Successful teriparatide treatment of atypical fracture after long-term use of alendronate without surgical procedure in a postmenopausal woman

Huang, Hsuan-Ti; Kang, Lin; Huang, Peng‐Ju; Fu, Yin‐Chih; Lin, Sung‐Yen; Hsieh, Chih-Hsin; Chen, Jian-Chih; Cheng, Yuh-Min; Ch, Chen

doi:10.1097/gme.0b013e318260143d

Cited by 45 publications

(31 citation statements)

References 28 publications

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“…When beaking is detected in the contralateral side, the recent ASBMR Task Force guidelines recommend ceasing bisphosphonate, the evaluation of calcium and vitamin D with supplementation in the case of insufficiency (deficiency), and intramedullary nailing if pain persists in the beaking site (12). Some Authors have indicated that teriparatide is effective (13,14). In our case, bisphosphonate was ceased immediately after the contralateral subtrochanteric fracture, and vitamin D therapy was initiated for her vitamin D deficiency.…”

Section: Discussionmentioning

confidence: 91%

Bilateral atypical femoral subtrochanteric fractures in a premenopausal patient receiving prolonged bisphosphonate therapy: evidence of severely suppressed bone turnover

Kondo

Yoda

Fujisawa

et al. 2015

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SummaryWe report a case of bilateral atypical femoral fractures that occurred in a patient who had been taking bisphosphonate long-term. A 36-year-old premenopausal female diagnosed with systemic lupus erythematosus and dermatomyositis had been treated with glucocorticoid and alendronate (5 mg/day) to prevent glucocorticoid-induced osteoporosis. She was taken to our hospital because she could not walk immediately after falling down from the standing position. A plain radiograph showed a subtrochanteric fracture of the left femur. Four months later, she fell again and sustained a contralateral subtrochanteric fracture. For each fracture, a femoral intramedullary nail was inserted. Delayed union was detected in both sides, and revision surgery with an iliac bone graft was required for implant breakage in the right side. Histomorphometric findings for the ilium revealed remarkably decreased osteoid volume with no osteoclasts and a minimally eroded surface, suggesting that bone turnover was severely suppressed. However, histology of the delayed union site revealed callus formation and some osteoclast appearance, suggesting that fracture healing was occurring. In total, it took 29 months (left) and 24 months (right) until fracture healing was achieved, showing delayed union. This case is extremely rare in that patient who presented with atypical femoral fractures in spite of her premenopausal status. The bone histomorphometric findings from this case suggest that severely suppressed bone turnover is associated with atypical femoral subtrochanteric fracture and can cause delayed union in patients treated with alendronate long-term.

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Section: Discussionmentioning

confidence: 91%

Bilateral atypical femoral subtrochanteric fractures in a premenopausal patient receiving prolonged bisphosphonate therapy: evidence of severely suppressed bone turnover

Kondo

Yoda

Fujisawa

et al. 2015

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“…Several cases have been reported in the literature where TPP had been used to treat incomplete or complete AFF (Table 2) [3][4][5][6][7][8]; however, none of them showed the effect of TPP on reducing the cortical thickening. We hereby presented a case of preventing near AFF with clinical symptoms; cortical thickness; no obvious radiographic radiolucent line and bone marrow edema by reducing cortical thickness with TPP use.…”

Section: Discussionmentioning

confidence: 99%

Teriparatide Prevented Near Atypical Femur Fracture by Reducing Cortical Thickening in a Symptomatic Patient With Prolonged Use of Oral Bisphosphonate: A Case Report

et al. 2016

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Long-term bisphosphonate (BP) treatment is associated with adverse event of atypical femur fracture (AFF) due to their long-lasting unique bone-seeking properties, and subsequent uptake by osteoclasts results in sustained inhibition of bone resorption even after their cessation. We report a case of postmenopausal women who presented with pain and severe femoral cortical thickening on alendronate for 10 years, but with no signs of obvious radiolucent fracture line on radiograph and bone marrow edema on magnetic resonance imaging representing impending AFF. Teriparatide (TPP) was started after discontinuation of BP which showed resolution of pain and reduction of femoral cortical thickness. We recommend biannual radiographs follow-up for evaluation of cortical thickening in patients taking BP along with the review of bone mineral density, and consideration of treatment with TPP if cortical thickening is present.

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“…However, there is inconsistent evidence that teriparatide may advance healing of AFFs (8,14). Few publications report fracture healing with teriparatide when there is no recovery with conservative therapy (14,16). Saleh et al (14) pointed out that the presence of a radiolucent line in an incomplete fracture poses a high risk of progression to a complete fracture.…”

Section: Discussionmentioning

confidence: 99%

“…In the literature, the treatment of AFF is based on post-fracture approaches and there are few studies on incomplete AFF treatment (16). Discontinuation of the antiresorptive agent and supplementation of vitamin D and calcium are general suggestions.…”

Section: Discussionmentioning

confidence: 99%

Bilateral Incomplete Atypical Femoral Fracture due to Long-Term Bisphosphonate Use: A Case Report

Başaran¹,

Benlidayı²,

Akın³

et al. 2017

meandros

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Although the overall safety profile of bisphosphonates (BP) is favorable, adverse effects associated with long-term use have came up during recent years. In this report, a case of bilateral incomplete atypical femoral fracture (AFF) due to prolonged BP use was presented. A 69-year-old patient, who has been in surgical menopause for 20 years and was started on BP following vertebral fracture almost 10 years ago, was admitted with thigh pain, which was increased two weeks ago. On physical examination, she had antalgic gait, increased thoracic kyphosis and tenderness to percussion over the thoracolumbar region. Lateral cortical thickness in the subtrochanteric region of both femurs and cortical radiolucency on the left femur were observed on plain radiography. Loss of height in L3 and L4 vertebrae was detected on vertebral radiography. Serum 25-hydroxy vitamin D [25(OH) D], parathyroid hormone, alkaline phosphatase and calcium levels, along with osteoporosis markers were all within the normal ranges. As the patient was diagnosed with AFF, BP therapy was terminated and vitamin D-calcium supplementation was continued. Since she did not have severe pain, conservative management (limited weight bearing, using a walking stick) was recommended for 3 months. Teriparatide therapy was started and she was discharged with recommendations. AFF, which is a rare disorder, should be kept in mind in patients on long-term BP treatment who are admitted with thigh pain and, necessary interventions should be tailored before the occurrence of complete fracture.Bifosfonatların (BP) güvenlik profili genel olarak iyi olmakla birlikte son zamanlarda uzun süreli kullanımları ile ilişkilendirilebilen yan etkiler gündeme gelmeye başlamıştır. Bu olgu raporunda uzun süre BP kullanımına bağlı olarak gelişen bilateral inkomplet atipik femur fraktürü (AFF) olgusu sunulmuştur. Yirmi yıldır cerrahi menapozda olup, 10 yıl kadar önce vertebra kırığı sonrasında BP tedavisi başlanan 69 yaşındaki hasta, 6 ay önce başlayan ve 2 haftadır artış gösteren uyluk ağrısı nedeniyle başvurdu. Fizik muayenesinde antaljik yürüyüşü mevcuttu. Torakal kifozu artmıştı. Künt perküsyonla torakolomber vertebral hassasiyeti mevcuttu. Direkt grafilerinde her iki femurda subtrokanterik bölgede lateral kortekste kalınlaşma ve solda kortekste radyolusen görünüm tespit edildi. Vertebra grafilerinde ise L3 ve L4 vertebralarda yükseklik kaybı mevcuttu. Serum 25-hidroksi vitamin D [25(OH)D], parathormon, alkalen fosfataz ve kalsiyum düzeyleri ile osteoporoz markerları normal sınırlardaydı. AFF olarak değerlendirilen hastanın BP tedavisi kesilerek kalsiyum ve vitamin D takviyesine

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Successful teriparatide treatment of atypical fracture after long-term use of alendronate without surgical procedure in a postmenopausal woman

Cited by 45 publications

References 28 publications

Bilateral atypical femoral subtrochanteric fractures in a premenopausal patient receiving prolonged bisphosphonate therapy: evidence of severely suppressed bone turnover

Bilateral atypical femoral subtrochanteric fractures in a premenopausal patient receiving prolonged bisphosphonate therapy: evidence of severely suppressed bone turnover

Teriparatide Prevented Near Atypical Femur Fracture by Reducing Cortical Thickening in a Symptomatic Patient With Prolonged Use of Oral Bisphosphonate: A Case Report

Bilateral Incomplete Atypical Femoral Fracture due to Long-Term Bisphosphonate Use: A Case Report

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