Atypical femoral fractures due to the use of bisphosphonates: epidemiologic study in a tertiary hospital / Fraturas atípicas de fêmur por uso de bifosfonatos: estudo epidemiológico em um hospital terciário

ABSTRACT Objective: Show the relationship between atypical femoral fractures and prolonged use of bisphosphonates and analyze the limit of its beneficial use. Methods: Retrospective cohort study (level of evidence 2B). From Atypical fracture cases, patients who used bisphosphonates were selected and the time period of their use was analyzed. Additionally, the variables sex, age, and the side most affected were studied. Results: Nine atypical femur fractures were found, all associated with the use of bisphosphonates. The average period of use of this medication was nine years (minimum of three years; maximum of 14 years). The patients' mean age was of 78 years (69-88 years) and all were women, with the right member being the most affected. Conclusion: The use of bisphosphonates to prevent osteoporotic fractures has been increasingly frequent and, when used for a prolonged period, it has been related to atypical fractures. Further scientific studies on doses, maximum periods of treatment, and risk-benefit in the indication of these medications are needed to assist in therapeutic management for each case. Level of Evidence II, Retrospective Study.

RESUMO Objetivo: Demonstrar relação entre as fraturas atípicas de fêmur e o uso prolongado de bifosfonatos, descrever sua incidência e analisar até qual momento o seu uso é benéfico. Métodos: Estudo de coorte retrospectivo (nível de evidência 2B). Análise de 151 prontuários de pacientes com diagnóstico de fratura de fêmur em um hospital terciário, no período de janeiro de 2013 a dezembro de 2018. Foram selecionados os casos de fraturas atípicas e, dentre esses, os que faziam uso de bifosfonatos e o tempo de utilização. Ademais, foram estudadas as variáveis sexo, idade e lado mais acometido. Resultados: Constatadas 9 fraturas atípicas de fêmur, todas associadas ao uso de bifosfonatos. O período médio de uso dessa medicação foi de 9 anos (mínimo - 3 anos; máximo - 14 anos). A idade média dos pacientes foi de 78 anos (69-88 anos) e ocorrência unicamente em mulheres, tendo como membro mais acometido o direito. Conclusão: O uso dos bifosfonatos na prevenção de fraturas osteoporóticas tem sido cada vez mais frequente e relacionado às fraturas atípicas, quando empregado por tempo prolongado. A coleta de mais informações científicas que estudem doses, períodos máximos de tratamento e risco-benefício na indicação dessas medicações é essencial para auxiliar no manejo terapêutico apropriado para cada caso. Nível de Evidência II, Estudo Retrospectivo .

Current research progress on pelvic insufficiency fractures after radiotherapy for pelvic neoplasms / 中华放射肿瘤学杂志

Pelvic insufficiency fractures ( PIF) is a vital complication after radiotherapy for pelvic neoplasms. It often leads to intractable pain and limited activity and is likely to be misdiagnosed as bone metastases and improperly treated. MRI is a common method for the diagnosis and differential diagnosis of PIF. The optimal approach to prevent PIF is to correctly identify the high-risk population and provide drug intervention when necessary. The low bone density state serves as a pivotal predictor at the beginning of radiotherapy. Reasonable selection of irradiation dose in pelvic lymphatic drainage area and minimizing the dose of pelvic bone probably reduce the incidence of PIF after radiotherapy.

Sacral Insufficiency Fractures: How to Classify?

OBJECTIVE: The diagnosis of insufficiency fractures of the sacrum in an elder population increases annually. Fractures show very different morphology. We aimed to classify sacral insufficiency fractures according to the position of cortical break and possible need for intervention.METHODS: Between January 1, 2008 and December 31, 2014, all patients with a proven fracture of the sacrum following a low-energy or an even unnoticed trauma were prospectively registered : 117 females and 13 males. All patients had a computer tomography of the pelvic ring, two patients had a magnetic resonance imaging additionally : localization and involvement of the fracture lines into the sacroiliac joint, neural foramina or the spinal canal were identified.RESULTS: Patients were aged between 46 and 98 years (mean, 79.8 years). Seventy-seven patients had an unilateral fracture of the sacral ala, 41 bilateral ala fractures and 12 patients showed a fracture of the sacral corpus : a total of 171 fractures were analyzed. The first group A included fractures of the sacral ala which were assessed to have no or less mechanical importance (n=53) : fractures with no cortical disruption (“bone bruise”) (A1; n=2), cortical deformation of the anterior cortical bone (A2; n=4), and fracture of the anterolateral rim of ala (A3; n=47). Complete fractures of the sacral ala (B; n=106) : parallel to the sacroiliac joint (B1; n=63), into the sacroiliac joint (B2; n=19), and involvement of the sacral foramina respectively the spinal canal (B3; n=24). Central fractures involving the sacral corpus (C; n=12) : fracture limited to the corpus or finishing into one ala (C1; n=3), unidirectional including the neural foramina or the spinal canal or both (C2; n=2), and horizontal fractures of the corpus with bilateral sagittal completion (C3; n=8). Sixty-eight fractures proceeded into the sacroiliac joint, 34 fractures showed an injury of foramina or canal.CONCLUSION: The new classification allowes the differentiation of fractures of less mechanical importance and a risk assessment for possible polymethyl methacrylate leaks during sacroplasty in the direction of the neurological structures. In addition, identification of instable fractures in need for laminectomy and surgical stabilization is possible.

Sacral Insufficiency Fractures: How to Classify?

OBJECTIVE: The diagnosis of insufficiency fractures of the sacrum in an elder population increases annually. Fractures show very different morphology. We aimed to classify sacral insufficiency fractures according to the position of cortical break and possible need for intervention. METHODS: Between January 1, 2008 and December 31, 2014, all patients with a proven fracture of the sacrum following a low-energy or an even unnoticed trauma were prospectively registered : 117 females and 13 males. All patients had a computer tomography of the pelvic ring, two patients had a magnetic resonance imaging additionally : localization and involvement of the fracture lines into the sacroiliac joint, neural foramina or the spinal canal were identified. RESULTS: Patients were aged between 46 and 98 years (mean, 79.8 years). Seventy-seven patients had an unilateral fracture of the sacral ala, 41 bilateral ala fractures and 12 patients showed a fracture of the sacral corpus : a total of 171 fractures were analyzed. The first group A included fractures of the sacral ala which were assessed to have no or less mechanical importance (n=53) : fractures with no cortical disruption (“bone bruise”) (A1; n=2), cortical deformation of the anterior cortical bone (A2; n=4), and fracture of the anterolateral rim of ala (A3; n=47). Complete fractures of the sacral ala (B; n=106) : parallel to the sacroiliac joint (B1; n=63), into the sacroiliac joint (B2; n=19), and involvement of the sacral foramina respectively the spinal canal (B3; n=24). Central fractures involving the sacral corpus (C; n=12) : fracture limited to the corpus or finishing into one ala (C1; n=3), unidirectional including the neural foramina or the spinal canal or both (C2; n=2), and horizontal fractures of the corpus with bilateral sagittal completion (C3; n=8). Sixty-eight fractures proceeded into the sacroiliac joint, 34 fractures showed an injury of foramina or canal. CONCLUSION: The new classification allowes the differentiation of fractures of less mechanical importance and a risk assessment for possible polymethyl methacrylate leaks during sacroplasty in the direction of the neurological structures. In addition, identification of instable fractures in need for laminectomy and surgical stabilization is possible.

Atraumatic Insufficiency Fractures of the Tarsal Bones-An Unusual Cause of Recurrent Heel Pain in a Patient with Rheumatoid Arthritis: A Case Report

@#The incidence of insufficiency fractures is approximately 1% in rheumatoid arthritis patients. The predisposing factors are chronic inflammation, skeletal deformities, biomechanical stresses and osteoporosis. The medications used in the treatment of rheumatoid arthritis such as Glucocorticosteroids and Methotrexate also contribute to the development of osteoporosis and insufficiency fractures. A 68-year old lady who was suffering from rheumatoid arthritis and on long term Methotrexate was seen in the outpatient clinic with recurrent episodes of heel pain. Examination revealed diffuse tenderness around the heel with full range of ankle movements but painful limitation of subtalar joint movements. Radiographic examination of the ankle showed a highly suspicious fracture of the calcaneus and confirmed on MRI as an insufficiency fracture. She was treated successfully with oral bisphosphonates and moon boot brace. She presented after two years with recurrent episodes of heel pain. The plain radiograph and MRI scan confirmed an insufficiency fracture of the talus. She was treated nonoperatively with intravenous Zolendronic acid and bracing. In chronic rheumatoid arthritis patients especially on Methotrexate and Glucocorticoids a high index of suspicion of insufficiency fractures should be considered if they present with bone pain. MRI scan is the investigation of choice and is conclusive.

The incidence and risk factors of pelvic insufficiency fracture in patients with cervical cancer after intensity-modulated radiotherapy / 中华放射医学与防护杂志

Objective To analyze the incidence and risk factors of pelvic insufficiency fractures (PIF) in patients with cervical cancer who received pelvic intensity-modulated radiotherapy.Methods This study a retrospective review of all patients was performed with cervical cancer who received pelvic intensity-modulated radiotherapy at our institution from November 2013 to December 2015,and the incidence and risk factors of insufficiency fractures were analyzed.Results Among the 104 patients,16 (with a total of 31 lesions) were diagnosed with pelvic insufficiency fracture.The occurrence rate of pelvic insufficiency was 15.4％.Ten patients (62.5％) had multiple fractures and five patients (31％) complained of pain.All patients' pain was relieved by rest or analgesic drugs.Insufficiency fractures were detected at a median of 6.5 months (range 1-16) from radiotherapy completion.The distribution of PIFs was followed:sacral had 16 cases (51.6％),sacroiliac joint had 7 cases (22.6％),iliac had 6 cases (19.4％),femoral head had 1 case (3.2％) and pubis had 1 case (3.2％).Univariate analysis and multiple analysis showed that postmenopausal status and low body weight (≤55 kg) were thought to be risk factors for PIF(P ＜ 0.05).Subgroup analysis also confirmed that postmenopausal status was a risk factor for PIF (P ＜ 0.05) in postoperative cervical cancer patients after pelvic intensity-modulated radiation therapy.Conclusions Cervical cancer patients with menopausal status and low body weight (≤55 kg) are at some risk for the development of PIF after pelvic intensity-modulated radiotherapy.

Oncogenic Osteomalacia with Multiple Insufficiency Fractures: A Case Report

Oncogenic osteomalacia is a rare paraneoplastic syndrome, characterized by hypophosphatemia, renal phosphate wasting, osteomalacia, and multiple insufficiency fractures, as a result of the tumor. A wide excision of the causative tumor is considered as the treatment of choice, following which, a dramatic recovery is expected. Authors report a case in which the symptoms and bone mineral density were dramatically recovered after an excision of the causative tumor around the tibialis posterior muscle in oncogenic osteomalacia.

Pelvic Insufficiency Fracture in Severe Osteoporosis Patient / 대한고관절학회지

PURPOSE: To evaluate clinical features and the effect of parathyroid hormone (PTH) on treatment outcomes of patients with pelvic insufficiency fractures. MATERIALS AND METHODS: Fifteen patients diagnosed with pelvic insufficiency fractures were evaluated retrospectively. All patients had osteoporosis with mean lumbar T score of −3.9 (range, −3.1 to −6.4) and the mean age was 76.5 years. In all cases, simple radiography and computed tomography was used for final diagnosis; additional magnetic resonance imaging and technetium bone scans were used to confirm the diagnosis in 2 and 6 patients, respectively. Initial conservative treatment was used in all cases; treatment with PTH was applied in 5 cases. Radiological follow-up was done every 4 weeks up to 6 months and every 3 months thereafter. Symptom improvement was measured using visual analogue scale (VAS) score. RESULTS: Fractures were located: i) sacrum and pubis (9 cases), ii) isolated sacrum (4 cases) and iii) isolated pubis (2 cases). One case showed fracture displacement and pain aggravation at 4 week follow-up which was treated with percutaneous sacro-iliac fixation using cannulated screws. Duration of bone union was significantly shorter in the patients who used PTH (P<0.05). VAS scores were also lower in the group treated with PTH; however, statistical significance was not reached. CONCLUSION: In patients with osteoporosis, a pelvic insufficiency fracture should be considered if pain is experienced in the pelvic area in the absence of major trauma. While nonoperatic has been shown to be sufficient for treatment, our study shows that PTH therapy shortens treatment period and could be a favorable treatment option.

Clinical Features and Outcomes of Pelvic Insufficiency Fractures

PURPOSE: The purpose of this study was to investigate the radiological and epidemiological characteristics, as well as the clinical course of pelvic insufficiency fractures in the elderly population. MATERIALS AND METHODS: At a Haeundae Paik Hospital, we retrospectively reviewed patients with pelvic insufficiency fractures between March 2010 and May 2017. The demographic data of patients were analyzed, and bone mineral density and bone turnover markers were evaluated to estimate the metabolic status of the bone. The radiological characteristics were evaluated by comparing the simple x-ray images with the computed tomography images, and the types of fractures were classified via computed tomography images. For clinical course evaluation, we investigated comorbid complications, and compared the walking ability scale before and 6 months after the fracture. RESULTS: A total of 42 patients were included, with an average age of 76.5 years. All were female except one case. In 5 cases where the initial medical examination was from another institution, the fracture was not found in 3 cases. All cases received conservative treatment. After the diagnosis of pelvic bone fracture using a simple x-ray imaging, additional fractures were found in 81.0% of the study population using a computed tomography. Initiation of gait occurred at an average of 2.8 weeks, and every case except 1 (97.6%) fully recovered their gait ability. CONCLUSION: We concluded that there was a limitation with diagnosing pelvic insufficiency fracture using only a simple x-ray imaging technique. In general, cases in this study showed conservative treatment yielded favorable clinical outcome with relatively less critical complications.

Repetitive Insufficiency Fractures of the Femoral Shaft: A Case Report

Stress fractures occur when the loads applied to a bone exceed the mechanical resistance and fall into two groups. Fatigue fractures, in which abnormal mechanical stress is applied to a normal bone, and insufficiency fractures, in which fracture occurs when stress of normal activity is applied to a bone that has decreased elastic resistance. Femoral shaft insufficiency fractures are reported rarely in patients with postmenopausal osteoporosis. We report a case of repetitive insufficiency fractures of the femoral shaft in 70 year-old female with marked osteoporosis.