Current concepts in the management of bisphosphonate associated atypical femoral fractures.

Bisphosphonates are a class of drugs used as the mainstay of treatment for osteoporosis. Bisphosphonates function by binding to hydroxyapatite, and subsequently targeting osteoclasts by altering their ability to resorb and remodel bone. Whilst aiming to reduce the risk of fragility fractures, bisphosphonates have been associated with atypical insufficiency fractures, specifically in the femur. Atypical femoral fractures occur distal to the lesser trochanter, until the supracondylar flare. There are a number of the differing clinical and radiological features between atypical femoral fractures and osteoporotic femoral fractures, indicating that there is a distinct difference in the respective underlying pathophysiology. At the point of presentation of an atypical femoral fracture, bisphosphonate should be discontinued. This is due to the proposed inhibition of osteoclasts and apoptosis, resulting in impaired callus healing. Conservative management consists primarily of cessation of bisphosphonate therapy and partial weightbearing activity. Nutritional deficiencies should be investigated and appropriately corrected, most notably dietary calcium and vitamin D. Currently there is no established treatment guidelines for either complete or incomplete fractures. There is agreement in the literature that nonoperative management of bisphosphonate-associated femoral fractures conveys poor outcomes. Currently, the favoured methods of surgical fixation are cephalomedullary nailing and plate fixation. Newer techniques advocate the use of both modalities as it gives the plate advantage of best reducing the fracture and compressing the lateral cortex, with the support of the intramedullary nail to stabilise an atypical fracture with increased ability to load-share, and a reduced bending moment across the fracture site. The evidence suggests that cephalomedullary nailing of the fracture has lower revision rates. However, it is important to appreciate that the anatomical location and patient factors may not always allow for this. Although causation between bisphosphonates and atypical fractures is yet to be demonstrated, there is a growing evidence base to suggest a higher incidence to atypical femoral fractures in patients who take bisphosphonates. As we encounter a growing co-morbid elderly population, the prevalence of this fracture-type will likely increase. Therefore, it is imperative clinicians continue to be attentive of atypical femoral fractures and treat them effectively.

Fashioning autologous bone graft from the fibula in the transfibular approach to open ankle arthrodesis.

Open ankle arthrodesis is one of the primary operations for disabling ankle arthrosis. The transfibular lateral approach to ankle fusion is a common approach for open ankle arthrodesis. Autologous bone graft can be harvested from the osteotomised fibula. We describe a safe technique of taking graduated slices of fibula bone graft, which allows optimal fibula length excision and are suitable in shape to pack into defects at the fusion site.

Coccygeal retroversion.

STUDY DESIGN: A retrospective review of a case of coccygodynia caused by a previously unreported coccygeal morphology. OBJECTIVES: To draw attention to a previously undiagnosed pathology. BACKGROUND: This case adds to the recently described variants of coccygeal anatomy. METHODS: The authors present the case of a 42-year-old woman with intractable coccygodynia and a retroverted coccyx. RESULTS: The histologic examination of the resected specimen after coccygectomy revealed a bony lesion covered with thick fibrous tissue and evidence of mature adipocytes within trabecular spaces. (The latter was described in a supplementary report as an intraosseous lipoma.) CONCLUSION: A retroverted coccyx and adventitious bursa represent a pathoanatomy not formally reported on in the literature. This type of coccyx that is symptomatic may not respond to the traditional prolonged period of conservative management.