1
|
Qiu S, Dhaliwal R, Divine G, Warner E, Rao SD. Differences in bone histomorphometry between White postmenopausal women with and without atypical femoral fracture after long-term bisphosphonate therapy. J Bone Miner Res 2024; 39:417-424. [PMID: 38477744 DOI: 10.1093/jbmr/zjae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 12/28/2023] [Accepted: 01/12/2024] [Indexed: 03/14/2024]
Abstract
Bone histomorphometric endpoints in transilial biopsies may be associated with an increased risk of atypical femoral fracture (AFF) in patients with osteoporosis who take antiresorptives, including bisphosphonates (BPs). One way to test this hypothesis is to evaluate bone histomorphometric endpoints in age-, gender-, and treatment time-matched patients who either had AFF or did not have AFF. In this study, we performed transiliac bone biopsies in 52 White postmenopausal women with (n = 20) and without (n = 32) AFFs, all of whom had been treated for osteoporosis continuously with alendronate for 4-17 yr. Despite the matched range of treatment duration (4-17 yr), AFF patients received alendronate for significantly longer time (10.7 yr) than non-AFF patients (8.0 yr) (P = .014). Bone histomorphometric endpoints reflecting microstructure and turnover were assessed in cancellous, intracortical, and endocortical envelopes from transilial biopsy specimens obtained from BP-treated patients 3-6 mo after AFF and from non-AFF patients with similar age-, gender-, and range of BP treatment duration. However, in both cancellous and intracortical envelopes, AFF patients had significantly lower wall thickness (W.Th) and higher osteoclast surface (Oc.S/BS) than non-AFF patients. In addition, AFF patients had significantly higher eroded surface (ES/BS) only in the intracortical envelope. None of the dynamic variables related to bone formation and turnover differed significantly between the groups. In conclusion, in the ilium of BP-treated patients with osteoporosis, AFF patients have lower thickness of superficial bone (lower W.Th) of the cancellous and cortical envelopes than non-AFF patients. AFF and non-AFF patients have a similar bone turnover rate in the ilium. Furthermore, in this population, as in previous work, AFF is more likely to occur in BP-treated patients with longer treatment duration.
Collapse
Affiliation(s)
- Shijing Qiu
- Bone and Mineral Research Laboratory, Henry Ford Health, Detroit, MI 48202, USA
| | - Ruban Dhaliwal
- Center for Mineral Metabolism and Clinical Research, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
- Division of Endocrinology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - George Divine
- Department of Public Health Sciences, Henry Ford Health, Detroit, MI 48202, USA
| | - Elizabeth Warner
- Division of Endocrinology, Diabetes, and Bone & Mineral Disorders, Henry Ford Health, Detroit, MI, 48202, USA and Michigan State University College of Human Medicine, East Lansing, MI, 48825, USA
| | - Sudhaker D Rao
- Bone and Mineral Research Laboratory, Henry Ford Health, Detroit, MI 48202, USA
- Division of Endocrinology, Diabetes, and Bone & Mineral Disorders, Henry Ford Health, Detroit, MI, 48202, USA and Michigan State University College of Human Medicine, East Lansing, MI, 48825, USA
| |
Collapse
|
2
|
Bliemel C, Birkelbach R, Knauf T, Pass B, Craiovan B, Schoeneberg C, Ruchholtz S, Bäumlein M. Surgical management and outcomes following atypical subtrochanteric femoral fractures - results from a matched-pair analysis of the registry for geriatric trauma of the German Trauma Society. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05297-3. [PMID: 38642159 DOI: 10.1007/s00402-024-05297-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 03/24/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND AND OBJECTIVES The outcomes of patients with atypical subtrochanteric fractures (ASFs) remain unclear. Data from a large international geriatric trauma registry were analysed to examine the outcome of patients with ASFs compared to patients with typical osteoporotic subtrochanteric fractures (TSFs). MATERIALS AND METHODS Data from the Registry for Geriatric Trauma of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie [DGU]) (ATR-DGU) were analysed. All patients treated surgically for ASFs or TSFs were included in this analysis. Across both fracture types, a paired matching approach was conducted, where statistical twins were formed based on background characteristics sex, age, American Society of Anesthesiologists (ASA) score and walking ability. In-house mortality and mortality rates at the 120-day follow-up, as well as mobility at 7 and 120 days, the reoperation rate, hospital discharge management, the hospital readmission rate at the 120-day follow-up, health-related quality of life, type of surgical treatment and anti-osteoporotic therapy at 7 and 120 days, were assessed as outcome measures using a multivariate logistic regression analysis. RESULTS Amongst the 1,800 included patients, 1,781 had TSFs and 19 had ASFs. Logistic regression analysis revealed that patients with ASFs were more often treated with closed intramedullary nailing (RR = 3.59, p < 0.001) and had a higher probability of vitamin D supplementation as osteoporosis therapy at 120 days (RR = 0.88, p < 0.002). Patients with ASFs were also more likely to live at home after surgery (RR = 1.43, p < 0.001), and they also tended to continue living at home more often than patients with TSFs (RR = 1.33, p < 0.001). Accordingly, patients with TSFs had a higher relative risk of losing their self-sufficient living status, as indicated by increased rates of patients living at home preoperatively and being discharged to nursing homes (RR = 0.19, p < 0.001) or other hospitals (RR = 0.00, p < 0.001) postoperatively. CONCLUSIONS Surgical treatment of ASFs was marked by more frequent use of closed intramedullary fracture reduction. Furthermore, patients with ASFs were more likely to be discharged home and died significantly less often in the given timeframe. The rate of perioperative complications, as indicated by nonsignificant reoperation rates, as well as patient walking abilities during the follow-up period, remained unaffected.
Collapse
Affiliation(s)
- Christopher Bliemel
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, 35043, Baldingerstrasse, Marburg, Germany.
- Philipps University of Marburg, Marburg, Germany.
| | | | - Tom Knauf
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, 35043, Baldingerstrasse, Marburg, Germany
| | - Bastian Pass
- Department of Orthopedic and Emergency Surgery, Alfried Krupp Hospital, Essen, Germany
| | - Benjamin Craiovan
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, 35043, Baldingerstrasse, Marburg, Germany
| | - Carsten Schoeneberg
- Department of Orthopedic and Emergency Surgery, Alfried Krupp Hospital, Essen, Germany
| | - Steffen Ruchholtz
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, 35043, Baldingerstrasse, Marburg, Germany
- Philipps University of Marburg, Marburg, Germany
| | - Martin Bäumlein
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, 35043, Baldingerstrasse, Marburg, Germany
- Philipps University of Marburg, Marburg, Germany
| |
Collapse
|
3
|
Hwang S, Seo M, Lim D, Choi MS, Park JW, Nam K. Bilateral Atypical Femoral Fractures after Bisphosphonate Treatment for Osteoporosis: A Literature Review. J Clin Med 2023; 12:jcm12031038. [PMID: 36769684 PMCID: PMC9917519 DOI: 10.3390/jcm12031038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION This literature review aimed to investigate the incidence, anatomical concerns, etiology, symptoms, diagnostic tools, management, and prognosis of bisphosphonate (BP)-associated bilateral atypical femoral fractures (AFFs). METHODS The PubMed, Cochrane Library, Web of Sciences, and CINAHL databases were searched up to 20 March 2022. All cases of bilateral AFFs were included, excluding those without any bisphosphonate treatment information and those in which the femoral fracture did not precisely fit into the diagnostic criteria for AFF. RESULTS We identified 43 patients with bilateral AFFs associated with BP use and conducted a comprehensive analysis. Among 43 patients, 29 (67%) had prodromal symptoms. Regarding the simultaneity of fracture, 21 cases (49%) occurred simultaneously, and 22 cases (51%) occurred sequentially. Alendronate was the most commonly used BP treatment (59%). Regardless of the medication type, BP intake duration was more than 5 years in 77%. The initial diagnosis was performed using X-rays in all cases. A total of 53% of patients had complete fractures, and all patients underwent surgical treatment. Among the remaining patients with incomplete fractures, 18% and 29% received surgical and medical treatments, respectively. After BP discontinuation, teriparatide was most commonly used (63%). CONCLUSIONS The careful evaluation of relevant imaging findings in patients with thigh/groin pain allows the identification of early incomplete fractures and timely management. Since the rate of contralateral side fractures is also high, imaging studies should be performed on the asymptomatic contralateral side.
Collapse
Affiliation(s)
- SeokJoon Hwang
- Department of Physical Medicine and Rehabilitation, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang-si 10326, Gyeonggi-do, Republic of Korea
| | - Minsu Seo
- Department of Physical Medicine and Rehabilitation, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang-si 10326, Gyeonggi-do, Republic of Korea
| | - Dongin Lim
- Department of Physical Medicine and Rehabilitation, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang-si 10326, Gyeonggi-do, Republic of Korea
| | - Min Suk Choi
- Department of Thoracic and Cardiovascular Surgery, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang-si 10326, Gyeonggi-do, Republic of Korea
| | - Jin-Woo Park
- Department of Physical Medicine and Rehabilitation, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang-si 10326, Gyeonggi-do, Republic of Korea
| | - Kiyeun Nam
- Department of Physical Medicine and Rehabilitation, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang-si 10326, Gyeonggi-do, Republic of Korea
- Correspondence: ; Tel.: +82-31-961-8460; Fax: +82-31-961-7488
| |
Collapse
|
4
|
Lee JM, Park CH, Yoo JI, Kim JT, Cha Y. Atypical periprosthetic femoral fracture with stem breakage: a case report. Osteoporos Int 2022; 33:2043-2047. [PMID: 35688896 DOI: 10.1007/s00198-022-06463-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/01/2022] [Indexed: 11/27/2022]
Abstract
Although the American Society for Bone and Mineral Research definition of atypical femoral fracture excludes periprosthetic fractures, fractures around the prosthesis with clinical features of atypical femoral fractures have been reported in the literature. All fractures reported thus far have been distal to the prosthetic segment; however, we encountered a case of a stress fracture in the middle of the femoral component segment. An 86-year-old woman with a history of bisphosphonate osteoporosis treatment and revisional total hip arthroplasty visited our outpatient clinic complaining of pain in the left thigh and groin. We diagnosed an incomplete atypical femoral fracture around the hip prosthesis; medical treatment was implemented. Two months later, the patient visited the emergency department with a complete subtrochanteric fracture with stem breakage. Without revision of the broken stem, two plates were applied after reduction. In this case, we recognized the possibility of a stress fracture but overlooked the possibility of stem breakage in an atypical femoral fracture. Even if it is not evident on the radiograph before complete fracture, clinicians should be alert to the signs of stress fracture in the middle of the femoral component segment, as they may be clues to atypical periprosthetic femoral fracture with stem failure. Isolated medical treatment plans are not recommended for incomplete subtrochanteric atypical periprosthetic femoral fracture. Instead, concomitant prophylactic plate fixation is recommended.
Collapse
Affiliation(s)
- J M Lee
- Department of Orthopedic Surgery, Ajou University School of Medicine, Ajou Medical Center, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, South Korea
| | - C H Park
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Daegu, South Korea
| | - J-I Yoo
- Department of Orthopedics, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - J-T Kim
- Department of Orthopedic Surgery, Ajou University School of Medicine, Ajou Medical Center, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, South Korea.
| | - Y Cha
- Department of Orthopedic Surgery, Daejeon Eulji Medical Center, Eulji University School of Medicine, 95 Dunsan-Seoro, Seo-gu, Daejeon, 302-799, South Korea.
| |
Collapse
|
5
|
Hussain MA, Joseph A, Cherian VM, Srivastava A, Cherian KE, Kapoor N, Paul TV. Bisphosphonate-induced atypical femoral fracture in tandem: long-term follow-up is warranted. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0249. [PMID: 36001019 PMCID: PMC9422258 DOI: 10.1530/edm-22-0249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/15/2022] [Indexed: 11/08/2022] Open
Abstract
Summary Although bisphosphonates (BPs) are mainly used for the treatment of osteoporosis and are generally safe, long-term use and more dosage as utilised in malignant conditions may be associated with the rare adverse event of an atypical femoral fracture (AFF). Occasionally, the risk of developing an AFF persists long after BPs are withdrawn. A 39-year-old woman who underwent chemotherapy and an autologous stem cell transplantation for multiple myeloma presented to us with history of pain in the left thigh. She had received multiple doses of oral and parenteral BPs for about 10 years in view of the underlying myeloma with osteoporosis. Her investigations showed a suppressed CTX of 192 pg/mL, and radiograph of pelvis displayed thickened cortices with beaking of the left femoral shaft, which was suggestive of an AFF. Following discontinuation of BPs, she underwent prophylactic intra-medullary nailing with which her symptoms improved. Five years later, she presented with similar complaints on the right side. Investigations showed that her bone turnover continued to be suppressed with Cross linked C- Telopeptide of type 1 collagen (CTX) of 165 pg/mL and an X-ray done showed AFF on the right side despite being off BPs. A second intra-medullary nailing was done and on follow-up, she has been symptom-free and independent in her daily activities. Discontinuation of BPs may not prevent the incident second AFF and, therefore, thus warranting long-term follow-up. Learning points Regular screening and follow-up of patients who receive long-term bisphosphonate (BP) therapy should be done. Discontinuation of BPs does not preclude the possibility of repeated occurrence of a second AFF. Long-term BP therapy warrants regular monitoring and follow-up should an AFF occur.
Collapse
Affiliation(s)
| | - Aneez Joseph
- Department of Endocrinology, Christian Medical College and Hospital, Vellore, India
| | - Vinoo Mathew Cherian
- Department of Orthopaedics, Christian Medical College and Hospital, Vellore, India
| | - Alok Srivastava
- Department of Haematology, Christian Medical College and Hospital, Vellore, India
| | | | - Nitin Kapoor
- Department of Endocrinology, Christian Medical College and Hospital, Vellore, India
| | - Thomas Vizhalil Paul
- Department of Endocrinology, Christian Medical College and Hospital, Vellore, India
| |
Collapse
|