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

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.

Effects of osteopathic manipulative treatment and bio-electromagnetic energy regulation therapy on lower back pain

CONTEXT

Lower back pain (LBP) is prevalent and is a leading contributor to disease burden worldwide. Osteopathic manipulative treatment (OMT) can alleviate alterations in the body that leads to musculoskeletal disorders such as LBP. Bio-electromagnetic Energy Regulation (BEMER; BEMER International AG), which has also been shown to relieve musculoskeletal pain, is a therapeutic modality that deploys a biorhythmically defined stimulus through a pulsed electromagnetic field (PEMF). Therefore, it is possible that combined OMT and BEMER therapy could reduce low back pain in adults more than the effect of either treatment modality alone.

OBJECTIVES

To investigate the individual and combined effects of OMT and BEMER therapy on LBP in adults.

METHODS

Employees and students at a medical college were recruited to this study by email. Participants were included if they self-reported chronic LBP of 3 months' duration or longer; participants were excluded if they were experiencing acute LBP of 2 weeks' duration or less, were currently being treated for LBP, were pregnant, or had a known medical history of several conditions. Ultimately, 40 participants were randomly assigned to four treatment groups: an OMT only, BEMER only, OMT+BEMER, or control (light touch and sham). Treatments were given regularly over a 3 week period. Data on LBP and quality of life were gathered through the Visual Analog Scale (VAS), Short Form 12 item (SF-12) health survey, and Oswestry Low Back Pain Questionnaire/Oswestry Disability Index prior to treatment and immediately after the 3 week intervention protocol. One-way analysis of variance (ANOVA) was performed retrospectively and absolute changes for each participant were calculated. Normal distribution and equal variances were confirmed by Shapiro-Wilk test (p>0.05) and Brown-Forsythe, respectively. Significance was set at p<0.05.

RESULTS

Despite a lack of statistical significance between groups, subjective reports of pain reported on the VAS showed a substantial mean percentage decrease (50.8%) from baseline in the OMT+BEMER group, compared with a 10.2% decrease in the OMT-only and 9.8% in BEMER-only groups when comparing the difference in VAS ratings from preintervention to postintervention. Participants also reported in quality of life assessed on the Oswestry Low Back Pain Questionnaire/Oswestry Disability Index, with the OMT+BEMER group showing a decrease of 30.3% in score, the most among all groups. The OMT+BEMER group also reported the greatest improvement in score in the physical component of the SF-12, with an increase of 21.8%.

CONCLUSIONS

The initial data from this study shows a potential additive effect of combination therapy (OMT and BEMER) for management of LBP, though the results did not achieve statistical significance.

Comparison of prostaglandin synthesis by endothelial cells from blood vessels originating in the rat, baboon, calf and human

The synthesis of prostaglandins (PGs) was determined in endothelial cells obtained from various vessels from baboon, human and rat both by radioimmunoassay and prelabel of the cells with [3H] arachidonate. Cells were stimulated with bradykinin, ionophore A23187 or 10 microM arachidonate. Although prostacyclin (PGI2) has proven to be the major prostaglandin product of human umbilical vein and calf pulmonary artery endothelial cells, our results show that PGI2 is frequently not the major prostaglandin product of endothelial cells from other vessels. For example baboon endothelial cells lining the large vessels, aorta and cephalic vein produce mainly PGF2a with only small amounts of PGE2 and PGI2. Human endothelial cells from saphenous vein also produce mainly PGF2a. Baboon, human and rat adipose capillary endothelial cells make predominantly PGE2 and PGI2 with rat making significant amounts of PGF2a in addition. Endothelial cells from the rat aorta produced predominantly prostacyclin.