Low-Energy Femoral Fractures Associated with the Long-Term Use of Bisphosphonates

Is bisphosphonate use a risk factor for atypical periprosthetic/peri-implant fractures? - A metanalysis of retrospective cohort studies and systematic review of the current evidence

INTRODUCTION

Atypical periprosthetic/peri-implant fractures are not recognised in any widely used classification and therefore little focus is given to them. Multiple case reports and case series demonstrate these fractures exist and are related to bisphosphonate (BP) use.

HYPOTHESIS

Are patients taking long-term BPs at an increased risk of developing an atypical periprosthetic/peri-implant fracture? Is a particular BP drug causing an increased risk of fracture? Is there a correlation between the time of BP use and the incidence of fractures? Do vitamin D analogues or parathyroid hormones reduce the time to union?

MATERIAL AND METHODS

Systematic review of all available evidence on the existence of periprosthetic/peri-implant atypical fractures in patients taking long-term BPs and metanalysis of available retrospective cohort studies. Selected 1 systematic review, 7 retrospective cohort studies (5 used for metanalysis) and 32 case reports.

RESULTS

Metanalysis reported a risk ratio of 14.1, p=0.25, suggesting bisphosphonates are a risk factor in the development of periprosthetic/peri-implant atypical fractures. The secondary outcomes couldn't be reliably identified due to the small size of available studies and risk of significant bias.

DISCUSSION

Atypical periprosthetic/peri-implant fractures are an entity and seem to be associated with the use of bisphosphonates. The benefits of bisphosphonates use outweigh the risks, but clinicians should be aware of atypical fractures and actively search for them when patients on long-term bisphosphonates attend with non-specific pain close to the implant/prosthesis or reduced mobility.

LEVEL OF EVIDENCE

II, Systematic review and metanalysis.

Fracture Risk Following an Atypical Femoral Fracture

Atypical femoral fractures (AFFs) occurring during the course of osteoporosis treatment usually lead to discontinuation of anti-resorptive (AR) drugs. However, the risk of fracture after an AFF is unknown. We conducted a follow-up study of patients with AFF matched 1:3 for age and gender with patients with a peripheral major osteoporotic fracture (pMOF), in the setting of a fracture liaison service, to investigate the incidence of subsequent low-trauma fractures. Fifty-five patients with AFF (95% women, age [mean ± standard deviation] 75 ± 10 years, 89% exposed to AR drugs), followed for 6.2 ± 3.7 years, were compared to 165 matched controls with a pMOF (hip 85%) followed for 4.3 ± 2.6 years. During the follow-up, 38% of patients in the AFF group and 16% in the pMOF group received AR therapies. Continuation of AR drugs after an AFF was associated with contralateral AFF in 27% of subjects. The risks of new low-trauma, major osteoporotic and imminent (within 2 years) fractures, were similar between the two groups: incidence rate ratio (95% confidence interval [CI]) of subsequent fracture following AFF relative to pMOF, 1.30 (95% CI, 0.82-2.04), 1.28 (95% CI, 0.74-2.15), and 1.11 (95% CI, 0.54-2.15), respectively. Moreover, the risk of sustaining multiple fractures per participant was significantly increased among patients with AFF compared to pMOF (hazard ratio 1.48 [95% CI, 1.00-2.19]; p = 0.049). When taking mortality into account, the risk of subsequent fractures tended to be higher in the AFF group (sub-hazard ratio 1.42 [95% CI, 0.95-2.12]). In conclusion, patients who sustained an AFF are at high risk of subsequent fragility fractures, at least equal or even greater to the risk observed after a pMOF. However, continuation of AR drugs increases the risk of contralateral AFF. Therefore, optimal modalities for secondary fracture prevention after AFF require further evaluation. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Patient-reported effectiveness and safety of Pamidronate in NSAIDs-refractory chronic recurrent multifocal osteomyelitis in children

To evaluate patient-reported effectiveness, safety and social influence of Pamidronate in the therapy of NSAIDs-refractory Chronic Recurrent Multifocal Osteomyelitis in children. Authors reviewed self-created questionnaires, which asked patients for symptoms alleviation, adverse drug reactions frequency and degree of severity and daily activities self-reliance. Only surveys with complete answers, which were returned to authors by an e-mail from juvenile patients treated for NSAIDs-refractory Chronic Recurrent Multifocal Osteomyelitis at the University Children’s Hospital of Cracow were analyzed. Between 2010 and 2019, 61 children were diagnosed with NSAIDs-refractory Chronic Recurrent Multifocal Osteomyelitis at our department. Out of 61 requests sent, 42 complete replies (33 females, 9 males) were gathered and analyzed. All patients included in this research were administered with at least one set of Pamidronate intravenously in the dose of 1 mg/kg/day for 3 consecutive days. Our analysis shows remarkable in terms of patient’s impressions decrease of pain intensity after 2.5 series of Pamidronate on average, and total pain resolution after 5.9 series on average. Overall number of adverse drug reaction events reported by responders was 105. One patient developed drug-dependent renal insufficiency in the course of therapy. Outcome assessment indicates that nearly 50% of the studied population was more eager to participate in social life just after the first infusion of the drug. 95% of the surveyed unanimously agreed to recommend Pamidronate therapy to cure NSAIDs-refractory CRMO. 39 out of 42 (93%) patients considered Pamidronate effective at the end of the treatment. Onset of Pamidronate’s action is gradual and differs in terms of symptoms alleviation between sexes. The therapy can induce considerable number of adverse drug reactions (2.5 per patient). Only 3 out of 42 (7%) patients were free from any ADRs. To demonstrate the impact of the use of Pamidronate on daily activities more precisely, further research with quantification of the quality of life is warranted.

The limitations of today’s clinical guidance: Atypical femoral fracture and long-term bone-modifying agents in the oncology setting

While bone-modifying agents such as bisphosphonates and denosumab are crucial to preventing skeletal-related events in patients with bone metastases, the optimal duration remains undefined. Extended duration may be associated with adverse effects such as osteonecrosis of the jaw and atypical femoral fracture. Although uncommon, atypical femoral fracture represents a serious consequence of prolonged bone-modifying agent use and are characterized by a prodrome and distinct radiographic findings. The oncology setting encompasses a unique set of atypical femoral fracture risk factors and considerations, with hormonal therapy in early stage disease, bone metastases in the advanced setting, and new targeted agents that may affect bone homeostasis. As outcomes in cancer treatment continue to improve, the questions of risks versus benefits of long-term bone-modifying agents and how to mitigate atypical femoral fracture risk become increasingly pertinent.

Increased rate of reoperation in atypical femoral fractures is related to patient characteristics and not fracture type. A nationwide cohort study

Atypical femoral fractures are burdened with a high rate of reoperation. In our nationwide analysis, the increased rate of reoperation was related to patient background characteristics, such as age and health status, rather than fracture type.

INTRODUCTION

Patients with atypical fractures are complex to treat and burdened with a high risk of reoperation. We hypothesized that patients with surgically treated, complete atypical fractures have a higher risk of any reoperation and reoperation related to healing complications than patients with common femoral shaft fractures but that this increase would become insignificant when adjusted for predefined characteristics.

METHODS

A cohort of 163 patients with atypical fractures and 862 patients with common femoral shaft or subtrochanteric fractures treated from 2008 to 2010 and who had follow-up radiographs and register data available until 31 December 2014 was included. Reoperations were identified by a complementary review of radiographs and register data and were used to calculate risks for any reoperation and reoperations related to healing complications.

RESULTS

Patients with atypical fractures were more likely to be reoperated for any reason, age-adjusted OR 1.76 (95% CI, 1.08 to 2.86). However, patients with common fractures had a shorter follow-up due to a threefold higher death rate. Accordingly, in a multivariable-adjusted time-to-event model, the increased risk lost statistical significance for any reoperations, cause-specific HR 1.34 (95% CI, 0.85 to 2.13), and for reoperations related to healing complications, HR 1.32 (95% CI, 0.58 to 3.0). Continued use of bisphosphonate in the first year after the fracture did not affect the reoperation rate.

CONCLUSIONS

Our findings suggest that the increased risk of reoperation after an atypical femur fracture is largely explained by patient characteristics and not fracture type.

Beneficial effects of Lactobacillus reuteri 6475 on bone density in male mice is dependent on lymphocytes

Oral treatment with probiotic bacteria has been shown to prevent bone loss in multiple models of osteoporosis. In previous studies we demonstrated that oral administration of Lactobacillus reuteri in healthy male mice increases bone density. The host and bacterial mechanisms of these effects however are not well understood. The objective of this study was to understand the role of lymphocytes in mediating the beneficial effects of L. reuteri on bone health in male mice. We administered L. reuteri in drinking water for 4 weeks to wild type or Rag knockout (lack mature T and B lymphocytes) male mice. While L. reuteri treatment increased bone density in wild type, no significant increases were seen in Rag knockout mice, suggesting that lymphocytes are critical for mediating the beneficial effects of L. reuteri on bone density. To understand the effect of L. reuteri on lymphocytes in the intestinal tissues, we isolated mesenteric lymph node (MLN) from naïve wild type mice. In ex vivo studies using whole mesenteric lymph node (MLN) as well as CD3+ T-cells, we demonstrate that live L. reuteri and its secreted factors have concentration-dependent effects on the expression of cytokines, including anti-inflammatory cytokine IL-10. Fractionation studies identified that the active component of L. reuteri is likely water soluble and small in size (<3 kDa) and its effects on lymphocytes are negatively regulated by a RIP2 inhibitor, suggesting a role for NOD signaling. Finally, we show that T-cells from MLNs treated with L. reuteri supernatants, secrete factors that enhance osterix (transcription factor involved in osteoblast differentiation) expression in MC3T3-E1 osteoblasts. Together, these data suggest that L. reuteri secreted factors regulate T-lymphocytes which play an important role in mediating the beneficial effects of L. reuteri on bone density.

Bisphosphonate associated femoral stress fracture distal to an orthopaedic implant: They are predictable!

Stress fractures are uncommon and often occur in young athletes with high intensity physical activity. These stress fractures occur in weight bearing long bones. Recent literature suggests association of thigh pain, tension side cortical thickening of femoral shaft or a femoral subtrochanteric atypical stress fractures in patients on long term bisphosphonate therapy. The reports of peri-implant bisphosphonate associated atypical stress fractures are very rare. We describe a series of three cases of femoral shaft stress phenomenon around orthopaedic implants who presented with similar prodromal thigh pain and tension side cortical thickening. Two patients sustained fractures as the condition was not recognised despite presenting with prodromal symptoms and one patient with a stress riser who was treated prophylactically. Thus this series aims to highlight the importance of identifying the stress phenomenon around orthopaedic implants, be it intra or extra-medullary implants. The location of these fractures is just distal to the implants and are classically transverse fractures. The treatment of peri-implant stress fractures needs a personalised approach in every case with appropriate choice of implants.

Spontaneous Insufficiency Fractures

Spontaneous insufficiency fractures are caused by normal or physiological stress on weakened bone. The leading cause of insufficiency fractures is osteoporosis which has a propensity to affect older patients. Other causes or associated factors are disorders which affect bone metabolism, collagen formation, bone remodelling and medications such as bisphosphonates and glucocorticoids. Pathological fractures and abuse are important causes of unexplained fractures which warrant careful consideration. Spontaneous fractures of the long bones affect on average 1% of nursing home residents per year and tend to occur in patients who are bed-bound with joint contractures. Preventative measures for spontaneous insufficiency fractures include optimising nutrition to include an adequate intake of protein, calcium and vitamin D, maintaining mobility and preventing long periods of bed-rest and treatment of underlying pre-disposing conditions.

Prevalence and Characteristics of Atypical Periprosthetic Femoral Fractures

Bisphosphonate use has been associated with atypical femoral fractures (AFFs), defined by the American Society of Bone and Mineral Research (ASBMR) Task Force criteria, which currently exclude periprosthetic fractures. The objectives of this study were to establish the prevalence of atypical periprosthetic femoral fractures (APFFs) in patients with hip and knee arthroplasties and to determine the clinical and radiological risk factors associated with these fractures. We performed a retrospective radiological review of all femoral fractures between January 1, 2006, and March 31, 2015, in Quebec City, Canada. Patients who sustained a periprosthetic femoral fracture (PFF) were identified and included in this study. We used the ASBMR Task Force criteria to identify atypical fractures and establish their prevalence. Data from medical records and radiological assessments of the femoral anatomy, the characteristics of the fracture, and the positioning of the prosthesis were collected. The prevalence of APFFs among PFFs was 8.3% (11/133). A strong association with bisphosphonates (p = 0.007) was observed, as well as an increased risk of APFFs among alendronate users compared to risedronate users (p = 0.04). A transverse fracture (p < 0.0001), a periosteal thickening of the lateral cortex at the fracture (p < 0.0001), a unicortical fracture (p = 0.02), and prodromal symptoms (p = 0.03) were associated with APFFs. The type of implant, its positioning, and the femoral geometry did not appear to be risk factors for APFFs compared to PFFs. © 2018 American Society for Bone and Mineral Research.

Korean Guideline for the Prevention and Treatment of Glucocorticoid-induced Osteoporosis

Background

To develop guidelines and recommendations to prevent and treat glucocorticoid (GC)-induced osteoporosis (GIOP) in Korea.

Methods

The Korean Society for Bone and Mineral Research and the Korean College of Rheumatology have developed this guideline based on Guidance for the Development of Clinical Practice Guidelines ver. 1.0 established by the National Evidence-Based Healthcare Collaborating Agency. This guideline was developed by adapting previously published guidelines, and a systematic review and quality assessment were performed.

Results

This guideline applies to adults aged ≥19 years who are using or plan to use GCs. It does not include children and adolescents. An initial assessment of fracture risk should be performed within 6 months of initial GC use. Fracture risk should be estimated using the fracture-risk assessment tool (FRAX) after adjustments for GC dose, history of osteoporotic fractures, and bone mineral density (BMD) results. All patients administered with prednisolone or an equivalent medication at a dose ≥2.5 mg/day for ≥3 months are recommended to use adequate calcium and vitamin D during treatment. Patients showing a moderate-to-high fracture risk should be treated with additional medication for osteoporosis. All patients continuing GC therapy should undergo annual BMD testing, vertebral X-ray, and fracture risk assessment using FRAX. When treatment failure is suspected, switching to another drug should be considered.

Conclusions

This guideline is intended to guide clinicians in the prevention and treatment of GIOP.

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.

Long-Term Proton Pump Inhibitor Use Is Not Associated With Changes in Bone Strength and Structure

OBJECTIVES

Multiple studies have reported an association between proton pump inhibitor (PPI) use and fracture. However, the causality of this association is questionable, as there is not a well defined mechanism of action, nor is there evidence of an effect on PPIs on areal bone mineral density (aBMD) using dual photon X-ray absorptiometry (DXA). It is possible that PPIs may induce changes in bone structure which would predispose to fracture in the absence of changes in aBMD. We used three-dimensional quantitative computed tomography (3D-QCT) imaging to determine if long-term PPI use was associated with structural changes in bone independent of aBMD.

METHODS

We enrolled a sample of long-term (≥5 years) PPI users matched to a similar cohort of persons with no PPI use in the previous 5 years. All subjects underwent assessment of aBMD using DXA, volumetric BMD using 3D-QCT, as well as markers of bone metabolism. Measures of bone strength, including buckling ratio and section modulus, were also compared between the two samples.

RESULTS

104 subjects were enrolled (52 PPI users and 52 PPI non-users). There were no differences detected in standard BMD, volumetric BMD, markers of bone metabolism or measures of bone strength between the two groups.

CONCLUSIONS

Long-term PPI use is not associated with any changes in bone mineral density or bone strength that would predispose to an increased risk of fracture. These findings provide further evidence that the association between PPI use and fracture is not causal.

Identification of a p.Arg708Gln variant in COL1A2 in atypical femoral fractures

OBJECTIVES

Long-term bisphosphonates exposure is a proven risk factor for atypical femoral fractures (AFF) but several cases occur in untreated patients. The identification of other risk factors for AFF is critical for the management of osteoporosis. We here assessed the genetic factors associated with AFF regardless of the treatment.

METHODS

Cases were identified through ICD-10 codes in 3 academic centers. Medical records were analyzed by 2 investigators that adjudicated X-rays for typical or atypical fractures. Genetic screening for ALPL, SOX9, COL1A1 and COL1A2 variants was performed after patient's information and consent.

RESULTS

A total of 389 cases were identified and 268 were ruled out according to the ASBMR Task Force recommendations. On the remaining 121, 14 (11.6%) were AFF. Anti-osteoporotic drugs were more frequent in the AFF group compared to the typical fracture group (35% vs 5%, P<0.001) but only 4 (28.6%) patients with AFF had been exposed to bisphosphonates. Genetic analysis performed in 5 patients found one with a heterozygous mutation in COL1A2 (rs72658163, NM_000089.3:c.2123G>A, p.Arg708Gln). This rare variant (Minor Allele Frequency=0.0008) causes a missense mutation that alters collagen fibrillogenesis. Eight heterozygous polymorphisms for ALPL were also found in 3 patients.

CONCLUSION

Genetic screening for variants in only 4 genes and 5 patients with AFF resulted in the identification of genetic variants in 3 patients including a rare variant in COL1A2, suggesting a possible genetic susceptibility to AFF. This finding should encourage clinician to further genotype patients with AFF in a collaborative multicentric project.

Incidence and Characteristics of Atypical Femoral Fractures: Clinical and Geometrical Data

Despite the multitude of studies published on atypical femoral fractures (AFFs), a profile for patients at risk does not exist. This study aimed first at estimating AFF incidence over a 19-month-period in Quebec City using the ASBMR Task force criteria to define AFF. The medical records of patients hospitalized for hip or femoral fracture between June 1, 2009, and December 31, 2010, were reviewed. Thirty-six cases of atypical fractures were identified during the 19-month period, representing an AFF incidence of 7.0 (range, 4.7 to 9.3) cases per 100,000 person-years. In the second part of the study, data regarding the characteristics suspected of increasing the risks of AFF were collected from medical and pharmacological records, proximal femur radiographs, and patient interviews. The data regarding each patient with an AFF during years 2008-2011 were compared to two controls with a hip or femoral fragility fracture or a traumatic fracture, paired for age and sex. Twenty patients with AFF were added to the 36 patients with AFF selected in the first part, thereby 56 patients with AFF were investigated. The association between the occurrence of AFF and bisphosphonates (BPs) use was proven statistically significant in multivariate analysis, odds ratio (OR) = 10.39 (95% CI, 2.22 to 48.58; p = 0.0029). Compared to controls, patients with AFF had excessive femoral offset (43.1 mm versus 38.3 mm, p = 0.0007), proximal femoral neck angle in varus (128.9 degrees versus 134.0 degrees, p < 0.0001), and had greater proximal cortical thickness. This retrospective study confirms the low incidence of AFF, confirms its significant association with exposure to BPs, and reveals the possible contribution of proximal femoral geometry in AFF occurrence.

Preclinical studies and clinical evaluation of compounds from the genus Epimedium for osteoporosis and bone health

The morbidity and mortality associated with fractures due to osteoporosis or "porous bone" contributes significantly to global healthcare costs and will increase exponentially with ageing populations. In menopausal women, the onset of menopause and rapid estrogen withdrawal leads to osteoporotic fractures. Healthy bone requires the coordinated remodeling function of osteoclasts, osteoblasts, and osteocytes in the basic bone multicellular unit, regulated by estrogen, RANKL/OPG, ROS, growth factors, and other kinase signaling pathways. Anti-osteoporotic drugs in current use such as hormone replacement therapy, selective estrogen receptor modulators, and bisphosphonates are designed to target these pathways, but all have their limitations. Extracts of the dried aerial parts of the traditional Chinese medicinal plant Epimedium (Berberidaceae) has long been used for bone health. Some nine Epimedium prenylflavonoid compounds have been reported to target estrogen signaling and other bone morphogenesis pathways in mesenchymal stem cell, osteoblast, and osteoclast cell lineages. Epimedium prenylflavonoids and enriched extracts can exert beneficial effects on bone health in estrogen-deficient and other osteoporosis animal models. The development of sensitive and rapid mass chromatographic techniques to quantify compounds extracted from Epimedium, including icariin and icaritin, has been used to standardize production and to study the pharmacokinetics and metabolism of Epimedium in animal models and humans. Recent clinical trials have reported positive effects on bone health, suggesting that compounds or extracts of Epimedium have the potential to be developed as agents, alone or in combination with other drugs, to prevent or delay the onset of osteoporosis and reduce the risk of hip fractures.

High revision rate but good healing capacity of atypical femoral fractures. A comparison with common shaft fractures

INTRODUCTION

Healing of complete, atypical femoral fractures is thought to be impaired, but the evidence is weak and appears to be based on the delayed healing observed in patients with incomplete atypical fractures. Time until fracture healing is difficult to assess, therefore we compared the reoperation rates between women with complete atypical femoral fractures and common femoral shaft fractures.

METHODS

We searched the orthopaedic surgical registry in Östergötland County for patients with subtrochanteric and femoral shaft fractures (ICD-10 diagnosis codes S72.2, S72.3 and M84.3F) between January 1st 2007 and December 31st 2013. Out of 895 patients with surgically treated femoral shaft fractures, 511 were women 50 years of age or older. Among these we identified 24 women with atypical femoral shaft fractures, and 71 with common shaft fractures.

RESULTS

Reoperations were performed in 6 and 5 patients, respectively, odds ratio 4.4 (95% CI 1.2 to 16.1). However, 5 reoperations in the atypical fracture group could not be ascribed to poor healing. In 3 patients the reoperation was due to a new fracture proximal to a standard intramedullary nail. In 2 patients the distal locking screws were removed due to callus formation that was deemed incomplete 5 months post-operatively. The one patient with poor healing showed faint callus formation at 5 months when the fracture was dynamised and callus remained sparse at 11 months. Among patients with common shaft fractures, 2 reoperations were performed to remove loose screws, 2 because of peri-implant fractures and 1 reoperation due to infection.

DISCUSSION

Reoperation rates in patients with complete atypical femoral fractures are higher than in patients with common shaft fractures. The main reason for failure was peri-implant fragility fractures which might be prevented with the use of cephalomedullary nails at the index surgery. Fracture healing however, seems generally good. A watchful waiting approach is advocated in patients with fractures that appear to heal slowly.

Bisphosphonates and their influence on fracture healing: a systematic review

Bisphosphonates are commonly used in osteoporosis, but concerns have been raised about possible negative effects on fracture healing. We systematically reviewed the literature and found that bisphosphonates significantly prolong union times of distal radius fractures but not femoral fractures. The timing of bisphosphonate introduction does not affect fracture union time.

INTRODUCTION

Bisphosphonates are the most commonly prescribed drugs in patients suffering from and at higher risk of developing osteoporosis. However, concerns have been raised as to whether these drugs have a negative effect on fracture healing. The aim of this systematic review is to explore further these concerns.

METHODS

A literature review was performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All relevant articles found via MEDLINE, Cochrane, CINAHL, EMBASE and Google Scholar were screened. Studies with information on bisphosphonates' effect on fracture healing in humans were included and systematically reviewed.

RESULTS

Patients with distal radius fractures on bisphosphonates had a significantly longer union time compared with controls, but not patients with femoral fractures. No correlation between timing of bisphosphonate introduction and union time for fractures was found. Although one study reported a higher humeral non-union associated with bisphosphonate introduction following the fracture, there was no evidence that bisphosphonate introduction, timing or dose resulted in a significant delay in union following other fractures.

CONCLUSIONS

This systematic review has shown that bisphosphonates significantly prolong union times of distal radius fractures. Some clinical findings are in contrast with preclinical studies highlighting the need to develop better animal models to study osteoporosis, treatment and fracture healing. There is also a need for more well-constructed studies looking at the clinical effect of bisphosphonate on fracture healing in a large number of patients. These robust studies need to look at union time and non-union rates as a function of duration and dose of different bisphosphonates in different upper and lower limb fractures.

Risk of Fracture and the Concomitant Use of Bisphosphonates With Osteoporosis-Inducing Medications

Objective: To review the literature on the concomitant use of bisphosphonates and medications that can influence bone metabolism and potentially attenuate bisphosphonate antifracture efficacy. Data Sources: MEDLINE and CINAHL were searched for articles published in English through December 2014 using the following terms: bisphosphonates, bone density conservation agents, acid-suppressive therapy, levothyroxine, thiazolidinediones (TZDs), selective serotonin reuptake inhibitors (SSRIs), bone fractures. Study Selection and Data Extraction: Studies were included if they reported results of concomitant use of any listed medications with bisphosphonates and risk of fractures and focused on women. Articles that focused generally on the use of one of the listed medications and fractures without explicitly examining the potential antifracture efficacy or attenuation of bisphosphonates were excluded. Data Synthesis: A total of 6 relevant studies were identified. Four epidemiological studies reported a statistically significant dose-dependent increase in the risk of fractures when bisphosphonates and acid-suppressive drugs were used together. One post hoc analysis of clinical trial data suggested no attenuation of the antifracture effects of bisphosphonates when used concomitantly with acid-suppressive therapy. One study involving bisphosphonates and SSRIs noted a statistically significant association between fracture risk and SSRI use. No study examining TZDs or levothyroxine with bisphosphonates was identified. Conclusions: Existing research suggests potential attenuation of bisphosphonate antifracture efficacy among patients taking acid-suppressive medications. Based on their pharmacological actions, TZDs, SSRIs, and levothyroxine have similar implications. The paucity of evidence in the literature associating the attenuation of bisphosphonate antifracture efficacy when combined with other medications suggests that further investigation is needed.

Risk of atypical femoral fracture during and after bisphosphonate use

BACKGROUND AND PURPOSE

Use of bisphosphonates in women is associated with higher risk of atypical femoral fractures. The risk in terms of timing of use and type of bisphosphonate, and in men, remains unclear.

PATIENTS AND METHODS

We reviewed radiographs of 5,342 Swedish women and men aged 55 years or more who had had a fracture of the femoral shaft in the 3-year period 2008-2010 (97% of those eligible), and found 172 patients with atypical fractures (93% of them women). We obtained data on medication and comorbidity. The risk of atypical fracture associated with bisphosphonate use was estimated in a nationwide cohort analysis. In addition, we performed a case-control analysis with comparison to 952 patients with ordinary shaft fractures. A short report of the findings has recently been presented (Schilcher et al. 2014a). Here we provide full details.

RESULTS

The age-adjusted relative risk (RR) of atypical fracture associated with bisphosphonate use was 55 (95% CI: 39-79) in women and 54 (CI: 15-192) in men. In bisphosphonate users, women had a 3-fold higher risk than men (RR = 3.1, CI: 1.1-8.4). Alendronate users had higher risk than risedronate users (RR = 1.9, CI: 1.1-3.3). The RR after 4 years or more of use reached 126 (CI: 55-288), with a corresponding absolute risk of 11 (CI: 7-14) fractures per 10,000 person-years of use. The risk decreased by 70% per year since last use.

INTERPRETATION

Women have a higher risk of atypical femoral fracture than men. The type of bisphosphonate used may affect risk estimates and the risk decreases rapidly after cessation.

Pharmacogenetics of osteoporosis

The challenge of personalized medicine is to move away from the traditional 'one-size-fits-all' pharmacology to genotype-based individualized therapies. As an individual's response to drugs is under the control of genes, personal genetic profiles could help clinicians to predict individual drug response and prescribe the right drug and dose, thereby optimising efficacy and avoiding risk of adverse effects. Currently, the concrete application of pharmacogenetics into clinical practice is limited to a few drugs, and the genetic prediction of drug response is far from clear for many of thve principal complex disorders. This is even more evident in the field of osteoporosis and metabolic bone disorders, for which few pharmacogenetic studies have been conducted, and no conclusive results are available. In this chapter, we review recent research on pharmacogenetics of osteoporosis, evaluate criticisms, and offer possible suggestions for improvements in this field and for possible future applications into clinical practice.

Healing delayed but generally reliable after bisphosphonate-associated complete femur fractures treated with IM nails

BACKGROUND

Bisphosphonate therapy for osteoporosis has been associated with atypical femoral fractures. To date, there have been few reports in the literature regarding the preoperative and postoperative courses of patients who have sustained bisphosphonate-associated complete atypical femur fractures.

OBJECTIVES/PURPOSES

The purposes of this study were to (1) characterize the preoperative course of patients who eventually presented with bisphosphonate-associated complete atypical femur fractures (duration of bisphosphonate treatment, pain history, risk of converting a nondisplaced fracture to a complete fracture); (2) evaluate the percentage of patients who achieved radiographic union of those fractures after treatment; and (3) determine the patients' recovery of function using the Short Musculoskeletal Functional Assessment.

METHODS

Thirty-three patients with 41 atypical, low-energy femur fractures associated with ≥ 5 years of bisphosphonate use were treated with intramedullary nailing between 2004 and 2011 at one center. The main outcome measurements were Short Musculoskeletal Functional Assessment for function and radiographic evaluation for fracture healing. Patients had been treated with bisphosphonates for an average of 8.8 years (range, 5-20 years) before presentation.

RESULTS

Patients reported a mean of 6 months of pain before presentation (range, 1-8 months). Sixty-six percent of patients with surgically treated complete fractures became pain-free and 98% were radiographically healed by 12 months. Sixty-four percent of patients who underwent intramedullary nailing reported a functional return to baseline within 1 year. Patients who reported major functional limitations at latest followup listed pain and apprehension as the major causes of their limitation.

CONCLUSIONS

Patients with surgically treated bisphosphonate-associated complete femur fractures achieved generally reliable although delayed fracture healing if malaligned, and nearly two-thirds of patients returned to self-reported baseline function within 1 year.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Histology of 8 atypical femoral fractures: remodeling but no healing

BACKGROUND AND PURPOSE

The pathophysiology behind bisphosphonate-associated atypical femoral fractures remains unclear. Histological findings at the fracture site itself may provide clues.

PATIENTS AND METHODS

Between 2008 and 2013, we collected bone biopsies including the fracture line from 4 complete and 4 incomplete atypical femoral fractures. 7 female patients reported continuous bisphosphonate use for 10 years on average. 1 patient was a man who was not using bisphosphonates. Dual-energy X-ray absorptiometry of the hip and spine showed no osteoporosis in 6 cases. The bone biopsies were evaluated by micro-computed tomography, infrared spectroscopy, and qualitative histology.

RESULTS

Incomplete fractures involved the whole cortical thickness and showed a continuous gap with a mean width of 180 µm. The gap contained amorphous material and was devoid of living cells. In contrast, the adjacent bone contained living cells, including active osteoclasts. The fracture surfaces sometimes consisted of woven bone, which may have formed in localized defects caused by surface fragmentation or resorption.

INTERPRETATION

Atypical femoral fractures show signs of attempted healing at the fracture site. The narrow width of the fracture gap and its necrotic contents are compatible with the idea that micromotion prevents healing because it leads to strains within the fracture gap that preclude cell survival.

Atypical femoral fractures, bisphosphonates, and mechanical stress

Atypical fractures are stress fractures occurring in the femoral shaft and closely related to bisphosphonate use. We here discuss their radiographic definition and different putative etiologies, apart from mechanical stress. Long time reduction of skeletal remodeling because of bisphosphonate use is thought to allow time for the bone to deteriorate mechanically, resulting in reduced toughness. However, the risk of atypical fracture diminishes rapidly after cessation of treatment, which suggests more acute effects of bisphosphonate use. Microdamage normally accumulates at areas of high stress. Possibly, ongoing bisphosphonate use reduces the ability to resorb and replace areas of microdamage by targeted remodeling. This could lead to crack propagation beyond a point of no return, ending in macroscopic stress fracture.

Efficacy of systemic bisphosphonate delivery on osseointegration of implants under osteoporotic conditions: lessons from animal studies

BACKGROUND

The aim was to systematically review the role of systemic bisphosphonate (BP) delivery on osseointegration of implants under osteoporotic conditions.

METHODS

The addressed focused question was "Does systemic BP delivery enhance osseointegration of implants under osteoporotic conditions?" PubMed/MEDLINE and Google-Scholar databases were searched from 1994 up to and including December 2013 using different combinations of the following keywords: "bone to implant contact", "implant", "bisphosphonate", "osseointegration" and "osteoporosis". Review articles, case-reports, commentaries, letters to the Editor, unpublished articles and articles published in languages other than English were excluded.

RESULTS

Fifteen animal studies fulfilled our eligibility criteria. Osteoporotic conditions were induced via bilateral ovariectomy (OVX). BPs used in the studies were ibandronate, zoledronic acid and alendronate. Results from 12 studies showed that systemic BP delivery significantly increased bone volume and bone-to-implant contact under osteoporotic conditions. Two studies reported no significant difference in osseointegration among OVX animals with and without systemic BP delivery. In one study, systemic BP delivery negatively influenced implant osseointegration. Rough-surfaced and polished implants were used in 11 and one study respectively. In 3 studies implant surface characteristics remained unclear.

CONCLUSION

Within the limits of the present study, it is concluded that systemic BP delivery enhances implant osseointegration in animals with induced osteoporotic conditions. However, in a clinical scenario, the potential risk of BP related ONJ in osteoporotic patients undergoing dental implant therapy cannot be disregarded.

Review: epidemiology and pathophysiology of atypical femur fractures

The recent recognition of the clinical phenomenon of atypical femoral fractures has garnered significant scientific interest. In this review, we will discuss and summarize the salient developments in the current understanding of the epidemiology, pathophysiology, and radiology of atypical femoral fractures.

Can long-term bisphosphonate use causes low-energy fractures? A case report

Bisphosphonates are inorganic pyrophosphate analog which accumulate on the bone surface, cause osteoclast apoptosis, and inhibit bone resorption. The nitrogen-containing bisphosphonates continue to be the drug of choice for the treatment of osteoporosis in both men and women. Although histomorphometric studies including bone biopsies have not shown any evidence of microcracks, recent studies have revealed that potent bisphosphonates are responsible for the oversuppression of bone turnover leading to microdamages, reduced bone strength, and increased fracture risk. There are individual cases reporting atypical femoral fractures and severely suppressed bone turnover along with long-term (≥ 5 years) use of biphosphonates. In this study, we report on a 74-year-old woman with a history of continuous alendronate use for nearly 16 years who presented to the emergency department with right proximal humerus and left femur fracture.

Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research

Bisphosphonates (BPs) and denosumab reduce the risk of spine and nonspine fractures. Atypical femur fractures (AFFs) located in the subtrochanteric region and diaphysis of the femur have been reported in patients taking BPs and in patients on denosumab, but they also occur in patients with no exposure to these drugs. In this report, we review studies on the epidemiology, pathogenesis, and medical management of AFFs, published since 2010. This newer evidence suggests that AFFs are stress or insufficiency fractures. The original case definition was revised to highlight radiographic features that distinguish AFFs from ordinary osteoporotic femoral diaphyseal fractures and to provide guidance on the importance of their transverse orientation. The requirement that fractures be noncomminuted was relaxed to include minimal comminution. The periosteal stress reaction at the fracture site was changed from a minor to a major feature. The association with specific diseases and drug exposures was removed from the minor features, because it was considered that these associations should be sought rather than be included in the case definition. Studies with radiographic review consistently report significant associations between AFFs and BP use, although the strength of associations and magnitude of effect vary. Although the relative risk of patients with AFFs taking BPs is high, the absolute risk of AFFs in patients on BPs is low, ranging from 3.2 to 50 cases per 100,000 person-years. However, long-term use may be associated with higher risk (∼100 per 100,000 person-years). BPs localize in areas that are developing stress fractures; suppression of targeted intracortical remodeling at the site of an AFF could impair the processes by which stress fractures normally heal. When BPs are stopped, risk of an AFF may decline. Lower limb geometry and Asian ethnicity may contribute to the risk of AFFs. There is inconsistent evidence that teriparatide may advance healing of AFFs.

Supplementation with fish oil and genistein, individually or in combination, protects bone against the adverse effects of methotrexate chemotherapy in rats

Cancer chemotherapy has been shown to induce long-term skeletal side effects such as osteoporosis and fractures; however, there are no preventative treatments. This study investigated the damaging effects of anti-metabolite methotrexate (MTX) subcutaneous injections (0.75 mg/kg BW) for five days and the potential protective benefits of daily oral gavage of fish oil at 0.5 mL/100 g BW (containing 375 mg of n-3 PUFA/100 g BW), genistein (2 mg/100 g BW), or their combination in young adult rats. MTX treatment alone significantly reduced primary spongiosa height and secondary spongiosa trabecular bone volume. Bone marrow stromal cells from the treated rats showed a significant reduction in osteogenic differentiation but an increase in adipogenesis ex vivo. Consistently, stromal cells had significantly higher mRNA levels of adipogenesis-related proliferator activator activated receptor-γ (PPAR-γ) and fatty acid binding protein (FABP4). MTX significantly increased the numbers of bone-resorbing osteoclasts and marrow osteoclast precursor cell pool while significantly enhancing the mRNA expression of receptor activator for nuclear factor kappa B ligand (RANKL), the RANKL/osteoprotegerin (OPG) ratio, interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α) in the bone. Supplementary treatment with fish oil and/or genistein significantly preserved trabecular bone volume and osteogenesis but suppressed MTX-induced adipogenesis and increases in osteoclast numbers and pro-osteoclastogenic cytokine expression. Thus, Fish oil and/or genistein supplementation during MTX treatment enabled not only preservation of osteogenic differentiation, osteoblast number and bone volume, but also prevention of MTX treatment-induced increases in bone marrow adiposity, osteoclastogenic cytokine expression and osteoclast formation, and thus bone loss.

Diagnosis and treatment of bisphosphonate-induced atypical femoral fractures

Atypical femoral fractures, deformities of the subtrochanteric region of the femur identified with plain anteroposterior or lateral lower extremity radiographs and characterized by a specific fracture pattern, are uncommon manifestations in osteoporotic patients. However, the high prevalence of these fractures in patients receiving long-term bisphosphonate therapy led to the many investigations of this association. The purpose of this article is to evaluate and address the link between this fracture type with long-term bisphosphonate therapy, outline the clinical scenario and better define treatment options for optimal care and recovery. In order to do this, a PubMed search was carried out for significant articles using the following keywords: ‘alendronate’, ‘fracture’, ‘atypical’ and ‘femur’.

Atypical incomplete femoral fractures in asymptomatic patients on long term bisphosphonate therapy

OBJECTIVES

Progression of an incomplete atypical femoral fracture (IF) to a complete fracture in patients on long term bisphosphonate (BP) therapy can be catastrophic. We aimed to determine the frequency and imaging features of IF in asymptomatic patients on long-term BP therapy and to identify distinguishing clinical and laboratory markers in the subset of patients who develop these fractures.

MATERIAL AND METHODS

From August 2009 to March 2011, 220 femoral radiographs in 110 asymptomatic patients (101 women, 9 men, age 47-94) were reviewed by 2 radiologists. All patients were on BP therapy for at least 3 years and had no history of hip/thigh pain or recent trauma. MRI was performed when a fracture was suspected on radiographs. Bone mineral density, serum calcium, 25-hydroxy vitamin D, intact parathyroid hormone, serum c-telopeptide and urine n-telopeptide were obtained in all patients.

RESULTS

Two of 110 patients (1.82%, confidence interval of 0.6% to 6.3%) had 3 IFs. Both patients, age 50 and 57, were Caucasian, active and on BP for 8 years. MRI confirmed radiographic findings in both patients. Both women had T-scores in the osteopenic range at 2 sites and osteoporotic range at 1 site.

CONCLUSION

The 1.82% frequency of IF in asymptomatic patients on long term BP therapy is higher than that suggested in the literature. Statistical differences between fracture and non-fracture groups were not presented as the patient population was too small to draw any significant conclusions.

Surgical treatment improves clinical and functional outcomes for patients who sustain incomplete bisphosphonate-related femur fractures

OBJECTIVE

To describe the outcomes for patients treated at a single institution, who sustained incomplete bisphosphonate-induced femoral fractures.

DESIGN

Retrospective review.

SETTING

University-based academic medical center.

PATIENTS

Thirty-one patients with 43 incomplete fractures met the inclusion criteria.

INTERVENTION

Nonoperative management or surgical intervention for fractures with refractory symptoms or progression of fracture lucency on radiographs.

MAIN OUTCOME MEASUREMENTS

Radiographic assessments and the Short Musculoskeletal Functional Assessment to gauge functional status.

RESULTS

The cohort was all women with an average age of 69.2 (range: 46-92) years and had been treated with bisphosphonate therapy for an average of 9.1 (range: 5-20) years. The average healing time for all incomplete fractures was 9.4 (range: 1.5-36) months. Forty-nine percent of the fractures (21 of 43 fractures) were ultimately treated with surgery for impending complete fracture or failure of nonsurgical management. Of the incomplete fractures treated with surgery, 81% became pain free and 100% were radiographically healed at a mean of 7.1 (range: 1.5-12) months. In contrast, of the nonoperatively treated incomplete fractures, only 64% were pain free at latest follow-up, with only 18% of fractures demonstrating radiographic evidence of healing at an average of 11 (range: 6-24) months. Standardized dysfunction index from the Short Musculoskeletal Functional Assessment was better (19.7) in the surgical group than in the nonsurgical group (19.7 vs. 25.7, P = 0.0017).

CONCLUSIONS

A higher percentage of patients treated surgically became asymptomatic and demonstrated radiographic evidence of healing earlier than those treated nonsurgically. Surgical intervention is effective for relief of symptoms when treating incomplete bisphosphonate-related femur fractures, and patients should be counseled to the potential benefits of prophylactic surgery.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

We need a break: Bisphosphonates

Bone is a dynamic tissue. It remodels, thereby maintaining serum calcium, repairing micro damage and maintaining strength. A reduction in the strength of bone leads to osteoporosis that may manifest clinically as low energy vertebral and non-vertebral fractures. The bone strength, in turn, is determined by its material, structural properties and on its remodeling potential. Commonly, osteoporosis is objectively evaluated by 'T' and 'Z' scores and these are the indicators of bone density as determined by Dexa scan; these scores correlate inversely with the fracture risk. Quite often, we forget that Dexa scan results are not the only factors determining bone strength and the association between bone density and bone strength is not fixed, and is exemplified by the example of "osteopetrosis". The same issue is happening with the prolonged use of bisphosphonates (BP's).

Bisphosphonates and nonhealing femoral fractures: analysis of the FDA Adverse Event Reporting System (FAERS) and international safety efforts: a systematic review from the Research on Adverse Drug Events And Reports (RADAR) project

BACKGROUND

In the United States, hip fracture rates have declined by 30% coincident with bisphosphonate use. However, bisphosphonates are associated with sporadic cases of atypical femoral fracture. Atypical femoral fractures are usually atraumatic, may be bilateral, are occasionally preceded by prodromal thigh pain, and may have delayed fracture-healing. This study assessed the occurrence of bisphosphonate-associated nonhealing femoral fractures through a review of data from the U.S. FDA (Food and Drug Administration) Adverse Event Reporting System (FAERS) (1996 to 2011), published case reports, and international safety efforts.

METHODS

We analyzed the FAERS database with use of the proportional reporting ratio (PRR) and empiric Bayesian geometric mean (EBGM) techniques to assess whether a safety signal existed. Additionally, we conducted a systematic literature review (1990 to February 2012).

RESULTS

The analysis of the FAERS database indicated a PRR of 4.51 (95% confidence interval [CI], 3.44 to 5.92) for bisphosphonate use and nonhealing femoral fractures. Most cases (n = 317) were attributed to use of alendronate (PRR = 3.32; 95% CI, 2.71 to 4.17). In 2008, international safety agencies issued warnings and required label changes. In 2010, the FDA issued a safety notification, and the American Society for Bone and Mineral Research (ASBMR) issued recommendations about bisphosphonate-associated atypical femoral fractures.

CONCLUSIONS

Nonhealing femoral fractures are unusual adverse drug reactions associated with bisphosphonate use, as up to 26% of published cases of atypical femoral fractures exhibited delayed healing or nonhealing.

Oral bisphosphonates are associated with increased risk of subtrochanteric and diaphyseal fractures in elderly women: a nested case-control study

OBJECTIVES

To evaluate the association between bisphosphonate use and the risk of atypical femoral fractures among women aged 65 or older.

DESIGN

Nested case-control study.

SETTING

General practice research database in Spain.

EXPOSURES

Use of oral bisphosphonates before the occurrence of atypical fractures among cases or the corresponding index date among controls. Bisphosphonate use was categorised as ever versus never users. Ever users were divided according to the total time since first prescription.

MAIN OUTCOME MEASURES

Cases were defined as women aged 65 years or older with a first diagnosis of subtrochanteric or diaphyseal fracture, recorded in the BIFAP database between 1 January 2005 and 31 December 2008, and with at least 1 year of follow-up before the index date. For each case, five age-matched and calendar-year-matched controls without a history of hip or atypical fracture were randomly selected from the database.

STATISTICAL ANALYSIS

OR of atypical femoral fracture by bisphosphonate use was determined using conditional logistic regression. Models were adjusted for comorbidities and use of other medications.

RESULTS

The analysis included 44 cases and 220 matched controls (mean age, 82 years). Ever use of bisphosphonates was more frequent in cases than controls (29.6% vs 10.5%). In multivariate analyses, OR (95% CI) of atypical femoral fracture was 4.30 (1.55 to 11.9) in ever versus never users of bisphosphonates. The risk increased with long-term use, with an OR of 9.46 (2.17 to 41.3) comparing those using bisphosphonates over 3 years versus no users (p for trend=0.01).

CONCLUSIONS

Bisphosphonate use was associated with an increased risk of subtrochanteric or diaphyseal fractures in elderly women in a low fracture risk population, with a higher risk among long-term bisphosphonate users.

Burden of bisphosphonate-associated femoral fractures

BACKGROUND

Bisphosphonates decrease the risk of typical low trauma fractures, and are commonly prescribed for this indication. The link between atypical fractures and bisphosphonate use is well established; however, who is susceptible to atypical fracture remains unclear. A number of large population-based studies have disregarded the atypical fracture risk as they have found the absolute risk to be low.

METHODS

This is a retrospective review of the radiographs and charts of all patients who presented with subtrochanteric and diaphyseal femoral fractures over a 5-year period. Patients were interviewed to determine functionality post-fracture.

RESULTS

Atypical fractures represented 30.3% of all diaphyseal and subtrochanteric femoral fractures. Ninety per cent of all atypical fractures were associated with bisphosphonate use. Atypical fracture patients were younger, more active and are independent prior to fracture and experienced significant complications and self-reported level of function and health declines post-fracture.

CONCLUSION

The burden of bisphosphonate-associated atypical fractures is significant. The aetiology of these fractures is unclear, and to date, no studies have demonstrated the significance of the injury for the patient. Prescription of bisphosphonate therapy for osteoporosis should be accompanied by ongoing surveillance and warning of the possibility of atypical and minimal trauma fractures.

Denosumab treatment in postmenopausal women with osteoporosis does not interfere with fracture-healing: results from the FREEDOM trial

BACKGROUND

Fracture is the major complication of osteoporosis, and it allows the identification of individuals needing medical intervention for osteoporosis. After nonvertebral fracture, patients often do not receive osteoporosis medical treatment despite evidence that this treatment reduces the risk of subsequent fracture. In this pre planned analysis of the results of the three-year, placebo-controlled FREEDOM trial, we evaluated the effect of denosumab administration on fracture-healing to address theoretical concerns related to initiating or continuing denosumab therapy in patients presenting with a nonvertebral fracture.

METHODS

Postmenopausal women aged sixty to ninety years with osteoporosis were randomized to receive 60 mg of denosumab (n = 3902) or a placebo (n = 3906) subcutaneously every six months for three years. Investigators reported complications associated with a fracture or its management and with fracture-healing for all nonvertebral fractures that occurred during the study. Delayed healing was defined as incomplete fracture-healing six months after the fracture.

RESULTS

Six hundred and sixty-seven subjects (303 treated with denosumab and 364 who received a placebo) had a total of 851 nonvertebral fractures (386 in the denosumab group and 465 in the placebo group), including 199 fractures (seventy-nine in the denosumab group and 120 in the placebo group) that were treated surgically. Delayed healing was reported in seven subjects (two in the denosumab group and five in the placebo group), including one with subsequent nonunion (in the placebo group). Neither delayed healing nor nonunion was observed in any subject who had received denosumab within six weeks preceding or following the fracture. A complication associated with the fracture or intervention occurred in five subjects (2%) and twenty subjects (5%) in the denosumab and placebo groups,respectively (p = 0.009).

CONCLUSIONS

Denosumab in a dose of 60 mg every six months does not seem to delay fracture-healing or contribute to other complications, even when it is administered at or near the time of the fracture.

Insufficiency fracture of ipsilateral femur neck in patient treated with long term bisphosphonate treatment - a case report -

Bisphosphonate is notable for the treatment of osteoporosis in the world. But recently if Bisphosphonate is taken for a long time, it causes an insufficiency fracture by suppression of bone turn-over and it is reported rarely on femur neck. Here we report a case of insufficiency fracture on ipsilateral femur neck in woman treated with long term Bisphosphonate therapy.

Low-energy spontaneous femoral fractures in patients with long-term bisphosphonate therapy

Long-term bisphosphonate therapy has been associated with low-energy subtrochanteric and femoral diaphyseal fractures in recent reports. We report three cases of a characteristic pathologic fracture of the subtrochanteric part of femoral, one of them bilateral.

Adverse drug reactions to osteoporosis treatments

Treatments for postmenopausal osteoporosis are generally safe, but are linked to some rare serious adverse drug reactions, for which causality is not always certain. The bisphosphonates are associated with gastrointestinal effects, acute phase reactions, and musculoskeletal pain, and, more rarely, cases of atrial fibrillation, subtrochanteric fracture, osteonecrosis of the jaw, cutaneous hypersensitivity reactions and renal impairment. It is too soon for pharmacovigilance data on denosumab, but it has been associated with cutaneous effects and possibly osteonecrosis of the jaw (to date, only in metastatic cancer). The selective estrogen receptor modulators may induce hot flushes and leg cramps, and--more rarely--venous thromboembolism and stroke. Strontium ranelate is associated with headache, nausea and diarrhea, and, more rarely, cutaneous hypersensitivity reactions and venous thromboembolism, while teriparatide and parathyroid hormone(1-84) are associated with headache, nausea, dizziness and limb pain. The management of osteoporosis should entail weighing the probability of adverse reactions against the benefits of therapy--that is, reduction of fracture risk.

A framework for the development of guidelines for the management of glucocorticoid-induced osteoporosis

This paper provides a framework for the development of national guidelines for the management of glucocorticoid-induced osteoporosis in men and women aged 18 years and over in whom oral glucocorticoid therapy is considered for 3 months or longer.

INTRODUCTION

The need for updated guidelines for Europe and other parts of the world was recognised by the International Osteoporosis Foundation and the European Calcified Tissue Society, which set up a joint Guideline Working Group at the end of 2010.

METHODS AND RESULTS

The epidemiology of GIO is reviewed. Assessment of risk used a fracture probability-based approach, and intervention thresholds were based on 10-year probabilities using FRAX. The efficacy of intervention was assessed by a systematic review.

CONCLUSIONS

Guidance for glucocorticoid-induced osteoporosis is updated in the light of new treatments and methods of assessment. National guidelines derived from this resource need to be tailored within the national healthcare framework of each country.

Pharmacogenetics of osteoporosis: what is the evidence?

The early genetic prediction of personal drug therapy outcome, both in terms of identification of poor responders or nonresponders, as well as of subjects at risk of developing adverse reactions, and its translation into the clinical practice are the main challenges of personalized medicine. The application of pharmacogenetic predictive tests will be very useful mostly in cases of chronic disorders, as in metabolic bone diseases, that require long-term treatments and for whom exist effective differently acting drugs to be alternatively chosen. Pharmacogenetic tests, prior to drug administration, would hypothetically grant the optimization of drug therapy, based on patient's genotype, to ensure maximum efficacy with minimal adverse effects. This review aims to offer an overview on the principal findings in the field of pharmacogenetics of osteoporosis, and it will discuss future perspectives and possible clinical applications of pharmacogenetic tests for antiresorptive drugs.