Iron-induced Hypophosphatemic Osteomalacia-An Atypical Case of Bilateral Femoral Stress Fractures.

We present a case of a 61-year-old healthy man who had bilateral femoral neck insufficiency fractures attributed to repeated iron transfusions, causing iron-induced hypophosphatemic rickets, requiring surgical intervention. Atraumatic insufficiency fractures present a diagnostic dilemma in orthopaedics. Chronic fractures with no acute precipitating trigger can often go unrecognized until complete fracturing or displacement occurs. Early identification of the risk factors in conjunction with a comprehensive history, clinical examination, and imaging can potentially avoid these serious complications. Atraumatic femoral neck insufficiency fractures have been sporadically reported in the literature, often unilateral and attributed to the use of long-term bisphosphonates. Through this case, we elaborate on the relatively unknown link between iron transfusions and insufficiency fractures. This case highlights the importance of early detection and imaging of such fractures from an orthopaedic perspective.

Reoperation rate and implant survivorship compared between cementless and cemented bipolar hemiarthroplasty in femoral neck fracture patients with chronic kidney disease.

BACKGROUND: Chronic kidney disease (CKD) is commonly associated with aging and disorders of mineral and bone metabolism. Femoral neck fracture (FNF) is one of the most common fractures among older adults with coexisting CKD, and bipolar hemiarthroplasty (BHA) is a preferred treatment. However, the optimal method of stem fixation has not been conclusively determined. Accordingly, this study aimed to investigate the reoperation rate and implant survivorship compared between cementless and cemented BHA in FNF patients with CKD. METHODS: A total of 183 FNF patients with moderate to severe CKD who underwent BHA during 2003 to 2019 were recruited and divided into either the cemented (CT group, n = 56) or cementless (CL group, 127) groups. Demographic data, preoperative laboratory investigations, preoperative radiographic outcomes, perioperative outcomes, and 90-day morbidity, mortality, and reoperation rates for any reason were recorded and compared between groups. Kaplan-Meier survival analysis was used to compare implant survivorship between the CT and CL groups. Cox proportional hazards regression model was used to identify independent risk factors for implant survivorship. RESULTS: There were no significant differences in patient characteristics or preoperative data between groups, except for Dorr's classification of proximal femoral geometry. The CT group had a significantly lower proportion of Dorr type A (p = 0.020), and a higher proportion of Dorr type C (p<0.001). The CT group also had significantly more intraoperative blood loss (p<0.01). No significant differences in morbidity or mortality were observed. The median follow-up time in the CT group and CL group was 22.6 months (range: 0-151) and 22.6 months (range 0-154), respectively (p = 0.607). The reoperation rate was 5.4% and 4.7% among CT and CL patients, respectively (p = 1.000). There was no significant difference in the mean survival time between the CT (139.5 ± 6.3 months, 95%CI: 127.1-151.8) and CL (142.5 ± 4.7 months, 95%CI: 133.2-151.7) groups (p = 0.880). Univariate and multivariate analyses revealed no independent risk factors for implant survivorship. CONCLUSION: The results of this study showed no significant differences in the reoperation rate or implant survivorship between cemented and cementless BHA for treating FNF in moderate to severe CKD patients. A well-designed larger and longer-term study is needed to confirm these results.

Atypical incomplete femoral neck fracture in patients taking long-term bisphosphonate: Case report, a report of 2 cases.

RATIONALE: We present 2 cases of lateral incomplete impending fracture of the femoral neck without trauma in elderly patients taking long-term bisphosphonate (BP) treatment, and we defined it as atypical femoral neck fracture (AFNF). To the best of our knowledge, this is the first report on the follow-up results of AFNF. PATIENT CONCERNS: Patients in both cases had been taking BP drugs for a long time with osteoporosis. The duration of BP treatment was 6 years, and there was no history of repeated stresses. DIAGNOSES: All fractures were linear at the lateral aspect of the mid portion of the femoral neck, and the BMD of the femoral neck was -0.9, and -1.8, respectively. INTERVENTIONS: Internal fixation was performed in both cases (73 years, 68 years) using cannulated screws. OUTCOMES: In both patients who underwent screw fixation, the fracture line started to extend distally at 4 weeks and 2 weeks following surgery. In the 3-month follow-up image, the length of the fracture increased by 20.1 mm and 9.9 mm, respectively. There was a problem with active rehabilitation, and the possibility of revision was also found to be a burden in terms of mortality and cost in older patients. LESSONS: In the case of AFNF, guidelines for treatment should be set in consideration of the decreased bone healing, even when the fracture pattern is simple. Arthroplasty based on a wider indication may be worth considering.

Low-energy atypical femoral shaft and ipsilateral neck fracture: a rare association.

This reports a case of a low-energy ipsilateral femoral shaft and neck fracture in a 69-year-old woman with vitamin D deficiency, who was taking long-term steroids and bisphosphonates. This is a fracture more commonly associated with a high-energy trauma. However, with an ageing global population and an increasing prevalence of bone insufficiency, we predict the incidence of this presentation to increase. Long-term bisphosphonate therapy has been associated with bone insufficiency and an increased rate of delayed union, adding to the complexity of management in these patients. There is currently no consensus regarding the choice of optimal implant or fixation technique to treat this challenging fracture pattern. We discuss the considerations that led to our management approach of a non-overlapping dynamic hip screw and femoral shaft plate construct which achieved uneventful bone healing and a good functional outcome within the first year of follow-up.

Bilateral non-traumatic hip fractures in a heavy smoker COPD patient on inhaled steroids.

INTRODUCTION: Bilateral proximal femoral fractures without trauma are very rare conditions. They have been reported in connection with osteoporosis, renal osteodystrophy, parathyroid disease, tumors, epileptic seizures, electroconvulsive therapy, and postirradiation. METHOD: We present a case of a 75-year-old man with bilateral hip fractures. No trauma, neurological, endocrinological disorder, or malignancy was reported in his history. He had a background of chronic obstructive pulmonary disease (COPD) and had been taking inhaled steroids (budesonide) 800 µg per day for 10 years. He was a heavy smoker with a smoking history of 120 packs/year. His complaints had initially started as pain on the left hip and groin and then had progressed to the right in 10 days. Plain x-rays of the pelvis showed left femoral neck and right subtrochanteric femoral fractures. Fixation with proximal femoral nail of the right hip and partial arthroplasty of the left hip was performed on the following day after his admission. Pathological examination revealed osteoporosis in bone samples from both hips. RESULT: COPD and osteoporosis have some common risk factors. Smoking, decreased exercise capacity, inhaled, or oral steroid therapy may increase osteoporosis and risk of bone fractures by decreasing bone mineral density. Non-traumatic femoral fractures may occur in patients on long-term inhaled steroid treatment for chronic airway diseases such as asthma and COPD. CONCLUSION: History of COPD with corticosteroid use may be used as a diagnostic tool to identify patients having osteoporosis. Preventive measures can be performed by monitoring high-risk patients with bone mineral densitometry, WHO fracture risk assessment tool (FRAX tool), serum calcium, and vitamin D levels to prevent bone fractures. Treating those patients with the lowest effective dose of corticosteroids should be targeted.

Effective treatment of a steroid-induced femoral neck fracture nonunion with a once-weekly administration of teriparatide in a rheumatoid patient: a case report.

INTRODUCTION: Nonunion of femoral neck fractures frequently occurs in elderly patients. In patients with rheumatoid arthritis, reoperation rates after internal fixation of a displaced femoral neck fracture increase by up to 60 %. Revision surgery with arthroplasty is often preferred for nonunion of femoral neck fractures because there are few effective options for conservative treatment. Teriparatide (TPTD) is a human parathyroid hormone analog and the only anabolic drug for the treatment of severe osteoporosis. DISCUSSION: There are two types of treatment regimens using TPTD: a once-daily administration of recombinant type TPTD and a once-weekly administration of a chemically synthesized type. Although there have been some reports showing that the once-daily recombinant type TPTD was effective for nonunion treatment, the effect of a once-weekly administration of the chemically synthesized type of TPTD is unknown. This report shows the efficacy of the chemically synthesized TPTD for the treatment of femoral neck fracture nonunion in a patient with risk factors that include rheumatoid arthritis and steroid intake.

Pathological femoral fractures due to osteomalacia associated with adefovir dipivoxil treatment for hepatitis B: a case report.

We present a case of a 62-year-old man who underwent total hip arthroplasty for treatment of pathologic femoral neck fracture associated with adefovir dipivoxil-induced osteomalacia. He had a 13-month history of bone pain involving his shoulders, hips, and knee. He received adefovir dipivoxil for treatment of lamivudine-resistant hepatitis B virus infection for 5 years before the occurrence of femoral neck fracture. Orthopedic surgeons should be aware of osteomalacia and pathological hip fracture caused by drug-induced renal dysfunction, which results in Fanconi's syndrome. VIRTUAL SLIDES: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1600344696739249.

Benefits and risks of bisphosphonate therapy for osteoporosis.

CONTEXT: There has been considerable concern recently in the scientific and lay media regarding the benefits vs. the risks of bisphosphonates for the treatment of osteoporosis. Risks include possible associations with osteonecrosis of the jaw (ONJ) and atypical femur fractures. In this perspective, we review the use of bisphosphonates for the treatment of osteoporosis, including an objective assessment of the risks vs. the benefits of these drugs. EVIDENCE ACQUISITION: Authors' knowledge of the field and results of focused literature searches are presented. EVIDENCE SYNTHESIS: Bisphosphonates have proven efficacy in the prevention of bone loss and in the reduction of fractures in postmenopausal women and men with established osteoporosis. Although bisphosphonates, at doses used to treat osteoporosis, may be associated with an increased risk of ONJ and atypical femur fractures, many more fractures are prevented by the use of these drugs compared to the relatively low risk of these complications. Although oral bisphosphonates are associated with upper gastrointestinal side effects and iv bisphosphonates with acute phase reactions, the association of bisphosphonate use with esophageal cancer and atrial fibrillation is not well supported by current data. CONCLUSIONS: Bisphosphonates have been proven to prevent fractures in patients with established osteoporosis or those who are at high risk of fracture. In contrast, the incidence of major complications associated with bisphosphonate use, such as ONJ and atypical femur fractures, is very low.

Unusual presentation of altered bone metabolism with long-term antiepileptic therapy: pathological fracture of neck of femur due to brown tumor at calcer.

The antiepileptic drugs are known to alter the bone metabolism and result in various range of pathological conditions (osteoporosis, osteomalacia, vitamin D deficiency, secondary hyperparathyroidism). These clinical conditions developed either due to direct effect of these therapeutic agents on bone or due to alteration in the homeostasis of other regulators of bone metabolism like serum calcium, vitamin D, and parathyroid hormone. Long-term therapy with antiepileptic agents results in higher incidence of pathological fracture, which is a consequence of either osteoporotic or osteomalasic (secondary to vitamin D deficiency) changes in bone produced by these drugs. Secondary hyperparathyroidism due to vitamin D deficiency following long-term polytherapy of antiepileptic drug ultimately leading to development of brown tumor and pathological fracture is very unusual.

[Multiple pathological fractures within the scope of DeToni-Debre-Fanconi syndrome after fumarate therapy in psoriasis]. / Multiple pathologische Frakturen im Rahmen eines DeToni-Debré-Fanconi-Syndroms nach Fumarattherapie bei Psoriasis.

We report about a rare case of a pathological fracture of the shank following earlier pathological fractures at other locations in a comparatively young female patient with no history of trauma. There were no known diseases other than psoriasis. The shank fracture was treated surgically by osteosynthesis. Osteoporosis, myeloma, or malignancy as causative factors of this fracture could be excluded. Scintigraphy showed an enhancement, especially at the extremities. Other than reactive bone growth, histological examination revealed no further aspects. Laboratory analysis indicated a massive lack of vitamin D3. After transferring the patient to the internal department of our hospital, long-term medication with fumaric acid was determined to be the reason for the osteomalacia of a Fanconi's syndrome. Three months after cessation of these medicaments and treatment with active vitamin D3 metabolites, the patient was free of complaints. The radiographs showed an essential improvement of the demineralization.

Spontaneous hip fractures in fluoride-treated patients: potential causative factors.

Spontaneous fractures were reported to be rare (less than 1%) in 1664 hospital admissions for hip fracture in the 1950s in Sweden. We report 11 fluoride-treated postmenopausal patients who developed spontaneous fractures of the femoral necks, all subcapital initially. In 7 patients who continued treatment there were later femoral neck or shaft fractures; in 6, these were bilateral (one followed a fall). In all there were 19 spontaneous fractures: 5 were asymptomatic, including 2 with deformity; 12 fractures required surgery. Five were incomplete (stress) fractures. All were treated with supplementary calcium 1 g daily; 10 had vitamin D supplementation. In all patients where the timing was known, the initial and subsequent fractures were preceded by, or associated with increased bone turnover as measured by plasma alkaline phosphatase (pAlP) (i.e., they were all "good responders"). Two had pretreatment hip fractures following falls. We compared these 11 (Group 1) and another identically treated group of 14 patients (Group 2), without spontaneous femoral fractures and not different in mean age, pretreatment vertebral fractures, years since menopause, fluoride dosage, and plasma creatinine. Group 1 had a lower (p less than 0.05) index of cortical bone in the femoral neck, as assessed by the ratio "calcar width/femoral neck minimum width." The 6 biopsied fluorotic patients from Group 1 had a higher (p less than 0.05) bone fluoride content than the 4 biopsied fluorotic patients from Group 2. Furthermore, histological cortical features of thinning, increased porosity, and advanced tunneling resorption characterized Group 1 posttreatment biopsies. There were no significant differences in peak pAlP responses in the two groups. Mild asymptomatic vitamin D excess may have been a contributing factor in three Group 1 patients. Two further treatment groups have been studied more recently by forearm single-photon absorptiometry (SPA) at two sites; a cyclic NaF group (Group 3) and a calcium +/- vitamin D group (Group 4). Neither showed significant changes in forearm cortical bone density on treatment for 2 and 1.5 years, respectively, but Group 3 showed a significant increase in density at an ultradistal (60% trabecular) site. The pAlP response in Group 3 was significantly less than in Group 1. Spontaneous femoral neck or shaft fractures did not occur in either Groups 3 or 4. Therefore, we recommend: (1) Avoidance of sodium fluoride (NaF) treatment if pretreatment femoral fracture or thin femoral neck cortices exist.(ABSTRACT TRUNCATED AT 400 WORDS)

Bilateral fractures of femoral neck in patients with moderate renal failure receiving fluoride for spinal osteoporosis.

Two patients with moderate renal failure sustained spontaneous bilateral hip fractures during treatment with fluoride, calcium, and vitamin D for osteoporosis. They had been taking sodium fluoride (40-60 mg/day) for 11 and 21 months, respectively. Histological examination of a specimen of the bone showed severe fluorosis in the first case, and quantitative analysis of bone showed osteomalacia and skeletal fluorosis in the other case. These abnormalities were considered to be the consequence of excessive retention of fluoride due to renal insufficiency. As bilateral femoral neck fractures are very rare these data suggest a causal link between fractures and fluoride in patients with renal failure. Thus fluoride should be given at a lower dosage, if at all, to patients with even mild renal failure.