Bilateral Insufficiency Research Articles

Bilateral Insufficiency Fracture of the Pelvis Following THA: A Case Report

Insufficiency fracture is of the stress fractures and is caused by repetitive stress on fragile bone. Insufficiency fractures of pubic rami are rare occurrences in association with total hip arthroplasty (THA). Postoperative stress fractures occur due to increase of patients activity following years of disability. The physician should consider the possibility of a pelvic insufficiency fracture in patients with RA after THA, if the patients present with groin pain. We demonstrate here the first case of bilateral insufficiency fracture of pubic rami and iliac bone following THA.

Bilateral tibial stress fractures: a case report.

A stress fracture can be defined as a fracture of a bone caused by repeated (rather than sudden) mechanical stress. They have been reported in almost all bones of the body, with the lower extremity weight bearing bones, especially the tibia, tarsals and metatarsals, being affected most often. These injuries have a broad spectrum of severity and prognosis. Although the pathology of this injury is understood, the aetiology is less agreed upon. This can make it difficult for clinicians to diagnose and treat this common injury. Stress fractures of the proximal tibiae are common in elderly patients with osteoarthritis, and they are also reported in children. Here, we report an unusual case of an otherwise fit, young, adult male who presented with bilateral insufficiency stress fractures occurring simultaneously in both proximal tibiae. Stress fractures should be a differential diagnosis in any young, fit adult who presents with spontaneous knee pain.

Bilateral hip pain

In October, 2008, a 40-year-old man was referred to our hospital because of pain in his right groin, which had started a few days after he fell on his back at work 10 days earlier. He had mild asthma, which was treated with an occasional dose of inhaled broncholytics. On physical examination, he had right groin tenderness, and pain that was provoked by weight-bearing. A pelvic radiograph was normal. A tendon or muscle injury was suspected, and ultrasonography suggested a partial rupture of the rectus femoris muscle. MRI was planned as an elective outpatient procedure to rule out a total rupture of the tendon. A month after the onset of symptoms, the pain on weight bearing in the right groin had decreased but not resolved. He had also started to have pain in the left groin, and on examination, pain on rotation of both hip joints. MRI showed bilateral insuffi ciency fractures of the femoral necks (fi gure). Although he denied any regular recreational sports activities, his new job as a delivery-van driver required a lot of climbing. He had no dietary restrictions. Elderly relatives of our patient had a history of osteoporosis and osteopenia. Our patient was asked to restrict weight-bearing. A dual-energy x-ray absorptiometry scan showed that his bone mineral density was osteopenic at the lumbar spine and right femoral neck. The left femoral neck showed osteoporotic values (0·706 g/cm2; T score –2·8; Z score –2·4). Biochemistry tests for parathyroid and coeliac disease excluded secondary reasons for osteoporosis. His serum 25-hydroxyvitamin D(3) concentration was 33 nmol/L (normal > 40nmol/L). He was referred for iliac crest bone biopsy after tetracycline double-labelling. Low trabecular bone volume was found by histomorphometry (BV/TV 9·0%), and confi rmed by microcomputed tomography (9·9%). The turnover rate was normal as shown by normal amounts of formation and erosion surfaces (OV/BV 1·5%, OS/BS 14·2%, ES/BS 7·0%). The osteoblast and osteoclast surfaces were normal (Ob.S/BS 1·9%, Oc.S/BS 0·0%) as was the amount of mineralising surface (MS/BS 8·0%), but the mineral apposition rate was slightly low (0·28 μm/day). The results were consistent with normal-turnover osteoporosis. In a repeat MRI 10 weeks after the beginning of the symptoms bone oedema was diminished and in the follow up visit in March 2009, the fractures had clinically healed. His osteoporosis was treated with daily calcium 1000 mg, vitamin D 800 IU supplementation and weekly alendronate 70 mg. When last seen in June, 2010, he was asymptomatic. The diagnosis of insuffi ciency fracture of the femoral neck is commonly missed in clinical practice. The diagnostic algorithm should include, but not be restricted to radiographs. A normal radiograph does not rule out insuffi ciency fractures, as our patient’s case demonstrates. Osteoporosis may in itself be an aetiological factor in the case of insuffi ciency fractures. Long term bisphosphonate therapy has been linked with insuffi ciency fracturees in the femoral shaft. However, our patient’s fractures did not show features of such atypical fractures.Although secondary osteoporosis should be considered in young male patients, primary osteoporosis remains the diagnosis for up to half of patients. In the case of insuffi ciency fractures, the possibility of bilateral injury should be considered. Early diagnosis is warranted because untreated insuffi ciency fracture of the femoral neck can lead to a displaced fracture.

Bilateral Femoral Insufficiency Fractures Likely Related to Long-Term Alendronate Therapy

Osteoporosis-related fractures are a major public health problem and one in two women and one in four men are affected with osteoporosis-related fractures. Alendronate (Fosamax) is one of the first bisphosphonates used to treat osteoporosis effectively. Recently, however, there is a concern regarding long bone insufficiency fractures related to long-term alendronate therapy. We report a case of bilateral femoral insufficiency fractures likely related to long-term alendronate therapy, the classic symptoms, signs, and treatment of these fractures.

Femoral Insufficiency Fractures Associated with Prolonged Bisphosphonate Therapy

Emerging evidence has linked the long-term use of bisphosphonates with femoral insufficiency fractures. It has been suggested that the prolonged effect on bone remodeling leads to the accumulation of microfractures and weakening of bone. We investigated the association between bisphosphonate use and femoral insufficiency fractures. We evaluated 100 patients with low-energy femoral shaft fractures before and after bisphosphonates became available for use. Twenty-one consecutive patients who presented between January 1995 and February 1997 were compared with 79 consecutive patients who presented between January 2007 and February 2009. The radiographs of all 100 patients were examined for evidence of preexisting insufficiency fractures. We identified insufficiency fractures by a transverse fracture line on the tension side of the femur with lateral cortical thickening immediately adjacent to the fracture. Relevant details from the history were recorded. Forty-one patients had an underlying femoral insufficiency fracture, all of whom had been receiving bisphosphonate therapy. Among the 21 patients with low-energy femoral fractures before the availability of bisphosphonates, none had insufficiency fractures. Of the 41 patients with insufficiency fractures, 29 (71%) had prodromal pain and 18 (44%) had bilateral insufficiency fractures. Bisphosphonate use was associated (odds ratio greater than 1000) with insufficiency fracture. The mean duration of bisphosphonate use in patients with insufficiency fractures was longer than in patients without fractures (7.1 versus 3.2 years). Long-term bisphosphonate use is associated with insufficiency fractures of the femoral shaft, which commonly present with prodromal thigh pain and may be bilateral. These fractures were not seen before bisphosphonates became available for use.

Bilateral insufficiency fracture of the femoral head and neck in a case of oncogenic osteomalacia

We describe a case of oncogenic osteomalacia in an adult male who presented with low back pain and bilateral hip pain. Extensive investigations had failed to find a cause. A plain pelvic radiograph showed Looser's zones in both femoral necks. MRI confirmed the presence of insufficiency fractures bilaterally in the femoral head and neck. Biochemical investigations confirmed osteomalacia which was unresponsive to treatment with vitamin D and calcium. A persistently low serum phosphate level suggested a diagnosis of hypophosphataemic osteomalacia. The level of fibroblast growth factor-23 was highly raised, indicating the cause as oncogenic osteomalacia. This was confirmed on positron-emission tomography, MRI and excision of a benign fibrous histiocytoma following a rapid recovery. The diagnosis of oncogenic osteomalacia may be delayed due to the non-specific presenting symptoms. Subchondral insufficiency fractures of the femoral head may be missed unless specifically looked for.

Venous obstruction and jugular valve insufficiency in idiopathic intracranial hypertension

The pathophysiology of elevated intracranial pressure in idiopathic intracranial hypertension (IIH) is unclear. Cerebral venous outflow obstruction and elevated intracranial venous pressure may play an etiological role. We examined jugular valve insufficiency as a potential factor contributing to intracranial hypertension. Jugular venous valve function was assessed bilaterally by duplex sonography in 20 consecutive patients with diagnosis of IIH and in 20 healthy controls matched for age, gender and body mass index. Diagnosis of valvular insufficiency was based on reflux duration during a controlled Valsalva maneuver. Intracranial venous outflow was evaluated in 11 patients (MR venography in 10, digital subtraction angiography (DSA) in two cases). As a principle result, valvular insufficiency was significantly more frequent in patients with IIH (70 vs. 30%; p < 0.05). This finding was associated with irregular leaflet structures on B-mode imaging (p < 0.01). Bilateral insufficiency was more frequent in the patient group which, however, was not significant (p = 0.08). In addition, sinovenous outflow obstruction was found in five of six patients that had undergone contrast-enhanced MR venography and DSA. The detection rate was inferior in phase-contrast MR imaging (one of five patients). In conclusion, this study gives evidence that valvular insufficiency may play a causal role in IIH. Obesity is a major risk factor for the disease and weight reduction leads to improvement of symptoms. Possibly, increased intra-abdominal pressure is transmitted into the intracranial venous system, causing intracranial hypertension. Jugular valve insufficiency may facilitate pressure transmission. As transverse sinus stenosis was a concomitant finding, these factors may be complementary.

Bilateral femoral insuffiency fractures treated with inflatable intramedullary nails: a case report

Stress fractures could be classified as fatigue fractures and insufficiency fractures (IF). Fatigue fractures occur when abnormal mechanical stress is applied to a normal bone, on the other hand insufficiency fractures occur when normal to moderate pressure is applied to a bone that has decreased resistance (Daffner and Pavlov in Am J Radiol 159:242-245, 1992). IF have been observed mainly in patients with postmenopausal osteoporosis, and are becoming more common with the increase of elderly population (Daffner and Pavlov in Am J Radiol 159:242-245, 1992). Other systemic and metabolic conditions that can result in osteopenia and IF include osteomalacia, hyperparathyroidism, hyperthyroidism, rheumatoid arthritis, fluoride treatment, diabetes mellitus, fibrous dysplasia, Paget's disease, irradiation and mechanical factors (Daffner and Pavlov in Am J Radiol 159:242-245, 1992; Soubrier et al. in Joint Bone Spine 70:209-218, 2003; Epps et al. in Am J Orthop 33:457-460, 2004; Austin and Chrissos in Orthopedics 28:795-797, 2005). In this case report, the authors present an osteoporotic woman who developed bilateral insufficiency fracture of the femoral shaft after longstanding steroid, thyroxine replacement and alendronate therapy due to partial empty sella syndrome and osteoporosis, resulting in the treatment of the fracture by inflatable intramedullary nailing.

Adrenal enlargement and insufficiency: A common presentation of intravascular large B-cell lymphoma

Intravascular large B-cell lymphoma (IVLL) is a rare subtype of extranodal diffuse large B-cell lymphoma and is very difficult to diagnose in patients antemortem due to nonspecific presentation of the disease. We report a case of IVLL in a 68-year-old white female who presented with 3-month history of fever of unknown origin (FUO), night sweat, and weight loss. Laboratory tests revealed bilateral adrenal enlargement and adrenal insufficiency. IVLL was diagnosed only at autopsy. A review of the English language medical literature indicates that it is not uncommon for IVLL presented initially with FUO, bilateral adrenal enlargement, and adrenal insufficiency. We present this case to call for heightened awareness of the possibility of IVLL, particularly in an elderly woman who presents with FUO, bilateral adrenal enlargement, and adrenal insufficiency. The pathophysiologic mechanisms of adrenal insufficiency in IVLL are also discussed.

Bilateral insufficiency fracture of the femoral neck; Report of a case

Bilateral insufficiency fracture of the femoral neck; Report of a case

Heroin induced osteopenia: a cause of bilateral insufficiency femoral neck fracture in a young adult

Stress fractures of the femoral neck are potentially disabling injuries if the diagnosis is missed or delayed and proper treatment is not provided. We report the first in the literature bilateral femoral neck insufficiency fracture in a young female, due to heroin and methadone use related osteoporosis. A high index of clinical suspicion and prompt imaging in the case of activity related hip pain could prevent missing such pathology in this cohort of patients, avoiding its devastating sequelae.

Bilateral Insufficiency Fractures of the Femoral Head : A Case Report

Bilateral Insufficiency Fractures of the Femoral Head : A Case Report

Poster 120 bilateral femoral insufficiency fractures as a presentation of vitamin d deficiency and osteopenia: A case report. Denise Chang (New York Presbyterian Hosp, New York, NY); David Lin; Julie Lin, e-mail: gotodeani@yahoo.com

Poster 120 bilateral femoral insufficiency fractures as a presentation of vitamin d deficiency and osteopenia: A case report. Denise Chang (New York Presbyterian Hosp, New York, NY); David Lin; Julie Lin, e-mail: gotodeani@yahoo.com

Sensorineural hearing loss in conjunction with aortic insufficiency in systemic lupus erythematosus

Sensorineural hearing loss may occur in SLE, but aortic insufficiency has been very rarely reported. We are describing two patients with well-established SLE who developed bilateral hearing loss and aortic insufficiency, associated with serological evidence of active lupus. Neither patient had evidence of keratitis, and thus did not satisfy criteria for Cogan's syndrome. The aortic insufficiency in one patient stabilized after treatment with high doses of steroids while in the second patient, who refused medical treatment, it progressed requiring surgical valve replacement. Our observations suggest that the aortic valve and the inner ear may share some antigenic crossreactivity not shared by the cornea. In SLE patients, with sensorineural hearing loss, echocardiography should be performed looking for evidence of aortic insufficiency, which may be steroid responsive.

Urolithiasis with Blind-Ending Ureteral Duplication and Azotemia Treated with Shock Wave Therapy

A case of bilateral urolithiasis and renal insufficiency with a blind-ending branch of the right bifid ureter is presented. The diagnosis was made by retrograde ureterogram which revealed a blind-ending branch originating in the middle third of the right ureter. Stones were treated with phased extracorporeal shock wave lithotripsy after preliminary bilateral JJ stenting. The renal parameters reverted to normal and the patient was stone-free.

Ureteral Obstruction and Hydronephrosis as a Complication of Lymphomatoid Granulomatosis: A Case Report and Literature Review

Lymphomatoid granulomatosis is an angioinvasive proliferation of atypical T lymphocytes, with frequent pulmonary, cutaneous and neurological manifestations. Urological complications are infrequent. We describe the case of a 40-year-old man who presented with typical intrathoracic findings of lymphomatoid granulomatosis. Following a chemotherapy-induced remission he had retroperitoneal recurrence with bilateral ureteral obstruction, hydronephrosis and renal insufficiency. Histological examination revealed, in addition to the characteristic lymphoid infiltrates of lymphomatoid granulomatosis, a sclerosing process similar to idiopathic retroperitoneal fibrosis.

Apropos of 2 cases of myocardial infarct with various disorders of auriculo-ventricular conduction

SummaryTwo cases of myocardial infarct complicated with variable defect of auriculo-ventricular conduction are presented. In these two cases, the lesion involved the posterior aspect of the left ventricle and a portion of the interventricular septum. There was a recent thrombus in the right coronary artery and the anterior descending artery was also obstructed by atheroma.The appearance of a complete auriculo-ventricular block in cardiac infarct can be related with obstructive lesion in both coronary arteries. Severe and bilateral insufficiency in coronary arteries can partly explain the very high rate of mortality in cardiac infarct complicated by complete auriculo-ventricular block.In these two cases, spontaneous regression of conduction troubles did not prevent a fatal outcome.