Search Results (11)

Background/Objectives: Bisphosphonates are effective in preventing osteoporotic fractures. However, the risk of atypical femur fractures (AFFs) increases with long-term bisphosphonate use. There are few existing publications on the analysis of clinical outcomes of atypical femur fracture cases in Chinese patients. Our objective was to review the clinical outcomes of AFF cases managed in a tertiary center in Hong Kong, China. Methods: Cases of AFF managed in the Prince of Wales Hospital from 2010 to 2024 were included. Data on demographics, type and duration of bisphosphonate use prior to AFF, fixation method, and mobility 1 year post-operation were retrospectively retrieved. One-way ANOVA was used to compare the duration of use prior to the development of AFF between different types of bisphosphonates. Results: Sixty-nine cases of AFF were included, with a mean age of 73.8 ± 9.7 years. A total of 95.6% of patients had a history of bisphosphonate use, with a mean duration of usage of 6.8 ± 5.6 years prior to the occurrence of AFF. The duration of bisphosphonate use prior to the development of AFF was comparable between alendronate, ibandronate, and a history of using more than one type of anti-resorptive agent. A non-union rate of 5.8% was observed in the current cohort, with 48.2% returning to pre-morbid mobility 1 year post-operation. Conclusions: AFF is more commonly seen in female patients with a history of bisphosphonate use. Considering the high success rate demonstrated in the current cohort, treating AFF with closed reduction followed by fixation with a long cephalomedullary device in dynamic locking together with immediate full-weight-bearing rehabilitation post-operation may be effective. Full article

Background and Objectives: The anterolateral bowing of the femur shows differences between races and has recently caused many clinical problems. Asians tend to have increased femoral bowing, but there is a lack of large-scale studies. We aim to identify the patterns of femoral bowing in the Korean population through comprehensive analysis and address its clinical implications. Materials and Methods: We analyzed 550 femoral radiographs from Korean patients using three different views: anteroposterior, lateral, and 15-degree internal rotation. Initial univariate analysis examined age and gender differences, followed by multivariate analysis incorporating height and weight to understand their combined effects on femoral bowing. Results: The study included 229 (41.6%) males and 321 (58.4%) females, with a mean age of 62.53 years (SD = 21.93). Initial analysis showed greater femoral bowing in females than males by 2.72° (p < 0.001) in anteroposterior views. However, multivariate analysis revealed age to be the primary significant factor affecting femoral bowing across all viewing angles (p < 0.001), while gender effects became non-significant when controlling for other variables. The AP angle regression model explained 26% of the total variance, with each year increase in age associated with a 0.12-degree increase in bowing angle. Conclusions: This study demonstrated that age is the primary factor influencing femoral bowing in the Korean population, with apparent gender differences potentially attributable to age distribution differences between groups. Anteroposterior radiographic imaging proved most suitable for assessing bowing angles. These findings provide important insights for surgical planning and implant selection, particularly in addressing potential mismatch issues in Asian populations. Full article

Incomplete Atypical Femoral Fracture (IAFF) is a precursor to Atypical Femoral Fracture (AFF). If untreated, it progresses to a complete fracture, increasing mortality risk. However, due to their small and ambiguous features, IAFFs are often misdiagnosed even by specialists. In this paper, we propose a novel approach for accurately classifying IAFFs in X-ray images across various radiographic views. We design a Dual Context-aware Complementary Extractor (DCCE) to capture both the overall femur characteristics and IAFF details with the surrounding context, minimizing information loss. We also develop a Level-wise Perspective-preserving Fusion Network (LPFN) that preserves the perspective of features while integrating them at different levels to enhance model representation and sensitivity by learning complex correlations and features that are difficult to obtain independently. Additionally, we incorporate the Spatial Anomaly Focus Enhancer (SAFE) to emphasize anomalous regions, preventing the model bias toward normal regions, and reducing False Negatives and missed IAFFs. Experimental results show significant improvements across all evaluation metrics, demonstrating high reliability in terms of accuracy (0.931), F1-score (0.9456), and AUROC (0.9692), proving the model’s potential for application in real medical settings. Full article

Background and Objectives: Osteoporosis is becoming more prevalent with the rise in the aging population, leading to the increased use of bisphosphonates for treatment. While these medications are effective in preventing osteoporotic fractures, long-term use has been associated with atypical insufficiency fractures, primarily in the femur. However, atypical fractures in other weight-bearing bones, such as the tibia, have rarely been reported. This study aims to present a case of an atypical insufficiency fracture of the tibia in an elderly female who has been on long-term bisphosphonate therapy and to review treatment outcomes within the context of the current literature. Patient concerns: A 76-year-old female presented with pain in the proximal right tibia, developing two months prior without trauma. She had been receiving long-term bisphosphonate therapy for osteoporosis, initially taking sodium risedronate orally for 4 years, followed by intravenous ibandronate for 10 years. Physical examination revealed localized tenderness, and radiographs showed cortical thickening and a horizontal fracture line in the proximal right tibia. MRI confirmed these findings, along with surrounding edema. The laboratory results were mostly normal, but the bone formation marker osteocalcin was significantly reduced. The patient had a history of insufficiency fractures in the ipsilateral tibia and contralateral femur, previously treated conservatively with teriparatide. A similar conservative approach was attempted but failed, leading to surgical intervention with intramedullary nailing and supplementary plating. At the 8-month follow-up, the patient showed successful fracture union and resolution of symptoms. Conclusion: Long-term use of bisphosphonates, though effective for osteoporosis, can lead to atypical insufficiency fractures, primarily in the femur but also occasionally in the tibia. Clinicians should consider this possibility when patients present with pain in weight-bearing bones without a history of trauma. Prompt diagnosis through thorough history-taking, physical examination, and appropriate imaging is essential to ensure timely management. Full article

The benefits of denosumab as an antiresorptive therapy and in reducing fragility fractures are well documented. However, its association with atypical femur fractures (AFFs), especially in the absence of prior bisphosphonate use, remains poorly understood and warrants further investigation. This case report presents a rare instance of bilateral AFFs in a 78-year-old bisphosphonate-naïve patient with a history of long-term denosumab therapy for previous metastatic breast cancer. Management involved intramedullary nail fixation after initial presentation with a unilateral AFF and a recommendation to cease denosumab therapy. However, the patient subsequently experienced a contralateral periprosthetic AFF below a total hip implant 5 months thereafter and was treated with open reduction internal fixation. This case report highlights the critical need for orthopedic surgeons to maintain a high level of suspicion and vigilance in screening for impending AFFs, especially in patients with a prolonged history of denosumab therapy without prior bisphosphonate use. Furthermore, the growing report of such cases emphasizes the urgent need for comprehensive research aimed at refining treatment protocols that balance the therapeutic benefits of denosumab and its associated risks of AFFs. Full article

Ceratophrys cranwelli, commonly known as the Cranwell’s horned frog or Pacman frog, is an amphibian species native to South America. This species has gained interest both as a pet among hobbyists and as a subject of scientific inquiry in veterinary medicine. A two-year-old pet male albino Ceratophrys cranwelli was presented exhibiting lethargy, weight loss, and anorexia, persisting for two months. Clinical examination revealed a fracture localized to the proximal third of the left femur accompanied by an osteolytic process. The patient was discharged with a treatment regimen for suspected secondary nutritional hyperparathyroidism and an ulcerative skin lesion. Nevertheless, due to the progressive deterioration of the left thigh, amputation of the affected limb was proposed and performed at the coxofemoral joint. Histopathological analysis of the excised mass revealed an atypical mesenchymal mass consistent with a fibromyxochondroma. The surgical procedure was conducted under anesthesia induced by a combination of alfaxalone, ketamine, medetomidine, and butorphanol, with postoperative treatment consisting of enrofloxacin, meloxicam, and butorphanol. The patient showed good post-surgical recovery, exhibiting normal physiological and behavioral activities. This report highlights the management and the diagnostic challenges of a progressive limb lesion in a Ceratophrys cranwelli, offering insights into potential therapeutic approaches for similar cases in amphibians. Full article

This study explores the genetic factors associated with atypical femoral fractures (AFF), rare fractures associated with prolonged anti-resorptive therapy. AFF are fragility fractures that typically appear in the subtrochanteric or diaphyseal regions of the femur. While some cases resemble fractures in rare genetic bone disorders, the exact cause remains unclear. This study investigates 457 genes related to skeletal homeostasis in 13 AFF patients by exome sequencing, comparing the results with osteoporotic patients (n = 27) and Iberian samples from the 1000 Genomes Project (n = 107). Only one AFF case carried a pathogenic variant in the gene set, specifically in the ALPL gene. The study then examined variant accumulation in the gene set, revealing significantly more variants in AFF patients than in osteoporotic patients without AFF (p = 3.7 × 10⁻⁵), particularly in ACAN, AKAP13, ARHGEF3, P4HB, PITX2, and SUCO genes, all of them related to osteogenesis. This suggests that variant accumulation in bone-related genes may contribute to AFF risk. The polygenic nature of AFF implies that a complex interplay of genetic factors determines the susceptibility to AFF, with ACAN, SUCO, AKAP13, ARHGEF3, PITX2, and P4HB as potential genetic risk factors. Larger studies are needed to confirm the utility of gene set analysis in identifying patients at high risk of AFF during anti-resorptive therapy. Full article

Background and objectives: Iatrogenic fractures are potential complications during intramedullary (IM) nailing for atypical femoral fractures (AFFs). The risk factors associated with iatrogenic fractures remain unclear, although excessive femoral bowing and osteoporosis are hypothesized to be contributing factors. The present study aimed to determine the risk factors for the occurrence of iatrogenic fractures during IM nailing in patients with AFFs. Materials and Methods: This retrospective cross-sectional study evaluated 95 patients with AFF (all female; age range: 49–87 years) who underwent IM nailing between June 2008 and December 2017. The patients were divided into two groups: Group I (with iatrogenic fracture: n = 20) and Group II (without iatrogenic fracture: n = 75). Background characteristics were retrieved from medical records and radiographic measurements were obtained. Univariate and multivariate logistic regression analyses were performed to identify risk factors for the occurrence of intraoperative iatrogenic fractures. Receiver operating curve (ROC) analysis was conducted to determine a cut-off value for the prediction of iatrogenic fracture occurrence. Results: Iatrogenic fractures occurred in 20 (21.1%) patients. The two groups exhibited no significant differences regarding age and other background characteristics. Group I exhibited significantly lower mean femoral bone mineral density (BMD) and significantly greater mean lateral and anterior femoral bowing angles than Group II (all p < 0.05). There were no significant differences in AFF location, nonunion, and IM nail diameter, length, or nail entry point between the two groups. In the univariate analysis, femoral BMD and lateral bowing of the femur differed significantly between the two groups. On multivariate analysis, only lateral bowing of the femur remained significantly associated with iatrogenic fracture occurrence. The ROC analysis determined a cut-off value of 9.3° in lateral bowing of the femur for prediction of iatrogenic fracture occurrence during IM nailing for AFF treatment. Conclusions: The lateral bowing angle of the femur is an important predictive factor for intraoperative iatrogenic fracture occurrence in patients undergoing IM nailing for AFF treatment. Full article

Fractures occur when bones become fragile and are subjected to external forces as occurring during falls. The use of drugs that increase bone fragility or fall risk increases the risk of fracture. This study investigates drug-induced fractures reported in the Japanese Adverse Drug Event Report (JADER) database in patients using 4892 drugs. Atypical femur fracture was the most frequently reported fracture, and 58 other fractures were also reported. Using Volcano plots and multiple logistic regression analysis, we identified the risk factors for drug-induced fractures as being female, of older age, higher body mass index, and using one of 90 drugs. The drug groups significantly associated with drug-induced fractures included bone resorption inhibitors, antiviral drugs, dopaminergic drugs, corticosteroids, and sleep sedatives. Principal component analysis was used to examine the relationship between the use of specific drugs and the site of drug-induced fracture. Bone resorption inhibitors and corticosteroids were associated with atypical femur fractures, jaw fractures, and ulna fractures through an osteoclast-mediated process. Other drugs were found to increase fracture risk via non-osteoclast-mediated mechanisms. These findings suggest that many drugs can result in drug-induced fractures through a variety of mechanisms. Full article

Background: Our objective was to develop and validate a predictive model for non-union following a subtrochanteric fracture of the femur. Methods: Following institutional board approval, 316 consecutive patients presenting to our institution (84 non-unions) who fulfilled the inclusion criteria were retrospectively identified. To identify potential unadjusted associations with progression to non-union, simple logistic regression models were used, followed by a revised adjusted model of multiple logistic regression. Results: Having established the risk factors for non-union, the coefficients were used to produce a risk score for predicting non-union. To identify the high-risk patients in the early post-operative period, self-dynamisation was excluded. The revised scoring system was the sum of the following: diabetes (6); deep wound infection (35); simple or severe comminution (13); presence of an atypical fracture (14); lateral cortex gap size ≥5 mm (11), varus malreduction (5–10 degrees) (9); varus malreduction (>10 degrees) (20). On the ROC (receiver operating characteristic) curve, the area under the curve (0.790) demonstrated very good discriminatory capability of the scoring system, with good calibration (Hosmer–Lemeshow test; p = 0.291). Moreover, 5-fold cross validation confirmed good fit of the model and internal validity (accuracy 0.806; Kappa 0.416). The cut-point determined by Youden’s formula was calculated as 18. Conclusion: This study demonstrates that the risk of non-union can be reliably estimated in patients presenting with a subtrochanteric fracture, from the immediate post-operative period. The resulting non-union risk score can be used not only to identify the high-risk patients early, offering them appropriate consultation and in some cases surgical intervention, but also informs surgeons of the modifiable surgery related factors that contribute to this risk. Full article

Background: The role of denosumab in patients with resectable giant cell tumour of bone remains unclear. We asked the following research question: for patients (aged ≥ 12 years) with resectable giant cell tumour of bone, what are the benefits and harms of denosumab compared with no denosumab in terms of (1) facilitation of surgery (operative time, blood loss), (2) disease recurrence, (3) pain control, (4) disease stability, and (5) adverse effects (e.g., malignant transformation, osteonecrosis of jaw, atypical femur fracture)? One previous systematic review addressed only one outcome—disease recurrence. Therefore, we undertook this new systematic review to address the above five outcomes. Methods: MEDLINE, EMBASE, PubMed, and Cochrane Database of Systematic Reviews databases were searched on June 30, 2020. Results: This systematic review included one previous systematic review and five comparative studies. Due to poor quality, non-randomized studies fraught with selection bias, it is difficult to determine if a significant difference exists in the outcomes for surgical giant cell tumour of bone with perioperative denosumab. There were no reported cases of adverse effects from denosumab. Conclusion: To date, there is insufficient evidence to understand the value of denosumab in the perioperative setting in patients with giant cell tumour of bone. Full article