Objective: In the past years, several cases of unusual fractures have been reported among bisphosphonate-treated woman at sites, such as subtrocanteric or diaphyseal femoral regions, that arenot included in osteoporotic fractures. Previous thigh pain, lack of trauma prior to fracture and specific radiological characteristics have also been reported. Suppression of bone turnover and long term use of bisphosphonates can potentially result in increased fracture risk. Material and Methods: We report 9 cases of atypical metadiaphyseal femoral fractures after long term oral bisphosphonate therapy. All patients were treated with weekly oral alendronate for 6–11 yr and only one patient was administered oral ibandronate in the last year. In 5 patients diaphyseal fracture occurred with little or no trauma and 4 of them reported preceding pain. Fractures were stabilized by intramedullary nailing. Evaluation for secondary causes of skeletal fragility was undertaken. Results: We found low levels of serum and urinary calcium in all patients. In 6 patients serum 25-hydroxyvitamin D levels were <20 ng/ml and 3 patients had a secondary hyperparathyroidism. One patient had subclinical hyperthyroidism and autoimmune thyroiditis. Three patients had normal BMD measured by DXA. In 4 patients X-rays showed a bilateral femoral involvement consisting of thickening of the diaphyseal cortex and of an abnormal area of increased uptake of controlateral femur at bone scintigraphy. Three of them underwent stabilization of contralateral femur by intramedullary nail fixation. In all patients we found a marked suppression of bone turnover markers. Conclusion: Our data indicate that concomitant circumstances may affect bone remodelling, beyond the effect of bisphosphonates alone. Therefore, all patients taking oral bisphosphonates should be investigated for secondary causes of skeletal fragility. Radiographic and scintigraphic findings, such as previous thigh pain, are paramount in the early diagnosis of atypical fractures.

TYPICAL PRESENTATION OF ATYPICAL FEMORAL FRACTURES: A POTENTIAL COMPLICATION OF LONG-TERM BIPHOSPHONATE THERAPY

LORUSSO, Vincenzo;CARUSO, Gaetano;MASSARI, Leo
2013

Abstract

Objective: In the past years, several cases of unusual fractures have been reported among bisphosphonate-treated woman at sites, such as subtrocanteric or diaphyseal femoral regions, that arenot included in osteoporotic fractures. Previous thigh pain, lack of trauma prior to fracture and specific radiological characteristics have also been reported. Suppression of bone turnover and long term use of bisphosphonates can potentially result in increased fracture risk. Material and Methods: We report 9 cases of atypical metadiaphyseal femoral fractures after long term oral bisphosphonate therapy. All patients were treated with weekly oral alendronate for 6–11 yr and only one patient was administered oral ibandronate in the last year. In 5 patients diaphyseal fracture occurred with little or no trauma and 4 of them reported preceding pain. Fractures were stabilized by intramedullary nailing. Evaluation for secondary causes of skeletal fragility was undertaken. Results: We found low levels of serum and urinary calcium in all patients. In 6 patients serum 25-hydroxyvitamin D levels were <20 ng/ml and 3 patients had a secondary hyperparathyroidism. One patient had subclinical hyperthyroidism and autoimmune thyroiditis. Three patients had normal BMD measured by DXA. In 4 patients X-rays showed a bilateral femoral involvement consisting of thickening of the diaphyseal cortex and of an abnormal area of increased uptake of controlateral femur at bone scintigraphy. Three of them underwent stabilization of contralateral femur by intramedullary nail fixation. In all patients we found a marked suppression of bone turnover markers. Conclusion: Our data indicate that concomitant circumstances may affect bone remodelling, beyond the effect of bisphosphonates alone. Therefore, all patients taking oral bisphosphonates should be investigated for secondary causes of skeletal fragility. Radiographic and scintigraphic findings, such as previous thigh pain, are paramount in the early diagnosis of atypical fractures.
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Utilizza questo identificativo per citare o creare un link a questo documento: https://hdl.handle.net/11392/2290017
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