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Osteoporosis International
Published in: Osteoporosis International 8/2017

01-08-2017 | Original Article

Undisturbed local bone formation capacity in patients with atypical femoral fractures: a case series

Authors: H. P. Bögl, P. Aspenberg, J. Schilcher

Published in: Osteoporosis International | Issue 8/2017

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Abstract

Summary

We excised the fracture site in 8 patients with incomplete atypical femoral fractures by drilling an 11-mm-diameter hole. New bone formation could be seen in the hole within a normal time frame. Delayed healing of these fractures might be unrelated to an impaired capacity to form bone.

Introduction

Incomplete atypical femoral fractures (undisplaced cracks) heal slowly or not at all, and often progress to a complete fracture with minimal trauma. The impaired healing has been attributed to an impaired biologic healing capacity related to bisphosphonate use, or, alternatively, to the mechanical environment within the fracture crack. This study aimed to investigate the capacity for bone formation after resection of the fracture site.

Methods

Between 2008 and 2014, we recruited eight patients with incomplete atypical femoral fractures. All used oral bisphosphonates before the fracture for on average 8 years (range 4 to 15) and complained of thigh pain. The fractures were stabilized with reamed cephalomedullary nails. During surgery, the fracture site in the lateral cortex was resected with a cylindrical drill (diameter 11.5 mm). The cylindrical cortical defect allowed radiographic evaluation of new bone formation, and the patients were followed clinically and radiologically for 24 months (range 15 to 92).

Results

After 3 months, newly formed bone could be seen in the cortical defects in all patients. After 13–26 months, the previous defects showed continuous cortical bone. At final follow-up, all patients reported full recovery of pre-surgical complaints. No complications occurred and no reoperations were performed.

Conclusions

New bone formation occurred within a time frame that appears normal for healing of cortical bone defects. This suggests that the capacity to form new bone is intact.
Literature
1.
Shane E, Burr D, Abrahamsen B et al (2014) Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res 29:1–23CrossRefPubMed
2.
Shane E, Burr D, Ebeling PR et al (2010) Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res 25:2267–2294CrossRefPubMed
3.
Shane E (2010) Evolving data about subtrochanteric fractures and bisphosphonates. N Engl J Med 362:1825–1827CrossRefPubMed
4.
Schilcher J, Koeppen V, Aspenberg P, Michaelsson K (2015) Risk of atypical femoral fracture during and after bisphosphonate use. Acta Orthop 86:100–107CrossRefPubMedPubMedCentral
5.
Schilcher J, Michaelsson K, Aspenberg P (2011) Bisphosphonate use and atypical fractures of the femoral shaft. N Engl J Med 364:1728–1737CrossRefPubMed
6.
7.
Dell RM, Adams AL, Greene DF, Funahashi TT, Silverman SL, Eisemon EO, Zhou H, Burchette RJ, Ott SM (2012) Incidence of atypical nontraumatic diaphyseal fractures of the femur. J Bone Miner Res 27:2544–2550CrossRefPubMed
8.
Meier RP, Perneger TV, Stern R, Rizzoli R, Peter RE (2012) Increasing occurrence of atypical femoral fractures associated with bisphosphonate use. Arch Intern Med 172:930–936PubMed
9.
Girgis CM, Sher D, Seibel MJ (2010) Atypical femoral fractures and bisphosphonate use. N Engl J Med 362:1848–1849CrossRefPubMed
10.
Egol KA, Park JH, Prensky C, Rosenberg ZS, Peck V, Tejwani NC (2013) Surgical treatment improves clinical and functional outcomes for patients who sustain incomplete bisphosphonate-related femur fractures. J Orthop Trauma 27:331–335CrossRefPubMed
11.
12.
Odvina CV, Zerwekh JE, Rao DS, Maalouf N, Gottschalk FA, Pak CY (2005) Severely suppressed bone turnover: a potential complication of alendronate therapy. J Clin Endocrinol Metab 90:1294–1301CrossRefPubMed
13.
Hagen JE, Miller AN, Ott SM, Gardner M, Morshed S, Jeray K, Alton TB, Ren D, Abblitt WP, Krieg JC (2014) Association of atypical femoral fractures with bisphosphonate use by patients with varus hip geometry. J Bone Joint Surg Am 96:1905–1909CrossRefPubMed
14.
Chen LP, Chang TK, Huang TY, Kwok TG, Lu YC (2014) The correlation between lateral bowing angle of the femur and the location of atypical femur fractures. Calcif Tissue Int
15.
Morin S, Godbout BW, Belzile MEL, Michou L, Ste-Marie L-G, Karaplis ACDGJA, Brown JP (2013) Femur geometrical parameters in the pathogenesis of atypical femur fractures. Bone Abstracts. Elsevier, Amsterdam
16.
Oh Y, Wakabayashi Y, Kurosa Y, Fujita K, Okawa A (2014) Potential pathogenic mechanism for stress fractures of the bowed femoral shaft in the elderly: mechanical analysis by the CT-based finite element method. Injury
17.
Taormina DP, Marcano AI, Karia R, Egol KA, Tejwani NC (2014) Symptomatic atypical femoral fractures are related to underlying hip geometry. Bone 63:1–6CrossRefPubMed
18.
Larsson S, Fazzalari NL (2014) Anti-osteoporosis therapy and fracture healing. Arch Orthop Trauma Surg 134:291–297CrossRefPubMed
19.
Gustafsson A, Schilcher J, Grassi L, Aspenberg P, Isaksson H (2016) Strains caused by daily loading might be responsible for delayed healing of an incomplete atypical femoral fracture. Bone 88:125–130CrossRefPubMed
20.
Burr DB, Liu Z, Allen MR (2015) Duration-dependent effects of clinically relevant oral alendronate doses on cortical bone toughness in beagle dogs. Bone 71:58–62CrossRefPubMed
21.
Donnelly E, Meredith DS, Nguyen JT, Gladnick BP, Rebolledo BJ, Shaffer AD, Lorich DG, Lane JM, Boskey AL (2012) Reduced cortical bone compositional heterogeneity with bisphosphonate treatment in postmenopausal women with intertrochanteric and subtrochanteric fractures. J Bone Miner Res 27:672–678CrossRefPubMedPubMedCentral
22.
Demirtas A, Curran E, Ural A (2016) Assessment of the effect of reduced compositional heterogeneity on fracture resistance of human cortical bone using finite element modeling. Bone 91:92–101CrossRefPubMed
23.
Iwata K, Mashiba T, Hitora T, Yamagami Y, Yamamoto T (2014) A large amount of microdamages in the cortical bone around fracture site in a patient of atypical femoral fracture after long-term bisphosphonate therapy. Bone 64:183–186CrossRefPubMed
24.
Yamagami Y, Mashiba T, Iwata K, Tanaka M, Nozaki K, Yamamoto T (2013) Effects of minodronic acid and alendronate on bone remodeling, microdamage accumulation, degree of mineralization and bone mechanical properties in ovariectomized cynomolgus monkeys. Bone 54:1–7CrossRefPubMed
25.
Egol KA, Park JH, Rosenberg ZS, Peck V, Tejwani NC (2014) Healing delayed but generally reliable after bisphosphonate-associated complete femur fractures treated with IM nails. Clin Orthop Relat Res 472:2728–2734CrossRefPubMed
26.
Prasarn ML, Ahn J, Helfet DL, Lane JM, Lorich DG (2012) Bisphosphonate-associated femur fractures have high complication rates with operative fixation. Clin Orthop Relat Res 470:2295–2301CrossRefPubMedPubMedCentral
27.
Das De S, Setiobudi T, Shen L, Das De S (2010) A rational approach to management of alendronate-related subtrochanteric fractures. J Bone Joint Surg Br 92:679–686CrossRefPubMed
28.
Teo BJ, Koh JS, Goh SK, Png MA, Chua DT, Howe TS (2014) Post-operative outcomes of atypical femoral subtrochanteric fracture in patients on bisphosphonate therapy. The bone & joint journal 96-B:658–664CrossRef
29.
Schilcher J, Koeppen V, Ranstam J, Skripitz R, Michaelsson K, Aspenberg P (2013) Atypical femoral fractures are a separate entity, characterized by highly specific radiographic features. A comparison of 59 cases and 218 controls. Bone 52:389–392CrossRefPubMed
30.
Amanat N, Brown R, Bilston LE, Little DG (2005) A single systemic dose of pamidronate improves bone mineral content and accelerates restoration of strength in a rat model of fracture repair. J Orthop Res 23:1029–1034CrossRefPubMed
31.
Hao Y, Wang X, Wang L, Lu Y, Mao Z, Ge S, Dai K (2015) Zoledronic acid suppresses callus remodeling but enhances callus strength in an osteoporotic rat model of fracture healing. Bone 81:702–711CrossRefPubMed
32.
Li J, Mori S, Kaji Y, Mashiba T, Kawanishi J, Norimatsu H (1999) Effect of bisphosphonate (incadronate) on fracture healing of long bones in rats. J Bone Miner Res 14:969–979CrossRefPubMed
33.
Gong HS, Song CH, Lee YH, Rhee SH, Lee HJ, Baek GH (2012) Early initiation of bisphosphonate does not affect healing and outcomes of volar plate fixation of osteoporotic distal radial fractures. J Bone Joint Surg Am 94:1729–1736CrossRefPubMed
34.
Seo JB, Yoo JS, Ryu JW, Yu KW (2016) Influence of early bisphosphonate administration for fracture healing in patients with osteoporotic proximal humerus fractures. Clin Orthop Surg 8:437–443CrossRefPubMedPubMedCentral
35.
Kim TY, Ha YC, Kang BJ, Lee YK, Koo KH (2012) Does early administration of bisphosphonate affect fracture healing in patients with intertrochanteric fractures? J Bone Joint Surg Br 94:956–960CrossRefPubMed
36.
Uchiyama S, Itsubo T, Nakamura K, Fujinaga Y, Sato N, Imaeda T, Kadoya M, Kato H (2013) Effect of early administration of alendronate after surgery for distal radial fragility fracture on radiological fracture healing time. The bone & joint journal 95-B:1544–1550CrossRef
37.
Harvey EJ (2016) Bisphosphonates are not always helpful: commentary on an article by Hae-Seong Lim, MD, et al.: "Factors associated with increased healing time in complete femoral fractures after long-term bisphosphonate therapy". J Bone Joint Surg Am 98:e107CrossRefPubMed
38.
Ha YC, Cho MR, Park KH, Kim SY, Koo KH (2010) Is surgery necessary for femoral insufficiency fractures after long-term bisphosphonate therapy? Clin Orthop Relat Res 468:3393–3398CrossRefPubMedPubMedCentral
39.
Koh JS, Goh SK, Png MA, Kwek EB, Howe TS (2010) Femoral cortical stress lesions in long-term bisphosphonate therapy: a herald of impending fracture? J Orthop Trauma 24:75–81CrossRefPubMed
40.
Perren SM (2002) Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br 84:1093–1110CrossRefPubMed
41.
Kidd LJ, Cowling NR, Wu AC, Kelly WL, Forwood MR (2011) Bisphosphonate treatment delays stress fracture remodeling in the rat ulna. J Orthop Res 29:1827–1833CrossRefPubMed
42.
Mori S, Burr DB (1993) Increased intracortical remodeling following fatigue damage. Bone 14:103–109CrossRefPubMed
43.
Fang C, Chau JY, Woo SB, Lau TW, Kwan K, Leung F (2014) Propagation of bisphosphonate-related femoral stress fractures despite femoral nailing: a cautionary tale from 2 cases. Geriatric orthopaedic surgery & rehabilitation 5:14–17CrossRef
Metadata
Title
Undisturbed local bone formation capacity in patients with atypical femoral fractures: a case series
Authors
H. P. Bögl
P. Aspenberg
J. Schilcher
Publication date
01-08-2017
Publisher
Springer London
Published in
Osteoporosis International / Issue 8/2017
Print ISSN: 0937-941X
Electronic ISSN: 1433-2965
DOI
https://doi.org/10.1007/s00198-017-4058-4

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