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Beall DP, Shonnard NH, Shonnard MC, Yoon ES, Norwitz J, Phillips JE, Phillips TR. An Interim Analysis of the First 102 Patients Treated in the Prospective Vertebral Augmentation Sacroplasty Fracture Registry. J Vasc Interv Radiol 2023; 34:1477-1484. [PMID: 37207812 DOI: 10.1016/j.jvir.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 05/01/2023] [Accepted: 05/10/2023] [Indexed: 05/21/2023] Open
Abstract
PURPOSE To evaluate the efficacy of sacroplasty for treating sacral insufficiency fractures, including the effect on pain relief, patient function and adverse event rates in an as-treated on-label prospective data registry. MATERIALS AND METHODS Observational data including patient reported outcomes (PROs), patient characteristics, osteoporosis treatment, fracture duration, cause of sacral fractures and image guidance used for treatment were collected for patients undergoing sacroplasty. The PROs were collected at baseline then at one, three, and at six months following the procedure. The primary outcomes were pain as measured by the Numerical Rating Scale (NRS) and function as measured by the Roland Morris Disability Questionnaire (RMDQ). Secondary outcomes included adverse events, cement leakage, new neurologic events, readmissions and death. RESULTS The interim results for the first 102 patients included significant pain reduction with mean pain improvement scores at six months decreasing from 7.8 to 0.9 (P < .001) and significant improvement in function with mean RMDQ scores improving from 17.7 to 5.2 (P < .001). Most procedures were performed under fluoroscopy (58%). There was cement leakage in 17.7% of the subjects but only one adverse event which was a new neurologic deficit related to cement extravasation. The readmission rate was 16% mostly due to additional back pain and fractures and there were no subject deaths. CONCLUSIONS Sacroplasty with cement augmentation for acute, subacute and chronic painful sacral insufficiency fractures caused by osteoporosis or neoplastic disorders results in highly significant improvements in pain and function with very low rate of procedural related adverse events.
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Affiliation(s)
- Douglas P Beall
- Comprehensive Specialty Care, Edmond, Oklahoma. https://twitter.com/@dougbeall
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Ruffer N, Stürznickel J, Rolvien T. Bilateral Stress Fractures of the Lower Extremity in Methotrexate Osteopathy. Dtsch Arztebl Int 2022; 119:231. [PMID: 35773989 PMCID: PMC9342124 DOI: 10.3238/arztebl.m2022.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Nikolas Ruffer
- *Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt
| | - Julian Stürznickel
- **Institut für Osteologie und Biomechanik, Universitätsklinikum Hamburg-Eppendorf
| | - Tim Rolvien
- ***Klinik für Unfallchirurgie und Orthopädie, Fachbereich Orthopädie, Universitätsklinikum Hamburg-Eppendorf,
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Ilyas G, Senyuva G. A Scapular Spine Fracture Defined on the Basis of a Bisphosphonate: a Case Report and Review of the Literature. Acta Chir Orthop Traumatol Cech 2022; 89:312-314. [PMID: 36055673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Bisphosphonates are commonly used in the treatment of osteoporosis. Long-term use without drug holiday causes the risk of atypical fractures. Subtrochanteric and femoral stress fractures are among the frequently described complications. In our case report; a stress fracture of the scapular spine, a previously undescribed adverse effect of bisphosphonates, is presented. Key words: bisphosphonates, scapular spine, stress fracture, drug holiday.
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Affiliation(s)
- G Ilyas
- Usak University Faculty of Medicine, Orthopaedics and Traumatology, Usak, Turkey
| | - G Senyuva
- Usak Training and Research Hospital, Orthopaedics and Traumatology, Usak, Turkey
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Gu KD, Ettinger B, Grimsrud CD, Lo JC. Progression of atypical femur stress fracture after discontinuation of bisphosphonate therapy. Osteoporos Int 2021; 32:2119-2123. [PMID: 33914104 DOI: 10.1007/s00198-021-05948-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 04/01/2021] [Indexed: 01/16/2023]
Abstract
Atypical femur fracture (AFF) is an uncommon complication of long-term bisphosphonate use, but the risk declines substantially after treatment cessation. We report a case of a 70-year-old woman with osteopenia treated with alendronate for 9 years who presented with right mid-thigh pain and radiographic findings of focal lateral cortical thickening in the right mid-femur and lateral cortex irregularity in the proximal-mid left femur. Alendronate was discontinued, but she remained on estrogen for menopausal symptoms. Four years later, a horizontal linear translucent defect was seen in the right mid-femur area of cortical hypertrophy, consistent with an incomplete AFF. The patient underwent prophylactic intramedullary rodding of the right femur and estrogen was discontinued. Three years later (7 years after initial presentation), the cortical irregularities in the left femur were more prominent and three small horizontal linear translucent defects were now evident, consistent with early incomplete atypical fracture development. The patient also suffered a wrist fracture. She was treated with teriparatide for 1.5 years with resolution of the translucent defects in the left but not the right femur, although abnormal thickening of the lateral cortex persisted in both femurs. Our case demonstrates incomplete atypical femur fracture progression in a patient with long-term bisphosphonate exposure, even after treatment cessation. These findings highlight the importance of follow-up for patients who develop diaphyseal femur stress fractures and the potential for early healing with anabolic therapy. This case also demonstrates the challenge in managing older patients with incomplete AFF at risk for progression to complete AFF and osteoporotic fracture.
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Affiliation(s)
- K D Gu
- Department of Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, 94611, USA
| | - B Ettinger
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - C D Grimsrud
- Department of Orthopedic Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
- The Permanente Medical Group, Oakland, CA, 94612, USA
| | - J C Lo
- Department of Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, 94611, USA.
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
- The Permanente Medical Group, Oakland, CA, 94612, USA.
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Rolvien T, Jandl NM, Stürznickel J, Beil FT, Kötter I, Oheim R, Lohse AW, Barvencik F, Amling M. Clinical and Radiological Characterization of Patients with Immobilizing and Progressive Stress Fractures in Methotrexate Osteopathy. Calcif Tissue Int 2021; 108:219-230. [PMID: 33064170 PMCID: PMC7819927 DOI: 10.1007/s00223-020-00765-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/29/2020] [Indexed: 11/06/2022]
Abstract
Methotrexate (MTX) is one of the most commonly prescribed drugs for autoimmune rheumatic diseases. As there is no consensus on its negative effects on bone, the purpose of this investigation was to determine the clinical spectrum of patients with stress fractures due to long-term MTX treatment (i.e., MTX osteopathy). We have retrospectively analyzed data from 34 patients with MTX treatment, severe lower extremity pain and immobilization. MRI scans, bone turnover markers, bone mineral density (DXA) and bone microarchitecture (HR-pQCT) were evaluated. Stress fractures were also imaged with cone beam CT. While the time between clinical onset and diagnosis was prolonged (17.4 ± 8.6 months), the stress fractures had a pathognomonic appearance (i.e., band-/meander-shaped, along the growth plate) and were diagnosed in the distal tibia (53%), the calcaneus (53%), around the knee (62%) and at multiple sites (68%). Skeletal deterioration was expressed by osteoporosis (62%) along with dissociation of low bone formation and increased bone resorption. MTX treatment was discontinued in 27/34 patients, and a combined denosumab-teriparatide treatment initiated. Ten patients re-evaluated at follow-up (2.6 ± 1.5 years) had improved clinically in terms of successful remobilization. Taken together, our findings provide the first in-depth skeletal characterization of patients with pathognomonic stress fractures after long-term MTX treatment.
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Affiliation(s)
- Tim Rolvien
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestraße 59, 22529, Hamburg, Germany
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Nico Maximilian Jandl
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestraße 59, 22529, Hamburg, Germany
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Julian Stürznickel
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestraße 59, 22529, Hamburg, Germany
| | - Frank Timo Beil
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Ina Kötter
- 3rd Department of Medicine (Rheumatology), University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Ralf Oheim
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestraße 59, 22529, Hamburg, Germany
| | - Ansgar W Lohse
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Florian Barvencik
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestraße 59, 22529, Hamburg, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestraße 59, 22529, Hamburg, Germany.
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Piponov HI, Goldstein JM, Eisenberg GM. Multiple ipsilateral femoral stress fractures in a patient taking denosumab for osteoporosis-a case report. Osteoporos Int 2020; 31:2263-2267. [PMID: 32561954 DOI: 10.1007/s00198-020-05499-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 06/08/2020] [Indexed: 01/18/2023]
Abstract
UNLABELLED This is the first report describing three ipsilateral femoral stress fractures in a patient taking denosumab. INTRODUCTION Multiple reports of atypical femur fractures (AFF) in patients receiving denosumab have emerged recently. Denosumab is an anti-resorptive agent approved for treatment of osteoporosis. It is a human monoclonal antibody which blocks osteoclast activation, maturation, and function. METHODS This is a case report of a 74-year-old female patient who sustained three stress fractures of her left femur. RESULTS The patient healed her fractures after intramedullary nailing of the femur and was able to return to her activities. CONCLUSIONS High index of suspicion is needed in any patient with osteoporosis on denosumab complaining of thigh or groin pain. Careful examination and radiographic studies of both femurs are warranted if AFF is discovered.
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Affiliation(s)
- H I Piponov
- Department of Orthopaedics, University of Illinois at Chicago, 835 S. Wolcott Avenue E-270 MSS MC 844, Chicago, IL, 60612-7342, USA.
- Advocate Lutheran General Hospital, Park Ridge, IL, USA.
| | - J M Goldstein
- Advocate Lutheran General Hospital, Park Ridge, IL, USA
- Illinois Bone and Joint Institute, Morton Grove, IL, USA
| | - G M Eisenberg
- Advocate Lutheran General Hospital, Park Ridge, IL, USA
- Illinois Bone and Joint Institute, Morton Grove, IL, USA
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Png MA, Mohan PC, Koh JSB, Howe CY, Howe TS. Natural history of incomplete atypical femoral fractures in patients after a prolonged and variable course of bisphosphonate therapy-a long-term radiological follow-up. Osteoporos Int 2019; 30:2417-2428. [PMID: 31435684 DOI: 10.1007/s00198-019-05067-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 06/19/2019] [Indexed: 01/25/2023]
Abstract
UNLABELLED Understanding the natural history of lateral femoral stress fractures helps to guide their management. Improvement in their radiographic characteristics is rare. Progression was generally sequential, most developing an incomplete fracture line before fracture displacement. Stopping bisphosphonates decreased the fracture rate, a feasible management option for lesions without incomplete fracture lines. INTRODUCTION Retrospective study evaluating the natural history of lateral femoral stress fractures (FSF) by serial radiography over a variable period of time in a cohort of patients treated for some time with bisphosphonates for osteoporosis, whilst also identifying the fracture response in cases where bisphosphonates were discontinued. METHODS The radiographs of 76 consecutive patients (92 femurs) with 161 FSF were reviewed to document their change over time. Femurs were classified into the following: A-normal, B-focal cortical thickening, C-dreaded black line and D-displaced fracture. Bisphosphonate history was recorded. RESULTS 66.5% FSF showed group stability between the first and last radiographs: group B (79.1%), group C (45.7%). 28.6% progressed, mostly following an ordered sequence starting from group A, progressing to B, then C, before culminating in D. Progression rate was as follows: A-100% (11/11), B-18.3% (21/115), C-40% (14/35). Regression in FSF was uncommon-5.6% (8/161). 34.8% (32/92) sustained displaced fractures. Kaplan-Meier analysis showed statistically significant difference between the groups; median survival (95% CI): A-4189 (-), B-3383.0 (-), C-1807 (0.0-3788.6) and progression to displaced fracture when bisphosphonate had been stopped for at least 6 months. The group without recent bisphosphonates had a lower group progression rate (17.1%, 12/70). Nevertheless, 10.9% (5/46) progressed to displaced fracture. This group also had the highest proportion of stable (77.1%, 54/70) and regressive lesions (5.7%, 4/70). CONCLUSIONS In FSF, there is natural progression from normal bone, to focal cortical thickening, to dreaded black line and eventually to displaced fracture. Most lesions persist, remaining static or progressing, especially if a dreaded black line is present and bisphosphonates are continued. Regression is uncommon and more frequent when bisphosphonates are discontinued. Despite stopping bisphosphonates, there remains a 10.9% risk of progression to displaced fracture.
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Affiliation(s)
- M A Png
- Department of Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
| | - P C Mohan
- Department of Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - J S B Koh
- Duke-NUS Medical School, Singapore, Singapore
- Department of Orthopedic Surgery, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - C Y Howe
- Faculty of Mathematics, University of Cambridge, Wilberforce Road, Cambridge, CB3 0WA, UK
| | - T S Howe
- Duke-NUS Medical School, Singapore, Singapore
- Department of Orthopedic Surgery, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
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Ames TD, Quatman CE, Phieffer LS, Van Steyn S. Bilateral thigh and knee pain · leg weakness · no history of trauma · Dx? J Fam Pract 2018; 67:E1-E3. [PMID: 29614149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Tyler D Ames
- Department of Orthopaedic Surgery, University of Cincinnati, Ohio, USA
| | - Carmen E Quatman
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Laura S Phieffer
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA
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Bögl HP, Aspenberg P, Schilcher J. Undisturbed local bone formation capacity in patients with atypical femoral fractures: a case series. Osteoporos Int 2017; 28:2439-2444. [PMID: 28474166 DOI: 10.1007/s00198-017-4058-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 04/12/2017] [Indexed: 01/13/2023]
Abstract
UNLABELLED We excised the fracture site in 8 patients with incomplete atypical femoral fractures by drilling an 11-mm-diameter hole. New bone formation could be seen in the hole within a normal time frame. Delayed healing of these fractures might be unrelated to an impaired capacity to form bone. INTRODUCTION Incomplete atypical femoral fractures (undisplaced cracks) heal slowly or not at all, and often progress to a complete fracture with minimal trauma. The impaired healing has been attributed to an impaired biologic healing capacity related to bisphosphonate use, or, alternatively, to the mechanical environment within the fracture crack. This study aimed to investigate the capacity for bone formation after resection of the fracture site. METHODS Between 2008 and 2014, we recruited eight patients with incomplete atypical femoral fractures. All used oral bisphosphonates before the fracture for on average 8 years (range 4 to 15) and complained of thigh pain. The fractures were stabilized with reamed cephalomedullary nails. During surgery, the fracture site in the lateral cortex was resected with a cylindrical drill (diameter 11.5 mm). The cylindrical cortical defect allowed radiographic evaluation of new bone formation, and the patients were followed clinically and radiologically for 24 months (range 15 to 92). RESULTS After 3 months, newly formed bone could be seen in the cortical defects in all patients. After 13-26 months, the previous defects showed continuous cortical bone. At final follow-up, all patients reported full recovery of pre-surgical complaints. No complications occurred and no reoperations were performed. CONCLUSIONS New bone formation occurred within a time frame that appears normal for healing of cortical bone defects. This suggests that the capacity to form new bone is intact.
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Affiliation(s)
- H P Bögl
- Department of Experimental and Clinical Medicine, Faculty of Health Science, Linköping University, SE-581 85, Linköping, Sweden
| | - P Aspenberg
- Department of Experimental and Clinical Medicine, Faculty of Health Science, Linköping University, SE-581 85, Linköping, Sweden
| | - J Schilcher
- Department of Orthopedic Surgery, Gävle hospital, SE-80 324, Gävle, Sweden.
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Sato H, Kondo N, Nakatsue T, Wada Y, Fujisawa J, Kazama JJ, Kuroda T, Suzuki Y, Nakano M, Endo N, Narita I. High and pointed type of femoral localized reaction frequently extends to complete and incomplete atypical femoral fracture in patients with autoimmune diseases on long-term glucocorticoids and bisphosphonates. Osteoporos Int 2017; 28:2367-2376. [PMID: 28409215 DOI: 10.1007/s00198-017-4038-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 04/03/2017] [Indexed: 01/22/2023]
Abstract
UNLABELLED Once a localized reaction (beaking) was detected, discontinuation of bisphosphonates (BPs) and switching to vitamin D supplementation or teriparatide therapy effectively improved its shape. When the localized reaction was high, of the pointed type, and/or accompanied by prodromal pain, the risks of complete and incomplete atypical femoral fracture increased and consideration of prophylactic fixation for such patients was required. INTRODUCTION Femoral localized reaction (localized periosteal thickening of the lateral cortex, beaking) is reported to precede atypical femoral fractures (AFFs) and to develop in 8-10% of patients with autoimmune diseases taking BPs and glucocorticoids. The aims of the present study were to retrospectively investigate the shapes of localized reaction to consider how to manage the condition. METHODS Twenty femora of 12 patients with autoimmune diseases who were on BPs and glucocorticoids exhibited femoral localized reaction. The heights of localized reaction were measured and the shapes classified as pointed, arched, and other. Localized reaction changes were divided into three categories: deterioration, no change, and improvement. A severe form of localized reaction was defined; this was associated with prodromal pain, de novo complete AFF, or incomplete AFF with a fracture line at the localized reaction. RESULTS The mean height of localized reaction was 2.3 ± 0.8 mm (range, 1.0-3.7 mm) and the pointed type was 35%. Localized reaction was significantly higher (3.3 ± 0.8 vs. 2.1 ± 0.7 mm; p = 0.003) and the pointed type more common (78 vs. 27%; p = 0.035) in those with the severe form of localized reaction. Seven patients with localized reactions discontinued BPs just after localized reaction was detected, but five continued on BPs for 2 years. Localized reaction deterioration was more common in patients who continued than discontinued BPs (100 vs. 29%; p = 0.027). After 2 years, all patients had discontinued BPs and localized reaction did not deteriorate further in any patient. CONCLUSIONS Once a localized reaction was detected, discontinuation of BPs and switching to vitamin D supplementation or teriparatide therapy effectively improved it. When the localized reaction was high, of the pointed type, and/or accompanied by prodromal pain, the risks of complete and incomplete AFF increased and consideration of prophylactic fixation for such patients was required.
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Affiliation(s)
- H Sato
- Health Administration Center, Niigata University, 2-8050 Ikarashi, Nishiku, Niigata City, 950-2181, Japan.
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuoku, Niigata City, 951-8510, Japan.
| | - N Kondo
- Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuoku, Niigata City, 951-8510, Japan
| | - T Nakatsue
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuoku, Niigata City, 951-8510, Japan
| | - Y Wada
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuoku, Niigata City, 951-8510, Japan
| | - J Fujisawa
- Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuoku, Niigata City, 951-8510, Japan
| | - J J Kazama
- Department of Nephrology and Hypertention, Fukushima Medical University, 1 Hikariga-oka, Fukushima City, 960-1295, Japan
| | - T Kuroda
- Health Administration Center, Niigata University, 2-8050 Ikarashi, Nishiku, Niigata City, 950-2181, Japan
| | - Y Suzuki
- Health Administration Center, Niigata University, 2-8050 Ikarashi, Nishiku, Niigata City, 950-2181, Japan
| | - M Nakano
- Department of Medical Technology, School of Health Sciences, Faculty of Medicine, Niigata University, 2-746 Asahimachi-Dori, Chuoku, Niigata City, 951-8518, Japan
| | - N Endo
- Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuoku, Niigata City, 951-8510, Japan
| | - I Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuoku, Niigata City, 951-8510, Japan
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Adams AL, Xue F, Chantra JQ, Dell RM, Ott SM, Silverman S, Giaconi JC, Critchlow C. Sensitivity and specificity of radiographic characteristics in atypical femoral fractures. Osteoporos Int 2017; 28:413-417. [PMID: 27766369 DOI: 10.1007/s00198-016-3809-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/11/2016] [Indexed: 12/30/2022]
Abstract
UNLABELLED Using the American Society for Bone and Mineral Research Task Force case definition for atypical femoral fractures, sensitivity and specificity of radiographic fracture characteristics were calculated. Fracture pattern was the most sensitive and specific characteristic. This suggests that some characteristics should be weighted more heavily when identifying these fractures. INTRODUCTION To estimate the sensitivity and specificity of each radiographic criterion in the 2013 ASBMR atypical femoral fracture (AFF) case definition for distinguishing AFF from other subtrochanteric/diaphyseal fractures (non-AFF) among women enrolled in a large integrated health care organization. METHODS Radiographs from 55 physician-confirmed AFFs and a sample of 39 non-AFFs were reviewed by four independent expert reviewers representing four medical specialties. One image per fracture was selected for review. Using a standardized data collection tool, based on the 2013 AFF case definition, reviewers indicated the presence or absence of the following characteristics viewable on radiograph: fracture pattern, comminution, periosteal and/or endosteal thickening, and cortical thickening. Sensitivity and specificity for each characteristic was calculated for each reviewer and summarized across reviewers with the mean and range. Agreement across reviewers was quantified using Fleiss's kappa (FK) statistic. RESULTS The most sensitive factors distinguishing AFF from non-AFF were lateral cortex transverse fracture pattern (mean 93.6 %, range 85.5-98.2 %), medial cortex transverse or oblique fracture pattern (mean 84.1 %, range 72.7-98.2 %), and minimal/non-comminution (mean 93.2 %, range 89.1-98.2 %). Specificity was the greatest for lateral cortex transverse fracture pattern (mean 95.5 %, range 92.3-97.4 %). Agreement across reviewers was the highest for lateral cortex transverse fracture pattern (FK 0.83) and incomplete fracture through the lateral cortex only (FK 0.80). CONCLUSION Lateral cortex transverse fracture pattern was the most sensitive and specific characteristic and the most highly agreed upon across reviewers. Other characteristics were less readily agreed upon across reviewers. Measurement of discrete combinations of individual characteristics may enhance sensitivity and/or specificity.
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Affiliation(s)
- A L Adams
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA.
| | - F Xue
- Center for Observational Research, Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA, 91320, USA
| | - J Q Chantra
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA
| | - R M Dell
- Department of Orthopedic Surgery, Kaiser Permanente Southern California, 9333 Imperial Hwy, Downey, CA, 90242, USA
| | - S M Ott
- Department of Medicine, University of Washington, 1959 NE Pacific Street, UW Mailbox 356426, Seattle, WA, 98195, USA
| | - S Silverman
- Department of Rheumatology, Cedars-Sinai/UCLA, 200 UCLA Medical Plaza, Los Angeles, CA, 90095, USA
| | - J C Giaconi
- Cedars Sinai Imaging Medical Group, Cedars Sinai Medical Center, 8700 Beverly Blvd.,, Los Angeles, CA, 90048, USA
| | - C Critchlow
- Center for Observational Research, Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA, 91320, USA
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12
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Favinger JL, Hippe D, Ha AS. Long-term radiographic follow-up of bisphosphonate-associated atypical femur fractures. Skeletal Radiol 2016; 45:627-33. [PMID: 26880003 DOI: 10.1007/s00256-016-2346-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 01/21/2016] [Accepted: 02/01/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the appearance of bisphosphonate-related femur insufficiency fractures on long-term follow-up radiographic studies and to describe the rate of fracture line obscuration and cortical beak healing over time. MATERIALS AND METHODS In this retrospective study, bisphosphonate-related femur fracture radiographs were reviewed by two radiologists for the presence of a fracture line, callus, and the characteristic cortical beak. Kaplan-Meier curves were used to analyze the time to first indication of healing. Femurs were also subdivided into those who underwent early versus late surgical fixation and those who underwent early versus late discontinuation of bisphosphonate. Clinical data including pain level and medication history were collected. RESULTS Forty-seven femurs with a bisphosphonate-related femur fracture were identified in 28 women. Eighty-five percent took a bisphosphonate for greater than 5 years and 59 % for greater than 10 years. The median time to beak healing was 265 weeks and the median time to fracture line healing was 56 weeks in the 31 femurs with a baseline fracture. No statistically significant difference was identified between surgical fixation and conservative management. CONCLUSIONS Bisphosphonate-related fractures demonstrate notably prolonged healing time on long-term follow-up.
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Affiliation(s)
- Jennifer L Favinger
- Department of Radiology, University of Washington, 1959 N.E. Pacific Street, Box 357115, Seattle, WA, 98195, USA
| | - Daniel Hippe
- Department of Radiology, University of Washington, 850 Republication St, Seattle, WA, 98109, USA
| | - Alice S Ha
- Department of Radiology, University of Washington, 4245 Roosevelt Way NE, Box 354755, Seattle, WA, 98105, USA.
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13
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Sato H, Kondo N, Wada Y, Nakatsue T, Iguchi S, Fujisawa J, Kazama JJ, Kuroda T, Nakano M, Endo N, Narita I. The cumulative incidence of and risk factors for latent beaking in patients with autoimmune diseases taking long-term glucocorticoids and bisphosphonates. Osteoporos Int 2016; 27:1217-1225. [PMID: 26519417 DOI: 10.1007/s00198-015-3382-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 10/20/2015] [Indexed: 02/25/2023]
Abstract
SUMMARY The incidence of beaking, which has been reported to precede atypical femoral fracture, was high and increased over 2 years in patients with autoimmune diseases who were taking bisphosphonates and glucocorticoids. Regular femoral X-rays are strongly recommended to screen for beaking, and bisphosphonate drug holidays should be considered. INTRODUCTION Atypical femoral fractures (AFFs) have been recently recognized as complications associated with bisphosphonate (BP) use. AFFs are considered to be stress fractures; localized periosteal thickening of the lateral cortex is often present at the fracture site; this thickening is termed "beaking." Beaking has been reported to precede AFF. The aims of the present study were to evaluate the incidence of latent beaking in patients with autoimmune diseases taking BPs and glucocorticoids and to identify risk factors for beaking. METHODS A total of 125 patients with autoimmune diseases who were taking BPs and glucocorticoids was included; 116 patients underwent X-rays and analysis of serum and urine bone metabolic markers annually for 2 years. Mean patient age was 54.5 years; there were 105 (90.5%) females and the mean duration of disease was 13.2 years. Focal lateral cortical thickening in femoral X-rays was defined as beaking. RESULTS Beaking was detected in 15 femora of 10 patients (8.0%) at the time of recruitment. Over the 2-year observation period, the incidence of beaking increased to 21 femora of 12 patients (10.3%), and a complete AFF at the location of beaking occurred in one patient. Beaking was associated with a longer duration of BP treatment (6.1 ± 1.0 years vs. 5.0 ± 2.9 years, p = 0.01). Age 40-60 years, BP therapy ≥4 years, and diabetes mellitus were significantly associated with beaking. CONCLUSIONS The incidence of beaking was high, and increased over 2 years, in patients with autoimmune diseases who were taking BPs and glucocorticoids. Regular femoral X-rays are strongly recommended to screen for beaking. Long-term BP/glucocorticoid use was a risk factor for beaking in patients with autoimmune diseases; BP drug holidays should be considered.
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Affiliation(s)
- H Sato
- Division of Clinical Nephrology and Rheumatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-Dori, Chuoku, Niigata City, 951-8510, Japan.
| | - N Kondo
- Division of Orthopedic Surgery, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-Dori, Chuoku, Niigata City, 951-8510, Japan
| | - Y Wada
- Division of Clinical Nephrology and Rheumatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-Dori, Chuoku, Niigata City, 951-8510, Japan
| | - T Nakatsue
- Division of Clinical Nephrology and Rheumatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-Dori, Chuoku, Niigata City, 951-8510, Japan
| | - S Iguchi
- Division of Clinical Nephrology and Rheumatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-Dori, Chuoku, Niigata City, 951-8510, Japan
| | - J Fujisawa
- Division of Orthopedic Surgery, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-Dori, Chuoku, Niigata City, 951-8510, Japan
| | - J J Kazama
- Division of Clinical Nephrology and Rheumatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-Dori, Chuoku, Niigata City, 951-8510, Japan
| | - T Kuroda
- Health Administration Center, Niigata University, 2-8050 Ikarashi, Nishiku, Niigata City, 950-2181, Japan
| | - M Nakano
- Department of Medical Technology, School of Health Sciences, Faculty of Medicine, Niigata University, 2-746 Asahimachi-Dori, Chuoku, Niigata City, 951-8518, Japan
| | - N Endo
- Division of Orthopedic Surgery, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-Dori, Chuoku, Niigata City, 951-8510, Japan
| | - I Narita
- Division of Clinical Nephrology and Rheumatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-Dori, Chuoku, Niigata City, 951-8510, Japan
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14
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Abstract
We report the case of a 53-year-old female, treated by bisphosphonate for 12 years, who presented atraumatic fractures of both fibulas. Her X-rays showed bilateral distal fibula fractures with radiological features similar to atypical femur fractures. The distal fibula should be considered as a potential site for stress fractures in bisphosphonate users. Bisphosphonates are the most widely used drugs in the treatment of osteoporosis. During the last decade, the occurrence of atypical fractures, mostly subtrochanteric and diaphyseal femoral fractures, has been acknowledged in patients with long-term use of bisphosphonates. We report the case of a 53-year-old female on alendronate therapy for the past 12 years who presented with a few months history of atraumatic right, and subsequently left, lateral ankle pain. Her X-rays showed bilateral distal fibula fractures with radiological features similar to atypical femur fractures. She had been treated conservatively with walking boots and her treatment with bisphosphonate had been stopped 5 months prior to the fractures. Callus was progressively seen on serial follow-up X-rays, and both fractures healed completely within a reasonable period of 1 year. Investigations did not reveal any secondary causes of osteoporosis or metabolic bone disorders. To our knowledge, this is the first reported case of bilateral distal fibula fractures in a patient on long-term bisphosphonate therapy.
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Affiliation(s)
- J C Murray
- Division of Orthopaedic Surgery, Department of Surgery, CHU de Québec and Université Laval, Québec, QC, Canada
| | - M C Audet
- Division of Rheumatology, Department of Medicine, Université Laval, Québec, QC, Canada
- Department of Rheumatology, CHU de Québec, Québec, QC, Canada
| | - M Bédard
- Division of Orthopaedic Surgery, Department of Surgery, CHU de Québec and Université Laval, Québec, QC, Canada
| | - L Michou
- Division of Rheumatology, Department of Medicine, Université Laval, Québec, QC, Canada.
- Department of Rheumatology, CHU de Québec, Québec, QC, Canada.
- CHU de Québec Research Centre, Québec, QC, G1V 4G2, Canada.
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15
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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] [What about the content of this article? (0)] [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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16
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Ramchand SK, Chiang CY, Zebaze RM, Seeman E. Recurrence of bilateral atypical femoral fractures associated with the sequential use of teriparatide and denosumab: a case report. Osteoporos Int 2016; 27:821-5. [PMID: 26458389 DOI: 10.1007/s00198-015-3354-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 09/29/2015] [Indexed: 01/23/2023]
Abstract
We report that a postmenopausal woman with osteoporosis developed bilateral incomplete atypical femoral fractures (AFFs) after seven years of bisphosphonate therapy. Cessation of the bisphosphonate and treatment with teriparatide was associated with near complete radiological resolution of the AFFs. After 12 months without treatment, denosumab was commenced to prevent structural deterioration. Six months later she developed recurrent bilateral AFFs. This case highlights the management dilemma in patients with ongoing bone loss but prone to stress fractures associated with antiresorptive therapy. Stopping the antiresorptive is recommended but structural decay will recur predisposing to fragility fractures. If the antiresorptive is continued, bone material composition will be further compromised predisposing to atypical fractures. Teriparatide may assist healing of stress fractures and improvement in bone matrix composition. Later antiresosrptive therapy to preserve bone microstructure may compromise material composition.
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Affiliation(s)
- S K Ramchand
- Department of Endocrinology, Austin Health, Level 2 Centaur Building Repatriation Campus, Heidelberg, Melbourne, VIC, 3084, Australia.
| | - C Y Chiang
- Department of Endocrinology, Austin Health, Level 2 Centaur Building Repatriation Campus, Heidelberg, Melbourne, VIC, 3084, Australia
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, Australia
| | - R M Zebaze
- Department of Endocrinology, Austin Health, Level 2 Centaur Building Repatriation Campus, Heidelberg, Melbourne, VIC, 3084, Australia
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, Australia
| | - E Seeman
- Department of Endocrinology, Austin Health, Level 2 Centaur Building Repatriation Campus, Heidelberg, Melbourne, VIC, 3084, Australia
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, Australia
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17
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Iwata K, Mashiba T. [Pathogenesis of atypical femoral fracture]. Clin Calcium 2016; 26:73-79. [PMID: 26728533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
We demonstrated microdamage accumulation in the fracture sites in the patients of subtrochanteric atypical femoral fracture with long term bisphosphonate therapy and of incomplete shaft fracture of lateral femoral bowing without bisphosphonate therapy. Based on these findings, pathogenesis of atypical femoral fracture is revealed stress fracture caused by accumulation of microdamages between distal to the lesser trochanter and proximal to the supracondylar flare in the femur in association with severely suppressed bone turnover and/or abnormal lower limb alignment, that causes stress concentration on the lateral side cortex of the femur.
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Affiliation(s)
- Ken Iwata
- Department of Orthopedic Surgery, Kagawa University Faculty of Medicine, Japan
| | - Tasuku Mashiba
- Department of Orthopedic Surgery, Kagawa University Faculty of Medicine, Japan
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18
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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19
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Tan SHS, Saseendar S, Tan BHM, Pawaskar A, Kumar VP. Ulnar fractures with bisphosphonate therapy: a systematic review of published case reports. Osteoporos Int 2015; 26:421-9. [PMID: 25227921 DOI: 10.1007/s00198-014-2885-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 09/03/2014] [Indexed: 10/24/2022]
Abstract
SUMMARY A systematic review of eight ulnar fractures in seven patients with bisphosphonate therapy was performed to describe the characteristics and predisposing factors. The proximal ulna is likely to be fractured, especially in the dominant limb of elderly female patients using walking aids after 7 to 15 years of bisphosphonate use. INTRODUCTION Long-term bisphosphonate use has been suggested to result in decreased bone remodelling and increased risk of atypical fractures. While the relationship between bisphosphonate use and atypical femoral fractures has been extensively studied, there is relative rarity and unawareness of these fractures in the forearm. We conducted a systematic review of existing case reports to better describe the characteristics and predisposing factors for fractures occurring in patients with bisphosphonate therapy. METHODS The systematic review was conducted according to PRISMA guidelines. All studies with ulnar fractures in individuals with history of bisphosphonate use were included, with data extracted and analysed in totality. RESULTS Seven patients with eight fractures are included. Predisposing factors include elderly females requiring walking aids. There is a propensity for the proximal ulna to be fractured, especially in the dominant limb used for ambulation or transfer. All patients were on bisphosphonate for 7 to 15 years. All fractures were atraumatic, non-comminuted, transverse in configuration, had localised periosteal or endosteal thickening at the fracture site and generalised cortical thickening of the diaphysis. CONCLUSION Ulnar fractures in patients with bisphosphonate therapy demonstrate features similar to those described for atypical femoral fractures, suggesting that these fractures could also possibly be due to bisphosphonate use. However, the ulna appears to be able to tolerate longer periods of alendronate use prior to fracture development. The mechanism and characteristics of these fractures additionally suggest the presence of repetitive stress that accumulates over time due to suppressed bone remodelling in patients on bisphosphonates, eventually resulting in these fractures.
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Affiliation(s)
- S H S Tan
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), 1E Kent Ridge Road, NUHS Tower Block, Level 11, Yong Loo Lin School of Medicine Dean's Office, Singapore, 119228, Singapore,
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20
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Rifai A, Pourtaheri S, Carbone A, Callaghan JJ, Stadler CM, Record N, Issa K. Bilateral femur fractures associated with short-term bisphosphonate use. Orthopedics 2015; 38:e139-42. [PMID: 25665120 DOI: 10.3928/01477447-20150204-90] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 06/24/2014] [Indexed: 02/03/2023]
Abstract
Bisphosphonates are the most commonly prescribed drugs to treat osteoporosis because they have been proposed to prevent bone loss. Nevertheless, in up to 0.1% of patients, long-term use may cause atypical stress or insufficiency femoral fractures. Bilateral femoral shaft fractures have been reported after long-term use of bisphosphonates; however, there is limited evidence of the effect of short-term use. The current study reports a case of bilateral femoral fractures after a low-energy fall in a 56-year-old woman and provides a review of the literature on bilateral femoral shaft fractures after long-term use of bisphosphonates. Patients should be educated about the potential for stress fractures with the use of this treatment. In patients with thigh pain, a thorough history and physical examination, including the contralateral thigh, may be beneficial to detect bilateral traumatic or atypical stress fracture patterns. More studies with larger sample sizes are necessary to better identify patients who may be at risk for fracture, including histomorphometric evidence of low bone turnover in patients with unfortunate bilateral cases.
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21
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Skoglund K, Hjortdal O. Femoral fracture and temporomandibular joint destruction following the use of bisphosphonates. Tidsskr Nor Laegeforen 2015; 135:116-7. [PMID: 25625987 DOI: 10.4045/tidsskr.14.1108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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22
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Cawley DT, Barrett HL, Harrington P. Obliteration of the medullary canal in an atypical bisphosphonate-related femoral fracture. BMJ Case Rep 2015; 2015:bcr2014205439. [PMID: 25568263 PMCID: PMC4289787 DOI: 10.1136/bcr-2014-205439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2014] [Indexed: 11/03/2022] Open
Abstract
We present a case of a patient with a bisphosphonate-related atypical femoral fracture. Her surgical management was complicated by obliteration of the medullary canal, which prohibited the passage of an intramedullary nail. The relevant literature is discussed.
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23
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Górski R, Żarek S, Modzelewski P, Dąbrowski F. Bilateral fatigue fractures of the bones of both crura in a patient with a history of abuse of alcohol and psychoactive substances treated with Ilizarov external fixator apparatus. Pol Orthop Traumatol 2014; 79:123-131. [PMID: 25083746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Fatigue (slow) fractures are a result of cyclic burden on the affected bones. At the same time, regeneration processes are disturbed or appropriate mechanical environment to promote healing is lacking. Fatigue fractures are classified into two types: stress fractures and deficiency fractures. The former occur as a result of excessive training in healthy individuals with normal bone structure, e.g. in sportsmen and soldiers. Deficiency-related fractures are most common in individuals with metabolic disorders that affect bone mineralization, such as osteomalacia or osteoporosis. CASE REPORT The article presents a case of a 37-year-old male with fatigue fractures within both crura. During the interview, the patient reported the abuse of alcohol and benzodiazepines and the history of using other psychoactive substances. CONCLUSIONS Fractures were treated using Ilizarov external fixator apparatus. Bone union was achieved after several months of external fixation.
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Affiliation(s)
- Radosław Górski
- Clinic and Chair of Motor Organ Orthopedics and Traumatology, First Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Sławomir Żarek
- Clinic and Chair of Motor Organ Orthopedics and Traumatology, First Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Modzelewski
- Clinic and Chair of Motor Organ Orthopedics and Traumatology, First Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Filip Dąbrowski
- Clinic and Chair of Motor Organ Orthopedics and Traumatology, First Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
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24
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Chiang GSH, Koh KWB, Chong TW, Tan BY. Stress fracture of the ulna associated with bisphosphonate therapy and use of walking aid. Osteoporos Int 2014; 25:2151-4. [PMID: 24833031 DOI: 10.1007/s00198-014-2739-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Accepted: 05/01/2014] [Indexed: 11/26/2022]
Abstract
We report a case of a stress fracture of the ulna secondary to long-term bisphosphonate therapy and walking cane. Physicians need to have a high index of suspicion of stress fractures occurring in patients complaining of chronic upper limb pain if they are on bisphosphonate therapy and are using walking aids. Stress fractures of the upper extremities are rare and are usually associated with athletes; however, a few recent case reports have shown an association between stress fractures of the upper extremities and the use of walking aids. The association between increased incidence of upper extremity stress fractures and the use of both bisphosphonates and walking aids in patients has not been well studied, with only one previously reported case. Here, we report a case of a complete stress fracture of the ulna in a 77-year-old female, premorbidly ambulant with walking cane, on long-term bisphosphonates without any pre-existing medical conditions which could result in secondary causes of bone loss. Investigations did not reveal any causes of pathological fracture. This fracture is attributed to the use of long-term bisphosphonate therapy in conjunction with the use of a walking cane. This case highlights the importance of entertaining the possibility of such fractures occurring in any patient who is on bisphosphonate therapy presenting with stress fractures of the upper extremity.
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25
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26
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Abstract
Stress fractures are repetitive strain injuries that occur in normal bones and in abnormal bones. Stress fractures share many features in common but differences depend on the status of the underlying bone. This review article for clinicians addresses aspects about stress fractures with particular respect to fatigue fractures, Looser zones of osteomalacia, atypical Looser zones, atypical femoral fractures associated with bisphosphonate therapy and stress fractures in Paget's disease of bone.
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Affiliation(s)
- M J McKenna
- Department of Endocrinology, St. Vincent's University Hospital, Dublin, Ireland.
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27
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Affiliation(s)
- Jörg Schilcher
- Orthopedic Surgeon Department of Orthopedic Surgery University Hospital Linköping 58246 Linköping +46 101034312
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28
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Abstract
We report a case of bilateral ulna stress fractures following bilateral femoral fractures associated with long-term bisphosphonate use. The patient is an 84-year-old woman receiving 15 years of bisphosphonate therapy. She did not have any preexisting medical conditions which are known secondary causes of bone loss. She was mostly housebound and used a walking frame for ambulation. She presented with atraumatic right ulna pain and subsequent atraumatic left ulna pain a month later. She was treated conservatively in backslabs and her bisphosphonate was stopped. Investigations did not reveal any secondary causes of osteoporosis or metabolic bone disorders.
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Affiliation(s)
- B F H Ang
- Singapore General Hospital, Outram Road, Singapore, Singapore, 169608.
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29
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Verdet M, Nicolau J, Lefaucheur R, Maltête D, Derrey S, Daragon A. Recurrent bilateral metatarsal "stress-and-insufficiency" fractures in a levodopa-treated young woman with Parkinson's disease. Osteoporos Int 2013; 24:1131-3. [PMID: 22875460 DOI: 10.1007/s00198-012-2104-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 05/29/2012] [Indexed: 11/27/2022]
Abstract
Levodopa treatment of Parkinson's disease is very effective, but many types of adverse events can complicate the disease course, especially dyskinesias. As reported by Lee et al. (Calcif Tissue Int 86:132-41, 2010), levodopa intake is associated with increased homocysteinemia that is known to be linked to poorer bone quality and, consequently, osteoporotic fractures. Herein, we report the case of a young woman who suffered recurrent metatarsal fractures in the context of levodopa-treated early-onset Parkinson's disease.
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Affiliation(s)
- M Verdet
- Service de Rhumatologie, CHU Hôpitaux de Rouen, Hôpital de Bois-Guillaume, 147 av du Mal Juin, 76230 Bois-Guillaume Cedex, France.
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30
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Shin DY, Ku CR, Kim KM, Choi HS, Rhee Y, Lee EJ, Lim SK. Spontaneous non-traumatic stress fractures in bilateral femoral shafts in a patient treated with bisphosphonates. Korean J Intern Med 2012; 27:98-102. [PMID: 22403507 PMCID: PMC3295996 DOI: 10.3904/kjim.2012.27.1.98] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Revised: 07/07/2008] [Accepted: 08/29/2008] [Indexed: 11/27/2022] Open
Abstract
Bisphosphonates are potent inhibitors of bone resorption and widely used to treat osteoporosis. Extensive studies have shown that therapy with bisphosphonates improves bone density and decreases fracture risk. However, concerns have been raised about potential over-suppression of bone turnover during long-term use of bisphosphonates, resulting in increased susceptibility to and delayed healing of non-spinal fractures. We report a patient who sustained non-traumatic stress fractures in bilateral femoral shafts with delayed healing after long-term bisphosphonate therapy. She underwent open reduction and surgical internal fixation. Although bisphosphonates effectively prevent vertebral fractures, and their safety has been tested in randomized trials, we must emphasize the need for awareness of the possibility that long-term suppression of bone turnover with bisphosphonates may eventually lead to an accumulation of fatigue-induced damage and adverse skeletal effects such as delayed fracture healing.
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Affiliation(s)
- Dong Yeob Shin
- Department of Internal Medicine and Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Cheol Ryong Ku
- Department of Internal Medicine and Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Min Kim
- Department of Internal Medicine and Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Han Seok Choi
- Department of Internal Medicine and Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yumie Rhee
- Department of Internal Medicine and Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Jig Lee
- Department of Internal Medicine and Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Kil Lim
- Department of Internal Medicine and Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Lenz R, Ellenrieder M, Skripitz R, Bader R, Pautke C, Mittelmeier W, Tischer T. [Biphosphonate-induced femoral stress fractures : A new problem and knowledge so far - case report]. Orthopade 2011; 40:1111-1118. [PMID: 21678088 DOI: 10.1007/s00132-011-1786-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
During the last several years the treatment of osteoporosis with bisphosphonates has become accepted as a safe and effective procedure. However, recently there have been increasing numbers of reports of rare complications in the literature. Particularly the occurrence of atypical fractures of the femur has become a focus of interest but the problem is insufficiently known and only rarely addressed in the scientific discussion. The case illustrated here and a survey of the important facts in the recent literature highlight essential aspects of long-term bisphosphonate therapy.
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Affiliation(s)
- R Lenz
- Orthopädische Klinik und Poliklinik, Universitätsklinikum Rostock, Doberanerstr. 142, 18057, Rostock, Deutschland.
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Murphy CG, O'Flanagan S, Keogh P, Kenny P. Subtrochanteric stress fractures in patients on oral bisphosphonate therapy: an emerging problem. Acta Orthop Belg 2011; 77:632-637. [PMID: 22187839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The emergence of a new variant of subtrochanteric stress fractures of the femur, affecting patients on oral bisphosphonate therapy, has only recently been described. This fracture is often preceded by pain and distinctive radiographic changes (lateral cortical thickening), and associated with a characteristic fracture pattern (transverse fracture line and medial cortical spike). A retrospective review (2007-2009) was carried out for patients who were taking oral bisphosphonates and who sustained a subtrochanteric fracture after a low velocity injury. Eleven fractures were found in 10 patients matching the inclusion criteria outlined. All were females, and taking bisphosphonates for a mean of 43 years. Five of the 10 patients mentioned prodromal symptoms, for an average of 9.4 months before the fracture. Although all fractures were deemed low velocity, 5 of 11 were even atraumatic. Two patients had previously sustained contralateral subtrochanteric fractures. Plain radiographs of two patients showed lateral cortical thickening on the contralateral unfractured femur; the bisphosphonate therapy was stopped and close surveillance was started. Patients taking oral bisphosphonates may be at risk of a new variant of stress fracture of the proximal femur. Awareness of the symptoms is the key to ensure that appropriate investigations are undertaken.
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Affiliation(s)
- Colin G Murphy
- Department of Orthopaedics, Connolly Hospital, Blanchardstown, Ireland.
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Abstract
The aim of this paper is to analyze on clinical cases specific features of femoral insufficiency fractures during bisphosphonates therapy. We are presenting two insufficiency femoral fractures (2 patients) in patients receiving bisphosphonate therapy. These two cases represent new type of femoral fractures. These are low energy or spontaneous fractures of diaphysis and subtrochanteric region. Prodromal pain is often observed. On x-rays thick lateral cortex, its ellipsoid thickening and transverse or oblique fracture line is observed. Many authors link such fractures to long-term bisphosphonate therapy. Patients on long term bisphosphonate therapy present with new and specific fracture pattern of femoral bone. Fractures of this pattern are extremely rare. The risk benefit ratio of bisphosphonates therapy is not changed.
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Affiliation(s)
- Andrzej Boszczyk
- Department of Traumatology and Orthopaedics, The Medical Centre of Postgraduate Education, Otwock, Poland. bosz czyk@ga ze ta.pl
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Sjödén G, Sayed-Noor A, Kadum B, Pettersson U. [Biphosphonate treatment can cause stress fracture. But treatment benefits significantly overweight the risk]. Lakartidningen 2010; 107:2482-2483. [PMID: 21137565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Agarwal S, Agarwal S, Gupta P, Agarwal PK, Agarwal G, Bansal A. Risk of atypical femoral fracture with long-term use of alendronate (bisphosphonates) : a systemic review of literature. Acta Orthop Belg 2010; 76:567-71. [PMID: 21138208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Several recent reports have described "atypical" fractures of the subtrochanteric and diaphyseal femoral shaft that occur with minimal or no trauma, associated with the use of bisphosphonates. Physicians treating bone diseases with bisphosphonate need, therefore, to be aware of this potential risk and plan the prophylaxis, early diagnosis and prevention of potential consequences. We review the literature on this newly described complication, with particular focus on pathogenesis, preventive measures suggested before and during therapy with bisphosphonates, and the most frequent clinical presentation of these lesions. The recommendations for the management and care of patients who are on long-term use of alendronate (bisphosphonates) are summarized.
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Affiliation(s)
- Sippy Agarwal
- Department of Gynaecology & Obstetrics, Sarojini Naidu Medical College, Agra, India
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Singh S, Singh V, Joshi A. Comment on Xue et al.: Alendronate treatment improves bone-pedicle screw interface fixation in posterior lateral spine fusion: an experimental study in a porcine model. Int Orthop 2010; 34:1359. [PMID: 20455062 DOI: 10.1007/s00264-010-1028-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2010] [Accepted: 04/12/2010] [Indexed: 11/27/2022]
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Edwards MH, McCrae FC, Young-Min SA. Alendronate-related femoral diaphysis fracture--what should be done to predict and prevent subsequent fracture of the contralateral side? Osteoporos Int 2010; 21:701-3. [PMID: 19562241 DOI: 10.1007/s00198-009-0986-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Accepted: 05/20/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Atypical fractures of the femoral diaphysis have recently been associated with alendronate therapy (Neviaser et al. J Orthop Trauma 22(5):346-350, 2008; Kwek et al. Injury 39:224-231, 2008; Lenart et al. N Engl J Med 358:1304-1306, 2008). METHODS In many cases, fractures have occurred bilaterally prompting debate regarding appropriate screening of the unaffected side (Kwek et al. N Engl J Med 359(3):316-317, 2008). CASE REPORT We report a case of sequential, bilateral, femoral diaphysis fractures associated with prolonged alendronate therapy and the failure to predict the subsequent fracture of the contralateral side despite radiological imaging. DISCUSSION We review the current literature and discuss potential management strategies.
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Affiliation(s)
- M H Edwards
- Rheumatology Department, Queen Alexandra Hospital, Portsmouth, Hampshire, UK.
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Abstract
BACKGROUND Recent case reports have identified an association between long-term bisphosphonate treatment and stress fractures of the femoral shaft. The risk of such fractures in bisphosphonate users has not been determined. METHODS We identified women over 55 years of age with the specific fracture pattern by searching the operation registry of the hospitals in 2 healthcare districts. Prevalence of bisphosphonate treatment was provided by a Swedish national registry covering all drugs delivered to all individuals since 2005. RESULTS The number of women on bisphosphonate treatment was 3,087. Of these, 5 had femoral stress fractures. They had been taking bisphosphonates for 3.5 to 8.5 years. The incidence density for a patient on bisphosphonate was 1/1,000 per year (95% CI: 0.3-2). In the remaining 88,869 women who were not taking bisphosphonates, there were 3 stress fractures. Thus, their risk (without correction for inhomogeneity in age distribution) was 46 times less (95% CI: 11-200). INTERPRETATION These results are rough estimations based on a comparatively small material. Still, a treatment-associated incidence density of 1/1,000 is acceptable, considering that bisphosphonate treatment is likely to reduce the incidence density of any fracture by 15/1,000 according to a large randomized trial (Black et al. 1996).
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Affiliation(s)
- Jörg Schilcher
- Department of Orthopedics, AIM/IKE, Faculty of Health Science, Linköping University, Linköping, Sweden
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Abstract
INTRODUCTION Microdamage accumulation due to fatigue loading may lead to fracture. In addition, several studies using animal models have suggested in recent years that bisphosphonates might increase microdamage accumulation. METHODS We have reviewed the literature after a PubMed search, to examine the techniques to look for microcracks, the relationship between microdamage and bone strength, and the influence of anti-osteoporosis agents. RESULTS Currently, the search for microcracks relies on bulk staining of bone samples, which are then examined on optic microscopy and fluorescence or confocal microscopy. The accumulation of microdamage is associated with fatigue loading and is likely to trigger targeted bone remodeling, especially in cortical bone. Several studies examining beagle dogs receiving bisphosphonates have shown a dose-dependent accumulation of microdamage in bone, with conflicting results regarding the consequences on bone mechanical properties. In living humans, obtaining data is limited to the iliac crest bone. The potential association between long-term bisphosphonate use and microcrack accumulation at the iliac crest bone has not been established unequivocally. CONCLUSIONS Bone microdamage is critical in the understanding of bone quality. Assessment of microdamage is technically difficult, especially in humans. The clinical impact of microdamage potentially induced by bone drugs has not been established in humans.
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Affiliation(s)
- R D Chapurlat
- INSERM Research Unit 831, Université de Lyon, Hôpital E Herriot, Hospices Civils de Lyon, 69437 Lyon cedex 03, France.
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40
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van der Bijl AE, Zijlstra TR, Engelage AH, Posthuma BJM, van Veen GJM. [Three patients with a fracture during methotrexate use, possibly due to methotrexate osteopathy]. Ned Tijdschr Geneeskd 2008; 152:2357-2360. [PMID: 19024069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Three female patients, aged 76, 64 and 74 years old, who were treated with low-dose methotrexate due to an inflammatory joint disorder, developed severe pain in a lower extremity. The pain increased on weight bearing and could not be explained by arthritis. Conventional x-ray investigation showed a fracture in the second patient. In the other two patients insufficiency fractures were visualized by MRI and bone scan. Because methotrexate osteopathy was suspected, treatment with methotrexate was stopped. All three patients made a rapid recovery after discontinuation. Methotrexate osteopathy is characterized by pain, osteoporosis and microfractures, and was first reported in children treated with high-dose methotrexate for a malignancy. Similar clinical features are reported in the literature in patients with chronic joint inflammation treated with low-dose methotrexate. The causal relationship between the insufficiency fractures and the use of methotrexate is still under debate. Although the clinical picture fits with methotrexate osteopathy, these patients often also have other risk factors for osteoporotic insufficiency fractures.
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Affiliation(s)
- A E van der Bijl
- Isala klinieken, locatie Weezenlanden, Postbus 10.500, 8000 GM Zwolle.
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Inada S. [Polymyalgia rheumatica]. Nihon Rinsho 2005; 63 Suppl 5:356-61. [PMID: 15954376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
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Gutteridge DH, Stewart GO, Prince RL, Price RI, Retallack RW, Dhaliwal SS, Stuckey BGA, Drury P, Jones CE, Faulkner DL, Kent GN, Bhagat CI, Nicholson GC, Jamrozik K. A randomized trial of sodium fluoride (60 mg) +/- estrogen in postmenopausal osteoporotic vertebral fractures: increased vertebral fractures and peripheral bone loss with sodium fluoride; concurrent estrogen prevents peripheral loss, but not vertebral fractures. Osteoporos Int 2002; 13:158-70. [PMID: 11908491 DOI: 10.1007/s001980200008] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Postmenopausal Caucasian women aged less than 80 years (n = 99) with one or more atraumatic vertebral fracture and no hip fractures, were treated by cyclical administration of enteric coated sodium fluoride (NaF) or no NaF for 27 months, with precautions to prevent excessive stimulation of bone turnover. In the first study 65 women, unexposed to estrogen (-E study), age 70.8 +/- 0.8 years (mean +/- SEM) were all treated with calcium (Ca) 1.0-1.2 g daily and ergocalciferol (D) 0.25 mg per 25 kg once weekly and were randomly assigned to cyclical NaF (6 months on, 3 months off, initial dose 60 mg/day; group F CaD, n = 34) or no NaF (group CaD, n = 31). In the second study 34 patients, age 65.5 +/- 1.2 years, on hormone replacement therapy (E) at baseline, had this standardized, and were all treated with Ca and D and similarly randomized (FE CaD, n = 17; E CaD, n = 17) (+E study). The patients were stratified according to E status and subsequently assigned randomly to +/- NaF. Seventy-five patients completed the trial. Both groups treated with NaF showed an increase in lumbar spinal density (by DXA) above baseline by 27 months: FE CaD + 16.2% and F CaD +9.3% (both p = 0.0001). In neither group CaD nor E CaD did lumbar spinal density increase. Peripheral bone loss occurred at most sites in the F CaD group at 27 months: tibia/fibula shaft -7.3% (p = 0.005); femoral shaft -7.1% (p = 0.004); distal forearm -4.0% (p=0.004); total hip -4.1% (p = 0.003); and femoral neck -3.5% (p = 0.006). No significant loss occurred in group FE CaD. Differences between the two NaF groups were greatest at the total hip at 27 months but were not significant [p < 0.05; in view of the multiple bone mineral density (BMD) sites, an alpha of 0.01 was employed to denote significance in BMD changes throughout this paper]. Using Cox's proportional hazards model, in the -E study there were significantly more patients with first fresh vertebral fractures in those treated with NaF than in those not so treated (RR = 24.2, p = 0.008, 95% CI 2.3-255). Patients developing first fresh fractures in the first 9 months were markedly different between groups: -23% of F CaD, 0 of CaD, 29% of FE CaD and 0 of E CaD. The incidence of incomplete (stress) fractures was similar in the two NaF-treated groups. Complete nonvertebral fractures did not occur in the two +E groups; there were no differences between groups F CaD and CaD. Baseline BMD (spine and femoral neck) was related to incident vertebral fractures in the control groups (no NaF), but not in the two NaF groups. Our results and a literature review indicate that fluoride salts, if used, should be at low dosage, with pretreatment and co-treatment with a bone resorption inhibitor.
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Affiliation(s)
- D H Gutteridge
- Department of Endocrinology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
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Affiliation(s)
- M Wijnands
- Department of Rheumatology, TweeSteden ziekenhuis, Tilburg, The Netherlands.
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45
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Schmutz JL, Barbaud A, Trechot P. [Adverse effects of methotrexate: lymphoma and fatigue fractures]. Ann Dermatol Venereol 1998; 124:365. [PMID: 9739949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- J L Schmutz
- Service de Dermatologie, Hôpital Fournier, Nancy
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46
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Singwe M, Le Gars L, Karneff A, Prier A, Kaplan G. Multiple stress fractures in a scleroderma patient on methotrexate therapy. Rev Rhum Engl Ed 1998; 65:508-10. [PMID: 9785399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
A patient on methotrexate therapy for scleroderma developed four stress fractures within a period of 13 months. She was not on steroid therapy and had no risk factors for osteoporosis. A review of the literature found 13 cases of stress fractures under methotrexate therapy. Whether methotrexate can induce bone changes remains controversial.
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Affiliation(s)
- M Singwe
- Rheumatology Department, Saint Antoine Teaching Hospital, Paris, France
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Abstract
Prolonged infusion of magnesium sulfate has been used for the treatment of refractory preterm labor. Long-term magnesium sulfate tocolytic therapy either alone or in combination with other tocolytic agents has been reported to be safe and effective with minimal maternal side effects. There has been only one previous report of a disturbance in maternal calcium homeostasis, which included decreased distal radius bone density and hypercalciuria as a result of prolonged magnesium sulfate infusion. This article reports the first case of bilateral fracture of the calcanei in the postpartum period secondary to osteoporosis associated with prolonged magnesium sulfate tocolysis and bed rest. A 35-year-old white female with a triplet pregnancy of 25 weeks' gestation was admitted in preterm labor. Bed rest, intravenous magnesium sulfate tocolysis, and intermittent subcutaneous terbutaline were necessary to maintain uterine quiescence for 65 days. The patient received weekly betamethasone for 6 weeks for the acceleration of fetal lung maturation. Daily prenatal multivitamins and low-dose subcutaneous heparin for thromboprophylaxis were given. Efforts at tocolysis were ultimately not successful and the patient underwent a cesarean section delivery at 34 2/7 weeks' gestation. The patient's postoperative course was complicated by osteoporosis and bilateral stress fractures of the calcanei. This case report demonstrates that stress fractures secondary to osteoporosis may be associated with prolonged magnesium sulfate therapy and bed rest in higher order multiple pregnancy. Other possible contributing factors to osteoporosis include heparin thromboprophylaxis and suboptimal calcium supplementation. Therefore, in circumstances of prolonged bed rest and magnesium sulfate tocolysis, additional daily calcium supplementation would be well advised.
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Affiliation(s)
- A L Levav
- Department of Obstetrics and Gynecology, Jefferson Medical College, Philadelphia, Pennsylvania, USA
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48
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Affiliation(s)
- F S Haddad
- Department of Orthopaedics, Royal Free Hospital, London, UK
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49
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McCarthy K, Neitzschman H. Radiology case of the month. Hip and back pain in the elderly. Stress injury of bone. J La State Med Soc 1997; 149:10-1. [PMID: 9033188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Zonneveld IM, Bakker WK, Dijkstra PF, Bos JD, van Soesbergen RM, Dinant HJ. Methotrexate osteopathy in long-term, low-dose methotrexate treatment for psoriasis and rheumatoid arthritis. Arch Dermatol 1996; 132:184-187. [PMID: 8629827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
BACKGROUND In dermatology and rheumatology, methotrexate is frequently prescribed in low dosages per week; in oncology, high dosages per week are prescribed. Methotrexate osteopathy was first reported in children with leukemia treated with high doses of methotrexate. In animal studies, low doses of methotrexate proved to have an adverse effect on bone metabolism, especially on osteoblast activity. OBSERVATIONS Methotrexate osteopathy is a relatively unknown complication of low-dose methotrexate treatment. We describe three patients treated with low-dose oral methotrexate in whom signs and symptoms were present that were similar to those found in children treated with high doses of methotrexate. All three patients had a triad of severe pain localized in the distal tibiae, osteoporosis, and compression fractures of the distal tibia, which could be identified with radiographs, technetium Tc 99m scanning, and magnetic resonance imaging. CONCLUSIONS Methotrexate osteopathy can occur in patients treated with low doses of methotrexate, even over a short period of time. As pain is localized in the distal tibia, it is easily misdiagnosed as psoriatic arthritis of the ankle, but the diagnosis can be correctly made by careful investigation and use of imaging techniques. The only therapy is withdrawal of methotrexate. It is important that more physicians become aware of this side effect of methotrexate therapy, which can occur along with arthritic symptoms.
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Affiliation(s)
- I M Zonneveld
- Department of Dermatology, Academic Medical Center, University of Amsterdam, The Netherlands
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