Osteosarcoma diagnostic delay associated with alendronate-induced pain relief.

A 32-year-old man with a painful osteoblastic osteosarcoma of the right hip was initially diagnosed as having Paget's disease of bone. He was treated with alendronate for presumptive Paget's disease. The patient's bone pain was dramatically reduced by the administration of alendronate for 7 months. Following discontinuation of alendronate, his pain promptly recurred, culminating in a more thorough evaluation that led to the correct diagnosis. Despite chemotherapy, the patient succumbed to metastatic osteosarcoma. The main purpose of this publication is to report the potential for pain relief when an osteosarcoma is treated with bisphosphonate medication. Clinicians are advised not to consider an alendronate-associated pain reduction in an osteoblastic lesion as an indicator of an underlying benign process of bone. The evaluation of painful sclerotic bone lesions is briefly reviewed.

Femoral stress fractures associated with long-term bisphosphonate treatment.

BACKGROUND: Recent studies have described unique clinical and radiographic characteristics of femoral stress fractures or low-energy fractures associated with long-term bisphosphonate therapy. However, it is unclear whether these fractures require subsequent surgery after the initial treatment. QUESTIONS/PURPOSES: We performed a cohort analysis of bisphosphonate-associated femoral stress fractures to (1) confirm the unique clinical and radiographic findings compared with existing literature, (2) determine whether any patients with completed fractures had no preexisting transverse stress fracture lines, (3) assess the need for additional surgical procedures, and (4) determine whether the hospital length of stay (LOS) differed for patients with prophylactic fixation of stress fractures versus fixation of completed fractures. METHODS: We retrospectively reviewed 16 patients with 24 diaphyseal and subtrochanteric femoral stress fractures (14) or low-energy fractures (10) who had been on bisphosphonates for 3 to 10 years. Data included demographics, symptoms, medication history, radiographic characteristics, treatment parameters, LOS, and outcome. Minimum followup was 9 months (average, 44.0 months; median, 31 months; range, 9-112 months). RESULTS: All patients had clinical and radiographic findings similar to those reported in the literature. Two of four patients sustained completed fractures after radiographs failed to reveal transverse lateral fracture lines. None of the 14 prophylactically treated impending fractures progressed or required additional surgery; however, in five of 10 femurs treated after fracture completion, six additional surgeries were performed. The average hospital LOS was shorter in patients who underwent prophylactic fixation (3.8 days) than in patients treated for completed fractures (5.6 days). CONCLUSIONS: Bisphosphonate-associated stress fractures and completed fractures are unique, possessing subtle characteristic radiographic features. Completed fractures may occur through the thickened bone in the absence of an appreciable transverse stress fracture line. Our observations suggest prophylactic reconstruction nail fixation may avoid fracture completion and may be associated with a shorter hospital LOS and less morbidity than treatment of completed fractures. LEVEL OF EVIDENCE: Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Primary total hip replacement versus hip resurfacing - hospital considerations.

Multiple factors regarding surgical procedures and patient selection affect hospital staffing needs as well as hospital revenues. In order to better understand the potential impact on hospitals that hip arthroplasty device selection (standard total hip arthroplasty vs. resurfacing) creates, a review of all primary hip arthroplasties performed at one institution was designed to identify factors that impacted hospital staffing needs and revenue generation. All primary hip arthroplasties undertaken over three fiscal years (2008 to 2010) were reviewed, utilizing only hospital business office data and medical records data that had been previously extracted prior for billing purposes. Analysis confirmed differing demographics for two hip arthroplasty populations, with the resurfacing patients (compared to the conventional total hip arthroplasty population) consisting of younger patients (mean age, 50 vs. 61 years), who were more often male (75% vs. 45%), were more likely to have osteoarthritis as their primary diagnosis (83 vs. 67%) and were more often covered by managed care or commercial insurance (83 vs. 34%). They also had shorter hospital stays (mean length of stay, 2.3 vs. 4.1 days) and consequently provided a more favorable financial revenue stream to the hospital on a per patient basis. Several trends appeared during the study periods. There was a steady increase in all procedures in all groups except for the resurfacings, which decreased 26% in males and 53% in females between 2009 and 2010. Differences were observed in the demographics of patients presenting for resurfacing, compared to those presenting for conventional total hip arthroplasty. In addition to the revenue stream considerations, institutions undertaking a resurfacing program must commit the resources and planning in order to rehabilitate these patients more expeditiously than is usually required with conventional hip arthroplasty patients.