of London, Lead for orthopaedic trauma, Barts Health, Mile End Rd, Bethnal Green, London E1 4NS, United Kingdom
| | - Ahmed Daoub
- Oswestry/Stoke Trauma and Orthopaedic Training Programme - Robert Jones and Agnes Hunt Hospital, Gobowen, Oswestry SY10 7AG, United Kingdom
| | - Debashis Dass
- Oswestry/Stoke Trauma and Orthopaedic Training Programme - Robert Jones and Agnes Hunt Hospital, Gobowen, Oswestry SY10 7AG, United Kingdom
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2
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Lo LWT, Koh JSB, Howe TS, Png MA, Lo NN. Incomplete Periprosthetic Atypical Femoral Fracture With Concomitant Hip and Knee Arthroplasties: A Case Report. JBJS Case Connect 2023; 13:01709767-202303000-00016. [PMID: 36706214 DOI: 10.2106/jbjs.cc.22.00211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 10/14/2022] [Indexed: 01/29/2023]
Abstract
CASE We present a case of an incomplete periprosthetic femoral fracture at the mid-distal third of the femoral stem after 11 months of bisphosphonate use. It is 1 of 4 cases of mid-distal periprosthetic atypical femoral fractures (PAFFs) found in our literature review. She was treated with protected weight-bearing, cessation of bisphosphonates, and teriparatide. Eighteen months after diagnosis, follow-up radiographs showed a bridging callus and reduction of a transverse fracture line. CONCLUSION The incomplete PAFF was contributed by both decreased bone turnover from bisphosphonate use and increased mechanical stress at the lateral femoral cortex. Her previous left bipolar hemiarthroplasty and subsequent Total Knee Arthroplasty shifted the mechanical alignment medially, hence increasing tensile stress.
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Lee JM, Park CH, Yoo JI, Kim JT, Cha Y. Atypical periprosthetic femoral fracture with stem breakage: a case report. Osteoporos Int 2022; 33:2043-2047. [PMID: 35688896 DOI: 10.1007/s00198-022-06463-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/01/2022] [Indexed: 11/27/2022]
Abstract
Although the American Society for Bone and Mineral Research definition of atypical femoral fracture excludes periprosthetic fractures, fractures around the prosthesis with clinical features of atypical femoral fractures have been reported in the literature. All fractures reported thus far have been distal to the prosthetic segment; however, we encountered a case of a stress fracture in the middle of the femoral component segment. An 86-year-old woman with a history of bisphosphonate osteoporosis treatment and revisional total hip arthroplasty visited our outpatient clinic complaining of pain in the left thigh and groin. We diagnosed an incomplete atypical femoral fracture around the hip prosthesis; medical treatment was implemented. Two months later, the patient visited the emergency department with a complete subtrochanteric fracture with stem breakage. Without revision of the broken stem, two plates were applied after reduction. In this case, we recognized the possibility of a stress fracture but overlooked the possibility of stem breakage in an atypical femoral fracture. Even if it is not evident on the radiograph before complete fracture, clinicians should be alert to the signs of stress fracture in the middle of the femoral component segment, as they may be clues to atypical periprosthetic femoral fracture with stem failure. Isolated medical treatment plans are not recommended for incomplete subtrochanteric atypical periprosthetic femoral fracture. Instead, concomitant prophylactic plate fixation is recommended.
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Affiliation(s)
- J M Lee
- Department of Orthopedic Surgery, Ajou University School of Medicine, Ajou Medical Center, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, South Korea
| | - C H Park
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Daegu, South Korea
| | - J-I Yoo
- Department of Orthopedics, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - J-T Kim
- Department of Orthopedic Surgery, Ajou University School of Medicine, Ajou Medical Center, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, South Korea.
| | - Y Cha
- Department of Orthopedic Surgery, Daejeon Eulji Medical Center, Eulji University School of Medicine, 95 Dunsan-Seoro, Seo-gu, Daejeon, 302-799, South Korea.
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Troiano E, Giacché T, Facchini A, Orlandi NC, Cacioppo M, Saviori M, Bottai V, Muratori F, Mondanelli N, Giannotti S. Surgical and Pharmacological Management of Periprosthetic Atypical Femoral Fractures: A Narrative Literature Review. Geriatr Orthop Surg Rehabil 2022; 13:21514593221090392. [PMID: 35433102 PMCID: PMC9006379 DOI: 10.1177/21514593221090392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 12/09/2021] [Accepted: 01/08/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction An increasing number of patients is annually undergoing total hip arthroplasty (THA), and a significant proportion of these patients are elderly and consequently at a higher risk of complications because of age, osteoporosis, and medical comorbidities. Periprosthetic femoral fractures (PFFs) are one of the worst complications of THA associated with high rates of unfavorable prognosis. Besides, in the last decade, a new independent disease entity called “atypical femoral fracture” (AFF) has been identified and defined by the American Society for Bone and Mineral Research (ASBMR) task force. Some PFFs present clinical history and radiographic aspect consistent with an AFF, meeting the ASBMR criteria for the diagnosis of AFF except that PFFs by themselves are an exclusion criterion for AFF. However, there is an increasing number of published studies suggesting that periprosthetic atypical femoral fractures (PAFFs) exist and should not be excluded by definition. Significance Nowadays, although there is an increasing interest in PAFFs, there are still very few studies published on the topic and a lack of consensus regarding their treatment. This narrative literature review aims to introduce this new emerging topic to a wider readership describing the characteristics of PAFFs and the state-of-the-art in their management. Conclusions Many authors agree that PAFFs should be considered as a subgroup of PFFs that have atypical characteristics; they also show a significant correlation with prolonged bisphosphonate use. A correct diagnosis is paramount for proper treatment of the disease that requires both surgical and medical actions to be taken.
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Affiliation(s)
- Elisa Troiano
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Tiziano Giacché
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Andrea Facchini
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Nicholas Crippa Orlandi
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Matteo Cacioppo
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Marco Saviori
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Vanna Bottai
- Second Clinic of Orthopedic and Traumatology, University of Pisa, Pisa, Italy
| | - Francesco Muratori
- Section of Orthopedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Nicola Mondanelli
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Stefano Giannotti
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
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De Cicco A, Toro G, Oliva F, Tarantino U, Schiavone Panni A, Maffulli N. Atypical periprosthetic femoral fractures of the hip: A PRISMA compliant systematic review. Injury 2021; 52:2407-2414. [PMID: 33810845 DOI: 10.1016/j.injury.2021.03.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/14/2021] [Accepted: 03/18/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Long-term use of bisphosphonates (BPs) is associated with Atypical Femoral Fracture (AFF). Theoretically, periprosthetic femoral fractures (PFF) should be excluded from the diagnosis of AFF. However, recently several studies reported the occurrence of PPFs around a hip arthroplasty presenting features of an AFF. The present study describes the characteristics of Atypical Periprosthetic Femoral Fracture (APFF) and evaluates the effectiveness of their management through a PRISMA compliant systematic review of the published case reports and series. MATERIALS AND METHODS A literature search was performed using "periprosthetic fracture" and "atypical femoral fracture" as keywords. Patients demographics, drug use, clinical and imaging characteristics, stem fixation and classification, management strategies for APFF and patients' outcomes, were also collected. RESULTS The present review included and analysed 17 patients from 12 studies. All APFFs occurred in females with a mean age of 75.9 years of age (range 43-87). In 11 patients, APFFs occurred around an uncemented stem, and in 6 around a cemented stem. Ten fractures were incomplete, and 7 complete. Conservative management was effective in 4 of 10 patients with incomplete fracture, while all patients with complete fractures underwent open reduction and internal fixation. A fracture non-union was observed in 5 patients and further surgery was required. DISCUSSIONS APFFs share several clinical and imaging characteristics with AFF. An appropriate and early diagnosis may allow to improve the outcome of these fractures, the management of which should be based on the same principles of that of AFFs. CONCLUSIONS Considering the low quality of published articles and the heterogeneity of the treatment used, a clear recommendation of the most appropriate treatment cannot be formulated.
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Affiliation(s)
- Annalisa De Cicco
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", via L. De Crecchio 4, 80138, Naples, Italy
| | - Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", via L. De Crecchio 4, 80138, Naples, Italy; Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, viale Oxford, 00133, Rome, Italy
| | - Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Largo Città di Ippocrate 84131 Salerno, Italy.
| | - Umberto Tarantino
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, viale Oxford, 00133, Rome, Italy.
| | - Alfredo Schiavone Panni
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", via L. De Crecchio 4, 80138, Naples, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Largo Città di Ippocrate 84131 Salerno, Italy; Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Turner Street, Whitechapel, London, UK.
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6
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Mondanelli N, Facchini A, Troiano E, Muratori F, Bottai V, Giannotti S. Periprosthetic Atypical Femoral Fractures Exist: A Retrospective Study at a Single Institution. Prevalence on 115 Periprosthetic Femoral Fractures Around a Primary Hip Stem. J Arthroplasty 2021; 36:2189-2196. [PMID: 33610412 DOI: 10.1016/j.arth.2021.01.066] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/19/2021] [Accepted: 01/23/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Some periprosthetic femoral fractures (PFFs) present history and radiographic aspect consistent with an atypical femoral fracture (AFF), fulfilling the criteria for AFF except that PFFs by themselves are excluded from the diagnosis of AFFs. The aim of this study is to evaluate in a single institution series of PFFs if any of them could be considered a periprosthetic atypical femoral fracture (PAFF), and their prevalence. METHODS Surgical records were searched for PFFs around a primary hip stem from January 2013 to December 2019. Cases were classified according to Vancouver classification. Demographic and medical history was extracted. Fisher's exact test was used for statistical analysis. RESULTS One hundred fifteen PFFs were identified, 59 of them were type B1 and 16 were type C. Radiographs and medical records were available for all patients. Twenty-four patients (32%) have been treated with bisphosphonates (BPs) for longer than 4 years. Four patients presented a fracture with characteristics of PAFF. When enlarged to all PFFs of the series, no other PAFF was found: prevalence of PAFFs was 5.3% for type B1 and C cases and 3.5% for all surgically treated PFFs. Statistical significative difference between PAFFs and PFFs was found for prolonged BP assumption and for the level of fracture clear of the stem. CONCLUSION Fracture with characteristics of AFFs can also happen over a prosthetic stem, configuring themselves as PAFFs, and they are related to prolonged BP use. As a correct diagnosis is mandatory for proper treatment, a revision of criteria for AFFs should be considered, accepting that PAFFs exist.
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Affiliation(s)
- Nicola Mondanelli
- Department of Medicine Surgery and Neurosciences, The Section of Orthopedics, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Andrea Facchini
- Department of Medicine Surgery and Neurosciences, The Section of Orthopedics, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Elisa Troiano
- Department of Medicine Surgery and Neurosciences, The Section of Orthopedics, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Francesco Muratori
- Department of Oncology, The Section of Orthopedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Vanna Bottai
- Department of Orthopedic and Trauma Surgery, Othopedic and Traumatology II, University of Pisa, Pisa, Italy
| | - Stefano Giannotti
- Department of Medicine Surgery and Neurosciences, The Section of Orthopedics, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
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7
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Caruso G, Corradi N, Amoroso T, Martini I, Lorusso V, Massari L. Atypical periprosthetic femur fracture on an underestimated atypical femoral pattern. A case report. Trauma Case Rep 2021; 32:100407. [PMID: 33665304 PMCID: PMC7900765 DOI: 10.1016/j.tcr.2021.100407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2021] [Indexed: 12/12/2022] Open
Abstract
Case Atypical fracture patterns, especially to the femur midshaft, have begun emerging since long-term bisphosphonate use was introduced. The same fracture pattern could arise around prosthetic hip implant, but the literature reports few cases regarding atypical periprosthetic femur fracture on previous total hip arthroplasty implant in patients on long-term bisphosphonate therapy. To our knowledge we report here the first case of atypical periprosthetic femur fracture arising after total hip arthroplasty implant on a previously identified but underestimated atypical femur pattern. Conclusion Surgeons should never underestimate an atypical femur pattern on x-rays and always relate groin and thigh pain to hip pathology before performing total hip arthroplasty.
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Affiliation(s)
- Gaetano Caruso
- Orthopedic and Traumatology Unit, Sant'Anna University Hospital of Ferrara, Via Aldo Moro 8, 44124 Cona, Ferrara, Italy.,Department of Neurosciences and Rehabilitation, University of Ferrara, Via Luigi Borsari 46, 44121, Ferrara, Italy
| | - Nicola Corradi
- Orthopedic and Traumatology Unit, Sant'Anna University Hospital of Ferrara, Via Aldo Moro 8, 44124 Cona, Ferrara, Italy
| | - Tommaso Amoroso
- Orthopedic and Traumatology Unit, Sant'Anna University Hospital of Ferrara, Via Aldo Moro 8, 44124 Cona, Ferrara, Italy
| | - Ilaria Martini
- Orthopedic and Traumatology Unit, Sant'Anna University Hospital of Ferrara, Via Aldo Moro 8, 44124 Cona, Ferrara, Italy
| | - Vincenzo Lorusso
- Orthopedic and Traumatology Unit, Sant'Anna University Hospital of Ferrara, Via Aldo Moro 8, 44124 Cona, Ferrara, Italy
| | - Leo Massari
- Orthopedic and Traumatology Unit, Sant'Anna University Hospital of Ferrara, Via Aldo Moro 8, 44124 Cona, Ferrara, Italy.,Department of Neurosciences and Rehabilitation, University of Ferrara, Via Luigi Borsari 46, 44121, Ferrara, Italy
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8
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Toro G, Di Fino C, De Cicco A, Toro G, Paoletta M, Toro A, Tarantino U, Iolascon G, Panni AS. Atypical periprosthetic femoral fractures of the hip: characterisation of three cases. Hip Int 2020; 30:77-85. [PMID: 33267685 DOI: 10.1177/1120700020971726] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Long-term use of bisphosphonates (BPs) has been associated with a specific type of tensile side femoral stress fracture known as Atypical Femoral Fracture (AFF). Theoretically periprosthetic femoral fractures (PFF) should be excluded from the diagnosis of AFF. However, emerging evidence correlates prolonged BPs use with the occurrence of a type of PFF with an atypical pattern (atypical PFF, APFF). The aim of the present study is to report 3 cases of APFF treated at a single centre. METHODS Clinical and radiographic records of PFF that occurred between January 2016 and August 2018 were retrospectively reviewed. All patients meeting the American Society for Bone and Mineral Research (ASBMR) criteria for definition of PFF were included. Management strategies for APFF and patient outcomes, including fracture healing and hip function (assessed by the Oxford Hip Score [OHS]) were collected. RESULTS 3 patients in the study period were identified as APFF (1 incomplete, 2 complete). All patients were females with a mean age of 83.3 years. All patients were treated with lateral plating. The application of a contralateral strut allograft resulted in fracture healing in cases of complete fractures. Mean OHS at final follow-up was 34.3. CONCLUSIONS Despite occurring around a hip stem like PFF, APFF had peculiar clinical and radiographic features, making them more similar to AFF. Therefore, the orthopaedic surgeon should also consider the natural history and healing problems associated with AFF prior in order to choose the most appropriate management for APFF.
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Affiliation(s)
- Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy.,Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Ciro Di Fino
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Annalisa De Cicco
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Marco Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonio Toro
- Unit of Orthopaedics and Traumatology, "Martiri del Villa Malta" Hospital, Sarno, Italy
| | - Umberto Tarantino
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Alfredo Schiavone Panni
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
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Nakamura S, Uezono S, Nagai Y, Kanetaka M, Wagatsuma K, Ishii K, Kumakawa T, Yasue K, Anamizu Y, Tokimura F, Miyazaki T. 18F-sodium fluoride positron emission tomography may help determine better treatment for thigh pain after hip arthroplasty-A case report. Clin Case Rep 2020; 8:1651-1658. [PMID: 32983470 PMCID: PMC7495866 DOI: 10.1002/ccr3.2920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/17/2020] [Accepted: 04/21/2020] [Indexed: 11/11/2022] Open
Abstract
Thigh pain after hip arthroplasty is multifactorial; uncovering its etiology is paramount for optimal treatment. This is the first case where 18F-sodium fluoride positron emission tomography substantially helped in diagnosing the post-hip arthroplasty persistent thigh pain and appropriate treatment selection. This imaging modality warrants further study and more widespread application.
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Affiliation(s)
- Shinya Nakamura
- Department of Orthopaedic SurgeryTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Shigehito Uezono
- Department of Orthopaedic SurgeryTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Yuko Nagai
- Department of Orthopaedic SurgeryTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Masakazu Kanetaka
- Department of Orthopaedic SurgeryTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Kei Wagatsuma
- Team for Neuroimaging ResearchTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Kenji Ishii
- Team for Neuroimaging ResearchTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Takeshi Kumakawa
- Department of Orthopaedic SurgeryTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Kensuke Yasue
- Department of Orthopaedic SurgeryTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Yorito Anamizu
- Department of Orthopaedic SurgeryTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Fumiaki Tokimura
- Department of Orthopaedic SurgeryTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
| | - Tsuyoshi Miyazaki
- Department of Orthopaedic SurgeryTokyo Metropolitan Geriatric Hospital and Institute of GerontologyTokyoJapan
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10
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Andrews KA, Wynkoop EI, Stokey PJ, Georgiadis GM. Impending Atypical Femur Fracture Presenting as Painful Total Knee Arthroplasty: A Report of 2 Cases. JBJS Case Connect 2020; 10:e0160. [PMID: 32224652 DOI: 10.2106/jbjs.cc.19.00160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
CASE We report on 2 patients with atypical femur fractures that initially presented as painful total knee arthroplasties. There was a history of long-term bisphosphonate use in each case. Knee radiographs and laboratory studies were normal, and the patients were managed conservatively. Both subsequently sustained atypical femur fractures and underwent surgical stabilization. CONCLUSIONS Referred pain from a bisphosphonate-related femoral stress fracture can masquerade as pain about a total knee arthroplasty. This should be included in the differential diagnosis in at-risk patients because it can result in an atypical femoral shaft fracture above the prosthesis if not properly treated.
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Affiliation(s)
- Kyle A Andrews
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Emily I Wynkoop
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Phillip J Stokey
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Gregory M Georgiadis
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
- Department of Orthopaedic Surgery, ProMedica Toledo Hospital, Toledo, Ohio
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11
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A Periprosthetic Femoral Fracture with Characteristics of Atypical Femoral Fracture. Case Rep Orthop 2019; 2019:1275369. [PMID: 31396425 PMCID: PMC6664512 DOI: 10.1155/2019/1275369] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 05/08/2019] [Indexed: 12/15/2022] Open
Abstract
Although the definition of atypical femoral fracture (AFF) excludes periprosthetic femoral fracture (PFF), the number of reports about PFF with characteristics of AFF is increasing. We present the case of such a fracture in this report. An 87-year-old woman who underwent bipolar hip arthroplasty for a femoral neck fracture 38 months prior reported left thigh pain with no history of trauma. Radiographs showed a simple transverse fracture at the level of the stem distal end with features of AFF: periosteal thickening of the lateral cortex, a medial spike, and a noncomminuted fracture. She presented other features resembling AFF: history of bisphosphonate use, prodromal symptoms, no associated trauma, and lateral bowing of the contralateral femur. The fracture showed nonunion after the initial osteosynthesis, and a revision surgery of the arthroplasty and osteosynthesis was performed. Nine months after the surgery, bony union was achieved and she regained the ability to walk. It is supposed that the fracture was influenced by a stress force related to implants and lateral bowing concentrating on the fracture site as a mechanical factor in addition to bisphosphonates as a biological factor. It would be important to recognize that AFF could occur at the peri-implant location, and early detection and treatment are essential.
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12
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Two Cases of Periprosthetic Atypical Femoral Fractures in Patients on Long-Term Bisphosphonate Treatment. Case Rep Surg 2019; 2019:9845320. [PMID: 30944750 PMCID: PMC6421721 DOI: 10.1155/2019/9845320] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 01/17/2019] [Indexed: 02/07/2023] Open
Abstract
The current definition of atypical femoral fractures (AFFs) excludes periprosthetic fractures. However, a few cases of bisphosphonates (BPs) -associated periprosthetic atypical femoral fractures (PAFFs) have been reported in the literature. Here, we report two rare cases of PAFFs that fulfilled the major criteria for AFFs in patients with prolonged use of BPs. Both cases progressed to a complete fracture with minor trauma from an incomplete fracture at the distal tip of the well-fixed femoral stem. The femoral stem effect on lateral femoral cortical bone, together with the decreased bone elastic resistance induced by BPs, was considered the cause of onset. In each case, we performed open reduction and internal fixation using a locking plate with cable grip and postoperatively prescribed teriparatide and low-intensity pulsed ultrasound (LIPUS). Both cases had a good clinical course. However, as conservative treatment was not effective in these cases, treatment such as non-weight-bearing exercises during hospitalization or prophylactic surgery may be necessary. Further studies are needed to determine the optimal treatment strategy.
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Kurinomaru N, Mori T, Tsukamoto M, Okada Y, Yumisashi K, Sakai A. Case Report and Literature Review of Periprosthetic Atypical Femoral Fractures After Total Hip Arthroplasty. J UOEH 2019; 41:409-416. [PMID: 31866658 DOI: 10.7888/juoeh.41.409] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
We describe a case of periprosthetic femoral fracture with 5 major features of an atypical femoral fracture (AFF) and localized cortical thickening at the fracture site, which is characteristic of an AFF. An 81-year-old female patient had undergone cementless total hip arthroplasty for a right femoral neck fracture at the age of 66, and had been taking oral alendronate since then. At the age of 79, she developed spontaneous right thigh pain. Radiographs showed lateral cortical thickening and pedestal formation around the end of the femoral component. She was advised to discontinue oral alendronate and change to eldecalcitol. At the age of 81, she developed sudden severe pain when standing up from a seated position and was not able to walk. Radiographs showed a periprosthetic femoral fracture with 5 major features of AFF at the site of localized cortical thickening. We diagnosed a Vancouver type B1 periprosthetic femoral fracture. She underwent open reduction and internal fixation (ORIF) with an NCB® Periprosthetic Femur Plate System with cable grips. Daily subcutaneous injection of teriparatide and low intensity pulsed ultrasound therapy were performed to stimulate bone healing. She was able to walk without assistance at 4 months after ORIF. Radiographs showed adequate bridging callus and a disappearing fracture line. This case was diagnosed as a periprosthetic atypical femoral fracture (PAFF), because a periprosthetic fracture is excluded from the definition of AFF. Similar to AFF, PAFF exhibits poor clinical outcomes. The approach to treating PAFF should be decided after considering the pathogenesis.
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Affiliation(s)
- Naoaki Kurinomaru
- Department of Orthopaedic Surgery, School of Medicine, University Hospital of Occupational and Environmental Health, Japan
| | - Toshiharu Mori
- Department of Orthopaedic Surgery, School of Medicine, University Hospital of Occupational and Environmental Health, Japan
| | - Manabu Tsukamoto
- Department of Orthopaedic Surgery, School of Medicine, University Hospital of Occupational and Environmental Health, Japan
| | - Yasuaki Okada
- Department of Orthopaedic Surgery, School of Medicine, University Hospital of Occupational and Environmental Health, Japan
| | - Keiichi Yumisashi
- Department of Orthopaedic Surgery, School of Medicine, University Hospital of Occupational and Environmental Health, Japan
| | - Akinori Sakai
- Department of Orthopaedic Surgery, School of Medicine, University Hospital of Occupational and Environmental Health, Japan
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Frequency and associated factor of atypical periprosthetic femoral fracture after hip arthroplasty. Injury 2018; 49:2264-2268. [PMID: 30245278 DOI: 10.1016/j.injury.2018.09.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 08/20/2018] [Accepted: 09/07/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Atypical femoral fracture (AFF) is a serious complication after the use of bisphosphonates, and periprosthetic femoral fracture (PFF) appeared as a common complication after hip arthroplasty, especially in senile patients. Although American Society for Bone and Mineral Research has excluded PFFs from the definition of AFFs, several case reports found PFF patients undergoing bisphosphonate treatment, have fractures resembling AFF and the authors suggested that AFF can also occur in operated femurs after hip arthroplasty. To date, the frequency and risk factors of atypical PFF are unknown. The purpose of our study was (1) to evaluate the proportion of atypical PFF among Vancouver type B PFFs, and (2) to determine the association between occurrence of atypical PFF and use of bisphosphonate. METHODS We reviewed medical records and radiographs of 67 Vancouver type B PFFs (67 patients) due to low-energy trauma and classified them into atypical PFF group and ordinary PFF group. We calculated the proportion of atypical PFFs among PFFs and identified risk factors for atypical PFF. RESULTS Among the 67 PFFs, 7 fractures (10.4%) were classified as atypical PFF. Longer duration of bisphosphonate use was an independent risk factor of atypical PFF. (Odds ratio 2.600, 95% CI 1.184-5.709, p = 0.017). CONCLUSION In accordance with wide use of bisphosphonate, atypical PFFs after hip arthroplasty are not rare anymore. Physicians should suspect the atypical PFF, when they meet low-energy fracture in bisphosphonate users, and radiographs show features of AFF.
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Abstract
Atypical femoral fractures (AFF) are stress or ‘insufficiency’ fractures, often complicated by the use of bisphosphonates or other bone turnover inhibitors. While these drugs are beneficial for the intact osteoporotic bone, they probably prevent a stress fracture from healing which thus progresses to a complete fracture. Key features of atypical femoral fractures, essential for the diagnosis, are: location in the subtrochanteric region and diaphysis; lack of trauma history and comminution; and a transverse or short oblique configuration. The relative risk of patients developing an atypical femoral fracture when taking bisphosphonates is high; however, the absolute risk of these fractures in patients on bisphosphonates is low, ranging from 3.2 to 50 cases per 100,000 person-years. Treatment strategy in patients with AFF involves: radiograph of the contralateral side (computed tomography and magnetic resonance imaging should also be considered); dietary calcium and vitamin D supplementation should be prescribed following assessment; bisphosphonates or other potent antiresorptive agents should be discontinued; prophylactic surgical treatment of incomplete AFF with cephalomedullary nail, unless pain free; cephalomedullary nailing for surgical fixation of complete fractures; avoidance of gaps in the lateral and anterior cortex; avoidance of varus malreduction.
Cite this article: EFORT Open Rev 2018;3:494-500. DOI: 10.1302/2058-5241.3.170070.
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Affiliation(s)
| | - Hagen Schmal
- Department of Orthopaedics and Traumatology, Odense University Hospital, Denmark
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