Talar-sided osteochondral lesion of the subtalar joint following the intra-articular calcaneal fracture: study via a modified computed tomography mapping analysis.

INTRODUCTION: This study is to report the prevalence of osteochondral lesions in subtalar joint following intra-articular calcaneal fracture, including the relationship between fracture severity and lesion characteristics, using modified computed tomography (CT) mapping analysis. METHODS: Thirty patients with intra-articular calcaneal fracture who were preoperatively imaged with modified CT mapping analysis were recruited. The presence of talar-sided osteochondral lesions (OLTS) of subtalar joint was noted with lesion area defined by Akiyama's mapping classification. Lesion severity was assessed via Ferkel's classification, and fracture severity via Sanders' classification. RESULTS: Lesions were found in 28 patients (93.3%), mostly at anterior [16 (57.1%) lesions] or central [13 (46.4%) lesions] areas of posterior talar facet. Most common grade of lesion severity was grade I (mild) seen in 24 (80%) patients. Most fractures were classified as Sanders' grade III and IV with 12 (40%) and 12 (40%) patients noted, respectively. High severity of fracture denoted by Sanders' grade IV showed a trend of higher prevalence of OLTS at anterior and central sites of posterior talar facet (P = 0.181). Lesion severity was significantly higher in patients with double lesions than patients with single lesions (P = 0.005). However, OLTS were not significantly related with osteoarthritic changes in follow-up radiographs (P > 0.05). CONCLUSIONS: The prevalence of OLTS is very high following intra-articular calcaneal fractures. Most lesions occur at anterior or central area of posterior talar facet and are more likely to occur in patients with higher fracture severity. Lesion severity was significantly higher in patients with double lesions than patients with single lesions.

Differentiation of benign and malignant ampullary obstruction by multi-row detector CT.

PURPOSE: To determine useful CT parameters to differentiate ampullary carcinomas from benign ampullary obstruction. MATERIALS AND METHODS: This study included 93 patients who underwent abdominal CT, 31 patients with ampullary carcinomas, and 62 patients with benign ampullary obstruction. Two radiologists independently evaluated CT parameters then reached consensus decisions. Statistically significant CT parameters were identified through univariate and multivariate analyses. RESULTS: In univariate analysis, the presence of ampullary mass, asymmetric, abrupt narrowing of distal common bile duct (CBD), dilated intrahepatic bile duct (IHD), dilated pancreatic duct (PD), peripancreatic lymphadenopathy, duodenal wall thickening, and delayed enhancement were more frequently in ampullary carcinomas observed (P < 0.05). Multivariate logistic regression analysis using significant CT parameters and clinical data from univariate analysis, and clinical symptom with jaundice (P = 0.005) was an independent predictor of ampullary carcinomas. For multivariate analysis using only significant CT parameters, abrupt narrowing of distal CBD was an independent predictor of ampullary carcinomas (P = 0.019). Among various CT criteria, abrupt narrowing of distal CBD and dilated IHD had highest sensitivity (77.4%) and highest accuracy (90.3%). CONCLUSION: The abrupt narrowing of distal CBD and dilated IHD is useful for differentiation of ampullary carcinomas from benign entity in patients without the presence of mass.

Does the addition of computed tomography to computed radiography provide more value to final outcomes and treatment decisions in displaced intra-articular calcaneal fractures?

BACKGROUND: Little is known about the additional prognostic value of computed tomography (CT) in addition to computed radiography in displaced intra-articular calcaneal fractures. Thepresent study was undertaken to examine and compare the final radiographic outcomes and the prevalence of treatment methods of displaced intra-articular calcaneal fractures in patients with preoperative computed radiography alone vs. a combination ofcomputed radiography and computed tomogra- phy. MATERIAL AND METHOD: Thirty-four patients with 38 displaced intra-articular calcaneal fractures were divided into two groups: a group that was evaluated with computed tomography and computed radiography (17 patients; 20 fractures) and a group that was evaluated with computed radiography alone (17 patients; 18 fractures). Patient demographics, pre- operative and postoperative Bohler's angles, and fracture classifications were recorded. Postoperative outcomes were evaluated using calcanealfracture radiographic scores (modified Zwipp score). RESULTS: The mean age ofour patients in the present study was 43.3 ± 12.3 years. The mean age ofthe patients in the computed tomography group (48.4 ± 11.6 years) was significantly higher than that of the non-computed tomography group (37.6 ± 10.7 years, p = 0.005). The mean follow-up time was 17.4 ± 9.8 months. There was a significantly higher prevalence of open reduction and internalfixation in the computed tomography group versus the non-computed tomography group (p = 0.019). However there was no significant difference observed for the mean radiographic scores. Postoperatively, outcomes were satisfactory in both groups, although intra-articular alignment was significantly better in the computed tomography group (p = 0.020). CONCLUSION: The overall outcomes were comparable between the patient groups with computed tomography vs. those without computed tomography, exceptfor the superiority of postoperative intra-articular alignment in patients with computed tomography. Open reduction and internal fixation were more frequently performed in the patients with computed tomography than patients without computed tomography.

Body MR imaging: fast, efficient, and comprehensive.

Magnetic resonance (MR) imaging plays an important role in assessment of the full range of abdominal disease. The appropriate use of cooperative and motion-resistant protocols can allow accurate determination of the character of focal lesions in the abdomen under most circumstances. This article discusses current MR techniques and the proper use of MR imaging in the diagnostic evaluation of cooperative and noncooperative patients.

Dealing with vascular conundrums with MR imaging.

Magnetic resonance (MR) imaging is a robust imaging modality for evaluation of vascular diseases. Technological advances have made MR imaging widely available for accurate and time-efficient vascular assessment. In this article the clinical usefulness of MR imaging techniques and their application are reviewed, using examples of vascular abnormalities commonly encountered in clinical practice, including abdominal, pelvic, and thoracic vessels. Common pitfalls and problem solving in interpretation of vascular findings in body MR imaging are also discussed.

Liver adenomatosis: serial investigation on MRI.

PURPOSE: To describe the natural history of liver adenomatosis (LA), including complications and changes in lesion size over time. MATERIALS AND METHODS: Eighteen patients with clinical diagnosis of LA were included. Clinical and biochemical information were collected. The initial and follow-up MR studies were reviewed retrospectively to determine change in lesion size and imaging features. RESULTS: Seventeen patients were women (94.4%). The mean age of the initial MR study was 37.0 years (18-52 years). The median size of the largest lesion was 6.7 cm (range 3.0-13.5 cm). Intratumoral bleeding was detected on MRI in 9 lesions, in 7 patients (38.8%). The median size for hemorrhagic lesions was 7.6 cm (range 4.1-13.5 cm). During the mean follow-up period of 29.4 (range 4-98) months, 10 patients had stable disease (55.6%), and 8 patients had tumor regression (44.4%). Of 8 patients who were followed without intervention, 3 patients (37.5%) had spontaneous regression. No malignant transformation or lesion progression was occurred. CONCLUSION: During an over 2-year follow-up period, the majority of lesions of LA appeared to remain stable or showed tumor regression. Spontaneous tumor regression can be observed in approximately 37% of individuals in the age range of 28-53 years.

Prevalence of bone mineral density testing and osteoporosis management following low- and high-energy fractures.

OBJECTIVE: The aim of this study was to report the prevalence of post-fracture bone mineral density (BMD) testing and osteoporosis treatment in patients admitted to the orthopedic department for low-energy or high-energy fractures and to identify factors affecting prevalence of post-fracture BMD testing and osteoporosis treatment. METHODS: A total of 265 patients aged 45 years or older admitted with low-energy or high-energy fractures were reviewed between January 2010 and May 2011. Information regarding age, gender, fracture site and history of post-fracture BMD testing and osteoporosis treatment, including data reporting experiences of attending orthopedists (young: <10, senior: >10 years of experience) were recorded. RESULTS: Of the 265 patients (175 female, 90 male), 259 (97.7%) patients had low-energy fractures and 6 (2.3%) suffered high-energy fractures. Of 259 low-energy fractures, 99 (38.2%) underwent BMD testing and had mean total T-scores of -2.04±1.01 (proximal-femur) and -2.12±1.27 (lumbar-spine). Only one high-energy fracture patient (16.7%) underwent BMD testing, with a T-score of -1.1 (proximal-femur) and -2.7 (lumbar-spine). Eighty-six (32.5%) patients (85 low-energy fractures; 1 high-energy fracture) with diagnosis of osteopenia/osteoporosis from BMD testing were treated with calcium, vitamin D, and bisphosphonates. Bone mineral density testing was significantly higher in low-energy fracture patients who were treated by a young orthopedist, a common fracture site (proximal-femur, distal-radius, vertebrae) or were female (p<0.05). CONCLUSION: Bone mineral density investigation and treatment rates are currently suboptimal. The current gap in adequate care necessitates multidisciplinary intervention in order to lessen the incidence of future fractures, particularly in patients over the age of 45.

Outcomes and quality of life after platelet-rich plasma therapy in patients with recalcitrant hindfoot and ankle diseases: a preliminary report of 12 patients.

The present study aimed to determine the outcomes and quality of life after platelet-rich plasma therapy in patients with chronic recalcitrant diseases of the hindfoot and ankle and to identify the crucial clinical variables. The records of 12 adult patients with diseases of the hindfoot and ankle were included in the present study. These patients had been treated with platelet-rich plasma from September 2010 to April 2011 after 3 to 6 months or more of conservative treatment had been unsuccessful. They had attended the follow-up visits, were consecutively enrolled, and retrospectively studied. A total of 3 mL of autologous platelet-rich plasma was injected under fluoroscopic or ultrasound guidance into the affected areas. All patients had been evaluated using visual analog scale foot and ankle scoring before treatment and at set intervals after treatment. According to their scores at the final follow-up visit (mean 16 months), the patients were allocated to the satisfactory (score ≥ 80; n = 8) and unsatisfactory (score < 80; n = 4) groups. The health-related quality of life was assessed using the Medical Outcomes Study short-form, 36-item survey at the final follow-up visit, because the study was retrospective, and the information was not available before treatment. The mean visual analog score at the final follow-up visit (79.71 ± 17.81) was significantly greater than the mean pretreatment score (57.89 ± 20.77; p = .002). Four patients (33%) had unsatisfactory results. The mean short-form, 36-item score for the satisfactory group (85.23 ± 11.30) was significantly greater than that (57.33 ± 12.91) of the unsatisfactory group (p = .003). No definitive factors influencing the outcome of this treatment were found. The substantial number of patients with an unsatisfactory outcome indicates that platelet-rich plasma injection might be an option but might not be a mainstay of nonoperative treatment of problematic conditions of the hindfoot and ankle. The actual benefit of this treatment, including the factors influencing its outcome, are still inconclusive.

Survival times of patients with a first hip fracture with and without subsequent major long-bone fractures.

OBJECTIVES: Survival rates are poorer after a second hip fracture than after a first hip fracture. Previous survival studies have included in-hospital mortality. Excluding in-hospital deaths from the analysis allows survival times to be evaluated in community-based patients. There is still a lack of data regarding the effects of subsequent fractures on survival times after hospital discharge following an initial hip fracture. This study compared the survival times of community-dwelling patients with hip fracture who had or did not have a subsequent major long-bone fracture. Hazard ratios and risk factors for subsequent fractures and mortality rates with and without subsequent fractures were calculated. MATERIALS AND METHODS: Of 844 patients with hip fracture from 2000 through 2008, 71 had a subsequent major long-bone fracture and 773 did not. Patients who died of other causes, such as perioperative complications, during hospitalization were excluded. Such exclusion allowed us to determine the effect of subsequent fracture on the survival of community-dwelling individuals after hospital discharge or after the time of the fracture if they did not need hospitalization. Demographic data, causes of death, and mortality rates were recorded. Differences in mortality rates between the patient groups and hazard ratios were calculated. RESULTS: Mortality rates during the first year and from 1 to 5 years after the most recent fracture were 5.6% and 1.4%, respectively, in patients with subsequent fractures, and 4.7% and 1.4%, respectively, in patients without subsequent fractures. These rates did not differ significantly between the groups. Cox regression analysis and calculation of hazard ratios did not show significant differences between patients with subsequent fractures and those without. On univariate and multivariate analyses, age <75 years and male sex were risk factors for subsequent fracture. CONCLUSIONS: This study found that survival times did not differ significantly between patients with and without subsequent major long-bone fractures after hip fracture. Therefore, all patients with hip fracture, with or without subsequent fractures, need the same robust holistic care. The risks of subsequent fractures should be addressed in patients with hip fracture and should be reduced where possible by education regarding fracture prevention and regular rehabilitation programs. Efforts should be made to decrease the rates of major long-bone fractures and their burdens, even though such fractures have only a minor effect on survival in community-dwelling individuals.

Outcomes of patients with elevated α-fetoprotein level and initial negative findings at MR imaging.

PURPOSE: To evaluate interval cancer diagnosis in patients with elevated α-fetoprotein (AFP) level and initial negative findings at magnetic resonance (MR) imaging. MATERIALS AND METHODS: The institutional review board approved this HIPAA-compliant retrospective study and waived informed consent. Seventeen patients with elevated AFP levels (>300 ng/mL [>300 µg/L]) and initial negative findings at hepatic MR imaging from 2002 to 2011 were identified. MR reports, pathology reports, and medical records were reviewed to determine outcome, including identification of hepatocellular carcinoma (HCC), and track changes in serum AFP level. Initial and follow-up MR images were reviewed to evaluate presence and size of hepatic nodules. Significance of AFP values was tested with repeated-measures analysis of variance. RESULTS: Ten (59%) of 17 patients developed HCCs (13 tumors) after a mean of 138 days (range, 41-247 days). Nine (90%) of 10 patients with HCCs underwent follow-up MR imaging, and one patient (10%) underwent liver transplantation without MR follow-up. Of 12 HCCs in nine patients who underwent follow-up MR imaging, 10 (83%) were noted at follow-up MR imaging and two were found only at surgery. Mean diameter of visualized HCCs was 3.4 cm. Of 10 HCCs detected at follow-up MR imaging, five were identifiable in retrospect at initial MR studies (mean diameter, 1.4 cm). Serum AFP levels in patients with HCCs were significantly higher than those in patients without HCCs and progressively increased over time (P = .012). CONCLUSION: Subsequent HCCs in patients with elevated AFP levels and initial negative findings at MR imaging are relatively common and demonstrable during short follow-up. Close follow-up (serial 3-month studies) is recommended in the setting of a steady increase in AFP level.

A comparison of survival rates for hip fracture patients with or without subsequent osteoporotic vertebral compression fractures.

Little is known about the effect of a subsequent osteoporotic vertebral compression fracture on the survival rate of patients with a previous hip fracture. In this study, we aimed to compare the survival rates of hip fracture patients with and without subsequent osteoporotic vertebral compression fractures and determine the risk factors associated with subsequent fracture. During 2000-2008, 933 initial hip fracture patients were reviewed and divided into two groups: subsequent fracture group (160 patients) and single hip fracture group (i.e., no subsequent fracture; 773 patients). All information pertaining to their most recent fracture event(s), including mortality causes/rates, were recorded. Differences in mortality rates and hazard ratios (HRs) between the two groups were also analyzed. The 1-year and 1-to-5-year mortality rates were 1.3% and 1.9%, respectively, in the subsequent fracture group, and 4.7% and 1.4%, respectively, in the single hip fracture group, with no significant differences observed. Interestingly, the HR for mortality was significantly higher in the single hip fracture group than in the subsequent fracture group (p < 0.05). The significant risk factors for subsequent fractures were identified as knee osteoarthritis, neurological disease, and an initial hip fracture with intertrochanteric involvement. Our findings indicate that the occurrence of a vertebral compression fracture after an initial hip fracture does not greatly impact patient survival. Conversely, patients presenting with a single hip fracture have a significantly higher mortality-HR, indicating that single hip fracture patients without subsequent fracture should be provided with the same standard of care as patients with subsequent fractures.

Herlyn-Werner-Wunderlich syndrome emphasizes ultrasonographic and MR findings: a case report and review of the literatures.

Herlyn-Werner-Wunderlich (HWW) syndrome is a rare developmental anomaly that is consists of uterus didelphys with obstructed hemivagina and ipsilateral renal agenesis. This rare entity is the spectrum of Mullerian duct anomalies (MDA) accompanied by developmental anomaly of one of Wolffian ducts. The present report demonstrated HWW syndrome and reviewed literatures in term of embryological etiology, clinical manifestation, radiographic findings and surgical management. In this case report is a 11-year-old girl presented with chronic pelvic pain. She had menarche at the age of 10 and her menstrual cycles were regular with moderate dysmenorrhea. Physical examination revealed palpable pelvic mass with tenderness. Transabdominal ultrasonography (US) and Magnetic resonance imaging (MRI) demonstrated uterine didelphys with right-sided hematometrocolpos and absent right kidney. Right hematosalpinx was also detected due to distal tubal occlusion from adhesion. These preoperative images can verify all of the features of this syndrome and correctly anticipated diagnosis was achieved. The patient underwent laparoscopic right tubal drainage with lysis of pelvic adhesion and hysteroscopic resection of vaginal septum. Her symptoms were improved uneventfully. In conclusion, HWW syndrome exhibits unique clinical presentation with characteristic radiographic findings and symptom can be relieved dramatically after receiving appropriate surgical management.

Modified uniportal endoscopic plantar fasciotomy: a technical report.

OBJECTIVE: Several authors have reported the benefits of the recent procedure of the dual portal endoscopic plantar fasciotomy (EPF). However, very little is known concerning its potential capability via the single portal EPF without special cutting device. The present study aimed to demonstrate the effectiveness of uniportal EPF in a patient with severe intractable plantar fasciitis following a failure of several conservative treatments. The recent technique; uniportal EPF under modified method, without a special cutting device, was reviewed in an effort to improve its capability for plantar release and to provide information for the avoidance of this procedure's complications. CASE REPORT: A patient, with the recalcitrant conditions and the progression of the severe plantar fasciitis of bilateral feet after a failure of the conservative treatments for 13-month period, was included in this report. All data of the preoperative and each successive postoperative period (1, 6 months and last follow-up) were prospectively collected including American Orthopedic Foot and Ankle Society (AOFAS) score, Visual Analogue Scale-Foot and Ankle (VAS-FA) score and any related complications. The operations were carried out by a single surgeon with the modified uniportal EPF via a simple hooked soft-tissue blade, without a special cutting device, on both feet simultaneously. All feet had uniportal EPF with transection of the medial 50% of the plantar fascia. Postoperatively, a patient was instructed to have partial-weight bearing for the first 2 weeks with wearing of full-length silicone insoles. Then, she is allowed to start to fully weightbear with the insoles. She is advised to cautiously return to daily activities and works at 2nd week after the operation. In regard to the EPF in two feet, there were clearly improvements in the comparison between preoperative and last follow-up period in terms of the increasing AOFAS scores, and VAS-FA scores. There were no significant iatrogenic-related complications including the lateral column pain in the present report. CONCLUSION: The recalcitrant condition of severe plantar fasciitis is not uncommon for several orthopedic surgeons. Regarding the emerging of several minimally invasive procedures for this condition, our modified uniportal EPF with a simple device was encouraging as a treatment option in releasing the plantar fascia with satisfactory effectiveness and lower risks of complications.

Recurrent eccrine poroma with malignant transformation and bony involvement of the foot: a case report and review of the literature.

OBJECTIVE: Eccrine poroma is a benign appendage tumor showing either eccrine or apocrine differentiation. However malignant transformation of this tumor is very rare. The present report demonstrated a case of the eccrine poroma with malignant transformation and its rarity in terms of its high degree of recurrences and its aggressiveness with bony invasion. CASE REPORT: A 67-year old female had a mass on plantar surface of 4th-5th intermetatarsal area of her left foot for 10 years with three recurrent episodes following excisions at local hospital with no pathological report. She was referred to our institute. A recurrent tumor was removed again with pathological findings as eccrine poroma with incomplete excision; however; the patient had a failure to follow-up. Four years later; she was back in our center again with 5th episode of recurrent tumor which was marginally excised with pathological findings revealing a malignant transformation of eccrine poroma with close resected margins. Unfortunately, the patient failed to follow-up again. Eventually, four years later she returned to our institute with 6th recurrent episode of tumor. Incisional biopsy was performed with pathological findings as appendage tumor with eccrine differentiation. Wide resection including removal of 5th metatarsal head-and-neck was performed due to aggressive behaviors of this tumor; particularly; history of malignant findings and multiple recurrences, significantly bony invasion. Final pathologicalfindings were malignant eccrine poroma with close resected margin. There were no metastases in evidence from all investigations. Local irradiation with the aim of eradication of microscopically residual tumor was initiated. CONCLUSION: Malignant transformation is a rare occurrence of eccrine poroma. It should be initially included in differential diagnoses, especially in a patient with long standing foot lesion or history of recurrent masses. Wide excision is recommended as basis treatment, especially in a patient with high likelihood of recurrences or positive malignant transformation.

Pretreatment and posttreatment radiography in patients with pulmonary tuberculosis with and without human immunodeficiency virus infection.

PURPOSE: The purpose of this study was to determine differences in pretreatment and posttreatment radiographic findings in pulmonary tuberculosis (PTB) patients with and without human immunodeficiency virus (HIV) infection. MATERIALS AND METHODS: All patients were reviewed in terms of pre- and posttreatment radiographic findings comparing non-HIV-related versus HIV-related PTB. RESULTS: Among 177 PTB patients, 38 (22%) were HIV seropositive and 139 (78%) were HIV-seronegative. The most common radiographic finding in non-HIV-related TB was reticular infiltration (66.2%), whereas the miliary pattern was the most common radiographic finding in HIV-related TB (34.2%). Radiographic findings in HIV related TB significantly presented with higher prevalence of the miliary pattern (P < 0.0001) and lower prevalence of reticular infiltration (P < 0.0001), cavitation (P = 0.003), and mass-like lesions (P = 0.039) compared to non-HIV-related TB. During the posttreatment period, normal chest radiographs were significantly present in the patients who had HIV-seropositivity, the miliary pattern, and sputum negative for acid-fast bacilli during the pretreatment period (P < 0.05). CONCLUSION: Pretreatment radiographic features of HIV-related TB had a significantly higher prevalence of the miliary pattern and lower prevalence of reticular infiltration, cavitation, and mass-like lesions. HIV-related TB and the miliary pattern seen by pretreatment radiography were significantly associated with normal chest radiographs during the posttreatment period.

Hallux valgus correction using a Mini TighTrope device: a report of the short-term outcomes in 3 feet.

OBJECTIVE: Bony works seems to be base procedure for hallux valgus correction. Due to the challenge and possible complications of these procedures, these issues generate 'Foot and Ankle Society' to consider alternative procedures. The 'Mini TightRope' (Arthrex, Inc., Naples, FL) or interrosseous suture/button device was introduced in 2007 to address the above mentioned point. Although its feasibility and utilization were attractive, some reports revealed its drawbacks and limitations. The present report is to demonstrate short-term outcomes and information that might be useful for avoidance of potential complications from application of this device. MATERIAL AND METHOD: Three involved-feet in 2 patients with recalcitrant conditions and progressive hallux valgus, with at least a 6-month course of conservative treatment, were included. Limitation criteria for using 'Mini TightRope' were; non-athletic demand, good bone-stock, moderate severity of their hallux valgus (hallux-valgus-angle (HVA): 30-40, intermetatarsal-angle (IMA): 14-20), no hypermobility of first tarsometatarsal joint, and no signs of degenerative joint disease of first metatarsophalangeal/tarsometatarsal joint. Baseline data, American-Orthopaedic-Foot-and-Ankle-Society (AOFAS) scores, Visual-Analogue-Scale Foot-and-Ankle (VAS-FA) scores (including radiographic parameters) were collected at pre- and post-operative periods. The operations were carried out by a single surgeon. Precision in the creation of the interosseous-tunnel between 1st-2nd metatarsals was critical for this device. All patients strictly followed a similar postoperative-protocol, with austere prohibition of premature weight-bearing at forefoot-and-midfoot areas in 1-month postoperative-period. RESULTS: Although pre-postoperative (6-month) AOFAS/VAS-FA scores and radiographic angular differences were nonsignificant as to p-value: 0.10, there were satisfactory improvements of all scores and angular values in all postoperative periods. Patient number-two reported some tightness at 1st-2nd intermetatarsal area on left-foot. This was controlled with oral-medications in 1-month postoperative-period. Besides, there were no significant complications in the present report. CONCLUSION: 'Mini TightRope' might be of merit in hallux valgus correction for well-selected patients provided that technical implementation is precise and postoperative-protocol is followed with proper discipline.

Unusual subtrochanteric femoral insufficiency fractures associated with the prolonged use of alendronate and risedronate: a report of two cases.

OBJECTIVE: Previous studies reported that prolonged alendronate use was related to insufficiency fractures. Fewer reports presented this phenomenon in patients with risedronate use. The present study reported on two patients, both of whom had long-term use of alendronate and risedronate then sustained subtrochanteric femoral insufficiency fractures with minimal trauma. CASE SUMMARY: One of the patients was treated with alendronate therapy in concern of her risk factors for osteoporosis (her previous a hysterectomy with bilateral oophorectomy) with unsubstantiated evidence of her pretreatment, bone-mineral-density measurements (BMD), for a 10-year prior episode of left prodromal thigh pain and an insufficiency fracture at 8 days post experiencing the pain. The other patient had a history of the hysterectomy and right salpingo-oophorectomy, a low-energy metatarsal fracture with resulting osteopenia verified with BMD measurements. She was treated with alendronate for 42 months before switching to risedronate for 6 months per patient's request but no history of prodromal thigh pain. Subsequently, she sustained an insufficiency fracture, while standing and turning her body. Both patients had the significant long-term uses of bisphosphonate and exhibited the typical radiographic characteristics of insufficiency fracture. From the present report, risedronate is another prospective medication that might be related to insufficiency fractures. CONCLUSION: The present study concluded that cautious consideration is essential for long-term alendronate and risedronate use for any individual patient. The index of suspicion for the subtrochanteric femoral insufficiency fracture should be higher in the patients presenting with prodromal thigh pain. Further studies are necessary to identify the class effect of other bisphosphonate drugs, the definitive mechanisms between all generations of bisphosphonate treatments and their complications, including the individual risk factors of the insufficiency fracture.