Bisphosphonate therapy associated with bilateral atypical femoral fracture and delayed union

Objectives

The aim of this study was to identify the risk factors for developing atypical femoral fractures (AFF) and to examine the effect of bisphosphonate (BP) therapy on delayed bone union and bilateral fractures.

Patients and methods

Between January 1^st, 2012 and December 31^st, 2020, a total of 74 AFF patients (8 males, 66 females; mean age: 75.4±7.2 years; range, 51 to 94 years) were recorded in two centers and retrospectively analyzed. A control fragility fracture group (n=143) was compared to the AFF group according to fracture characteristics, surgical fixation methods, comorbidities, and medications. The AFF patients were selected and subdivided according to their BP therapy: Group 1 (without BP) and Group 2 (with BP). Group 2 was further classified into Group 2a (<5 years of BP) and Group 2b (<5 years of BP).

Results

The multivariate logistic regression model showed that, BP drug use was the most significant risk factor in development of AFF (p<0.001, odds ratio= 10.749, 95% confidence interval: 3.886-29.733). The patients on BP showed longer bone union (Group 2 - 8.3±3.5 vs. Group 1 - 6.4±3.1 months, p=0.02; Group 2b - 9±3.8 vs. Group 2a - 7.3 ±3.9 months, p=0.09). Of all 19 cases of bilateral fractures, 14 were in Group 2 with BP use (p=0.11). Of 74 cases, 26 (35%) contralateral femoral X-rays were taken on admission and 24 (92%) showed AFF minor criteria signs. Of these 24 patients, 10 (42%) developed contralateral AFF.

Conclusion

The most significant risk factor in development of AFF was BP drug use. Longer BP therapy (>5 years) showed longer delayed bone union, which was not significant. There was a relatively high risk of developing AFFs and bilateral fractures on BP therapy. In case of an AFF, a contralateral femoral X-ray must be always performed for signs of an impending fracture.

Atypical periprosthetic femoral fracture associated with long-term bisphosphonate therapy

Background

Atypical femoral fracture is one of the many complications after the long-term use of bisphosphonates. The American Society for Bone and Mineral Research has officially excluded periprosthetic femoral fractures (PFFs) from the definition of atypical femoral fractures (AFFs). Several case reports found that PFFs can occur with characteristics similar to those of AFFs. The purpose of our study was to evaluate the proportion of atypical fractures among Vancouver type B1 fractures, and to determine the association between the long-term use of bisphosphonates and the occurrence of atypical periprosthetic femoral fractures (APFFs).

Methods

In this retrospective study, we reviewed 41 patients with Vancouver type B1 periprosthetic fractures between January 1, 2011 and December 31, 2018. We classified them into two groups, namely atypical and typical PFFs, based on the fracture morphology. We noted the proportion of atypical periprosthetic fractures among B1 fractures and identified risk factors.

Results

Among the 41 PFFs, 5 (13%) fractures were classified as atypical PFF based on the radiological characteristics. The longer duration of bisphosphonate use was probably the only independent risk factor that significantly increases the occurrence of APFF (p = 0.03, 0.08 (CI 0.008 – 0.16)). There were no significant differences in age, gender, body mass index, comorbidities, corticosteroid use, positioning of the femoral stem, the method of fixation (cemented or cementless) and time lapse from before the primary prosthesis implantation to the PFF in the development of atypical fracture type.

Conclusions

There seems to be a correlation between the long-term intake of bisphosphonates and the atypical periprosthetic fracture. Atypical femoral fracture can also occur in the periprosthetic form.

Trial registration

Study number: 22/2019-SZTE, http://www.klinikaikutatas.hu/hu/kutatasetika/jovahagyott-vizsgalatok-koezerdeku-adatai/category/25-jovahagyott-vizsgalatok-kozerdeku-adatai-rkeb-2019.html?download=985:22-2019.

[Drainage data analysis of chest-injured patients]

INTRODUCTION

Chest injuries cause a significant number of pneumothorax (PTX) and hemothorax (HTX). The most commonly used treatment is chest-tube drainage. The position of the tube is a prime necessity to achieve adequate drainage.

AIM

To analyze the duration of chest drainage at the occurrence of PTX and HTX. To find what the underlying cause of drainage insufficiency is and whether there is any relation between the surgical qualification needed to the procedure.

METHOD

Clinical data of 110 injured patients from 2011 to 2015 were collected and retrospectively analyzed. In the case of tube breaking or drainage insufficiency it was investigated if repositioning, usage of new tubes or insertion of additional tubes resolved the drainage insufficiency. Authors investigated the location of the tube on x-ray and CT, and the connection between the drainage insufficiency and the surgical qualifications needed to the procedure.

RESULTS

The average duration of chest drainage was 6.5 days. The duration of drainage was shorter by 1.9 days regarding the tube inserted in the middle section of the chest compared to the upper one and shorter by 1.2 days regarding the tube inserted in the lower section of the chest compared to the upper one. In the case of HTX, the duration of drainage was shorter by 2.8 days regarding the lower and by 3.6 days regarding the middle section compared to the upper position. Drainage insufficiency occurred in 30% of all cases. The duration of chest drainage was shorter after application of new tubes (9.5 days) than after reposition (10.2 days), but there was no significant difference.

CONCLUSION

Chest injury is a wide entity, thus one standard protocol cannot be developed on the management of these injuries. Authors concluded that drainage duration decreases significantly if the position of the tube is in the middle or lower section of the chest. The high occurrence of drainage insufficiency was caused by inadequate tube positioning and tube breaking. The practical qualification of trauma surgeons did not play a significant role regarding the prevalence of drainage insufficiency rather if the tube positioning was appropriate. Orv Hetil. 2019; 160(5): 172-178.

[The prognostic value of the hip screw position in intertrochanteric fractures]

INTRODUCTION

In our study, we analyzed one of the Hungarian population's most frequent injuries, the hip fracture, focusing mainly on the lateral femoral neck and the pertrochanteric fractures. According to the classification of the Swiss Association for Ostheosynthesis (AO), we focused on 31-A1 and 31-A2 fractures, the incidence of which increases by ageing.

METHOD

Between 2010 and 2016, we analyzed the data of 1179 patients. All of the fractures were stabilized with intramedullary nails. 992 patients received Stryker Gamma3^®, whereas 187 patients' fractures were solved with Synthes PFNA^® nail. In all cases, closed reduction method was used with fluoroscopy on an extension table. The surgeries were done in general or epidural anesthesia and performed by traumatology residents or specialists using standard lateral exploration. Data were collected using GEPACS software and statistical analysis was done with MS Excel.

RESULTS

Cut-out occurred in 33 cases (2,79%): out of that 21 (1.78%) were left sided and 12 were (1,01%) right sided. 29 (87.87%) patients were treated with Gamma3 nail, and in 4 (12,12%) cases PFNA nail was used. The average TAD-index was 18 mm.

CONCLUSION

According to recommendations of the TAD-index value, when using dynamic hip screw, it should be 20 mm or lower. The average index value was 18 mm which was equal in the complicated and non-complicated groups. Our study shows that the cut-out is independent from the TAD-index value, thus this recommendation cannot be applied for intramedullary nails. Orv Hetil. 2019; 160(9): 338-342.