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Choudry MS, Daniel A, Stead T, Mangal R, Ganti L. Femoral insufficiency fracture related to bisphosphonate use. Radiol Case Rep 2024; 19:122-125. [PMID: 37941990 PMCID: PMC10628787 DOI: 10.1016/j.radcr.2023.09.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 11/10/2023] Open
Abstract
This case report details the symptoms, diagnostic results, and surgical treatment of a 66-year-old woman who presented to the emergency department complaining of excruciating pain in her right leg after being injured while doing Pilates. After an accident involving a ball during a Pilates exercise, the patient reported feeling pain. Upon physical examination, the right leg was found to be shortened and externally rotated, with the foot's sensation and mobility unaffected. A displaced proximal subtrochanteric femur fracture was detected via plain film radiography.
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Affiliation(s)
| | | | - Thor Stead
- The Warren Alpert Meidcal School of Brown University, Providence, RI, USA
| | - Rohan Mangal
- Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Latha Ganti
- The Warren Alpert Meidcal School of Brown University, Providence, RI, USA
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2
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Ong CJ, Mourad T, Weiss P, Martin R, Palaparty G, Allam E. Sternal stress fracture presenting as acute chest pain. Radiol Case Rep 2023; 18:4435-4438. [PMID: 37823050 PMCID: PMC10563007 DOI: 10.1016/j.radcr.2023.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/05/2023] [Accepted: 09/10/2023] [Indexed: 10/13/2023] Open
Abstract
Sternal fractures are rare and are typically caused by major trauma such as motor vehicle collisions. However, sternal insufficiency fractures can occur with minimal to no trauma in patients with exaggerated thoracic kyphosis from multiple thoracic compression fractures, especially in the setting of osteoporosis. We describe a case of a sternal insufficiency fracture that presented as chest pain resembling a myocardial infarction. As sternal insufficiency fractures may vary in clinical presentation, this case demonstrates that radiologists should carefully evaluate the sternum, especially when risk factors are present. Furthermore, awareness and identification of these fractures can prevent unnecessary cardiac workups.
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Affiliation(s)
- Chiew-Jen Ong
- Loyola University Chicago and Loyola University Medical Center, Department of Radiology, 2160 S 1st Ave, Maywood, IL, 60153, USA
| | - Talal Mourad
- University of Illinois College of Medicine Peoria, Peoria, IL, 61605, USA
| | - Parker Weiss
- Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, IL, 60515, USA
| | - Ryan Martin
- Loyola University Chicago and Loyola University Medical Center, Department of Radiology, 2160 S 1st Ave, Maywood, IL, 60153, USA
| | - Grace Palaparty
- Loyola University Chicago and Loyola University Medical Center, Department of Radiology, 2160 S 1st Ave, Maywood, IL, 60153, USA
| | - Emad Allam
- Loyola University Chicago and Loyola University Medical Center, Department of Radiology, 2160 S 1st Ave, Maywood, IL, 60153, USA
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Arand C, Mehler D, Sauer A, Hartung C, Gercek E, Rommens PM, Wagner D. Do we need to fix the anterior fracture component in insufficiency fractures of the pelvis? A biomechanical comparison on an FFP type IIIc fracture in an osteoporotic pelvic bone model. Injury 2023; 54:111096. [PMID: 37833233 DOI: 10.1016/j.injury.2023.111096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/27/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023]
Abstract
There is a growing understanding of the specific characteristics of insufficiency fractures of the pelvis and of general requirements for the treatment of affected patients with focus on early mobilization and effective pain reduction as the main goals of therapy. While there is consensus on the significance of achieving stability of the dorsal pelvic ring structures there is still an open discussion about the potential benefits of additional stabilization of an anterior fracture component. Within a biomechanical test setup, two established methods of dorsal fracture fixation were tested under axial loading (25-1200 N; 1000 test cycles) on an explicit osteoporotic bone model (n = 32) with a standardized FFP type IIIc fracture with and without additional fixation of the anterior fracture component. Dorsal fixation was performed with and long and a short 7.3 mm cannulated screw in S1 in one group (n = 16), and a trans sacral bar with an additional short 7.3 mm cannulated screw in S1 in the other group (n = 16). Half of the samples received a 7.3 mm cannulated retrograde transpubic screw for anterior fixation. The fixation with the trans sacral bar and the additional anterior screw fixation showed the highest rate of stability (p = 0.0014), followed by the double SI-screw fixation with stabilization of the anterior fracture (p = 0.0002). During testing, we observed the occurrence of new sacral fractures contralateral to the initial fracture in 22/32 samples. The results let us assume that stabilization of an additional anterior fracture component relevantly improves the stability of the entire ring construct and might prevent failure of the dorsal stabilization or further fracture progression.
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Affiliation(s)
- Charlotte Arand
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Langenbeckstraße 1, Mainz 55131, Germany.
| | - Dorothea Mehler
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Langenbeckstraße 1, Mainz 55131, Germany
| | - Anne Sauer
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Langenbeckstraße 1, Mainz 55131, Germany
| | - Christian Hartung
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Langenbeckstraße 1, Mainz 55131, Germany
| | - Erol Gercek
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Langenbeckstraße 1, Mainz 55131, Germany
| | - Pol M Rommens
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Langenbeckstraße 1, Mainz 55131, Germany
| | - Daniel Wagner
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Langenbeckstraße 1, Mainz 55131, Germany; Department of Orthopedics and Trauamtology, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland
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Malghem J, Lecouvet F, Vande Berg B, Kirchgesner T, Omoumi P. Subchondral insufficiency fractures, subchondral insufficiency fractures with osteonecrosis, and other apparently spontaneous subchondral bone lesions of the knee-pathogenesis and diagnosis at imaging. Insights Imaging 2023; 14:164. [PMID: 37782395 PMCID: PMC10545656 DOI: 10.1186/s13244-023-01495-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 07/17/2023] [Indexed: 10/03/2023] Open
Abstract
Subchondral insufficiency fractures (SIFs) and SIFs with osteonecrosis (SIF-ONs) of the knee (previously misnamed spontaneous osteonecrosis of the knee (SONK)) are bone lesions that appear without prior traumatic, tumoral, or inflammatory event.Both conditions are characterized in the early stages by epiphyseal bone marrow edema (BME)-like signal at MRI. However, while SIFs usually heal spontaneously, they can also evolve to osteonecrosis (i.e., SIF-ON), which may progress to an irreversible collapse of the articular surface. Careful analysis of other MRI signs may help differentiate the two conditions in the early phase. In SIFs, the BME edema-like signal extends to the area immediately adjacent to the subchondral plate, while in SIF-ONs, this subchondral area shows low signal intensity on fluid-sensitive MR images due to altered bone marrow. The thickness and length of subchondral areas with low fluid-sensitive signal intensity are important factors that determine the prognosis of SIF-ONs. If they are thicker than 4 mm or longer than 14 mm, the prognosis is poor. The differential diagnosis of SIFs and SIF-ONs include bone lesions associated with the "complex regional pain syndrome" (CRPS), epiphyseal osteonecrosis of systemic origin, and those related to cartilage pathology.Clinical relevance statement Imaging plays an essential role in diagnosing subchondral insufficiency fractures (SIFs) from subchondral insufficiency fractures with osteonecrosis (SIF-ONs) and collapse, as well as in distinguishing them from other spontaneous knee subchondral bone lesions presenting with bone marrow edema-like signal.Key points• Subchondral insufficiency fractures may affect the knee, especially in older adults.• Subchondral insufficiency fractures usually heal spontaneously.• Sometimes, subchondral osteonecrosis and collapse may complicate subchondral insufficiency fractures.• Bone marrow-like edema is an aspecific sign seen in all these lesions.• Degraded marrow in osteonecrosis complicating fractures is hypointense on fluid-sensitive sequences.
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Affiliation(s)
- Jacques Malghem
- Department of Radiology, Cliniques Universitaires Saint-Luc, UCLouvain, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Frédéric Lecouvet
- Department of Radiology, Cliniques Universitaires Saint-Luc, UCLouvain, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Bruno Vande Berg
- Department of Medical Imaging, Clinique CHC Montlégia, Boulevard Patience Et Beaujonc 2, 4000, Liège, Belgium
| | - Thomas Kirchgesner
- Department of Radiology, Cliniques Universitaires Saint-Luc, UCLouvain, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Patrick Omoumi
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV) and University of Lausanne, Rue du Bugnon 46, 1010, Lausanne, Switzerland.
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Schröder G, Baginski AM, Schulze M, Hiepe L, Bugaichuk S, Martin H, Andresen JR, Moritz M, Andresen R, Schober HC. Regional variations in the intra- and intervertebral trabecular microarchitecture of the osteoporotic axial skeleton. Anat Sci Int 2023:10.1007/s12565-023-00726-6. [PMID: 37093524 DOI: 10.1007/s12565-023-00726-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 04/08/2023] [Indexed: 04/25/2023]
Abstract
Trabecular structures in vertebral bodies are unequally distributed in the cervical, thoracic and lumbar spine, and also within individual vertebrae. Knowledge of the microstructure of these entities could influence our comprehension and treatment of osteoporotic fractures, and even surgical procedures. Appropriate investigations may clarify the pathomechanisms of various osteoporotic fractures (fish, wedge-shaped, and flat vertebrae). We obtained three cancellous bone cylinders from the centers and margins of cervical vertebra 3 to lumbar vertebra 5, and investigated these in regard of bone volume fraction, trabecular thickness, separation, trabecular number, trabecular bone pattern factor, connectivity density, and degree of anisotropy. Using a Jamshidi needle®, we obtained samples from three quadrants (QI: right-sided edge, QII: central, QIII: left-sided edge) of 242 prepared vertebrae, and investigated these on a micro-CT device. In all, 726 bone samples were taken from eleven body donors. Bone volume fraction, trabecular thickness, and the degree of anisotropy were significantly lower in QII than in QI and QIII. Trabecular pattern factor, however, was significantly higher in QII than in QI and QIII. The results helped to explain fish vertebrae. Wedge fractures and flat vertebrae are most likely caused by the complex destruction of trabecular and cortical structures. The higher bone volume fraction in the cervical spine compared to the thoracic and lumbar spine accounts for the small number of fractures in the cervical spine. The marked trabecular pattern factor in the center of thoracic and lumbar vertebrae could be a reason for the surgeon to use different screw designs for individual vertebrae.
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Affiliation(s)
- Guido Schröder
- Warnow Clinic, Clinic for Orthopedics and Trauma Surgery, Am Forsthof 3, 18246, Buetzow, Germany.
| | | | - Marko Schulze
- Institute for Anatomy and Cell Biology, University of Bielefeld, Bielefeld, Germany
| | - Laura Hiepe
- Institute for Anatomy, University Medical Center Rostock, Rostock, Germany
| | | | - Heiner Martin
- Institute for Biomedical Engineering, University Medical Center Rostock, Rostock-Warnemuende, Germany
| | - Julian Ramin Andresen
- Clinic for Orthopedic, Trauma and Reconstructive Surgery, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Mario Moritz
- Clinic of Internal Medicine IV, Suedstadt Clinic Rostock, Academic Teaching Hospital of the University of Rostock, Rostock, Germany
| | - Reimer Andresen
- Institute for Diagnostic and Interventional Radiology/Neuroradiology, Westkuestenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Luebeck und Hamburg, Heide, Germany
| | - Hans-Christof Schober
- Clinic of Internal Medicine IV, Suedstadt Clinic Rostock, Academic Teaching Hospital of the University of Rostock, Rostock, Germany
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Cahill DG, Yam MKH, Griffith JF. Imaging of the Acutely Injured Hip. Radiol Clin North Am 2023; 61:203-217. [PMID: 36739142 DOI: 10.1016/j.rcl.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Acute hip pain following injury more commonly originates locally in and around the hip joint rather than being referred from the lumbar spine, sacroiliac joints, groin, or pelvis. Clinical assessment can usually localize the pain source to the hip region. Thereafter, imaging helps define the precise cause of acute hip pain. This review discusses the imaging of common causes of acute hip pain following injury in adults, addressing injuries in and around the hip joint. Pediatric and postsurgical causes of hip pain following injury are not discussed.
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Affiliation(s)
- Donal G Cahill
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, The Prince of Wales Hospital, Ngai Shing Street, Shatin, Hong Kong
| | - Max K H Yam
- Department of Radiology, North District Hospital, 9 Po Kin Road, Sheung Shui, Hong Kong
| | - James F Griffith
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, The Prince of Wales Hospital, Ngai Shing Street, Shatin, Hong Kong.
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Cantrell CK, Butler BA. A Review on Management of Insufficiency Fractures of the Pelvis and Acetabulum. Orthop Clin North Am 2022; 53:431-443. [PMID: 36208886 DOI: 10.1016/j.ocl.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
"Insufficiency fractures of the pelvis and acetabulum are occurring at increasing rates. Osteoporosis is the most prevalent risk fracture. Diagnosis begins with plain radiographs followed by advanced imaging with computed tomography and/or MRI. Pelvic ring fragility injuries are classified by the Fragility fractures of the pelvis system. Elderly acetabular fractures may be classified by the Letournel system. Management of these injuries is primarily nonoperative with early immobilization when allowed by fracture characteristics. When warranted, percutaneous fixation and open reduction internal fixation are options for both. Both acute and delayed total hip arthroplasty are options for acetabular fractures."
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Affiliation(s)
- Colin K Cantrell
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 North Saint Clair, Suite 1350, Chicago, IL 60611, USA.
| | - Bennet A Butler
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 North Saint Clair, Suite 1350, Chicago, IL 60611, USA
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White WD, Mansfield JT, Gosai EV, Groah SL. Vertebral insufficiency fractures as a cause of autonomic dysreflexia in a patient with chronic tetraplegia: A case report. J Spinal Cord Med 2022; 45:769-772. [PMID: 33054643 PMCID: PMC9542342 DOI: 10.1080/10790268.2020.1829421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Context: Osteoporosis is a known complication in spinal cord injury patients and can result in an increased risk of fractures and associated morbidity. Bone demineralization is most common in long bones below the level of injury. The pathogenesis is complex and not fully understood.Findings: We present the case of a 65-year-old male with chronic spinal cord injury who was found to have multiple vertebral compression fractures causing autonomic dysreflexia and new onset spasticity.Conclusion/Clinical Relevance: This case illustrates the need for improved awareness, diagnosis, and prevention for this disease process.
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Affiliation(s)
- William D. White
- Department of Rehabilitation Medicine, MedStar Georgetown University, Washington, DC, USA,MedStar National Rehabilitation Hospital, Washington, DC, USA,Correspondence to: W. Daniel White, Department of Rehabilitation Medicine, MedStar Georgetown University, 102 Irving St. NW, Washington, DC, 20010, USA; Ph: 202-877-1000.
| | - John T. Mansfield
- Department of Rehabilitation Medicine, MedStar Georgetown University, Washington, DC, USA,MedStar National Rehabilitation Hospital, Washington, DC, USA
| | - Erika V. Gosai
- MedStar National Rehabilitation Hospital, Washington, DC, USA
| | - Suzanne L. Groah
- Department of Rehabilitation Medicine, MedStar Georgetown University, Washington, DC, USA,MedStar National Rehabilitation Hospital, Washington, DC, USA
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Hwang D, Kim CH, Lee Y, Kim JW. Association of atypical femoral fracture location and lower limb mechanical axis: a computed tomography-based finite element analysis. Osteoporos Int 2022; 33:1285-1293. [PMID: 35112136 DOI: 10.1007/s00198-021-06173-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 09/23/2021] [Indexed: 11/27/2022]
Abstract
UNLABELLED Atypical femoral fractures (AFFs) are categorized as low-energy fractures of the femoral shaft or subtrochanteric region. The use of computed tomography-based finite element analysis demonstrated that the femoral weakest point against tensile stress coincided with AFF location, which was determined by the lower limb axis and femoral bowing. INTRODUCTION This study aimed to assess the relationship between the femoral weakest point against tensile stress and the lower limb axis and geometry, including femoral bowing, using a computed tomography (CT)-based finite element analysis (FEA) model. METHODS We retrospectively reviewed 19 patients with AFFs and analyzed their CT images of the contralateral intact femur. We performed FEA to find the maximum principal stress (MPS) and maximal tensile stress loading area (femoral weakest point, FWP) of each patient and matched the FWP with the real location of AFF. We applied mechanical axes differently, as neutral, varus, and valgus, in the FEA model, when we analyzed the change in MPS and FWP based on lower limb alignment. We compared the degree of agreement between the real fracture location and FWP before and after knee mechanical axis adjustment. RESULTS The average participant age was 75.9 (range, 61-87) years, and all participants were women. In the 19 patients included, we observed 20 and 7 shaft and subtrochanteric AFFs, respectively. The average mechanical axis at the knee joint level was 22.6 mm (range, 0-70 mm) of the varus. All the patients showed an increasing trend of MPS and a distal movement of FWP when the mechanical axis of the knee was applied from the valgus to varus alignment. The root mean square errors between the FWP and real fracture location were 14.58% and 10.87% before and after adjustment, respectively, implying that the degree of agreement was better in patients who underwent mechanical adjustment. CONCLUSION The use of CT/FEA demonstrated that the FWP against tensile stress coincided with AFF location, which was determined by the lower limb axis and femoral bowing.
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Affiliation(s)
- Donghwan Hwang
- Medical Device Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu, Republic of Korea
| | - Chul-Ho Kim
- Department of Orthopaedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Yongkoo Lee
- Korea Institute of Machinery and Materials, Daegu, Republic of Korea
| | - Ji Wan Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, Republic of Korea.
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Beelen GWCM, Loggers SAI, de Wit BWK, Schakenraad D, Hofstee DJ, Joosse P, Ponsen KJ. Additional clinical value of routine CT imaging in fragility fractures of the pelvis: a prospective cohort study (ARTIFACT). Eur J Trauma Emerg Surg 2022. [PMID: 35596074 DOI: 10.1007/s00068-022-01989-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 04/24/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Additional CT imaging for fragility fractures of the pelvis (FFP) has a high detection rate for concomitant posterior ring fractures (cPRFs). However, the clinical value of routine additional CT imaging is unknown. This study aimed to determine the additional clinical value of routine CT imaging by changes in treatment policy and to establish the predictive value of pain localized around the sacroiliac joint (SIJ) for cPRFs. METHODS A prospective cohort study was conducted in a single teaching hospital in the Netherlands between November 2019 and November 2020. Patients were included if they were ≥ 65 years and had a (suspected) FFP on the pelvic radiograph. All patients underwent additional CT imaging. Changes in treatment policies ((possible) surgery, restrictive weight-bearing, hospital admission and outpatient follow-up) after CT imaging were registered. RESULTS Fifty-one patients (44 female) were included with a mean age of 80.6 years. Routine CT imaging revealed an additional cPRF in 27 patients (53%). A change in treatment occurred in 29 patients (57%), of which 7 (12%) were managed either surgical or with restrictive weight-bearing. The presence of pain around the SIJ had a sensitivity of 89% and specificity of 61% for detecting a cPRF. CONCLUSION Routine additional CT imaging has few direct therapeutic consequences with regards to surgical management or restrictive weight-bearing. These findings may be altered when considering a lower threshold for surgical intervention. The presence of pain around the SIJ was highly predictive for a clinically relevant cPRF. TRIAL REGISTRATION NL8011 on 02-09-2019.
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Zhong X, Zhang L, Dong T, Mai H, Lu B, Huang L, Li J. Clinical and MRI features of sacral insufficiency fractures after radiotherapy in patients with cervical cancer. BMC Womens Health 2022; 22:166. [PMID: 35562706 PMCID: PMC9102937 DOI: 10.1186/s12905-022-01758-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 05/05/2022] [Indexed: 11/26/2022] Open
Abstract
Background To determine the incidence, clinical and MRI features of sacral insufficiency fracture (SIF) after radiotherapy (RT) in patients with cervical cancer. Methods Our study included 167 patients with cervical cancer after radiotherapy that underwent pelvic MRI for follow-up. MRIs included pre-enhanced T1-weighted, coronal fat-Suppressed T2-weighted (FS-T2W) and enhanced T1-weighted imaging. The clinical and MRI dates were reviewed. The gold standard of SIF was based on radiologic findings, clinical data and follow-up at least 12 months. Results 28 patients (10.8%) with 47 sites were diagnosed with SIFs, including 9 patients with unilateral SIF and 19 patients with bilateral SIFs. The median age was 60 years (range 41–72 years), and 89.3% (25/28) of patients were postmenopausal. 64.3% (18/28) of patients were symptomatic, and 53.6% of patients (15/28) had concomitant pelvic fractures. The median interval time from RT to SIFs was 10 months (range 3–34 months). For the lesion-wise analysis based on all MR images, all lesions were detected by visualizing bone marrow edema patterns, and fracture lines were detected in 64.6% (31/47) of SIFs. No soft-tissue tumors were founded. For each MRI sequence analysis, coronal FS-T2WI detected the most bone marrow edema pattern and fracture line than T1WI or enhanced T1WI. Conclusion SIF is a common complication in cervical cancer after radiotherapy, which has some certain clinical and MRI features. Coronal FS-T2WI may be more useful to detect and characterize these fractures than other imaging sequences.
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Affiliation(s)
- Xi Zhong
- Department of Medical Imaging, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, 510095, People's Republic of China
| | - Linqi Zhang
- Department of Nuclear Medicine, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, 510095, People's Republic of China
| | - Tianfa Dong
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, People's Republic of China
| | - Hui Mai
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, People's Republic of China
| | - Bingui Lu
- Department of Medical Imaging, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, 510095, People's Republic of China
| | - Lu Huang
- Department of Medical Imaging, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, 510095, People's Republic of China
| | - Jiansheng Li
- Department of Medical Imaging, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, 510095, People's Republic of China.
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Kresse ME, Nacey NC. Stress Imaging of Bone. Clin Sports Med 2021; 40:765-79. [PMID: 34509210 DOI: 10.1016/j.csm.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This article defines stress injury, including insufficiency and fatigue fractures. The pathophysiology and risk factors for development of stress injuries are also discussed. The most common locations, including specific imaging examples, are reviewed with an emphasis on early detection and differentiation of high-risk and low-risk locations. Optimal imaging modalities with associated imaging findings are covered, as well as some potential pitfalls to avoid. The importance of correlating imaging findings with symptoms and the prognostic value of imaging grading are also discussed.
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Seo JY, Ha KY, Kim YH, Park HY, Chang DG, Choi YH, Rho YH, Kim SI. Analysis of Fracture Patterns and Characteristics in Sacral Insufficiency Fracture: Do Sacral Fractures Occur in Patients Who Had Previous Lumbosacral Fusion Insufficiency Fractures or Stress Fractures? Asian Spine J 2021; 15:769-777. [PMID: 33915616 PMCID: PMC8696056 DOI: 10.31616/asj.2020.0466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/08/2020] [Indexed: 11/23/2022] Open
Abstract
Study Design This study is a retrospective analysis of a case. Purpose The purpose of this study is to investigate the fracture patterns and risk factors of sacral insufficiency fractures (SIFs) to improve their diagnosis in clinical practice. Overview of Literature SIFs occur when normal stresses are applied to a bone with decreased density, most often due to osteoporosis. Individuals who receive lumbosacral fusion procedures may also suffer from increased incidents of SIFs because of decreased bone density related to aging. Methods In total, 55 patients with SIFs were retrospectively investigated in this study. The study population was divided into lumbosacral fusion (n=20) and non-fusion (n=35) groups. Subsequently, the patients' demographic characteristics, comorbidities, medication history, results of diagnostic imaging studies, and bone mineral density were assessed. The fracture patterns were classified either according to the five typical types (H-pattern bilateral vertical plus horizontal component, unilateral vertical only, bilateral vertical only, unilateral vertical plus horizontal component, and horizontal only fracture) or atypical types. Results In total, 44 of 55 patients (80%) suffered from more than one senile disease and received corresponding medications that caused secondary osteoporosis. A total of 12 patients had S1 lumbosacral fixation. Moreover, three of these 12 patients who developed a SIF immediately after a lumbosacral fracture had an unstable sacral U fracture. The remaining nine patients showed fracture patterns similar to the non-fusion patients. Single-photon emission computed tomography (SPECT)/computed tomography (CT) can identify fracture recurrence in previously healed fractures. In total, 24 patients (43.6%) had fractures of the pelvis, femur, and thoracolumbar spine. Conclusions SIF develops in elderly patients with multiple adult diseases that can induce secondary osteoporosis. Such fractures may occur in the patients with instrumented lumbosacral fusion. Importantly, some patients showed stress fractures after multilevel instrumented lumbosacral fusion, whereas others showed insufficiency fractures. The different fracture patterns correspond to different grades of SIF, and SPECT/CT can easily identify the fracture status.
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Affiliation(s)
- Jun-Yeong Seo
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea.,St. Mary's Goodheal Orthopaedics, Seoul, Korea
| | - Kee-Yong Ha
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Young-Hoon Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyung-Youl Park
- Department of Orthopaedic Surgery, Eunpyeong St. Mary's Hospital, Seoul, Korea
| | - Dong-Gune Chang
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Yong-Hwan Choi
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Young-Ho Rho
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Sang-Il Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Karakostas P, Dolscheid-Pommerich R, Hass MD, Weber N, Brossart P, Schäfer VS. [Prevalence of hypophosphatasia in adult patients in rheumatology]. Z Rheumatol 2021; 81:513-519. [PMID: 33852075 PMCID: PMC9338116 DOI: 10.1007/s00393-021-00994-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2021] [Indexed: 11/29/2022]
Abstract
Hintergrund Die Hypophosphatasie (HPP) ist eine genetische Erkrankung, die durch eine oder mehrere Mutationen im Gen für alkalische Phosphatase (ALP) verursacht wird, verantwortlich für die Kodierung der gewebespezifischen ALP und für den Mineralisierungsprozess. Ziel der Arbeit Bestimmung der Prävalenz der HPP bei rheumatologischen Patienten. Material und Methoden Retrospektive Analyse der Krankenakten aller erwachsener Patienten mit pathologisch erniedrigten gesamt ALP-Werten (<35 U/l), die zwischen Januar 2017 und Juni 2019 in der Rheumatologie der Medizinischen Klinik III am Universitätsklinikum Bonn behandelt wurden. Die Analyse wurde in Bezug auf klinische Zeichen sowie auf die Ergebnisse der Gentests für HPP untersucht. Ergebnisse Bei 60 von 2289 Patienten (2,62 %) zeigten sich pathologisch niedrige ALP-Werte, bei 30 von ihnen (1,31 %) wurden persistierend niedrige ALP-Werte festgestellt. Bei 19 dieser 30 Patienten wurde ein Gentest für ALP-Genmutationen durchgeführt. Sieben der 19 Patienten (36,84 %) hatten HPP-Zeichen (Insuffizienzfrakturen oder schlechter Zahnstatus seit der Kindheit), alle mit pathologischer ALP-Mutation. Drei dieser Patienten (15,78 %) hatten jeweils eine Insuffizienzfraktur mit normwertiger Knochendichtemessung in der Vorgeschichte. Insgesamt 13 von 19 Patienten wiesen (68,42 %) Mutationen im ALP-Gen auf. Interessanterweise wurde keine Assoziation mit einer Chondrokalzinose festgestellt. Diskussion Die HPP scheint eine unterdiagnostizierte Erkrankung mit einem höheren Anteil betroffener Patienten, welche in der Rheumatologie vorstellig werden, zu sein. Daher sollten zukünftige Studien darauf abzielen, ein Diagnostikprotokoll in der klinischen Praxis zu entwickeln.
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Affiliation(s)
- P Karakostas
- Klinik für Innere Medizin III, Onkologie, Hämatologie, Rheumatologie und Klinische Immunologie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland.
| | - R Dolscheid-Pommerich
- Institut für Klinische Chemie und Klinische Pharmakologie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - M D Hass
- Zentrum für Blutgerinnungsstörungen und Transfusionsmedizin Bonn, Bonn, Deutschland
| | - N Weber
- Klinik für Innere Medizin III, Onkologie, Hämatologie, Rheumatologie und Klinische Immunologie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
| | - P Brossart
- Klinik für Innere Medizin III, Onkologie, Hämatologie, Rheumatologie und Klinische Immunologie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
| | - V S Schäfer
- Klinik für Innere Medizin III, Onkologie, Hämatologie, Rheumatologie und Klinische Immunologie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
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15
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Carli AV, Gkiatas I, Bauer TW, Wright TM, Gonzalez FQ, Sculco PK. Sister, Sister! Siblings With Simultaneous Early Femoral Insufficiency Fractures After Total Knee Arthroplasty. Arthroplast Today 2021; 7:188-193. [PMID: 33553548 PMCID: PMC7856391 DOI: 10.1016/j.artd.2020.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/06/2020] [Accepted: 12/13/2020] [Indexed: 11/30/2022] Open
Abstract
Early periprosthetic fractures after total knee arthroplasty are rare but devastating complications which require revision surgery and lead to poor patient satisfaction. We present 2 siblings who underwent primary total knee arthroplasty on the same day and then both presented 2 weeks after surgery with atraumatic periprosthetic femur fractures. The first patient underwent revision for a cemented distal femoral replacement with stemmed tibial fixation. The second patient underwent an isolated femoral component revision with a stemmed femoral component and distal augment. Histological evaluation identified significant peri-implant osteoporosis. The variation in complexity associated with early periprosthetic femoral insufficiency fractures is highlighted by these 2 cases. Surgeons may consider using stemmed femoral components in similar patients if poor distal femoral bone stock is encountered intraoperatively.
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Affiliation(s)
- Alberto V Carli
- The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Ioannis Gkiatas
- The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Thomas W Bauer
- Department of Pathology and Laboratory Medicine, Hospital for Special Surgery, New York, NY, USA
| | - Timothy M Wright
- Department of Biomechanics, Hospital for Special Surgery, New York, NY, USA
| | | | - Peter K Sculco
- The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Krappinger D, Kaser V, Merkel A, Neururer S, Lindtner RA. An alphanumeric classification of osteoporotic pelvic ring injuries. Arch Orthop Trauma Surg 2021; 141:861-869. [PMID: 32737571 PMCID: PMC8049897 DOI: 10.1007/s00402-020-03546-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 07/15/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Classification and management of osteoporotic pelvic ring injuries (OPRI) continue to pose a considerable challenge to orthopaedic traumatologists. The currently used fragility fractures of the pelvis (FFP) classification of OPRI has recently been shown to have significant weaknesses. The aim of this study therefore was to propose a new, simple, yet comprehensive alphanumeric classification (ANC) of OPRI and to assess its intra- and interobserver reliability. Furthermore, its potential advantages over the FFP classification are discussed. MATERIALS AND METHODS One hundred consecutive CT scans from patients with OPRI were evaluated by three orthopaedic traumatologists with varying levels of experience and one musculoskeletal radiologist. Intra- and interobserver reliability of the proposed classification system was assessed using weighted kappa (κ) statistics and percentage agreement. In addition, the Fleiss' kappa statistic was computed to assess interobserver agreement among all four raters. RESULTS Overall intraobserver reliability of the proposed ANC was substantial [κ ranging from 0.71 to 0.80; percentage agreement: 70% (range, 67-76%)]. Overall interobserver reliability between pairs of raters was substantial as well [κ ranging from 0.61 to 0.68; percentage agreement: 58% (range, 53-61%)]. For ANC types, groups and subgroups, intra- and interobserver reliability were substantial to almost perfect. Interobserver agreement among all four raters was moderate to substantial, with Fleiss' kappa values of 0.48, 0.69, 0.71 and 0.52 for ANC overall, types, groups and subgroups, respectively. CONCLUSION The proposed ANC of OPRI demonstrated overall reliability comparable to that of the FFP classification. The ANC, however, is simple, more comprehensive, and consistently relates to injury severity.
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Affiliation(s)
- Dietmar Krappinger
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Verena Kaser
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Anke Merkel
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Sabrina Neururer
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Richard A. Lindtner
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
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Husain R, Nesbitt J, Tank D, Verastegui MO, Gould ES, Huang M. Spontaneous osteonecrosis of the knee (SONK): The role of MR imaging in predicting clinical outcome. J Orthop 2020; 22:606-611. [PMID: 33311863 DOI: 10.1016/j.jor.2020.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/15/2020] [Indexed: 10/23/2022] Open
Abstract
Background/aim We try to investigate the association between patterns of imaging findings in patients who had a diagnosis of subchondral fracture around the knee, formerly known as SONK and their clinical outcome. Materials and methods We retrospectively identified 43 knees of 37 patients (28 males, 15 females) who had diagnosis of subchondral fractures around the knee. The mean age is 56-year-old (range 17-83). Musculoskeletal fellowship trained radiologist evaluated all 43 knee MRI in: 1)location of marrow edema 2)peri-osseous edema; 3) subchondral fracture line; 4) subchondral articular surface contour; 5)meniscal tear and extrusion; 6)adjacent soft tissue edema; 7) joint effusion. Independent clinical chart review was performed for clinical outcome with follow up time average of 13.3 months (range 0-88 months). Bad outcome was defined as worsening on imaging, continued complaint with surgical management and knee replacement or another episode of SONK. Chi-square analysis and Student's T tests were conducted to test the statistical significance of association between MR findings and outcomes. Statistical significance was set at p = 0.05 level. Results Of 43 knees, 6 patients had another episodes of SONK (14%), 11 patients were not improving or needed injection vs arthroscopy (26%), 4 patients required arthroplasty (9%), 22 patients had no negative outcome (51%). Gender, age, diabetic status, and location of the subchondral fracture show no influence on outcome. Worse outcome group had a significantly higher average BMI (31.7 vs. 28.0, P = 0.02). Positive change of subchondral articular surface contour is the only imaging finding with positive association with worse outcome (80% vs. 39.9%, P = 0.02). Presence of positive findings of above 3), 4), 5) and 6) had higher percentage of bad outcome (77.8%) compared to those with less positive findings (47.2%). Conclusion MR imaging findings may help at identifying SONK patient with potential risk of developing bad outcome.
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Affiliation(s)
- Rola Husain
- Diagnostic, Molecular and Interventional Radiology, Mount Sinai Health System, New York, NY, USA
| | - Jared Nesbitt
- Department of Radiology, Stony Brook Medicine, NY, USA
| | - Dharmesh Tank
- Department of Radiology, Stony Brook Medicine, NY, USA
| | | | | | - Mingqian Huang
- Diagnostic, Molecular and Interventional Radiology, Mount Sinai Health System, New York, NY, USA
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Miyasaka Y, Okonogi N, Fukahori M, Furuichi W, Wakatsuki M, Kato S, Ohno T, Nakano T, Tsuji H. Pelvic insufficiency fractures following carbon-ion radiotherapy for uterine carcinomas. Radiother Oncol 2020; 156:56-61. [PMID: 33278405 DOI: 10.1016/j.radonc.2020.11.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/18/2020] [Accepted: 11/25/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE There is growing evidence on the role of carbon-ion radiotherapy (C-ion RT) for gynaecological tumours. Pelvic insufficiency fracture (PIF) decreases the quality of life after photon beam radiotherapy (RT). However, there is little information on PIF after C-ion RT. This study retrospectively assessed incidence of PIF after C-ion RT for uterine carcinomas (UCs) and the associations of clinical and dosimetric parameters with PIF incidence. MATERIAL AND METHODS We performed a pooled analysis of 102 patients with UCs who underwent definitive C-ion RT alone and were followed up for >6 months without any additional RT in the pelvic region. PIF occurrence was surveyed using magnetic resonance imaging and/or computed tomography. Associations of clinical and dosimetric parameters with PIF incidence were analysed. RESULTS The 2- and 5-year actuarial incidences of ≥grade 1 PIF in all pelvic regions were 22.3% and 42.4%, respectively. The most frequent site of involvement was the sacrum. Log-rank tests showed that higher volumes receiving >10 Gy (relative biological effectiveness) (V10), V20, V30, and V40, body mass index (BMI) under 18.5, and current smoking were associated with increased incidence of ≥grade 1 PIF in the sacrum. CONCLUSIONS We clarified the actuarial incidence of PIF after C-ion RT for UCs. Higher V10, V20, V30, V40, D50%, Dmean, current smoking, BMI <18.5, and using the anterior-posterior direction in whole pelvic irradiation were associated with higher incidences of PIF in the sacrum. The present results may lead to further improvement of C-ion RT for UCs.
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Affiliation(s)
- Yuhei Miyasaka
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan; Department of Radiation Oncology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Noriyuki Okonogi
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan.
| | - Mai Fukahori
- Department of Nuclear Safety and Security, International Atomic Energy Agency, Vienna International Centre, Vienna, Austria.
| | | | - Masaru Wakatsuki
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan.
| | - Shingo Kato
- Department of Radiation Oncology, Saitama Medical University International Medical Center, Hidaka, Japan.
| | - Tatsuya Ohno
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, Maebashi, Japan.
| | - Takashi Nakano
- Quantum Medical Science Directorate, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan.
| | - Hiroshi Tsuji
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan.
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Schmerwitz IU, Jungebluth P, Lehmann W, Hockertz TJ. Minimally invasive posterior locked compression plate osteosynthesis shows excellent results in elderly patients with fragility fractures of the pelvis. Eur J Trauma Emerg Surg 2021; 47:37-45. [PMID: 33104870 DOI: 10.1007/s00068-020-01498-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/08/2020] [Indexed: 02/06/2023]
Abstract
Purpose Fragility fractures of the pelvis (FFP) are common in older patients. We evaluated the clinical outcome of using a minimally invasive posterior locked compression plate (MIPLCP) as therapeutic alternative. Methods 53 Patients with insufficiency fractures of the posterior pelvic ring were treated with MIPLCP when suffering from persistent pain and immobility under conservative treatment. After initial X-ray, CT-scans of the pelvis were performed. In some cases an MRI was also performed to detect occult fractures. Postoperatively patients underwent conventional X-ray controls. Data were retrospectively analyzed for surgical and radiation time, complication rate, clinical outcome and compared to the literature. Results Patients (average age 79.1 years) underwent surgery with operation time of 52.3 min (SD 13.9), intra-operative X-ray time of 9.42 s (SD 9.6), mean dose length product of 70.1 mGycm (SD 57.9) and a mean hospital stay of 21.2 days (SD 7.7). 13% patients (n = 7) showed surgery-related complications, such as wound infection, prolonged wound secretion, irritation of the sacral root or clinically inapparent screw malpositioning. 17% (n = 9) showed postoperative complications (one patient died due to pneumonia 24 days after surgery, eight patients developed urinal tract infections). 42 patients managed to return to previous living situation. 34 were followed-up after a mean period of 31.5 (6–90) months and pain level at post-hospital examination of 2.4 (VAS) with an IOWA Pelvic Score of 85.6 (55–99). Conclusion We showed that MIPLCP osteosynthesis is a safe surgical alternative in patients with FFP 3 and FFP 4. This treatment is another way of maintaining a high level of stability in the osteoporotic pelvic ring with a relatively low complication rate, low radiation and moderate operation time and a good functional outcome.
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Zhong X, Jiang H, Mai H, Xiang J, Li J, Huang Z, Wu S, Luo L, Jiang K. Radiation-induced occult insufficiency fracture or bone metastasis after radiotherapy for cervical cancer? The nomogram based on quantitative apparent diffusion coefficients for discrimination. Cancer Imaging 2020; 20:76. [PMID: 33097093 PMCID: PMC7583230 DOI: 10.1186/s40644-020-00353-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 09/30/2020] [Indexed: 11/10/2022] Open
Abstract
Background Radiation-induced insufficiency fractures (IF) is frequently occult without fracture line, which may be mistaken as metastasis. Quantitative apparent diffusion coefficient (ADC) shows potential value for characterization of benign and malignant bone marrow diseases. The purpose of this study was to develop a nomogram based on multi-parametric ADCs in the differntiation of occult IF from bone metastasis after radiotherapy (RT) for cervical cancer. Methods This study included forty-seven patients with cervical cancer that showed emerging new bone lesions in RT field during the follow-up. Multi-parametric quantitative ADC values were measured for each lesion by manually setting region of interests (ROIs) on ADC maps, and the ROIs were copied to adjacent normal muscle and bone marrow. Six parameters were calculated, including ADCmean, ADCmin, ADCmax, ADCstd, ADCmean ratio (lesion/normal bone) and ADCmean ratio (lesion/muscle). For univariate analysis, receiver operating characteristic curve (ROC) analysis was performed to assess the performance. For combined diagnosis, a nomogram model was developed by using a multivariate logistic regression analysis. Results A total of 75 bone lesions were identified, including 48 occult IFs and 27 bone metastases. There were significant differences in the six ADC parameters between occult IFs and bone metastases (p < 0.05), the ADC ratio (lesion/ muscle) showed an optimal diagnostic efficacy, with an area under ROC (AUC) of 0.887, the sensitivity of 95.8%, the specificity of 81.5%, respectively. Regarding combined diagnosis, ADCstd and ADCmean ratio (lesion/muscle) were identified as independent factors and were selected to generate a nomogram model. The nomogram model showed a better performance, yielded an AUC of 0.92, the sensitivity of 91.7%, the specificity of 96.3%, positive predictive value (PPV) of 97.8% and negative predictive value (NPV) of 86.7%, respectively. Conclusions Multi-parametric ADC values demonstrate potential value for differentiating occult IFs from bone metastasis, a nomogram based on the combination of ADCstd and ADCmean ratio (lesion/muscle) may provide an improved classification performance.
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Affiliation(s)
- Xi Zhong
- Department of Medical Imaging, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, 510095, China
| | - Huali Jiang
- Department of Cardiovascularology, Tungwah Hospital of Sun Yat-Sen University, Dong cheng East Road, Dong guan, 523110, Guangdong, China
| | - Hui Mai
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Jialin Xiang
- Department of Radiology, Guangdong Women and Children Hospital, Guangzhou, 510000, China
| | - Jiansheng Li
- Department of Medical Imaging, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, 510095, China
| | - Zhiqing Huang
- Department of Radiology, Guangdong Women and Children Hospital, Guangzhou, 510000, China
| | - Songxin Wu
- Department of Radiology, Guangdong Women and Children Hospital, Guangzhou, 510000, China
| | - Liangping Luo
- Department of Medical Imaging, First Affiliated Hospital of Jinan University, Guangzhou, 510000, China.
| | - Kuiming Jiang
- Department of Radiology, Guangdong Women and Children Hospital, Guangzhou, 510000, China.
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Mansour J, Yammine K, El Alam A, Al-Hajj G, Assi C. Bilateral subtrochanteric insufficiency fracture following mini-gastric bypass. A case report. SICOT J 2020; 6:32. [PMID: 32857035 PMCID: PMC7453788 DOI: 10.1051/sicotj/2020034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 08/14/2020] [Indexed: 11/14/2022] Open
Abstract
Insufficiency fractures are a common complication of bisphosphonate use and have recently been reported in association with Roux-en-Y Gastric Bypass Surgery (RYGB). This study reports a case of a 62-year-old female, 6 years status post Mini Gastric Bypass – One Anastomosis Gastric Bypass (MGB-OAGB), presenting to our institution with bilateral groin pain of 8 months duration unresponsive to conservative management. Diagnostic workup revealed bilateral medial sub-trochanteric insufficiency fractures. She underwent bilateral intramedullary fixation with satisfactory results. This case might suggest a particular fracture pattern in patients undergoing MGB-OAGB, and raises awareness to screen patients with such presentation to rule out a fracture or to prevent the extension of an existing one.
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Affiliation(s)
- Jad Mansour
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University School of Medicine, P.O. Box 11-3288, Beirut, Lebanon - The Center for Evidence-Based Anatomy, Sports & Orthopedic Research, Dubai, United Arab Emirates
| | - Kaissar Yammine
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University School of Medicine, P.O. Box 11-3288, Beirut, Lebanon - The Center for Evidence-Based Anatomy, Sports & Orthopedic Research, Dubai, United Arab Emirates
| | - Anthony El Alam
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University School of Medicine, P.O. Box 11-3288, Beirut, Lebanon
| | - George Al-Hajj
- Department of General Surgery, Lebanese American University Medical Center-Rizk Hospital, Beirut, and Middle East Institute of Health, Bsalim, Lebanon
| | - Chahine Assi
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University School of Medicine, P.O. Box 11-3288, Beirut, Lebanon - The Center for Evidence-Based Anatomy, Sports & Orthopedic Research, Dubai, United Arab Emirates
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Seong YJ, Shin JK, Park WR. Early detected femoral neck insufficiency fracture in a patient treated with long-term bisphosphonate therapy for osteoporosis: A need for MRI. Int J Surg Case Rep 2020; 70:213-215. [PMID: 32417741 PMCID: PMC7229416 DOI: 10.1016/j.ijscr.2020.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/23/2020] [Accepted: 04/01/2020] [Indexed: 12/03/2022] Open
Abstract
If long term bisphosphonate users complain of non-traumatic hip pain, medical examination should be taken with care. Even though no fractures are identified in their radiographs, it is recommended to check an MRI. If the fracture can be identified before cortical breakage, the treatment success rate for the fracture will be high.
Introduction Atypical femoral fracture is an uncommon complication of prolonged use of bisphosphonates, mainly occurring in the femoral shaft. We report a case of an atraumatic insufficiency fracture of femoral neck after four years of treatment with a bisphosphonate. Presentation of case A 71-year-old female presented with history of pain on Lt. hip and difficulty in walking. Although there was no fracture on the radiographs, diagnosis could be made early using magnetic resonance imaging (MRI) scans. She was treated by internal fixation using cannulated screws. Discussion Because bisphosphonate prevents bone healing and remodeling, it is difficult to accomplish the bony union despite of proper treatment in patients who have fractured after long-term use of bisphosphonate. Conclusion A high suspicion index and early diagnosis through the use of MRI are essential for the successful treatment of these fractures.
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Affiliation(s)
- Yoon Jae Seong
- Department of Orthopaedic Surgery, Dongeui Medical Center, 62 Yangjung-ro, Jin-gu, Busan, 47227, South Korea
| | - Jong Ki Shin
- Department of Orthopaedic Surgery, Dongeui Medical Center, 62 Yangjung-ro, Jin-gu, Busan, 47227, South Korea
| | - Won Ro Park
- Department of Orthopaedic Surgery, Dongeui Medical Center, 62 Yangjung-ro, Jin-gu, Busan, 47227, South Korea.
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Petryla G, Uvarovas V, Bobina R, Kurtinaitis J, Khan SA, Versocki A, Porvaneckas N, Šatkauskas I. The one-year mortality rate in elderly patients with osteoporotic fractures of the pelvis. Arch Osteoporos 2020; 15:15. [PMID: 32078053 DOI: 10.1007/s11657-020-0689-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/14/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED Osteoporosis is a common condition for elderly people. The incidence of osteoporotic pelvic fractures has been increasing. Osteoporotic pelvic fractures are associated with increased mortality rates. Based on the aim of our study, we found out that one-year mortality rate after a pelvic fracture is high and depends on the fracture type. PURPOSE The aim of this study was to determine the one-year mortality rate in patients aged 65+ with osteoporotic pelvic fractures depending on the type of fracture according to AO/OTA classification. METHODS Patients aged 65+ with pelvic insufficiency fractures admitted to a single center between 1 June 2013 and 31 December 2016 were enrolled in the study. The fractures were classified according to AO/OTA classification. The start of the survival time analysis was the date of the injury. The end of the analysis was 31 December 2017 or the date of the patient's death. Mortality rates were assessed with respect to fracture types using Kaplan-Meier curves. The Cox proportional hazards model was applied to assess the dependence of mortality on the fracture type. RESULTS A total of 105 patients with 95 (90.5%) being female were enrolled in this prospective study. The average age was 80.3 years (95% CI 78.8-81.7). Mean follow-up time was 23.5 months (95% CI 20.7-26.4). According to AO/OTA classification, 30 (28.6%) patients had a type A pelvic fracture, 73 (69.5%) patients-type B fracture, and 2 (1.9%)-type C fracture. Overall, the one-year mortality rate was 23.8% (95% CI 16.8-33.2%). For patients with type A fracture, the one-year mortality rate was 13.3% (95% CI 5.2-31.7%) compared with 27.4% (95% CI 18.6-39.2%) in the group with type B fracture, and this difference was statistically significant (p < 0.001). CONCLUSIONS We found that within a year after an osteoporotic pelvic fracture, the number of deaths in the patients having type B pelvic fracture was twice higher than in the patients with type A fracture.
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Tozzi D, Tozzi J. Osteomalacia and Insufficiency Fractures Secondary to Intravenous Iron Therapy: A Case Report. J Orthop Case Rep 2020; 10. [PMID: 32547968 PMCID: PMC7276570 DOI: 10.13107/jocr.2020.v10.i01.1612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Intravenous (IV) iron therapy is associated with hypophosphatemia, and long-term administration may lead to osteomalacia and insufficiency fracture. Awareness of this complication could severely reduce patient morbidity. Our patient continued her iron therapy for 17 months after her initial complaint. After switching iron medications, the patient's fractures healed completely and she is now pain free. Case Report A 61-year-old woman presented with a fracture in her right femoral neck and a non-displaced fracture in her left femoral neck. After total hip arthroplasty and pinning, the patient returned with bilateral insufficiency fractures of the medial tibial plateau. The fractures were secondary to her iron medication, ferric carboxymaltose (FCM). Conclusion Fibroblast growth factor 23 (FGF23) is a protein that increases renal phosphate wasting and certain parenteral iron therapies may increase the activity of FGF23. Most IV iron medications have been shown to cause hypophosphatemia, but literature has indicated that FCM is associated with the highest risk of developing hypophosphatemia and possibly osteomalacia.
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Affiliation(s)
- Declan Tozzi
- Robert Wood Johnson Medical School, 675 Hoes Ln W, Piscataway Township, New Jersey 08854, United States,Address of Correspondence: Dr. Declan Tozzi, Robert Wood Johnson Medical School, 675 Hoes Ln W, Piscataway Township, New Jersey 08854, United States. E-mail:
| | - John Tozzi
- Chairman Department of Orthopedics, Jersey Shore University Medical Center 1945 NJ-33, Neptune City,NJ,07753, United States
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Nuber S, Ovalle D, Förch S, Plath J, Nuber M, Mayr E. [Three-point buttressing with internal fixator for minimally invasive stabilization of the anterior pelvic ring : Operative technique and first clinical results]. Unfallchirurg 2019; 122:870-9. [PMID: 30617539 DOI: 10.1007/s00113-018-0599-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The changing age distribution in society inevitably leads to a percentage increase in osteoporotic and fatigue fractures as well as the absolute number of insufficiency fractures of the pelvic ring. Due to pain these fractures lead to a loss of mobility and autonomy. To prevent these consequences surgical treatment is increasingly being performed. OBJECTIVE This article presents a new configuration of an internal fixator on the anterior pelvic ring, the principle of which correlates to a three-point buttressing. METHODS In addition to a description of the configuration of the internal fixator on the anterior pelvic ring and the surgical technique, the article presents the results after the first 23 applications. RESULTS The first results after application of the new internal fixator on the pelvic ring show a low risk, sufficient and minimally invasive stabilization with an encouraging clinical and radiological outcome. CONCLUSION Missing long-term results, also taking into account a higher number of patients, as well as the biomechanical examination of the presented fixator configuration still have to be evaluated.
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Png MA, Mohan PC, Koh JSB, Howe CY, Howe TS. Natural history of incomplete atypical femoral fractures in patients after a prolonged and variable course of bisphosphonate therapy-a long-term radiological follow-up. Osteoporos Int 2019; 30:2417-2428. [PMID: 31435684 DOI: 10.1007/s00198-019-05067-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 06/19/2019] [Indexed: 01/25/2023]
Abstract
UNLABELLED Understanding the natural history of lateral femoral stress fractures helps to guide their management. Improvement in their radiographic characteristics is rare. Progression was generally sequential, most developing an incomplete fracture line before fracture displacement. Stopping bisphosphonates decreased the fracture rate, a feasible management option for lesions without incomplete fracture lines. INTRODUCTION Retrospective study evaluating the natural history of lateral femoral stress fractures (FSF) by serial radiography over a variable period of time in a cohort of patients treated for some time with bisphosphonates for osteoporosis, whilst also identifying the fracture response in cases where bisphosphonates were discontinued. METHODS The radiographs of 76 consecutive patients (92 femurs) with 161 FSF were reviewed to document their change over time. Femurs were classified into the following: A-normal, B-focal cortical thickening, C-dreaded black line and D-displaced fracture. Bisphosphonate history was recorded. RESULTS 66.5% FSF showed group stability between the first and last radiographs: group B (79.1%), group C (45.7%). 28.6% progressed, mostly following an ordered sequence starting from group A, progressing to B, then C, before culminating in D. Progression rate was as follows: A-100% (11/11), B-18.3% (21/115), C-40% (14/35). Regression in FSF was uncommon-5.6% (8/161). 34.8% (32/92) sustained displaced fractures. Kaplan-Meier analysis showed statistically significant difference between the groups; median survival (95% CI): A-4189 (-), B-3383.0 (-), C-1807 (0.0-3788.6) and progression to displaced fracture when bisphosphonate had been stopped for at least 6 months. The group without recent bisphosphonates had a lower group progression rate (17.1%, 12/70). Nevertheless, 10.9% (5/46) progressed to displaced fracture. This group also had the highest proportion of stable (77.1%, 54/70) and regressive lesions (5.7%, 4/70). CONCLUSIONS In FSF, there is natural progression from normal bone, to focal cortical thickening, to dreaded black line and eventually to displaced fracture. Most lesions persist, remaining static or progressing, especially if a dreaded black line is present and bisphosphonates are continued. Regression is uncommon and more frequent when bisphosphonates are discontinued. Despite stopping bisphosphonates, there remains a 10.9% risk of progression to displaced fracture.
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Affiliation(s)
- M A Png
- Department of Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
| | - P C Mohan
- Department of Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - J S B Koh
- Duke-NUS Medical School, Singapore, Singapore
- Department of Orthopedic Surgery, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - C Y Howe
- Faculty of Mathematics, University of Cambridge, Wilberforce Road, Cambridge, CB3 0WA, UK
| | - T S Howe
- Duke-NUS Medical School, Singapore, Singapore
- Department of Orthopedic Surgery, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
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Kronborg CJ, Jørgensen JB, Petersen JB, Nyvang Jensen L, Iversen LH, Pedersen BG, Spindler KLG. Pelvic insufficiency fractures, dose volume parameters and plan optimization after radiotherapy for rectal cancer. Clin Transl Radiat Oncol 2019; 19:72-76. [PMID: 31646202 PMCID: PMC6804461 DOI: 10.1016/j.ctro.2019.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 09/07/2019] [Indexed: 12/13/2022] Open
Abstract
High rates of PIF are detected 3 years after VMAT based CRT for rectal cancer. Patients with PIFs received non-significantly higher V30 Gy to sacroiliac joints. 3 arc VMAT techniques can be optimized for bone. Proton beam therapy has the potential for further optimization for bone.
Pelvic insufficiency fractures (PIF) is a known but under-acknowledged late effect of pelvic radiotherapy. In rectal cancer, studies describing incidence of PIF and relation to dose volume relationships are lacking. The aim of this study was (i) to analyse dose volume histograms (DVH) from pelvic bones in patients with and without PIF, and (ii) to determine bone sparing capacity of 2 and 3 arc volumetric arc therapy (VMAT), intensity modulated radiotherapy (IMRT) and proton beam therapy (PBT), in rectal cancer patients treated with chemoradiotherapy (CRT). Material and methods Patients treated with CRT for primary rectal cancer underwent a 3-year pelvic MRI for identification of PIFs. Bone structures were retrospectively delineated, and DVHs were re-calculated. Comparative planning was done with 2 (original) and 3 arc VMAT, fixed field IMRT and PBT plans. Results 27 patients (18 men, mean age 64 years) were included and PIFs were identified in 9 (33%), most (n = 6) had multiple fracture sites. In general, patients with PIFs received higher doses to pelvic bones, and V30 Gy to the sacroiliac joint was non-significantly higher in patients with PIF 68.5% (60.1–69.3 IQR) vs. 56% (54.1–66.6 IQR), p = 0.064. Comparative planning showed that especially 3 arc VMAT and proton beam therapy could be optimized for bone. Conclusions Patients, treated with VMAT based CRT for rectal cancer, have high rates of PIFs after 3 years. Patients with PIFs tended to have received higher doses to sacroiliac joints. Comparative planning demonstrated most pronounced bone sparing capacity of 3 arc VMAT and with PBT having the potential to further lower doses. These results should be validated in larger and preferably prospective cohorts.
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Affiliation(s)
- Camilla J.S. Kronborg
- Department of Oncology Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
- Danish Centre for Particle Therapy, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
- Corresponding author at: Palle Juul Jensens Blvd. 99, 8200 Aarhus N, Denmark.
| | - Jesper B. Jørgensen
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Jørgen B.B. Petersen
- Department of Medical Physics, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
- Danish Centre for Particle Therapy, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Lars Nyvang Jensen
- Department of Medical Physics, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Lene H. Iversen
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Bodil Ginnerup Pedersen
- Department of Radiology, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Karen-Lise G. Spindler
- Department of Oncology Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
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Abstract
As a result of immense heterogeneity with regard to morphology and stability, the recent literature lacks consensus concerning the treatment of sacral insufficiency fractures. We report the case of a 79-year-old woman with bilateral sacral insufficiency fractures following anterior pelvic ring fractures who was treated with teriparatide. During a two-week hospital stay, the patient was successfully mobilised and the regularly conducted pelvic X‑ray controls showed full consolidation of the fractures.
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Krappinger D, Kaser V, Kammerlander C, Neuerburg C, Merkel A, Lindtner RA. Inter- and intraobserver reliability and critical analysis of the FFP classification of osteoporotic pelvic ring injuries. Injury 2019; 50:337-343. [PMID: 30482410 DOI: 10.1016/j.injury.2018.11.027] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/13/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The classification and management of osteoporotic pelvic ring injuries (OPRI) remain challenging. The fragility fractures of the pelvis (FFP) classification system proposed by Rommens and Hofmann constitutes the first comprehensive classification system of OPRI and may contribute to a more thorough assessment and grading of these injuries. The reliability of the FFP classification system, however, has not been evaluated yet. The purpose of this study therefore was to determine the inter- and intraobserver reliability of the FFP classification system and to critically analyse its strengths and weaknesses. MATERIALS AND METHODS One-hundred pelvic CT scans obtained from a consecutive series of patients aged 70 years and older who sustained a low-energy pelvic ring injury were included in this study. Three orthopaedic traumatologists of varying levels of experience (one experienced pelvic surgeon, one consultant, one resident) and one musculoskeletal radiologist independently classified each OPRI according to the FFP classification in two different sessions. Intra- and interobserver reliability were determined using percentage agreement and Cohen's Kappa coefficients. RESULTS The observed relative distribution of FFP fracture types was comparable to that reported in the original study by Rommens and Hofmann. Overall interobserver reliability for all 100 cases was moderate with Kappa values from 0.42 to 0.59 (mean percentage agreement: 61% (54%-68%)), while intraobserver reliability was substantial with Kappa values from 0.68 to 0.72 (mean percentage agreement: 77% (76%-78%)). Subgroup analysis revealed lowest reliability for the classification of Type IIc, IIIc and IVb injuries (32 cases). Within this subgroup of combined anterior and posterior OPRI involving a complete nondisplaced or displaced (uni- or bilateral) sacral fracture, Kappa values for interobserver reliability ranged from 0.10 to 0.52, while those for intraobserver reliability ranged from 0.29 to 0.66. CONCLUSION Overall interobserver reliability of the FFP classification system was moderate, while intraobserver reliability was substantial. Despite the acceptable overall reliability, classification of FFP subtypes involving a complete nondisplaced or displaced sacral fracture showed relatively poor reliability. The latter limits the usefulness of the FFP classification for both clinical and research purposes and needs to be addressed in future studies.
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Affiliation(s)
| | - Verena Kaser
- Department of Radiology, Medical University of Innsbruck, Austria
| | - Christian Kammerlander
- Department of General, Trauma and Reconstructive Surgery, Ludwig Maximilian University Munich, Germany
| | - Carl Neuerburg
- Department of General, Trauma and Reconstructive Surgery, Ludwig Maximilian University Munich, Germany
| | - Anke Merkel
- Department of Trauma Surgery, Medical University of Innsbruck, Austria
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Abstract
Osteoporosis is common throughout the world. Complications include fragility fractures. In this paper I will describe the condition as it relates to athletes young and old. It will be seen that osteoporosis may result from poorly managed sporting activities at the same time it may be ameliorated by exercise in those susceptible to the disorder. I will discuss the epidemiology, the protective effect of exercise, the therapeutic benefits of sport and exercise in the older population with fragility fractures, the effects of weight limited sport and the severe risks to those who diet and exercise intensely at the same time. I will cover the range of diagnostic investigations including imaging and non-radiological techniques and focus on advice to the coach and athlete to maintain bone health throughout an athletic and sporting lifetime.
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Yaprak G, Gemici C, Temizkan S, Ozdemir S, Dogan BC, Seseogullari OO. Osteoporosis development and vertebral fractures after abdominal irradiation in patients with gastric cancer. BMC Cancer 2018; 18:972. [PMID: 30309324 PMCID: PMC6182865 DOI: 10.1186/s12885-018-4899-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 10/03/2018] [Indexed: 11/18/2022] Open
Abstract
Background Decrease in bone mineral density, osteoporosis development, bone toxicity and resulting insufficiency fractures as late effect of radiotherapy are not well known. Osteoporosis development related to radiotherapy has not been investigated properly and insufficiency fractures are rarely reported for vertebral bones. Methods Ninety-seven patients with gastric adenocarcinoma were evaluated for adjuvant treatment after surgery. While 73 out of 97 patients treated with adjuvant chemoradiotherapy comprised the study group, 24 out of 97 patients with early stage disease without need of adjuvant treatment comprised the control group. Bone mineral densities (BMD) of lumbar spine and femoral neck were measured by dual energy x-ray absorptiometry after surgery, and one year later in both groups. Results There was statistically significant decline in BMDs after one year in each group itself, however the decline in BMDs of the patients in the irradiated group was more pronounced when compared with the patients in the control group; p values were 0.02 for the decline in BMDs of lumbar spine, and 0.01 for femoral neck respectively. Insufficiency fractures were observed only in the irradiated patients (7 out of 73 patients) with a cumulative incidence of 9.6%. Conclusions Abdominal irradiation as in the adjuvant treatment of gastric cancer results in decrease in BMD and osteoporosis. Insufficiency fracture risk in the radiation exposed vertabral bones is increased. Calcium and vitamin D replacement and other measures for prevention of osteoporosis and insufficiency fractures should be considered after abdominal irradiation.
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Affiliation(s)
- Gokhan Yaprak
- Department of Radiation Oncology, Dr. Lutfi Kirdar Kartal Education and Research Hospital, Istanbul, Turkey
| | - Cengiz Gemici
- Department of Radiation Oncology, Dr. Lutfi Kirdar Kartal Education and Research Hospital, Istanbul, Turkey.
| | - Sule Temizkan
- Department Endocrinology, Dr. Lutfi Kirdar Kartal Education and Research Hospital, Istanbul, Turkey
| | - Sevim Ozdemir
- Department of Radiation Oncology, Dr. Lutfi Kirdar Kartal Education and Research Hospital, Istanbul, Turkey
| | - Berfu Cinkit Dogan
- Department of Family Physician, Dr. Lutfi Kirdar Education and Research Hospital, Istanbul, Turkey
| | - Ozgur Ozan Seseogullari
- Department of Radiation Oncology, Biruni University Medicana International Hospital, Istanbul, Turkey
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Sakamoto A, Okamoto T, Matsuda S. Insufficiency fracture at an osteochondroma bridging the proximal fibula and the tibia: Case report. J Orthop 2018; 15:384-387. [PMID: 29881159 DOI: 10.1016/j.jor.2018.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 03/16/2018] [Indexed: 10/17/2022] Open
Abstract
Osteochondromas are benign bone tumors that protrude from underlying bone. A fracture of an osteochondroma is rare, and no insufficiency fractures of an osteochondroma have been reported. A 57-year-old female complained of pain in her proximal leg that increased during walking. A computed tomographic image depicted bridging that had extended to the tibia. An incomplete fracture line was observed at the osteochondroma. The osteochondroma was resected to remove the bridge. The preoperative symptoms disappeared after surgery. It was challenging to diagnose an osteochondroma with an insufficiency fracture because the symptoms varied in accordance with daily activity.
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Affiliation(s)
- Akio Sakamoto
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Shogoin, Kawahara-cho 54, Sakyo-ku, Kyoto 606-8507, Japan
| | - Takeshi Okamoto
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Shogoin, Kawahara-cho 54, Sakyo-ku, Kyoto 606-8507, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Shogoin, Kawahara-cho 54, Sakyo-ku, Kyoto 606-8507, Japan
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Wakasugi T, Shirasaka R, Fujita K. Insufficiency Fracture of the Radial Diaphysis Following a Sauve-Kapandji Procedure for Osteoarthritis of the Distal Radioulnar Joint: A Case Report. J Hand Surg Asian Pac Vol 2018; 23:270-273. [PMID: 29734895 DOI: 10.1142/s2424835518720153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The Sauve-Kapandji (SK) procedure for distal radioulnar joint osteoarthritis have complications including pain over the proximal ulnar stump, nonunion of the fused distal radioulnar joint, and less frequently, insufficiency fracture of the distal radius. We report a case of insufficiency fracture of the radial diaphysis as a rare complication of the SK procedure.
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Affiliation(s)
- Takuma Wakasugi
- * Department of Orthopaedic Surgery, Tsuchiura Kyodo Hospital, Ibaraki, Japan
| | - Ritsuro Shirasaka
- * Department of Orthopaedic Surgery, Tsuchiura Kyodo Hospital, Ibaraki, Japan
| | - Koji Fujita
- † Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
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Vestermark GL, Odum SM, Springer BD. Early femoral condyle insufficiency fractures after total knee arthroplasty: treatment with delayed surgery and femoral component revision. Arthroplast Today 2018; 4:249-253. [PMID: 29896563 PMCID: PMC5994640 DOI: 10.1016/j.artd.2018.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 02/26/2018] [Accepted: 02/26/2018] [Indexed: 01/16/2023] Open
Abstract
Background Periprosthetic fracture following total knee arthroplasty (TKA) is usually associated with a traumatic event and typically treated with fracture fixation techniques. However, we report on a series of patients with early atraumatic condyle fractures that occurred as a result of insufficiency of the unloaded preoperative femoral condyle treated with delayed reconstruction. Methods We retrospectively reviewed a series of 7 patients who sustained femoral condyle fractures following TKA and evaluated risk factors for insufficiency. Results There were 6 females and 1 male with an average age of 65.5 (range, 63-75) years and an average body mass index of 29.4 (range, 27-32). Fracture occurred on average 24.9 days from the index surgery and secondary to a low energy mechanism. Five patients had valgus alignment (mean, 15.2°) preoperatively and sustained fracture of the unloaded medial femoral condyle. Two patients had varus alignment (mean, 7.0°) preoperatively and both fractured the unloaded lateral condyle. One patient underwent early intervention requiring distal femoral replacement secondary to femoral bone loss. The remaining 6 patients underwent delayed surgery for an average of 6 weeks to allow for fracture healing followed by femoral component revision. At last follow-up (average, 48.5 months), 1 patient required a tibial component revision; however, no revision of the femoral component was required. Conclusions Early femoral condyle insufficiency fractures following TKA may be a risk in females with poor bone quality and preoperative valgus alignment. Delayed surgery and femoral component revision is a treatment strategy that prevented the need for other tertiary reconstruction.
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Affiliation(s)
| | - Susan M Odum
- OrthoCarolina Research Institute, Charlotte, NC, USA
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Takai H, Kii S, Murayama M, Nakane N, Takahashi T. Ipsilateral stress fracture of the proximal fibula after total knee arthroplasty in a patient with severe valgus knee deformity on a background of Rheumatoid arthritis. Int J Surg Case Rep 2018; 45:17-21. [PMID: 29567569 DOI: 10.1016/j.ijscr.2018.02.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/13/2018] [Accepted: 02/25/2018] [Indexed: 11/22/2022] Open
Abstract
Stress fracture of the fibula after TKA is extremely rare. A severe valgus knee can be associated with a fibular stress fracture. Fibular fracture after a TKA has a risk of joint instability or aseptic loosening. Watchful waiting and close clinico-radiographic observation is essential in the follow-up of all post-operative TKA patients, especially those whom have had a TKA for a significant valgus knee deformity correction, as in this case.
Introduction Previous studies have reported a lower extremity stress fracture after total knee arthroplasty (TKA). However, a fibular fracture after TKA is quite rare. We report a case of proximal fibula fracture after TKA in a patient with rheumatoid arthritis (RA). Presentation of case A 45 year old woman with RA had severe knee and foot pain with an antalgic gait disturbance. There was a significant joint deformity in many of lower limb joints. Interval bilateral TKAs were performed two weeks apart. Right TKA was performed using a constraint-type prosthesis, through lateral parapatellar approach. Left TKA was performed using a posterior-stabilized (PS) prosthesis through the more commonly employed, medial parapatellar approach. Seven weeks after the right TKA, the patient was found to have an atraumatic proximal fibular fracture. The fracture went on to heal conservatively. Discussion The fracture was considered to have occurred after the TKA. The callus appeared eleven weeks after the TKA. The factors that contributed to the fracture were thought to be overload of the fragile bone secondarily to disuse osteopaenia, RA or potentially the significant valgus malalignment correction. The surgical approach, the implant or implantation or the persisting joint deformity, were thought to be contributing factors to the aetiology of the stress fracture. The resultant change in clinical outcome/course is outlined in this case report. Conclusion A stress fracture of the proximal fibula has the potential in the aetiology of may cause other stress fractures, joint other instability, and/or malalignment of the total lower extremity.
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Matar HE, Tripathi S, Miller DJ. Iliac crest apophyseal insufficiency avulsion fractures. Ann R Coll Surg Engl 2018; 100:e4-e6. [PMID: 29046079 PMCID: PMC5838676 DOI: 10.1308/rcsann.2017.0175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2017] [Indexed: 11/22/2022] Open
Abstract
Iliac crest apophyseal avulsion fractures are rare injuries caused mainly through forceful contraction of attached muscles during high level sporting activities. We present the first case of a spontaneous iliac crest apophyseal avulsion insufficiency fracture in a patient with severe atopic eczema on oral steroids and review the relevant literature.
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Affiliation(s)
- H E Matar
- Department of Trauma and Orthopaedics, Leighton Hospital , Crewe
| | - S Tripathi
- Department of Trauma and Orthopaedics, Leighton Hospital , Crewe
| | - D J Miller
- Department of Trauma and Orthopaedics, Leighton Hospital , Crewe
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Choi Y, Kwon YW, Sim YS, Kim T, Song D, Lee S. Achilles tenodesis for calcaneal insufficiency avulsion fractures associated with diabetes mellitus. J Orthop Surg Res 2017; 12:192. [PMID: 29237480 PMCID: PMC5729400 DOI: 10.1186/s13018-017-0695-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 11/24/2017] [Indexed: 12/26/2022] Open
Abstract
Background Calcaneal insufficiency avulsion (CIA) fractures often present with neuropathic etiology, such as Charcot neuroarthropathy (CN). Under the same surgical procedures, the outcomes of CIA fractures are less desirable, compared to the outcomes of the traumatic calcaneal avulsion fractures. Here, the study suggests Achilles tenodesis technique using suture anchor after resection of the CIA fracture fragments could provide satisfactory clinical results in the cases of surgically indicated CIA fractures. Materials and methods This retrospective study included seven patients of calcaneal avulsion fracture who had underlying diabetes mellitus (DM) and no specific traumatic event. The patients were treated with Achilles tenodesis techniques for their CIA fractures. Achilles tenodesis was performed using suture anchor with removal of the fracture fragments. The patients were evaluated with the Foot and Ankle Outcome Score (FAOS), visual analogue scale (VAS), single-heel rise test, and X-ray images on their final follow-ups. Results Initially, three of the CIA fracture cases treated with traditional open reduction and internal fixation reported pullout failure. Consequently, all patients received Achilles tenodesis using suture anchor after bone fragment resection and had good clinical outcomes. Only one subject with low compliance reported poor outcome. The FAOS of each patient were obtained at a mean of 16.3 months after surgery. The results are as follows: pain 80.6 (SD = 6.2), symptom 83.8 (SD = 4.9), activities of daily living 80.5 (SD = 8.0), sport and recreation function 75.6 (SD = 11.93), and foot- and ankle-related quality of life 77.9 (SD = 6.7). On their final follow-ups, the average VAS was 2.6 (range, 1 to 4). Conclusion Achilles tenodesis using suture anchor after bone fragment resection achieved competent clinical results in the patients with CIA fractures. The study proposes that this surgical procedure could be an appropriate treatment option for patients with CIA fractures. Trial registration The study was approved by the institutional review board (IRB) of our medical center (IRB File No. 2016-07-043), retrospectively registered.
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Affiliation(s)
- Youngrak Choi
- Department of Orthopedic Surgery, CHA Bundang Medical Center, CHA University, 16, Yatap-ro 65-beon-gil, Bundang-gu,, Sungnam-si, Gyunggi-do, 13497, Republic of Korea
| | - Young-Woo Kwon
- Department of Orthopedic Surgery, CHA Bundang Medical Center, CHA University, 16, Yatap-ro 65-beon-gil, Bundang-gu,, Sungnam-si, Gyunggi-do, 13497, Republic of Korea
| | - Young-Suk Sim
- Department of Orthopedic Surgery, CHA Bundang Medical Center, CHA University, 16, Yatap-ro 65-beon-gil, Bundang-gu,, Sungnam-si, Gyunggi-do, 13497, Republic of Korea
| | - Taeho Kim
- Department of Orthopedic Surgery, CHA Bundang Medical Center, CHA University, 16, Yatap-ro 65-beon-gil, Bundang-gu,, Sungnam-si, Gyunggi-do, 13497, Republic of Korea
| | - Dayoung Song
- School of Medicine, CHA University, 120, Haeryong-ro, Pocheon-si, Gyeonggi-do, Republic of Korea
| | - Soohyun Lee
- Department of Orthopedic Surgery, CHA Bundang Medical Center, CHA University, 16, Yatap-ro 65-beon-gil, Bundang-gu,, Sungnam-si, Gyunggi-do, 13497, Republic of Korea.
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Kwak SJ, Cho YJ, Jung GY, Lee JH, Chun YS, Rhyu KH. Acetabular Insufficiency Fracture Following Prolonged Alendronate Use and the Failure of Total Hip Arthroplasty in "Frozen" Bone: Two Cases Report. Hip Pelvis 2017; 29:286-290. [PMID: 29250504 PMCID: PMC5729172 DOI: 10.5371/hp.2017.29.4.286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 08/23/2017] [Accepted: 08/25/2017] [Indexed: 11/24/2022] Open
Abstract
Atypical insufficiency fracture of the femur following prolonged bisphosphonate use is well described. Regardless of the cause, insufficiency fracture of the acetabulum is extremely rare, and no reports have described insufficiency fractures of the acetabulum that are associated with prolonged bisphosphonate use. This report demonstrates the possibility of insufficiency fracture at the acetabulum following long-term alendronate use and the necessity of particular care in managing insufficiency fractures in “frozen” bone. We describe two cases of insufficiency fracture of the acetabulum following 6 years of alendronate use. Given the patients' medical histories and bone biopsy findings, these insufficiency fractures were thought to be attributable to alendronate use. One case involved the left hip and the presence of pelvic fractures on the opposite side. The patient was treated using cementless total hip arthroplasty (THA), which failed 1 year after surgery. The hip was revised with a massive bone graft and a supportive wire mesh. The other case was managed via THA with a Ganz reinforcement ring due to concerns regarding the use of a cementless implant.
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Affiliation(s)
- Sang-Joon Kwak
- Department of Orthopaedic Surgery, Kyung Hee Medical Center, Kyung Hee University College of Medicine, Seoul, Korea.,Department of Orthopaedic Surgery, Hallym University Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Yoon-Je Cho
- Department of Orthopaedic Surgery, Kyung Hee Medical Center, Kyung Hee University College of Medicine, Seoul, Korea
| | - Gwang-Young Jung
- Department of Orthopaedic Surgery, Kyung Hee Medical Center, Kyung Hee University College of Medicine, Seoul, Korea
| | - Joo-Hyun Lee
- Department of Orthopaedic Surgery, Kyung Hee Medical Center, Kyung Hee University College of Medicine, Seoul, Korea
| | - Young-Soo Chun
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Kee-Hyung Rhyu
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
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Noordin S, Allana S, Masri BA. Establishing a hospital based fracture liaison service to prevent secondary insufficiency fractures. Int J Surg 2017; 54:328-332. [PMID: 28919380 DOI: 10.1016/j.ijsu.2017.09.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 08/08/2017] [Accepted: 09/06/2017] [Indexed: 11/29/2022]
Abstract
In the aging population worldwide, osteoporosis is a relatively common condition and a major cause of long-term morbidity. Initial fragility fractures can lead to subsequent fractures. After a vertebral fracture, the risk of any another fracture increases 200% and that of a subsequent hip fracture increases 300%. For starting a hospital based Fracture Liaison Service (FLS) program, the nucleus is based on a physician champion, a FLS coordinator, and a nurse manager. A Fracture Liaison Service (FLS) is a multidisciplinary system approach to reducing subsequent fracture risk in patients with a recent fragility fracture due to compromised bone health by identifying them at or close to the time when they are treated at the hospital for fracture and providing them with easy access to osteoporosis care. It has been shown that when compared to other models such as referral letters to primary care physicians or endocrinologists, the FLS model results in a higher rate of diagnosis and treatment with less attrition in the posffracture phase. Insufficiency fracture care requires more than surgery to stabilize a fractured bone. The FLS program provides an opportunity to treat osteoporosis from a public health perspective rather than leaving this to the whims of individual physicians. This is achieved by providing a seamless integration of care by health care providers, nursing staff and administration. The FLS can be adapted to any model of care including academic health systems. FLS provides a holistic approach to identify patients as well as to provide evidence-based interventions to prevent subsequent fractures. The long term goal is that internationally FLS will result in in decreased fracture-related morbidity, mortality and overall health care expenditure.
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Affiliation(s)
- Shahryar Noordin
- Associate Professor, Orthopaedic Surgery, Aga Khan University, Karachi, Pakistan.
| | - Salim Allana
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, USA
| | - Bassam A Masri
- Department of Orthopaedics, University of British Columbia, Vacnouver, Canada
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Abstract
Introduction: Although periprosthetic fractures of the femur have been well documented, insufficiency fractures following total hip arthroplasty (THA) have been rarely described. We report a case of an insufficiency fracture in the distal tibia and fibula that occurred after THA. Case Report: A 54-year-old woman presented with severe pain in the bilateral hip joints and was diagnosed with end-stage osteoarthritis. She underwent THA on the right side. Although the postoperative course was uneventful, she suddenly experienced severe pain and swelling in the right leg without any history of trauma 22 weeks after the surgery. She was first diagnosed with cellulitis by her local doctor and was treated with oral antibiotics. Her symptoms persisted, and she returned to our hospital 1 month later. Her right distal leg and ankle were diffusely swollen and tender. Plain radiographs revealed a sclerotic linear zone in the distal tibia and fibula. She was diagnosed with insufficiency fractures in the distal tibia and fibula following THA. Local disuse osteoporosis and increased mechanical stress after THA as a result of pain relief could be the causes for her fracture. Her right leg and ankle were immobilized with a splint for another 4 weeks. Her symptoms subsided gradually, and fracture union was confirmed on the follow-up X-ray. Conclusion: Insufficiency fractures should be suspected in patients complaining of unexplainable pain, even in the distant area of the affected limb, for at least 6 months following THA
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Affiliation(s)
- Ryu Kojima
- Department of Orthopaedic Surgery, JR Tokyo General Hospital, Tokyo, Japan
| | - Toshiki Miura
- Department of Orthopaedic Surgery, JR Tokyo General Hospital, Tokyo, Japan
| | - Eisei Fukatani
- Department of Orthopaedic Surgery, JR Tokyo General Hospital, Tokyo, Japan
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Lovy AJ, Patterson D, Skeeles L, Ghillani R, Joseph D, Wu Y, Hasija R. Atraumatic segmental atypical femur fracture secondary to bisphosphonate use: A case report. J Clin Orthop Trauma 2017; 8:S67-S71. [PMID: 28878545 PMCID: PMC5574839 DOI: 10.1016/j.jcot.2017.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 02/24/2017] [Accepted: 03/16/2017] [Indexed: 10/19/2022] Open
Abstract
Atypical femur fractures as a result of long term bisphosphonate use are characterized by several unique radiographic features. We describe an atypical femur fracture treated by cephalomedullary nail with a previously undescribed segmental fracture pattern. Other than 1.5 years of bisphosphonate use the patient did not have any other risk factors known to cause atypical femur fractures. Judicious bisphosphonate use as well as increased awareness of the associated complications may help reduce the rate of bisphosphonate associated atypical femur fractures.
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Affiliation(s)
- Andrew J. Lovy
- Mount Sinai Hospital, Department of Orthopaedic Surgery, 5 E 98th St., New York, NY 10029, United States
| | - Diana Patterson
- Mount Sinai Hospital, Department of Orthopaedic Surgery, 5 E 98th St., New York, NY 10029, United States
| | - Laura Skeeles
- Elmhurst Hospital Center, Department of Orthopaedic Surgery, 79-01 Broadway, Queens, NY 11373, United States
| | - Richard Ghillani
- Mount Sinai Hospital, Department of Orthopaedic Surgery, 5 E 98th St., New York, NY 10029, United States,Elmhurst Hospital Center, Department of Orthopaedic Surgery, 79-01 Broadway, Queens, NY 11373, United States
| | - David Joseph
- Mount Sinai Hospital, Department of Orthopaedic Surgery, 5 E 98th St., New York, NY 10029, United States,Elmhurst Hospital Center, Department of Orthopaedic Surgery, 79-01 Broadway, Queens, NY 11373, United States
| | - Yangguan Wu
- Elmhurst Hospital Center, Department of Orthopaedic Surgery, 79-01 Broadway, Queens, NY 11373, United States
| | - Rohit Hasija
- Elmhurst Hospital Center, Department of Orthopaedic Surgery, 79-01 Broadway, Queens, NY 11373, United States,Corresponding author at: Department of Orthopaedic Surgery, 79-01 Broadway Elmhurst Hospital Center, Elmhurst, New York, United States
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Andresen R, Radmer S, Wollny M, Andresen JR, Nissen U, Schober HC. CT-guided cement sacroplasty (CSP) as pain therapy in non-dislocated insufficiency fractures. Eur J Orthop Surg Traumatol 2017; 27:1045-50. [PMID: 28653101 DOI: 10.1007/s00590-017-2001-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 05/30/2017] [Indexed: 11/16/2022]
Abstract
Introduction In elderly patients with reduced bone quality, insufficiency fractures of the sacrum are relatively common and are typically associated with severe disabling pain. The objective of the present study was to examine the feasibility of cement augmentation by CSP, to determine post-interventional leakages and other complications, and to present the outcome of pain over the course of 18 months. Materials and methods In 23 patients (20 women and 3 men) with an average age of 81.3 (71–92) years, a total of 41 sacral fractures were detected by MRI, 5 of them unilateral and 18 bilateral. Conservative treatment initially performed over a period of 3 weeks did not bring any satisfactory reduction in the severe disabling pain. The indication for intervention was established after an interdisciplinary case conference. The intervention was performed under intubation anaesthesia. Single-shot antibiotic prophylaxis was given routinely immediately prior to the intervention. Under sterile conditions, a Jamshidi needle was then advanced into the respective fracture zone in the sacrum from dorsal to ventral (short axis) or from lateral to medial transiliac (transiliac axis). After removing the inner needle, a flexible osteotome was inserted through the positioned hollow needle and used to extend the spongious space in the fracture zone and thus prepare a cavity for the cement filling. High-viscosity PMMA cement was then inserted discontinuously with the aid of a pressure gauge under low-dose CT control. Cement leakages were determined in the CT image on the day after the intervention, all cement outside of the cortical boundary being rated as a leakage. Pain was documented on a visual analogue scale (VAS) on the day before the intervention, on the second day, and 6, 12, and 18 months after the intervention. Additionally occurring complications were recorded, and the patients were asked to rate their satisfaction after 6 and 18 months. Results CSP was technically feasible in all patients. In the control CT scan, sufficient cement distribution and interlocking with vital bone were found along the course of the fracture in the sacrum. An average of 6.0 ± 0.83 ml of cement was inserted per fracture. Leakage was found in 5 of 41 (12.2%) of the fractures treated, although none were symptomatic. The mean pain score on the VAS was 8.8 ± 0.59 before the intervention, a significant pain reduction (p < 0.0005) was seen on the second post-operative day, with an average value of 2.1 ± 0.36, and this was stable at 2.2 ± 0.28 after 6, 2.3 ± 0.31 after 12, and 2.2 ± 0.41 after 18 months. Now that they no longer experienced disabling pain, all of the patients were fully remobilised and discharged back home. A high level of patient satisfaction was found after 6 and 18 months. Conclusion As a minimally invasive procedure, CSP is an effective treatment method for rapid, significant, and sustained pain reduction.
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Aytekin E, Kovalak E. A repetitive spontaneous distal tibial insufficiency fracture: an unusual case report. Turk J Phys Med Rehabil 2017; 63:189-92. [PMID: 31453451 DOI: 10.5606/tftrd.2017.88555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 10/21/2015] [Indexed: 11/21/2022] Open
Abstract
Stress fractures typically occur, when cyclic loading to the healthy bone exceeds the normal carrying range capacity. These fractures are most commonly seen in athletes and military recruits who are engaged with intensive physical exercise in their daily lives. Stress fractures can also occur in a variety of conditions, in which the mineral content or the elasticity of bone is abnormal and defined as an insufficiency fracture. The tibia is the most frequent location for stress fractures, while bilateral tibial fractures are extremely rare. Herein, we report a repetitive spontaneous distal tibial insufficiency fracture in the right and left distal tibia and discuss predisposing factors, diagnosis, and treatment in the light of the current literature.
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Maier GS, Kolbow K, Lazovic D, Horas K, Roth KE, Seeger JB, Maus U. Risk factors for pelvic insufficiency fractures and outcome after conservative therapy. Arch Gerontol Geriatr 2016. [PMID: 27448040 DOI: 10.1016/j.arch⁃ger.2016.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
PURPOSE The prevalence of osteoporosis has continuously increased over the past decades and it is set to increase substantially as life expectancy rises steadily. Fragility or osteoporotic fractures of the pelvis often occur after low energy falls e.g. from standing, however, some patients present with assumed insufficiency fractures of the pelvis without a previous trauma. Osteoporotic fractures impose a tremendous economic burden and these fractures deserve attention as they lead to a decrease in mobility with an increase in dependency and are associated with a high rate of mortality. To date, little is known about potential risk factors for pelvic insufficiency fractures. Furthermore, information on clinical outcome is scarce. In view of this rather limited knowledge, we aimed to identify potential risk factors for pelvic insufficiency fractures and to collect information on their short- and long-term outcomes. METHODS Files of all consecutive patients admitted between January 2010 and December 2013 for a pelvic insufficiency fracture were enrolled in this study. Pelvic fractures that occurred on tumorous bone or after high-energy trauma were excluded. Fractures of the pelvis included all pelvic bones except the coccyx. For all patients, we recorded clinical and biological parameters available from their medical history. For comparison, the same biological and clinical parameters were evaluated in an age matched control group of 1083 patients aged over 70 who were admitted to our orthopaedic department to undergo knee or hip arthroplasty. The statistical analyses used or Fisher test for percentages comparison, 2-tailed t-tests and Mann Whitney for mean comparison. To determine what factors are predictors and what factors are confounders of pelvic insufficiency fractures, multivariate linear regression analysis using the fracture as a continuous variable was performed. RESULTS Ninety-three patients with a pelvic insufficiency fracture were identified. Following the Rommens and Hofmann classification for fragility fractures of the pelvis (FFP), 51 were FFP Type Ia, 26 were FFP Type IIb lesions and 26 were FFP Type IIc. Osteoporosis was found to be significantly associated with pelvic insufficiency fractures (p=0.003), as was hypertension (p=0.036), diabetes (p=0.021), vitamin D deficiency (p=0.004), hypocalcaemia (p=0.002) and nicotine abuse (p=0.0012) after adjustment for possible confounders in the multivariate linear regression analysis. Comparing the autonomous state before and after pelvic fracture, a high loss of autonomy was observed. Patients needing daily assistance nearly doubled their number. Overall mortality was high (20%). CONCLUSIONS In conclusion, this study showed multiple risk factors for pelvic insufficiency fractures. Some, like vitamin D deficiency, can benefit easy preventive measures. Outcome of conservative therapy is poor, with loss of social and physical independence and autonomy. The mortality rate is high. Efforts should be made in preventing pelvic insufficiency fractures. All patients should be treated for the severe osteoporosis being associated with these fracture type.
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Affiliation(s)
- Gerrit Steffen Maier
- University Hospital of Orthopaedic Surgery, Pius-Hospital, Carl-von-Ossietzky-University, Oldenburg, Germany.
| | - Kristina Kolbow
- University Hospital of Orthopaedic Surgery, Pius-Hospital, Carl-von-Ossietzky-University, Oldenburg, Germany
| | - Djordje Lazovic
- University Hospital of Orthopaedic Surgery, Pius-Hospital, Carl-von-Ossietzky-University, Oldenburg, Germany
| | - Konstantin Horas
- Department of Orthopaedic Surgery, König Ludwig Haus, Julius-Maximilians-University, Würzburg, Germany
| | - Klaus Edgar Roth
- Department of Orthopaedic Surgery, Johannes-Gutenberg-University, Mainz, Germany
| | - Jörn Bengt Seeger
- Department of Orthopaedic Surgery, Justus-Liebig-University, Gießen, Germany
| | - Uwe Maus
- University Hospital of Orthopaedic Surgery, Pius-Hospital, Carl-von-Ossietzky-University, Oldenburg, Germany
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Abstract
Stress fractures and other bony stress injuries occur along a spectrum of severity which can impact treatment and prognosis. When treating these injuries, it should be borne in mind that no two stress fractures behave exactly alike. Given that they are not a consistent injury, standardized treatment protocols can be challenging to develop. Treatment should be individualized to the patient or athlete, the causative activity, the anatomical site, and the severity of the injury. A holistic approach to the treatment of the most difficult stress fractures should be taken by orthopedists and sports medicine specialists. This approach is necessary to obtain optimal outcomes, minimize loss of fitness and time away from sports participation, and decrease the risk of recurrence.
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Affiliation(s)
- Timothy L. Miller
- Orthopaedic Surgery and Sports Medicine, The Ohio State University Wexner Medical Center, Columbus, OH USA
- Capital University Athletics, 920 North Hamilton Road, Suite 600, Gahanna, OH 43230 USA
| | - Thomas M. Best
- Academic Affairs, Department of Family Medicine, The Ohio State University Wexner Medical Center, Columbus, OH USA
- Biomedical Engineering, The Ohio State University, Columbus, OH USA
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Wilmot AS, Ruutiainen AT, Bakhru PT, Schweitzer ME, Shabshin N. Subchondral insufficiency fracture of the knee: A recognizable associated soft tissue edema pattern and a similar distribution among men and women. Eur J Radiol 2016; 85:2096-2103. [PMID: 27776664 DOI: 10.1016/j.ejrad.2016.08.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 08/15/2016] [Accepted: 08/24/2016] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Primary: to describe the presence and pattern of soft tissue edema in subchondral insufficiency fractures of the knee (SIFK). Secondary: to investigate the gender distribution and identify factors associated with disease progression. METHODS MR images of 74 SIFKs in 74 patients were retrospectively reviewed for soft tissue edema presence and location, meniscal tears and extrusion and synovitis. The clinical records were reviewed for age, gender, and BMI. Follow up examinations were reviewed to assess for progression. Data were analyzed for gender distribution and for association between each imaging finding as a predictor of SIFK location and progression. RESULTS Soft tissue edema was present in 89% (66/74) of SIFK. It was located around the MCL in 78% (58/74), posterior to and abutting on the posterior distal femur in 68% (50/74), around to the tibia in only 18% (13/74), but when present it strongly predicted the presence of a medial tibial plateau SIFK (p=5.6×10^-12). Edema extended to the vastus medialis fascia in 51% (38/74) and vastus lateralis fascia in 24% (18/74). Gender distribution was 1:1 (males=38, females=36), most common in the 6th decade (29/74, 39%). Lesion progression showed a trend towards being more common in females (8/9, 89%) compared to males (9/16, 56%), and in patients with meniscal extrusion (≥3mm) (13/14, 93%) compared to those with no extrusion (2/7, 29%). CONCLUSION A recognizable soft tissue edema pattern is seen in SIFK and may have an important role in early diagnosis. Also, SIFK may affect equally males and females in the 6th decade and may progress more in females. Meniscal extrusion may predispose to disease progression.
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Affiliation(s)
- Andrew S Wilmot
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States; Department of Radiology, UPMC Department of Radiology, 200 Lothrop Street, UPMC Montefiore, Room NE 595, Pittsburgh, PA 15213, United States.
| | - Alexander T Ruutiainen
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States; Michael J. Crescenz VA Medical Center in Philadelphia, 3900 Woodland Avenue, Philadelphia, PA 19104, United States.
| | - Prashant T Bakhru
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States; Princeton Radiology Associates, Kendall Park, NJ 08824, United States.
| | - Mark E Schweitzer
- Stonybrook "University Medical Center, Stonybrook, NY, United States.
| | - Nogah Shabshin
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States; Department of Radiology, HaEmek Medical Center, Afula, Israel.
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Hosokawa T, Oda R, Toyama S, Taniguchi D, Tokunaga D, Fujiwara H, Kubo T. Spontaneous flexor tendon rupture due to an insufficiency fracture of the hamate hook in a patient with systemic lupus erythematosus: A case report. Int J Surg Case Rep 2016; 27:63-65. [PMID: 27552031 PMCID: PMC4995535 DOI: 10.1016/j.ijscr.2016.06.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 06/30/2016] [Accepted: 06/30/2016] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Spontaneous flexor tendon rupture is usually caused by trauma, systemic diseases, or carpal bone and joint disorders. Here we report a case of spontaneous flexor tendon rupture occurring in a systemic lupus erythematosus (SLE) patient following nonunion of the hamate hook after an insufficiency fracture, and which was also associated with tendon degeneration caused by SLE. CASE PRESENTATION A 57-year-old woman was diagnosed with SLE 22 years ago and being treated with oral prednisolone. She became unable to flex her left little finger without any history of trauma or sporting activity. CT showed nonunion of the hamate hook. MRI showed rupture of the flexor digitorum profundus tendon of the little finger. We performed tendon transfer and excision of the hamate hook. She recovered active flexion of the little finger at 4 months postoperatively with full satisfaction. DISCUSSION There was no history of trauma that could have caused nonunion of the hamate hook. We considered that the insufficiency fracture of the hamate hook occurred as a result of osteoporosis caused by SLE and long-term steroid use. Nonunion of the hamate hook caused mechanical attrition of the tendons, and in combination with the tendon degeneration caused by SLE, further resulted in rupture of the flexor tendon. CONCLUSION When we encounter a case of spontaneous flexor tendon rupture in a patient with systemic disease such as SLE or long-term steroid use, attention should be paid to the state of the carpal bones and joints as they sometimes accompany unexpected causes.
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Affiliation(s)
- Toshihiro Hosokawa
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan.
| | - Ryo Oda
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan.
| | - Shogo Toyama
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan.
| | - Daigo Taniguchi
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan.
| | - Daisaku Tokunaga
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan.
| | - Hiroyoshi Fujiwara
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan.
| | - Toshikazu Kubo
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan.
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Kubo Y, Yamamoto T, Motomura G, Kido S, Karasuyama K, Sonoda K, Iwamoto Y. Transient epiphyseal lesion of the femoral head after traumatic hip dislocation: A case report. Int J Surg Case Rep 2016; 24:46-9. [PMID: 27179337 PMCID: PMC4873613 DOI: 10.1016/j.ijscr.2016.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 04/02/2016] [Accepted: 05/03/2016] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION We experienced a rare case in which magnetic resonance imaging (MRI) showed a transient epiphyseal lesion of the femoral head four months after traumatic hip dislocation. To our knowledge, there have been no previously published reports on the development of such transient lesions after traumatic hip dislocation involving no abnormalities just after dislocation. PRESENTATION OF CASE We report a 22-year-old man who showed a transient epiphyseal lesion of the femoral head after traumatic hip dislocation. On MRI performed two days after dislocation, no bony injuries were observed around the hip joint. Four months after dislocation, the patient suddenly experienced right hip pain without any new trauma or injury. A low-intensity band convex to the articular surface was apparent above the epiphyseal scar on T1-weighted imaging, and bone marrow edema was observed around the band lesion on short-tau inversion recovery imaging. Following a two-month period of non-surgical conservative therapy, the patient's hip pain resolved and the low-intensity band was no longer observed on follow-up MRI. DISCUSSION Although the detailed pathogenesis of this transient changes was unclear, we speculate that prolonged rest after traumatic hip dislocation may contribute to bone insufficiency, resulting in an insufficiency fracture of the femoral head. CONCLUSION This study suggests that transient epiphyseal lesions of the femoral head may occur in patients with a history of traumatic hip dislocation associated with an adapted long-term rest.
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Affiliation(s)
- Yusuke Kubo
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Takuaki Yamamoto
- Department of Orthopaedic Surgery, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan.
| | - Goro Motomura
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Satoshi Kido
- Department of Orthopaedic Surgery, Yamaguchi Red Cross Hospital, 53-1 Yahatababa, Yamaguchi 753-8519, Japan
| | - Kazuyuki Karasuyama
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Kazuhiko Sonoda
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Yukihide Iwamoto
- Department of Orthopaedic Surgery, Kyushu Rosai Hospital, 1-3-1, Kuzuharatakamatsu, Kokuraminami-ku, Kitakyushu 800-0296, Japan
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Petraszko A, Siegal D, Flynn M, Rao SD, Peterson E, van Holsbeeck M. The advantages of tomosynthesis for evaluating bisphosphonate-related atypical femur fractures compared to radiography. Skeletal Radiol 2016; 45:615-23. [PMID: 26861160 DOI: 10.1007/s00256-016-2342-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 01/19/2016] [Accepted: 01/25/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the advantages of using tomosynthesis (TS) compared to radiographs in the detection, characterization, and follow-up of bisphosphonate-related atypical femur fractures (BP-AFF). SUBJECTS AND METHODS Eight patients were identified retrospectively who underwent TS for radiographic findings suspicious for BP-AFF. Two radiologists independently interpreted 15 radiographs and 16 TS examinations, indicating the presence or absence of the following: (1) cortical "beaking" on radiographs, (2) radiolucent fracture line on radiographs, and (3) fracture lucency on TS corresponding to the site of radiographic abnormality. Radiation dose data were calculated for radiographs and TS using Monte Carlo analysis. RESULTS There was agreement on 100 % of radiographs regarding the presence or absence of a cortical beak. Regarding the presence or absence of a fracture lucency, there was agreement on 100 % of TS examinations (Kappa = 1.0) and 73 % of radiographs (Kappa = 0.40 ± 0.24). For the 46 % of radiographs in which one or both radiologists did not visualize a fracture line, there was 100 % agreement for the presence of a fracture line on the corresponding TS. The interobserver agreement for fracture line detection was significantly higher for TS than for radiographs (p = 0.012). The effective radiation dose using TS was approximately 96 % lower compared to radiography. CONCLUSION TS outperformed radiographs in the detection and characterization of BP-AFF. TS may also have advantages over radiography for BP-AFF follow-up through its unique ability to visualize fracture healing with lower effective radiation doses to the patient.
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Matcuk GR, Mahanty SR, Skalski MR, Patel DB, White EA, Gottsegen CJ. Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options. Emerg Radiol 2016; 23:365-75. [PMID: 27002328 DOI: 10.1007/s10140-016-1390-5] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 03/09/2016] [Indexed: 12/13/2022]
Abstract
Stress fracture, in its most inclusive description, includes both fatigue and insufficiency fracture. Fatigue fractures, sometimes equated with the term "stress fractures," are most common in runners and other athletes and typically occur in the lower extremities. These fractures are the result of abnormal, cyclical loading on normal bone leading to local cortical resorption and fracture. Insufficiency fractures are common in elderly populations, secondary to osteoporosis, and are typically located in and around the pelvis. They are a result of normal or traumatic loading on abnormal bone. Subchondral insufficiency fractures of the hip or knee may cause acute pain that may present in the emergency setting. Medial tibial stress syndrome is a type of stress injury of the tibia related to activity and is a clinical syndrome encompassing a range of injuries from stress edema to frank-displaced fracture. Atypical subtrochanteric femoral fracture associated with long-term bisphosphonate therapy is also a recently discovered entity that needs early recognition to prevent progression to a complete fracture. Imaging recommendations for evaluation of stress fractures include initial plain radiographs followed, if necessary, by magnetic resonance imaging (MRI), which is preferred over computed tomography (CT) and bone scintigraphy. Radiographs are the first-line modality and may reveal linear sclerosis and periosteal reaction prior to the development of a frank fracture. MRI is highly sensitive with findings ranging from periosteal edema to bone marrow and intracortical signal abnormality. Additionally, a brief description of relevant clinical management of stress fractures is included.
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Affiliation(s)
- George R Matcuk
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA.
| | - Scott R Mahanty
- Department of Radiology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Matthew R Skalski
- Department of Radiology, Southern California University of Health Sciences, Whittier, CA, 90604, USA
| | - Dakshesh B Patel
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Eric A White
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Christopher J Gottsegen
- Department of Radiology, New York University, Langone Medical Center, New York, NY, 10016, USA
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