Pseudoarthrosis in atypical femoral fracture: case report

Use of Teriparatide in preventing delayed bone healing and nonunion: a multicentric study on a series of 20 patients

BACKGROUND

Delayed bone healing and nonunions represent a great challenge for the orthopedic surgeon. In addition to traditional surgical approaches, increasing attention is being given to the use of systemic anabolic therapy with Teriparatide, whose efficacy in preventing osteoporotic fractures is widely validated and whose application as a promoter of bone healing has been described but it is still debated. The aim of the study was to evaluate bone healing in a series of patients with delayed unions or nonunions treated with Teriparatide in conjunction with eventual appropriate surgical procedure.

METHODS

Twenty patients with an unconsolidated fracture that were treated at our Institutions from 2011 to 2020 with Teriparatide were retrospectively included into the study. The pharmacological anabolic support was used off-label with a planned duration of 6 months; radiographic healing was evaluated at 1-, 3- and 6-months follow-up outpatient visits over plain radiographs. Also, eventual side-effects were registered.

RESULTS

Radiographic signs indicative of favorable evolution of the bone callus were observed as early as at 1 month of therapy in 15% of cases; at 3 months, healing progression was appreciated in 80% of cases and complete healing in 10%; at 6 months, 85% of delayed and nonunions had healed. In all patients, the anabolic therapy was well tolerated.

CONCLUSIONS

In accordance to Literature, this study suggests that Teriparatide plays a potentially important role in the treatment of some forms of delayed unions or nou-nions, even in the presence of failure of hardware. The results suggest a greater effect of the drug when associated with a condition in which the bone is in an active phase of callogenesis, or with a "revitalizing" treatment which represents a local (mechanical and/or biological) stimulus to the healing process. Despite the small sample size and the variety of cases, the efficacy of Teriparatide in treating delayed unions or nonunions emerged, highlighting how this anabolic therapy can represent a useful pharmacological support in the treatment of such a pathology. Although the results obtained are encouraging, further studies, particularly prospective and randomized, are needed to confirm the efficacy of the drug, and define a specific treatment algorithm.

Surgical and Pharmacological Management of Periprosthetic Atypical Femoral Fractures: A Narrative Literature Review

Introduction

An increasing number of patients is annually undergoing total hip arthroplasty (THA), and a significant proportion of these patients are elderly and consequently at a higher risk of complications because of age, osteoporosis, and medical comorbidities. Periprosthetic femoral fractures (PFFs) are one of the worst complications of THA associated with high rates of unfavorable prognosis. Besides, in the last decade, a new independent disease entity called “atypical femoral fracture” (AFF) has been identified and defined by the American Society for Bone and Mineral Research (ASBMR) task force. Some PFFs present clinical history and radiographic aspect consistent with an AFF, meeting the ASBMR criteria for the diagnosis of AFF except that PFFs by themselves are an exclusion criterion for AFF. However, there is an increasing number of published studies suggesting that periprosthetic atypical femoral fractures (PAFFs) exist and should not be excluded by definition.

Significance

Nowadays, although there is an increasing interest in PAFFs, there are still very few studies published on the topic and a lack of consensus regarding their treatment. This narrative literature review aims to introduce this new emerging topic to a wider readership describing the characteristics of PAFFs and the state-of-the-art in their management.

Conclusions

Many authors agree that PAFFs should be considered as a subgroup of PFFs that have atypical characteristics; they also show a significant correlation with prolonged bisphosphonate use. A correct diagnosis is paramount for proper treatment of the disease that requires both surgical and medical actions to be taken.

Combined Surgical and Medical Treatment for Vancouver B1 and C Periprosthetic Femoral Fractures: A Proposal of a Therapeutic Algorithm While Retaining the Original Stable Stem

INTRODUCTION

There is lack of consensus regarding best operative fixation strategy for periprosthetic femoral fractures (PFFs) around a stable stem. Evidence exists that some patterns of fracture around a stable stem are better treated with revision surgery than with standard fixation. Anyway, a more aggressive surgical procedure together with medical treatment could allow for stem retention, and reduced risk of nonunion/hardware failure, even in these cases.

SIGNIFICANCE

This paper is placed in a broader context of lack of studies on the matter, and its aim is to shed some light on the management of PFFs around a stable stem, when peculiar mechanical and biological aspects are present.

RESULTS

Based on our casuistry in the treatment of nonunions after PFF successfully treated with original stem retention, and on review of Literature about risk factors for fixation failure, an algorithm is proposed that can guide in choosing the ideal surgical technique even for first-time PFFs with a stable stem, without resorting to revision. Mechanical (major and minor) and biological (local and systemic) factors that may influence fracture healing, leading to nonunion and hardware failure, and subsequent need for re-operation, are considered. The proposed surgical technique consists of rigid fixation with absolute stability (using a plate and structural allograft) plus local biological support (structural allograft and autologous bone marrow concentrate over a platelet-rich plasma-based scaffold) at fracture site. Systemic anabolic treatment (Teriparatide) is also administered in the post-operative period.

CONCLUSION

Mechanical factors are not the only issues to be considered when choosing the surgical approach to PFFs over a stable stem. Systemic and local biological conditions should be taken into account, as well. A therapeutic algorithm is proposed, given the prosthetic stem to be stable, considering mechanical and biological criteria.

Periprosthetic Atypical Femoral Fractures Exist: A Retrospective Study at a Single Institution. Prevalence on 115 Periprosthetic Femoral Fractures Around a Primary Hip Stem

BACKGROUND

Some periprosthetic femoral fractures (PFFs) present history and radiographic aspect consistent with an atypical femoral fracture (AFF), fulfilling the criteria for AFF except that PFFs by themselves are excluded from the diagnosis of AFFs. The aim of this study is to evaluate in a single institution series of PFFs if any of them could be considered a periprosthetic atypical femoral fracture (PAFF), and their prevalence.

METHODS

Surgical records were searched for PFFs around a primary hip stem from January 2013 to December 2019. Cases were classified according to Vancouver classification. Demographic and medical history was extracted. Fisher's exact test was used for statistical analysis.

RESULTS

One hundred fifteen PFFs were identified, 59 of them were type B1 and 16 were type C. Radiographs and medical records were available for all patients. Twenty-four patients (32%) have been treated with bisphosphonates (BPs) for longer than 4 years. Four patients presented a fracture with characteristics of PAFF. When enlarged to all PFFs of the series, no other PAFF was found: prevalence of PAFFs was 5.3% for type B1 and C cases and 3.5% for all surgically treated PFFs. Statistical significative difference between PAFFs and PFFs was found for prolonged BP assumption and for the level of fracture clear of the stem.

CONCLUSION

Fracture with characteristics of AFFs can also happen over a prosthetic stem, configuring themselves as PAFFs, and they are related to prolonged BP use. As a correct diagnosis is mandatory for proper treatment, a revision of criteria for AFFs should be considered, accepting that PAFFs exist.

Exchange K-nailing, Augmented Plating Technique for Atypical Femur Diaphyseal Non-union, and Implant Failure - A Case Report

Introduction:

Atypical femoral fractures (AFFs) have an unpredictable healing process leading to higher complication rates. The literature describes various treatment modalities of non-unions in AFF. We aimed to report a case of non-union with AFF and successful union with exchange K-nailing and augmented plating techniques.

Case Report:

A 75-year-old lady with 5 years of bisphosphonate intake sustained an AFF at the mid-diaphyseal level after a trivial injury which was fixed with closed intramedullary nailing. Nine months after fixation, she developed refracture at the fracture site with segmental breakage of the nail suggesting non-union. This was managed by the removal of fibrous structures at the fracture site, removal of a broken nail, exchange K-nailing, augmented plating, and iliac crest bone grafting. The fracture healed at 15 months from the injury and achieved good functional outcome at a short-term follow-up of 1 year.

Conclusion:

Our case report highlights the challenges of treating diaphyseal AFF and the combined benefit of exchange nailing and augmented plating with bone grafting in treating AFFs with non-union.

Medical Management of Patients After Atypical Femur Fractures: a Systematic Review and Recommendations From the European Calcified Tissue Society

CONTEXT

Atypical femur fractures (AFFs) are serious adverse events associated with bisphosphonates and often show poor healing.

EVIDENCE ACQUISITION

We performed a systematic review to evaluate effects of teriparatide, raloxifene, and denosumab on healing and occurrence of AFF.

EVIDENCE SYNTHESIS

We retrieved 910 references and reviewed 67 papers, including 31 case reports, 9 retrospective and 3 prospective studies on teriparatide. There were no RCTs. We pooled data on fracture union (n = 98 AFFs on teriparatide) and found that radiological healing occurred within 6 months of teriparatide in 13 of 30 (43%) conservatively managed incomplete AFFs, 9 of 10 (90%) incomplete AFFs with surgical intervention, and 44 of 58 (75%) complete AFFs. In 9 of 30 (30%) nonoperated incomplete AFFs, no union was achieved after 12 months and 4 (13%) fractures became complete on teriparatide. Eight patients had new AFFs during or after teriparatide. AFF on denosumab was reported in 22 patients, including 11 patients treated for bone metastases and 8 without bisphosphonate exposure. Denosumab after AFF was associated with recurrent incomplete AFFs in 1 patient and 2 patients of contralateral complete AFF. Eight patients had used raloxifene before AFF occurred, including 1 bisphosphonate-naïve patient.

CONCLUSIONS

There is no evidence-based indication in patients with AFF for teriparatide apart from reducing the risk of typical fragility fractures, although observational data suggest that teriparatide might result in faster healing of surgically treated AFFs. Awaiting further evidence, we formulate recommendations for treatment after an AFF based on expert opinion.

A Case Series and Discussion on Surgical Treatment Strategy for Atypical Proximal Femoral Fractures Associated with Bisphosphonate Use

The aim of this study was to determine the incidence of atypical femoral fractures in our local population, study their current outcomes and present a novel surgical strategy based on these data. Patients who received surgical fixation of an atypical pattern proximal femoral fracture over a four-year period were identified and followed up in the clinic until union, revision surgery or death.

The local incidence of atypical femoral fractures is 1.1 per 1000 per annum amongst patients receiving bisphosphonates. Twelve fixation procedures were carried out in 10 patients. Intra-operative reduction and nailing led to an average deformity of 8.5° varus and 13° apex anterior. Five cases required revision surgery. Fifty percent of primary procedures resulted in radiographic union within two years. We suggest that the lateral side of the fracture should be considered a primary nonunion. We advocate undertaking a wedge excision to correct the bone to a valgus morphology and stabilising with an intramedullary nail and a lateral tension plate. Multicentre studies are needed to demonstrate the efficacy of any particular approach.

Salvage of failed osteosynthesis for an atypical subtrochanteric femoral fracture associated with long-term bisphosphonate treatment using a 95° angled blade plate

AIMS

The aim of this study was to evaluate the outcomes of a salvage procedure using a 95° angled blade plate for failed osteosynthesis of atypical subtrochanteric femoral fractures associated with the long-term use of bisphosphonates. These were compared with those for failed osteosynthesis of subtrochanteric fractures not associated with bisphosphonate treatment.

PATIENTS AND METHODS

Between October 2008 and July 2016, 14 patients with failed osteosynthesis of an atypical subtrochanteric femoral fracture were treated with a blade plate (atypical group). Their mean age was 67.8 years (60 to 74); all were female. During the same period, 21 patients with failed osteosynthesis of a typical subtrochanteric fracture underwent restabilization using a blade plate (typical group). Outcome variables included the time of union, postoperative complications, Harris Hip Score, and Sanders functional rating scale.

RESULTS

In the atypical group, union was achieved in 12 patients (85.7%) at a mean of 8.4 months (4 to 12). The mean follow-up was 31.2 months (12 to 92) The plate broke in one patient requiring further stabilization with a longer plate and strut-allograft. Another patient with failure of fixation and varus angulation at the fracture site declined further surgery. In the typical group, union was achieved in 18 patients (85.7%) at a mean of 7.9 months (4 to 12). There was no difference in the mean Harris Hip Score between the two groups (83.1 points vs 86.8 points; p = 0.522) at the time of final follow-up. Sanders functional rating scores were good or excellent in 78.6% of the atypical group and in 81.0% of the typical group.

CONCLUSION

The 95° angled blade plate was shown to be an effective fixation modality for nonunion of atypical subtrochanteric fractures with a high rate of union and functional improvement, comparable to those after fractures not associated with bisphosphonate treatment. Cite this article: Bone Joint J 2018;100-B:1511-17.

Histological study of atraumatic periprosthetic fractures: does atypical periprosthetic fracture exist?

Purpose

Is it possible a correlation between some periprosthetic femoral fractures and atypical fractures?

Case

We present a case of a 77-year-old woman with atypical periprosthetic femoral fracture. The patient had a history of long-term bisphosphonate use. We performed an open reduction, a synthesis of the fracture and a histological exam. The patient stopped the bisphosphonate (BF) therapy. Three months later, before starting the teriparatide treatment, the patient had a re-fracture so we did a second osteosynthesis and began a teriparatide therapy. After six months, the radiography showed a bone healing at the fracture site.

Result

The histological examination confirmed the diagnosis of atypical femoral fracture.

Conclusion

At first, the fracture showed a delayed union which led to a new surgery, as often happens in BF-related atypical fractures. Appropriate treatment (BF suspension and teriparatide beginning) permitted fracture healing. The atypical characteristic of the fracture was confirmed by histological exam.Some periprosthetic femoral fractures in patients treated with BF, especially in long time therapies, should be suspected as atypical fractures and a specific medical treatment should be performed, as well as a correct surgical treatment.

Atypical femoral fractures in Italy: a retrospective analysis in a large urban emergency department during a 7-year period (2007-2013)

The aim of this study was to determine the incidence of atypical femoral fractures (AFFs) seen in a large emergency department in Italy. It was a retrospective study of all men and women aged 40 years or older admitted to the Emergency Department of Parma University Hospital for a femoral fracture. Cases were identified in the hospital database with use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 820 or 821 or text strings. All the radiographic images of fractures not clearly identified as proximal or condylar were retrieved and evaluated by three independent reviewers. Fractures were considered as atypical if all three reviewers agreed on at least four of five major features defined by the 2013 American Society for Bone and Mineral Research criteria. In the 7-year period (2007-2013), with a total follow-up of 1,383,154 patient-years, we found 22 AFFs in 21 patients, accounting for 7.1% of low-trauma subtrochanteric/femoral shaft fractures and 0.6% of all femoral fractures. The incidence was very low (1.6 in 100,000 patient-years in both sexes combined). In contrast, the incidence of classic fractures of the proximal end of the femur was at least two orders of magnitude higher (typical/atypical rate ratio 152). Bisphosphonate use was reported in 13 patients (62%; mean treatment duration 9 years; range 5-14 years). Among 286 patients with typical subtrochanteric/femoral shaft fractures, 20 were being treated with bisphosphonate (7%; odds ratio 22; 95% confidence interval 8-58; p < 0.001). This study confirms the very low incidence of AFFs in the largest Italian cohort of patients to date. Even though the risk is higher in patients treated with bisphosphonates, AFFs are very rare, and typical femoral fractures are at least 100-fold more frequent.

Atypical femoral fractures related to bisphosphonate treatment: issues and controversies related to their surgical management

AIMS

Treatment guidelines for atypical femoral fractures associated with bisphosphonates have not been established. We conducted a systematic review of the treatment of atypical femoral fractures first, to evaluate the outcomes of surgical fixation of complete atypical fractures and secondly, to assess whether prophylactic surgery is necessary for incomplete atypical fractures.

MATERIALS AND METHODS

Case reports and series were identified from the PubMed database and were included if they described the treatment of atypical femoral fractures. In total, 77 publications met our inclusion criteria and 733 patients with 834 atypical complete or incomplete femoral fractures were identified.

RESULTS

For complete fractures, internal fixation was predominantly achieved by intramedullary nailing. The mean time to healing post-operatively was 7.3 months (2 to 31). Revision surgery for nonunion or implant failure was needed in 77 fractures (12.6%). A greater percentage of fractures treated with plate fixation (31.3%) required revision surgery than those treated with intramedullary nailing (12.9%) (p < 0.01). Non-operative treatment of incomplete fractures failed and surgery was eventually needed in nearly half of the patients (47%), whereas prophylactic surgery was successful and achieved a 97% rate of healing.

CONCLUSION

Intramedullary nailing is the first-line treatment for a complete fracture, although the risk of delayed healing and revision surgery seems to be higher than with a typical femoral fracture. Non-operative treatment does not appear to be a reliable way of treating an incomplete fracture: prophylactic intramedullary nailing should be considered if the patient is in intractable pain. Radiographs of the opposite side should be obtained routinely looking for an asymptomatic fracture. Bisphosphonates must be discontinued but ongoing metabolic management in the form of calcium and/or vitamin D supplements is advisable. Teriparatide therapy can be considered as an alternative treatment. Cite this article: Bone Joint J 2017;99-B:295-302.

Management of atypical femoral fracture: a scoping review and comprehensive algorithm

BACKGROUND

Atypical femoral fractures (AFF) are a rare type of femoral stress fracture recently described, potentially associated with prolonged bisphosphonate therapy. Evidence-based recommendations regarding diagnosis and management of these fractures are scarce. The purpose of this study is to propose an algorithm for the diagnosis and management of AFF.

METHODS

We performed a PubMed search of the last ten years using the keywords "atypical femoral fractures" and identified further articles through an evaluation of the publications cited in these articles. Relevant studies were included by agreement between researchers, depending on their specialization. Pertinent points of debate were discussed based on the available literature, allowing for consensus regarding the proposed management algorithm.

RESULTS

Using a systematic approach we performed a scoping review that included a total of 137 articles.

CONCLUSIONS

A practical guide for diagnosis and management of AFF based on the current concepts is proposed. In spite of the impressive large volume of published literature available since AFF were initially identified, the level of evidence is mostly poor, in particular regarding treatment choice. Therefore, further studies are required.

Construct Failure in an Atypical Femoral Fracture treated with Intramedullary Nailing: A Case Report

ABSTRACT

The aim of this paper is to document a rare case of construct failure in a 68-year old Filipina who sustained an atypical femoral fracture (AFF) in her left subtrochanteric area. The patient previously had a 40-month history of alendronate 70mg + vitamin D 5600u therapy for osteoporosis and underwent closed intramedullary nailing for the AFF. Six months postoperatively, she began to experience progressive pain in her operated thigh. Radiographs revealed a broken nail at the proximal screw hole and non-union of the AFF. The patient was treated with exposure of the fracture site, removal of the broken device, exchange intramedullary nailing, and iliac bone grafting. She had radiographic and clinical union and was full weight bearing after three months.

The hip prosthesis in lateral femur fracture: current concepts and surgical technique

The third proximal femur fractures are divided into medial and lateral ones. For medial fractures already exists unanimity of thought for the choice of treatment that involves the prosthetic replacement of the hip joint in patients over 60 without indications to the synthesis. Regarding the lateral femur fractures this unanimity does not exist yet even if the majority of surgeons practice treatment with osteosynthesis. We want to highlight if there are any types of lateral fractures associated with patient's clinical condition in which it might be more useful to a prosthetic replacement with the aim of being able to allow a total load and earlier deambulation, reducing complications related to a possible patient immobilization.

Atypical femoral fractures: retrospective radiological study of 319 femoral fractures and presentation of clinical cases

SUMMARY

There is still no clarity on the etiology and epidemiology of atypical femoral fractures. The purpose is to show, after a radiological review, that the incidence of atypical fractures is higher than that reported in the literature when compared to "typical" fractures that occurred in the same anatomical site.

INTRODUCTION

At present, it is difficult to define the true incidence of atypical fractures associated with bisphosphonate. Our purpose is to show that the incidence of atypical fractures is higher than that reported in the literature when compared to "typical" fractures that occurred in the same anatomical site.

METHODS

The authors analyzed 319 femoral fracture Rxs of patients over 60 who have had access to the PS of Clinical Orthopaedics and Traumatology II of the University of Pisa from January 2011 to February 2013. The atypical fractures have been investigated from clinical point of view, biohumoral exams, densitometry and contralateral femur X-rays, and in one case using SPECT-Tc.

RESULTS

The total number of femoral fractures was 319. The medial femur fractures were 60 (46 females and 14 males), and the lateral ones were 316 (237 females and 79 males). Subtrochanteric and diaphyseal fractures were 40 (29 females and 11 males). Among these cases, two atypical fracture cases were related to female patients, one was 79 years old and the other was 77.

CONCLUSIONS

The most recent literature reports that the incidence of atypical fractures is 0.6 %. However, taking into consideration only the fracture locations suitable for the identification of atypical fractures, the percentage rises to 5 %. To date, there is still no clarity on the exact etiology of fractures even if it seems to be related to a bone mineral component alteration.

Current medical treatment strategies concerning fracture healing

The morbidity and socioeconomic costs associated with bone healing are considerable. A number of fractures are complicated by impaired healing. This is prevalent in certain risk groups such as elderly, osteoporotics, post-menopausal women, and in people with malnutrition. The biologic process of fracture healing is complex and impacted by multiple factors. Some of them, such as the nutritional and health conditions, are patient-dependent, while others depend on the trauma experienced and stability of the fracture. Fracture healing disorders negatively affect the patient's quality of life and result in high health-care costs, as a second surgery is required to stabilize the fracture and stimulate bone biology. Future biotechnologies that accelerate fracture healing may be useful tools, which might also prevent the onset of these disorders. We list the characteristics of the drugs used for osteoporosis, but we point out in particular the use of strontium ranelate and teriparatide in our clinical practice in elderly patients, especially females, who reported fractures with risk of nonunion. This medical treatment could impaired fracture healing however, most of the evidence is obtained in animal studies and very few studies have been done in humans. Thus one could hypothesize the possibility of a medical treatment both as a preventive and as support to the synthesis. However, no clinical studies are available so far, and such studies are warranted before any conclusions can be drawn. A positive effect of osteoporosis treatments on bone healing is an interesting possibility and merits further clinical research.

Disuse osteoporosis of the upper limb: assessment of thirty patients

Osteoporosis is a multifactorial skeletal disorder characterized by the decrease of bone mass and the alteration of bone microarchitecture that leads to the increase of fracture risks. Traditionally, osteoporosis has been classified into primary and secondary osteoporosis. Primary osteoporosis refers to osteoporotic conditions which are not related to other chronic illnesses and is usually associated with aging and decreased gonadal function, such as decreased level of estrogen, whereas secondary osteoporosis is the type of osteoporosis caused by other health problems. Disuse is one of the many reasons inducing bone loss and resulting in secondary osteoporosis. The disuse osteoporosis appeared for the first time in the literature in 1974 when Minaire reported some histomorphometric analysis of iliac crest bone biopsies performed after a spinal cord injury. The most common skeleton sites in which disuse osteoporosis can be observed are knees and ankles. THERE ARE THREE CLINICAL SITUATION IN WHICH THIS DISEASE CAN BE OBSERVED: neurological or muscular disease that causes a pathological and prolonged immobilization. The most frequent is caused by a spinal cord injury, long term bed rest or space flight that causes the immobilization linked to changes in mechanical environment and experimental immobilizations in healthy subjects. Physical exercise is essential for increasing or maintaining bone mass and strength. In our study we wondered if the disuse of the upper limbs of a certain entity, lasting for a long time, can cause a decrease in BMD quantifiable with a densitometric evaluation of the distal radius and with an evaluation of the humeral cortical index such as to define a real osteoporosis from disuse. We analyzed 30 female patients without secondary osteoporosis older than 60 years: everyone underwent to vit D evaluation, densitometric exams of spine, hip and distal radius, Constant score and femoral and humeral cortical index evaluation. We observed that the distal radius BMD and humeral cortical index were worse in patients with low upper limb functionality than in patients with normal shoulder function. The results of this study suggest that humeral cortical index and radial BMD can be useful methods of upper limb bone density evaluation and that they can be useful to select a correct surgical treatment in orthopaedic and traumatologic diseases.