Insufficiency Fractures In Patients Research Articles

Novel Standalone Motion-Sparing Pelvic Fixation Prevents Short-Term Insufficiency Fractures After Midsacrectomies Without Sacrificing Normal, Mobile Lumbar Segments Traditionally Used for Stabilization.

Sacrectomy is often the treatment of choice to provide the greatest chance of progression-free and overall survival for patients with primary malignant bone tumors of the sacrum. After midsacrectomy, the stability of the sacropelvic interface is diminished, resulting in insufficiency fractures. Traditional stabilization involves lumbopelvic fixation but subjects normal mobile segments to fusion. The purpose of this study was to determine whether standalone intrapelvic fixation is a safe adjunct to midsacrectomy, avoiding both sacral insufficiency fractures and the morbidity of instrumenting into the mobile spine. A retrospective study identified all patients who underwent resection of sacral tumors at 2 comprehensive cancer centers between June 2020 and July 2022. Demographic, tumor-specific, operative characteristics and outcome data were collected. The primary outcome was presence of sacral insufficiency fractures. A retrospective data set of patients undergoing midsacrectomy without hardware placement was collected as a control. Nine patients (5 male, 4 female), median age 59 years, underwent midsacrectomy with concomitant placement of standalone pelvic fixation. No patients developed insufficiency fractures during the 216 days of clinical and 207 days of radiographic follow-up. There were no adverse events attributable to the addition of standalone pelvic fixation. In our historical cohort of partial sacrectomies without stabilization, there were 4/25 patients (16%) with sacral insufficiency fractures. These fractures appeared between 0 and 5 months postoperatively. A novel standalone intrapelvic fixation after partial sacrectomy is a safe adjunct to prevent postoperative sacral insufficiency fractures in patients undergoing midsacrectomy for tumor. Such a technique may allow for long-term sacropelvic stability without sacrificing mobile lumbar segments.

Patterns of symptoms and insufficiency fractures in patients with tumour-induced osteomalacia

The aim of this study was to report the patterns of symptoms and insufficiency fractures in patients with tumour-induced osteomalacia (TIO) to allow the early diagnosis of this rare condition. The study included 33 patients with TIO who were treated between January 2000 and June 2022. The causative tumour was detected in all patients. We investigated the symptoms and evaluated the radiological patterns of insufficiency fractures of the rib, spine, and limbs. The mean age of the patients was 57 years (24 to 87), and the mean duration of pain from onset to time of presentation was 3.9 years (0.75 to 23). The primary symptoms were low back pain (ten patients), chest wall pain (eight patients), and hip pain (eight patients). There were symptoms at more sites at the time of presentation compared with that at the time of the onset of symptoms. Bone scans showed the uptake of tracer in the rib (100%), thoracic and lumbar vertebrae (83%), proximal femur (62%), distal femur (66%), and proximal tibia (72%). Plain radiographs or MRI scans identified femoral neck fractures in 14 patients, subchondral insufficiency fractures of the femoral head and knee in ten and six patients, respectively, distal femoral fractures in nine patients, and proximal tibial fractures in 12 patients. Thoracic or lumbar vertebral fractures were identified in 23 of 29 patients (79.3%) when using any imaging study, and a biconcave deformity was the most common type of fracture. Insufficiency fractures in patients with TIO caused spinal pain, chest wall pain, and periarticular pain in the lower limbs. Vertebral fractures tended to be biconcave deformities, and periarticular fractures of the hips and knees included subchondral insufficiency fractures and epiphyseal or metaphyseal fractures. In patients with a tumour, the presence of one or more of these symptoms and an insufficiency fracture should suggest the diagnosis of TIO.

Pelvic Insufficiency Fractures in Patients with Rheumatoid Arthritis: A single Case Report

Pelvic Insufficiency Fractures in Patients with Rheumatoid Arthritis: A single Case Report

High Prevalence of Foot Insufficiency Fractures in Patients With Inflammatory Rheumatic Musculoskeletal Diseases.

To assess the prevalence of foot insufficiency fractures (IF) in patients with rheumatic musculoskeletal disease (RMD) with foot pain. In a retrospective design, 1752 magnetic resonance imaging (MRI) scans of consecutive patients presenting with foot pain in 2 time periods between 2016 and 2018 were evaluated. The group with IF was matched with controls with foot pain without IF. Bone mineral density (BMD) was assessed by dual-energy x-ray absorptiometry. Multivariate analyses were performed. A total of 1145 MRI scans of patients (median age 59 yrs, 82.9% female) with an inflammatory (65.4%) and of 607 with no inflammatory (34.6%) RMD (median age 58 yrs, 80.8% female) were available. Most patients had rheumatoid arthritis (RA; 42.2%), and others had psoriatic arthritis (22.4%), axial spondyloarthritis (11.1%), or connective tissue disease (CTD; 7.6%). Foot IF were found in 129 MRI scans of patients (7.5%). There was no difference between time periods. The prevalence of IF was highest in CTD (23%) and RA (11.4%). More patients with an inflammatory than a noninflammatory RMD had IF (9.1% vs 4.1%, respectively; P < 0.001). Using conventional radiography, IF were only detected in 25%. Low BMD and a history of fractures were more frequent in patients with IF than without (42.6% vs 16.2% and 34.9% vs 8.6%, respectively; P < 0.001). A high prevalence of foot fractures was found in MRI scans of patients with RMD, many without osteoporosis. MRI was more sensitive than radiographs to detect IF.

P136 Methotrexate osteopathy - clinical and radiological characteristics in a case series of twenty-one patients

Abstract Background/Aims Methotrexate osteopathy was originally described in the 1980s as a combination of bone pain, osteoporosis and insufficiency fractures in paediatric patients receiving high-dose methotrexate for leukaemia. Since then, cases of insufficiency fractures in patients on long-term, low-dose methotrexate for rheumatic disease have been sporadically reported as methotrexate osteopathy. This case series aims to characterise the clinical and radiological features of this poorly defined condition. Methods Patients were identified by searching the MRI reports of rheumatology patients in NHS Lothian for the term ‘insufficiency fracture’ and asking consultant rheumatologists to submit cases where methotrexate osteopathy was suspected. Patient demographics, clinical and radiological features were analysed. Results We identified 21 patients with insufficiency fractures taking long-term methotrexate. The mean age at presentation with methotrexate osteopathy was 66.9± 9.5 years. 20 of the patients (95%) were women. 18 of the patients (86%) had rheumatoid arthritis. The average BMI of the cohort was 25.7± 5.4. The average duration of methotrexate use was 7.5± 4.5 years. The most common sites of fracture were the calcaneus (12 patients, 57%) and the metaphysis of the distal tibia (13 patients, 62%). Other frequent fracture sites included the proximal tibia, talus, and distal femur. 13 of the patients (62%) had more than one fracture and 12 (57%) had bilateral fractures. 12 of the patients (57%) required an MRI to identify the fracture and there was an average delay of 4.8± 4.0 months between the initial presenting symptoms and imaging confirming a fracture. Osteoporosis was found in 12 of the 15 patients (80%) who had a DEXA scan, with an average T-score of -2.23± 1.14 for the spine and -2.64± 0.78 for the femoral neck. 14 of the 21 (66.6%) patients received antiresorptive osteoporosis treatment. Only 2 of the patients (9.5%) were on long-term steroids at the time of diagnosis. Conclusion Methotrexate osteopathy should be suspected in patients on long-term methotrexate with unexplained pain in the lower limbs. There are often multiple, bilateral fractures which most commonly affect the distal tibia and calcaneus. Fractures may not be visible on X-ray, and pain from the fractures may mimic synovitis, causing a delay in diagnosis. A high index of suspicion and detailed imaging with MRI is often required to identify insufficiency fractures associated with methotrexate osteopathy. If the condition is suspected, a detailed fracture risk assessment should be organised, and the cessation of methotrexate considered. Disclosure A.T. Merriman: None. J. Foley: None. J. Golla: None. E. McRorie: None. B. Hauser: None.

An easy way to determine bone mineral density and predict pelvic insufficiency fractures in patients treated with radiotherapy for cervical cancer

PurposeThe aim of this study was to investigate whether bone mineral density (BMD) as measured in planning computed tomographies (CTs) by a new method is a risk factor for pelvic insufficiency fractures (PIF) after radio(chemo)therapy (R(C)T) for cervical cancer.Methods62 patients with cervical cancer who received definitive or adjuvant radio(chemo)therapy between 2013 and 2017 were reviewed. The PIF were detected on follow-up magntic resonance imaging (MRI). The MRI of the PIF patients was registered to the planning CT and the PIF contoured. On the contralateral side of the fracture, a mirrored structure of the fracture was generated (mPIF). For the whole sacral bone, three lumbar vertebrae, the first and second sacral vertebrae, and the PIF, we analyzed the BMD (mg/cm3), V50Gy, Dmean, and Dmax.ResultsOut of 62 patients, 6 (9.7%) had a fracture. Two out of the 6 patients had a bilateral fracture with only one of them being symptomatic. PIF patients showed a significantly lower BMD in the sacral and the lumbar vertebrae (p < 0.05). The BMD of the contoured PIF, however, when comparing to the mPIF, did not reach significance (p < 0.49). The difference of the V50Gy of the sacrum in the PIF group compared to the other (OTH) patients, i.e. those without PIF, did not reach significance.ConclusionThe dose does not seem to have a relevant impact on the incidence of PIF in our patients. One of the predisposing factors for developing PIF after radiotherapy seems to be the low BMD. We presented an easy method to assess the BMD in planning CTs.

Pelvic insufficiency fractures –a late effect of radiotherapy

Keywords, late effects, pelvic radiotherapy Introduction: Pelvic insufficiency fractures are stress fractures caused by normal or physiological stress on weakened bone . Radiotherapy increases the risk of insufficiency fractures in patients(1). These fractures are underdiagnosed in younger women. Presenting symptoms include pelvic and back pain of which can substantially affect quality of life. Aim- To evaluate the characteristics of patients with pelvic insufficiency fractures following radiotherapy Methods: Four patients presented to pelvic late effects clinic between Jan-June 2019, with confirmed sacral insufficiency fractures on diagnostic magnetic resonance imaging (MRI). Radiotherapy technique 4 field brick 3D CRT (n=1), volumetric modulated arc therapy (VMAT) (n=3), 1 of these with a library of 3 adaptive plans. All patients had concurrent weekly cisplatin. Dose prescribed 50Gy/25# (n=2) and 45Gy/25# (n=2). All Ca Cervix patients had 4 Brachytherapy insertions (24Gy) and Ca Endometrium patient had no insertions. All patients presented with lower back pain. Retrospective planning CT dosimetric analysis, by delineation of the sacrum in Eclipse V15.5 (Varian Medical Systems,Palo Alto). A structure was created using boolean operator to define sacrum overlap with PTV. Dose volume histograms were exported for the sacrum structure and planning characteristics recorded. Results: Age range of patients was 32-73. Radiotherapy complete between Feb 2013-June 2018 for Ca Cervix (n=3) stages 2B (n=2), 11b2 (n=1) and Ca Endometrium grade 3 1B(n=1). 2 patients were pre-menopausal on hormone replacement therapy (HRT) with 2 remaining patients on no HRT. Time to confirmed diagnosis of insufficiency fractures from radiotherapy completion was mean 13 (4-26) months. The mean sacrum volume was 149.6cm3 (130.97-186.61). The mean sacrum overlap with PTV volume was 35.99 cm3 (30.73-40.75). The max dose to the sacrum was 53.27Gy and minimum 16.22Gy. The mean D50% of the sacrum was 40.24Gy (38.69-44.98) and mean D40% 42.91Gy (39.29-74.77). Conclusion/Discussion: The dose-effect relationship has been defined with a 22% risk of fracture at 35Gy and 45% at 40Gy for D50%(2). Our patients D50% were all above 35Gy. Dose received from Brachytherapy has not been accounted for. There is potential using dosimetric analysis to identify patients at high risk of fractures. Numerical

Ulnar Insufficiency Fractures in Patients on Prolonged Bisphosphonate Therapy: A Case Report

Ulnar Insufficiency Fractures in Patients on Prolonged Bisphosphonate Therapy: A Case Report

Dosimetric Predictors of Sacral Insufficiency Fractures in Patients With Cervical and Endometrial Cancer Treated With Postoperative Intensity Modulated Radiation Treatment

Dosimetric Predictors of Sacral Insufficiency Fractures in Patients With Cervical and Endometrial Cancer Treated With Postoperative Intensity Modulated Radiation Treatment

Sacral Insufficiency Fractures are Common After High-dose Radiation for Sacral Chordomas Treated With or Without Surgery.

Surgery with high-dose radiation and high-dose radiation alone for sacral chordomas have shown promising local control rates. However, we have noted frequent sacral insufficiency fractures and perceived this rate to be higher than previously reported. We wished (1) to characterize the incidence of sacral insufficiency fractures in patients with chordomas of the sacrum who received high-dose radiation, and (2) to determine whether patients treated with surgery plus high-dose radiation or high-dose radiation alone are more likely to experience a sacral fracture, and to compare time to fracture in these groups. Sixty-two patients who received high-dose radiation for sacral chordomas with (n = 44) or without surgical resection (n = 18) between 1992 and 2013 were included in this retrospective study. At our institution, sacral chordomas generally are treated by preoperative radiotherapy, followed by en bloc resection, and postoperative radiotherapy. Radiation alone, with an intent to cure, is offered to patients who otherwise are not good surgical candidates or patients who elect radiotherapy based on tumor location and the anticipated morbidity after surgery (such as sexual, bowel, or bladder dysfunction). MRI and CT scans were evaluated for evidence of sacral insufficiency fractures. Complete followup was available at a minimum of 2 years (or until fracture or death) for all 18 patients who underwent radiation alone, whereas 14% (six of 44 patients) in the surgery plus radiation group (9% [three of 33] after high sacrectomy and 27% [three of 11] after low sacrectomy) were lost to followup before 2 years. Sacral insufficiency fractures occurred in 29 of the 62 patients (47%). A total of 25 of 33 patients (76%) with high sacrectomy had fractures develop compared with zero of 11 (0%) after low sacrectomy, and four of the 18 patients (22%) who had high-dose radiation alone (p < 0.001). The fracture rate was greater in the high sacrectomy group than in the low sacrectomy group (p < 0.001) and the radiation only group (p < 0.001). There was no difference with the numbers evaluated in fracture probability between patients in the low-sacrectomy group and those treated with radiation alone (p = 0.112). The fracture-free survival probability was 0.99 for the low sacrectomy group at all times as there were no insufficiency fractures in this group; the 1-year fracture-free survival probability was 0.53 (95% CI, 0.35-0.69) after high sacrectomy, 0.83 (95% CI, 0.57-0.94) after radiation alone; the 2-year fracture-free survival probability was 0.36 (95% CI, 0.19-0.52) after high sacrectomy and 0.77 (95% CI, 0.50-0.91) after radiation alone; and the 5-year fracture-free survival probability was 0.14 (95% CI, 0.04-0.30) after high sacrectomy and 0.77 (95% CI, 0.50-0.91) after radiation alone. Acknowledging the limitations of potential differences in baseline and followup among treatment groups in our study, we found that almost ½ of our patients experienced an insufficiency fracture. We found that the fracture rate was greater in the surgery group compared with the radiation alone group and that high sacrectomy accounted for all fractures in the surgery group. These findings can be used to inform patients and also support the need for further research to elucidate the influence of high-dose radiation on bone quality. Level III, therapeutic study.

Foot and Ankle Insufficiency Fractures in Rheumatoid Arthritis

Objectives: To evaluate causes of foot and ankle insufficiency fractures in patients with rheumatoid arthritis. To conduct a literature review of low dose methotrexate induced osteopathy. Case series: Three patients with rheumatoid arthritis who sustained foot and ankle insufficiency fractures which were only detected on MRI. All three patients were on biologic treatment and methotrexate for RA, and two had evidence of hind-foot deformity. All had evidence of osteoporosis on bone density scan, and two were already on intravenous zolendronic acid. Conclusion: Insufficiency fractures occur in approximately 1% of patients with rheumatoid arthritis [1]. Contributing factors include chronic inflammation; skeletal deformities; biomechanical stresses; use of glucocorticoids; and osteoporosis. An additional pathophysiological mechanism may be low-dose methotrexate induced osteopathy. However, there is currently insufficient evidence to conclude this.

Oncogenic Osteomalacia Caused by a Phosphaturic Mesenchymal Tumor of the Proximal Femur

Background: Oncogenic osteomalacia is a rare paraneoplastic syndrome, with only about 100 reported cases in the literature. It is characterized by renal phosphate wasting, hypophosphatemia, low functional vitamin D, normocalcemia, normal PTH, and increased levels of alkaline phosphatase. The majority of oncogenic osteomalacia is usually caused by phosphaturic mesenchymal tumors of mixed connective tissue. Case Description: In this case report, the authors present a case of oncogenic osteomalacia in a patient who initially presented with hip pain for bilateral femoral head osteonecrosis and was noted to have multiple insufficiency fractures of unknown cause. The patient was eventually worked up with a PET/CT scan which showed a 2cm tumor in his right proximal femur. A core biopsy of this lesion revealed it was a mesenchymal tumor. Given the patient’s osteonecrosis of the bilateral proximal femurs, we chose to treat him with a right total hip arthroplasty. As part of this surgery requires making a femoral neck cut and removing the head and neck of the femur, the femoral lesion was completely excised, and this led to resolution of his hypophosphatemia, and improvement in his symptoms.Literature Review: There have been only three case reports of a similar lesion in the proximal femur causing oncogenic osteomalacia in the literature, and each was treated differently with varying outcomes.Clinical Relevance: Although an extremely rare disease, clinicians and pathologists should be aware of oncogenic osteomalacia and phosphaturic mesenchymal tumors as a cause of unexplained insufficiency fractures in patients with hypophosphatemia.

A Dual Biomechanical Failure: Exeter Stem and Pubic Rami Insufficiency Fracture, following Hybrid Total Hip Arthroplasty.

Introduction. Incidence of Exeter stem fracture is extremely uncommon. Pubic rami insufficiency fractures following arthroplasty are also rare. To our knowledge no cases of spontaneous stem failure with previous insufficiency fractures have yet been reported. Case Presentation. This report describes a case of spontaneous fracture through a cemented Exeter stem in a 66-year-old patient who had previously undergone a hybrid total hip replacement and was found to have bifocal pubic rami insufficiency fractures. The patient presented 18-year postprimary surgery with spontaneous fracture of the middle third of the cemented femoral stem and adjacent proximal femur. Conclusion. This report demonstrates a unique case of Exeter stem fracture with previous pelvic insufficiency fractures. The case adds to the rare occurrences of Exeter stem failure in the literature and highlights the risk of potential insufficiency fractures in patients undergoing total hip replacement.

Insufficiency fractures in patients treated with pelvic radiotherapy and chemotherapy for uterine and cervical cancer

Insufficiency fractures are recognised consequences of radiotherapy in gynaecological malignancy with reported incidences between 2.7% and 89%. We aimed to determine the incidence and risk factors for insufficiency fractures in patients receiving radical pelvic radiotherapy for uterine and cervical cancer. A case-note review was undertaken of patients treated between January 2007 and December 2008. Insufficiency fractures were identified from radiographs, computed tomography and magnetic resonance images. Chi-squared and Mann-Whitney tests were performed to determine associations between insufficiency fractures and chemotherapy, steroids and age. A total of 285 patients received pelvic radiotherapy, 137 with uterine and 148 with cervical cancer. Mean age was 59 years. A total of 144 patients received chemotherapy, 101 concurrently and 35 adjuvantly. Bone abnormalities affected 67 patients, 33 had pelvic insufficiency fractures, 12 had multiple fractures and 3 patients developed femoral head avascular necrosis. Use of chemotherapy was not associated with development of fractures (P = 0.949). However, cervical cancer patients had a significantly higher incidence of insufficiency fractures (P = 0.018) and bone pain (P = 0.03) compared with uterine cancer patients. This suggests concurrent chemotherapy may be a significant factor in increasing insufficiency fractures and bone morbidity in these patients and highlights a need for further research to identify, prevent and reduce these long-term complications.

Pelvic insufficiency fractures in patients with cervical and endometrial cancer treated with postoperative pelvic radiation

ObjectiveThere is an increased awareness of pelvic insufficiency fractures (PIF) as a potential morbidity of pelvic radiotherapy (RT). The purpose of this study was to determine the incidence of PIF and assess prognostic factors, including intensity-modulated RT (IMRT), in gynecologic oncology patients treated with postoperative pelvic RT. MethodsWe performed a retrospective review of all patients with endometrial or cervical carcinoma who received postoperative pelvic RT at our institution during 2000–2008. Patients who received definitive or palliative RT were excluded. ResultsA total of 222 patients were identified, of whom 11 (5%) developed PIF at a median time of 11.5months (range, 5.5–87.3months) from RT completion. The 5-year actuarial rate was 5.1% (95% CI 3.3–6.9). In patients with osteoporosis, the 5-year rate was 15.6% compared with 2.9% for those without (P=0.01). Similarly, patients who were on prior hormone-replacement therapy (HRT) had a higher rate (14.8% vs 4.1%, P=0.009). The median body-mass index (BMI) for patients who developed PIF was significantly lower than those who didn't (25.9 vs 27.2, P=0.016). The rate of PIF was 4.9% whether patients received IMRT or conventional RT. ConclusionsThe 5-year risk of PIF for postoperative pelvic RT in cervical and endometrial cancer is 5.1%. Women with history of osteoporosis, prior HRT, or low BMI need to be counseled about the risk of PIF. The use of IMRT did not decrease PIF, but further studies are needed to determine if a dose/volume relationship exists between RT and PIF.

Mechanisms of bone fragility in a mouse model of glucocorticoid‐treated rheumatoid arthritis: Implications for insufficiency fracture risk

Glucocorticoid (GC) therapy is associated with increased risk of fracture in patients with rheumatoid arthritis (RA). To elucidate the cause of this increased risk, we examined the effects of chronic erosive inflammatory arthritis and GC treatment on bone quality, structure, and biomechanical properties in a murine model. Mice with established arthritis and expressing human tumor necrosis factor α (TNFα) transgene (Tg) and their wild-type (WT) littermates were continually treated with GC (prednisolone 5 mg/kg/day via subcutaneous controlled-release pellet) or placebo for 14, 28, or 42 days. Microstructure, biomechanical properties, chemical composition, and morphology of the tibiae and lumbar vertebral bodies were assessed by micro-computed tomography, biomechanical testing, Raman spectroscopy, and histology, respectively. Serum markers of bone turnover were also determined. TNF-Tg and GC treatment additively decreased mechanical strength and stiffness in both the tibiae and the vertebral bodies. GC treatment in the TNF-Tg mice increased the ductility of tibiae under torsional loading. These changes were associated with significant alterations in the biochemical and structural composition of the mineral and organic components of the bone matrix, a decrease in osteoblast activity and bone formation, and an increase in osteoclast activity. Our findings indicate that the concomitant decrease in bone strength and increase in bone ductility associated with chronic inflammation and GC therapy, coupled with the significant changes in the bone quality and structure, may increase the susceptibility of the bone to failure under low-energy loading. This may explain the mechanism of symptomatic insufficiency fractures in patients with RA receiving GC therapy who do not have radiographic manifestations of fracture.

Insuffizienzfrakturen an Fuß und Unterschenkel bei rheumatoider Arthritis

Insufficiency fractures are generally a rare event, especially of the hindfoot. These are often overlooked in the initial stage, however, they must be regarded as a differential diagnosis in the range of possible causes in patients with rheumatoid arthritis and unclear complaints. Outpatients in an arthritis care unit from 2009-2011 were analyzed for fractures of the hindfoot and distal tibia. A total of six patients with seven fractures without adequate trauma were found in the cohort. All patients had received disease modifying therapy and corticosteroids. All fractures could be successfully treated without surgery. Insufficiency fractures in patients with rheumatoid arthritis are a typical finding after several years of the disease. They are directly related to the disease and medication and can usually be successfully treated conservatively.

Diagnosis of Proximal Femoral Insufficiency Fractures in Patients Receiving Bisphosphonate Therapy

The purpose of this article is to describe the imaging features of proximal femoral insufficiency fractures in patients on long-term bisphosphonate therapy. The imaging findings of bisphosphonate-related femoral insufficiency fractures, which include a typical proximal diaphyseal location and transverse liner radiolucency through localized thickening of the lateral cortex, allow a specific diagnosis.

Atypical Insufficiency Fracture of the Tibia Associated With Long-Term Bisphosphonate Therapy

Osteoporosis is a major public health threat affecting millions of individuals in the United States. Bisphosphonate therapy is currently recognized as a first-line treatment of osteoporosis through the inhibition of osteoclast activity. Concerns have been raised about potential oversuppression of bone turnover and the development of atypical skeletal fragility associated with long-term use of bisphosphonates. A number of case reports in the literature have documented atypical insufficiency fractures in patients on long-term bisphosphonate therapy. This case outlines what we believe is the second documented atypical tibial insufficiency fracture in a patient on long-term bisphosphonate therapy, and highlights the need for increased awareness of atypical insufficiency fractures as well as the need for more data concerning the long-term effects of bisphosphonate therapy.

Association of low-energy femoral fractures with prolonged bisphosphonate use: a case control study

Recent evidence has linked long-term bisphosphonate use with insufficiency fractures of the femur in postmenopausal women. In this case-control study, we have identified a significant association between a unique fracture of the femoral shaft, a transverse fracture in an area of thickened cortices, and long-term bisphosphonate use. Further studies are warranted. Although clinical trials confirm the anti-fracture efficacy of bisphosphonates over 3-5 years, the long-term effects of bisphosphonate use on bone metabolism are unknown. Femoral insufficiency fractures in patients on prolonged treatment have been reported. We performed a retrospective case-control study of postmenopausal women who presented with low-energy femoral fractures from 2000 to 2007. Forty-one subtrochanteric and femoral shaft fracture cases were identified and matched by age, race, and body mass index to one intertrochanteric and femoral neck fracture each. Bisphosphonate use was observed in 15 of the 41 subtrochanteric/shaft cases, compared to nine of the 82 intertrochanteric/femoral neck controls (Mantel-Haenszel odds ratio (OR), 4.44 [95% confidence interval (CI) 1.77-11.35]; P = 0.002). A common X-ray pattern was identified in ten of the 15 subtrochanteric/shaft cases on a bisphosphonate. This X-ray pattern was highly associated with bisphosphonate use (OR, 15.33 [95% CI 3.06-76.90]; P < 0.001). Duration of bisphosphonate use was longer in subtrochanteric/shaft cases compared to both hip fracture controls groups (P = 0.001). We found a significantly greater proportion of patients with subtrochanteric/shaft fractures to be on long-term bisphosphonates than intertrochanteric/femoral neck fractures. Bisphosphonate use was highly associated with a unique X-ray pattern. Further studies are warranted.