Weekly Teriparatide for Delayed Unions of Atypical Subtrochanteric Femur Fractures.
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ABSTRACT: Introduction
The occurrence of atypical femur fractures (AFFs) in patients on prolonged bisphosphonate treatment has been gaining medical attention, but the use of pharmacotherapy for these fractures has not been explored in detail. The authors describe a case of AFFs successfully treated with once-weekly administration of 56.5 μg teriparatide (TPTD).Case presentation
The patient was a 74-year-old female patient who had been taking alendronate for approximately 6 years and who suffered with a fall while walking. X-rays revealed a subtrochanteric right femur fracture. The contralateral femur showed cortical thickening and a transverse radiolucent fracture line. Based on these specific features, the patient was diagnosed with AFF. The patient underwent osteosynthesis with intramedullary nailing for the right fracture. Alendronate treatment was discontinued. Low-intensity pulsed ultrasonography therapy did not affect the healing of the fracture with delayed union, even after 3 months of application. Prophylactic osteosynthesis was performed for the subtrochanteric left femur. Bone tissue collected from the left fracture site during surgery showed severe suppression of bone turnover. Union of bilateral femurs was achieved after 3 months of a once-weekly administration of TPTD.Conclusion
Once-weekly TPTD treatment is shown to be beneficial for improving the healing of AFFs showing delayed union.
SUBMITTER: Fukuda F
PROVIDER: S-EPMC4254865 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Bisphosphonates are the primary therapy for postmenopausal and glucocorticoid-induced osteoporosis. Case series suggest a potential link between prolonged use of bisphosphonates and low-energy fracture of subtrochanteric or diaphyseal femur as a consequence of oversuppression of bone resorption. Using health care utilization data, we conducted a propensity score-matched cohort study to examine the incidence rates (IRs) and risk of subtrochanteric or diaphyseal femur fractures among oral bisphosphonate users compared with raloxifene or calcitonin users. A Cox proportional hazards model evaluated the risk of these fractures associated with duration of osteoporosis treatment. A total of 104 subtrochanteric or diaphyseal femur fractures were observed among 33,815 patients. The estimated IR of subtrochanteric or diaphyseal femur fractures per 1000 person-years was 1.46 [95% confidence interval (CI) 1.11-1.88] among the bisphosphonate users and 1.43 (95% CI 1.06-1.89) among raloxifene/calcitonin users. No significant association between bisphosphonate use and subtrochanteric or diaphyseal femur fractures was found [hazard ratio (HR)?=?1.03, 95% CI 0.70-1.52] compared with raloxifene/calcitonin. Even with this large study size, we had little precision in estimating the risk of subtrochanteric or diaphyseal femur fractures in patients treated with bisphosphonates for longer than 5 years (HR?=?2.02, 95% CI 0.41-10.00). The occurrence of subtrochanteric or diaphyseal femur fracture was rare. There was no evidence of an increased risk of subtrochanteric or diaphyseal femur fractures in bisphosphonate users compared with raloxifene/calcitonin users. However, this study cannot exclude the possibility that long-term bisphosphonate use may increase the risk of these fractures.
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Project description:Hypophosphatasia (HPP) is a congenital, rare and heterogeneous bone disorder, characterized by a deficit of calcified tissue mineralization, leading to skeletal deformities and osteomalacia in adults, rickets in infants and children, and fragility fractures and premature loss of dentition in children and adults. The disease is caused by a reduced or absent expression and activity of the tissue non-specific alkaline phosphatase (TNSALP) enzyme, derived from inactivating mutations of the alkaline phosphatase (ALPL) gene. Six different clinical variants have been reported, defined by the onset age and characterized by different degrees of severity. The adult form of HPP presents a wide range of clinical manifestations, many of which are non-specific, mild, and often overlapping with other metabolic bone diseases. Consequently, many cases of adult HPP are, commonly, undiagnosed or misdiagnosed, and, subsequently, wrongly or non-treated with severe consequences for patients and a very negative impact on their quality of life and life expectancy, as well as with costs due to the administration of wrong therapies and treatments of their side effects. The occurrence of a fragility atypical femur fracture in the adulthood can be suspected as a clinical indication of an undiagnosed adult mild form of HPP; and the presence of at least one of this kind of fracture can help in the diagnosis of adult HPP, together with conventional HPP biochemical signs.
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Project description:BackgroundHip fractures usually occur in old aged patients with osteoporotic bone. Management of hip fractures in old aged patient is aimed to ambulate patient immediately and to restore the pre-operative ambulation. Proximal femur replacement is an effective treatment option in elderly patient with osteoporotic bones. It allow immediate weight bearing and early return to preoperative ambulatory status and minimizes the chances of systemic complication associated with prolong bed rest associated with internal fixation. This study is aimed to review the outcome of the patients whom underwent proximal femur replacement as primary treatment for the patient with comminuted intertrochanteric and sub trochanteric fracture.Patients and methodThis is a study conducted in our university hospital which is a tertiary-care level-1 trauma center. A retrospective analysis of 21 patients who underwent proximal femur replacement for comminuted intertrochanteric and sub trochanteric fracture, age more than 60 years during the period from April 2011 to March 2018 was conducted. Data collected included: age, gender, comorbidities, mechanism of injury, type of fracture, functional outcome (calculated via Harris Hip Score) and one year mortality.ResultsThe mean age of the patients was 74.05(range 64-91) years, out of which 13 (61.8%) were female and 8 (38.0%) were male. The mean follow up was 32.6(8-91 months).Immediate post-operative ambulation status was full weight bearing (FWB) in 17 patients (80.9%) of the patients while three patients (19.0%) had non-weight bearing (NWB) due to associated co-morbidities. The mean preoperative Harris Hip score was 68.0, while the mean postoperative Harris Hip score was 66.5 at last follow up. Post operatively one patient (4.7%) developed pulmonary embolism, one patient developed dislocation. One patent (4.7%) died of sepsis from implant infection at 8 months after surgery.ConclusionPrimary Proximal femoral replacement in a viable option in old aged patients with poor bone quality who developed intertrochanteric and subtrochanteric fracture. According to our study, with mortality rate comparable to that of primary fixation, yet with the added advantage of immediate post op ambulation and reduced incidences of decubitus ulcers, atelectasis and DVT.
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Project description:Atypical femur fractures (AFFs) are rare complications of anti-resorptive therapy. Devastating to the affected individual, they pose a public health concern because of reduced uptake of an effective treatment for osteoporosis due to patient concern. The risk of AFF is increased sixfold to sevenfold in patients of Asian ethnicity compared with Europeans. Genetic factors may underlie the AFF phenotype. Given the rarity of AFFs, studying familial AFF cases is valuable in providing insights into any genetic predisposition. We present two Singaporean families, one comprising a mother (1-a) and a daughter (1-b), and the other comprising two sisters (2-a and 2-b). All four cases presented with bisphosphonate-associated AFF. Whole-exome sequencing (WES) was performed on 1-b, 2-a, and 2-b. DNA for 1-a was not available. Variants were examined using a candidate gene approach comprising a list of genes previously associated with AFF in the literature, as well as using unbiased filtering based on dominant and/or recessive inheritance patterns. Using a candidate gene approach, rare variants shared between all three cases were not identified. A rare variant in TMEM25, shared by the two sisters (2-a and 2-b), was identified. A rare heterozygous PLOD2 variant was present in the daughter case with AFF (1-b), but not in the sisters. A list of potential genetic variants for AFF was identified after variant filtering and annotation analysis of the two sisters (2-a and 2-b), including a Gly35Arg variant in TRAF4, a gene required for normal skeletal development. Although the findings from this genetic analysis are inconclusive, a familial aggregation of AFFs is suggestive of a genetic component in AFF pathogenesis. We provide a comprehensive list of rare variants identified in these AFF familial cases to aid future genetic studies. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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