Atypical insufficiency fractures confused with looser zones of osteomalacia

McKenna, Malachi J.; Kleerekoper, Michael; Ellis, Burton I.; Rao, D. Srinivasa; Parfitt, A. M.

doi:10.1016/8756-3282(87)90073-1

Cited by 44 publications

(12 citation statements)

References 12 publications

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“…The latter are broad lucent bands perpendicular to the cortex, with minimal or absent callus or sclerosis, and present mainly on the compressed medial cortex. 23 In contrast the thickening seen in our patients is sclerotic, without a band of central lucency, and on the lateral, tension, aspect of the cortex. In our series, this radiological feature seemed to correlate strongly with alendronate usage, with no relation to ethnicity or gender and none of these patients had features of underlying osteomalacia.…”

Section: Discussioncontrasting

confidence: 78%

A rational approach to management of alendronate-related subtrochanteric fractures

Setiobudi¹,

Shen

De³

2010

The Journal of Bone and Joint Surgery. British volume

109

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There have been recent reports linking alendronate and a specific pattern of subtrochanteric insufficiency fracture. We performed a retrospective review of all subtrochanteric fractures admitted to our institution between 2001 and 2007. There were 20 patients who met the inclusion criteria, 12 of whom were on long-term alendronate. Alendronate-associated fractures tend to be bilateral (Fisher's exact test, p = 0.018), have unique radiological features (p < 0.0005), be associated radiologically with a pre-existing ellipsoid thickening of the lateral femoral cortex and are likely to be preceded by prodromal pain. Biomechanical investigations did not suggest overt metabolic bone disease. Only one patient on alendronate had osteoporosis prior to the start of therapy. We used these findings to develop a management protocol to optimise fracture healing. We also advocate careful surveillance in individuals at-risk, and present our experience with screening and prophylactic fixation in selected patients.

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Section: Discussioncontrasting

confidence: 78%

A rational approach to management of alendronate-related subtrochanteric fractures

Setiobudi¹,

Shen

De³

2010

The Journal of Bone and Joint Surgery. British volume

109

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“…Again, with good management of patients with ESRD, features of osteomalacia should not be evident radiographically. Looser's zones must be differentiated from insufficiency fractures (osteoporosis) (8) that occur in the pubic rami, sacrum, and calcaneum, often accompanied by florid callus, and from incremental fractures in Paget's disease of bone, which tend to occur in the outer cortex of bone with characteristic mixed sclerosis, radiolucency, and disorganized trabecular pattern.…”

Section: Vitamin D Deficiencymentioning

confidence: 99%

Imaging in the dialysis patient: Dialysis Bone Disease

Adams

2002

Seminars in Dialysis

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The bone disease associated with end-stage renal failure (ESRD) and treatment are complex and multifactorial, and has changed in both clinical and imaging features over the past three decades. Whereas previously features of vitamin D deficiency (rickets/osteomalacia) and intense, and prolonged, secondary hyperparathyroidism (bone resorption, osteosclerosis, metastatic calcification) predominated, these features are now rarely evident radiologically. This has occurred through the better understanding of vitamin D metabolism and improvements in therapeutic management. However, metastatic calcification in soft tissues and 'adynamic" bone continue to be problematic. New complications have developed as a consequence of treatment (dialysis and transplantation), including amyloid deposition, noninfective sponyloarthropathy, osteonecrosis, and osteopenia/osteoporosis). Radiographs remain the most widely used imaging technique in examining for skeletal disease in patients with ESRD on maintenance dialysis. Occasionally, more sophisticated imaging (CT, MRI, nuclear medicine scanning) are helpful (parathyroid tumor localization, differentiation between infection and amyloid deposition). Developments in quantitative methods to assess bone density enable the effects of ESRD and treatment to be studied and monitored. Technical developments in computed tomography (rapid, multislice scanning) allow quantitation and monitoring of metastatic cardiac calcification in patients on hemodialysis, which has relevance to prognosis.

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“…The repair of microdamage by bone remodelling normally keeps pace with its production, but if repair is incomplete or delayed for too long, fatigue damage will accumulate [32]. This factor may contribute to the risk of overt fracture [33] or to the occurrence of brittle bone [34] in the diabetic state.…”

Section: Discussionmentioning

confidence: 99%

Importance of sustained high glucose condition in the development of diabetic osteopenia: Possible involvement of the polyol pathway

et al. 1997

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Diabetes mellitus is associated with various disorders of calcium (Ca) metabolism, such as impairment of Ca absorption [1,2] and loss of Ca from bone [3], which can be followed by the development of diabetic osteopenia [4][5][6][7][8]. The degree of osteopenia certainly depends on the quality of diabetic control [9,10]. Regarding the pathogenetic mechanism of diabetic osteopenia, greater loss of Ca into urine as a result of hyperglycemia and/or glycosuria has been proposed as a major cause of bone loss [11][12][13] by inducing secondary hyperparathyroidism. However, it should be emphasized that, in diabetics, bone formation does not increase sufficiently to compensate for an increase in bone resorption [14]. Therefore, impaired bone formation due to a deficiency of osteoblasts has recently been proposed as the most important factor [15,16]. This hypothesis is supportd by data indicating a decrease in serum levels of osteocalcin (OC) in diabetic patients [17,18], since OC is specifically produced by osteoblasts and is thus a clinically useful marker for osteoblast function [19]. It is not known whether a decrease in serum OC levels in diabetics derives from the loss of insulin stimulation of osteoblasts [14,20] or from defective cell function following long exposure to high glucose levels.This review focuses on the effect of sustained high glucose condition on bone and mineral metabolism in the diabetic state, and in particular on the involvement of the polyol pathway.Sustained 7-day exposure to high glucose significantly inhibited growth of human osteoblast-like MG-63 cells Correspondence and offprint requests to: Masaaki Inaba, MD, Second Il I. Fax: +8 !-6-645-2Il 2.in a dose-dependent manner up to 49.5 mM, as compared with cells maintained under normal glucose (5.5 mM) or a high mannitol condition (iso-osmolar control). It is of interest that the inhibitory effect of high glucose was partially reversed by the simultaneous addition of the aldose reductase inhibitors (ARl), epalrestat. High glucose also attenuated the insulin-like growth factor I (IGF-I)-induced stimulation of cell growth. Again the effect of glucose was not mimicked by mannitol, strongly suggesting a specific effect of glucose [21].These observations suggested that high glucose per se may significantly impair the proliferation of osteoblasts in either the basal or IGF-I-stimulated condition, and that the inhibitory effect of high glucose may be in part explained by an intracellular accumulation of sorbitol. Effect 01 HighGlucose on the Responsiveness 01 MG-63 Cells to Parathyroid Hormone (PTH) and 1,25-Dihydroxyvitamin D J (1,25-(OHhD J )Human PTH (1-34) induced a prompt rise in intracellular cAMP and cytosolic Ca 2 + in MG-63 cells in a time-and dose-dependent manner. Sustained 7-day exposure to high glucose significantly impaired cellular responsiveness to human PTH (1-34) in either response as compared with cells maintained under normal glucose [22].1,25-(OHhD 3 , an active form of vitamin D 3 , stimulated OC secretion from MG-63 cells in a t...

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Atypical insufficiency fractures confused with looser zones of osteomalacia

Cited by 44 publications

References 12 publications

A rational approach to management of alendronate-related subtrochanteric fractures

A rational approach to management of alendronate-related subtrochanteric fractures

Imaging in the dialysis patient: Dialysis Bone Disease

Importance of sustained high glucose condition in the development of diabetic osteopenia: Possible involvement of the polyol pathway

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