Fergus McKiernan

Atypical Subtrochanteric and Diaphyseal Femoral Fractures: Report of a Task Force of the American Society for Bone and Mineral Research

Bisphosphonates (BPs) and denosumab reduce the risk of spine and nonspine fractures. Atypical femur fractures (AFFs) located in the subtrochanteric region and diaphysis of the femur have been reported in patients taking BPs and in patients on denosumab, but they also occur in patients with no exposure to these drugs. In this report, we review studies on the epidemiology, pathogenesis, and medical management of AFFs, published since 2010. This newer evidence suggests that AFFs are stress or insufficiency fractures. The original case definition was revised to highlight radiographic features that distinguish AFFs from ordinary osteoporotic femoral diaphyseal fractures and to provide guidance on the importance of their transverse orientation. The requirement that fractures be noncomminuted was relaxed to include minimal comminution. The periosteal stress reaction at the fracture site was changed from a minor to a major feature. The association with specific diseases and drug exposures was removed from the minor features, because it was considered that these associations should be sought rather than be included in the case definition. Studies with radiographic review consistently report significant associations between AFFs and BP use, although the strength of associations and magnitude of effect vary. Although the relative risk of patients with AFFs taking BPs is high, the absolute risk of AFFs in patients on BPs is low, ranging from 3.2 to 50 cases per 100,000 person‐years. However, long‐term use may be associated with higher risk (∼100 per 100,000 person‐years). BPs localize in areas that are developing stress fractures; suppression of targeted intracortical remodeling at the site of an AFF could impair the processes by which stress fractures normally heal. When BPs are stopped, risk of an AFF may decline. Lower limb geometry and Asian ethnicity may contribute to the risk of AFFs. There is inconsistent evidence that teriparatide may advance healing of AFFs.

The Dynamic Mobility of Vertebral Compression Fractures

We have observed that some osteoporotic vertebral compression fractures (VCFs) are mobile. The purpose of this report was to document the existence of dynamic fracture mobility, estimate the frequency of dynamic mobility in patients referred for vertebroplasty, define the magnitude and nature of dynamic mobility, and consider the implications of the dynamic mobility of osteoporotic VCFs. This was a prospective radiographic analysis of 41 consecutive patients with 65 VCFs who underwent vertebroplasty. Preoperative standing lateral radiographs of the fractured vertebrae were compared with supine cross‐table lateral radiographs to determine the presence or absence of dynamic mobility. Postoperative standing lateral radiographs were evaluated to document fracture mobility and assess final vertebral height restoration. Radiographs were manually digitized to calculate vertebral body morphometrics. Dynamic fracture mobility was demonstrated in 44% of patients (35% of treated vertebrae) who underwent vertebroplasty. Postoperatively, in mobile fractures, average anterior vertebral height increased 106% compared with initial fracture height (absolute increase, 8.41 ± 0.4 mm). Mean lateral vertebral area increased from 48% to 80% of normal, and kyphotic angle decreased 40%. Mobile fractures dominated at the thoracolumbar junction. Intravertebral clefts were defined and identified in every mobile fracture and were absent from every nonmobile (fixed) fracture. This radiographic series documents the previously unrecognized occurrence of dynamic fracture mobility in many osteoporotic VCFs. Fracture mobility can be substantial and clinically significant. Any intervention that claims vertebral height restoration must control for the occurrence of dynamic fracture mobility.

Severely suppressed bone turnover and atypical skeletal fragility.

CONTEXT Since their introduction into clinical medicine, bisphosphonates have revolutionized clinical osteoporosis care. Ironically, in rare circumstances, long-term, combined anti-remodeling therapy may be associated with skeletal harm. EVIDENCE ACQUISITION We report atypical skeletal fragility in three subjects after long-term, combined anti-remodeling therapy. EVIDENCE SYNTHESIS Three subjects experienced spontaneous or minimal-trauma chalk-stick type metadiaphyseal femoral fractures while on long-term bisphosphonate therapy. The fracture location, type, bilaterality, prodromal pain, and delayed healing were atypical for uncomplicated postmenopausal osteoporosis. All three subjects had concomitant circumstances (endogenous estrogen) or medications (glucocorticoids, hormone replacement therapy, and raloxifene) that likely suppressed bone remodeling beyond the effect of the bisphosphonate alone. Biochemical markers of bone turnover were very low or in the low premenopausal range. Double tetracycline-labeled bone biopsy showed very low activation frequency in one subject and limited single tetracycline label in a second consistent with severely suppressed bone turnover (SSBT). These three cases resemble previous descriptions of SSBT. CONCLUSION Atypical skeletal fragility may signify SSBT in the setting of long-term, combined anti-remodeling therapy. We speculate that osteoclast tolerance for pharmacological suppression may vary among individual patients and that in some cases combined anti-remodeling therapy may result in skeletal harm.

Quality of Life Following Vertebroplasty

BACKGROUND Percutaneous vertebroplasty may be indicated when a patient with a painful osteoporotic vertebral compression fracture remains intolerably symptomatic in spite of comprehensive, nonoperative management. Relief of pain and quality of life following percutaneous vertebroplasty, however, remain incompletely defined. We investigated these outcomes with use of a visual analog scale and a validated, osteoporosis-specific health-related quality-of-life instrument. METHODS We performed a prospective study of consecutive patients who underwent percutaneous vertebroplasty. At the time of enrollment, all patients completed the Osteoporosis Quality of Life Questionnaire, a validated thirty-item, five-domain, 7-point response-option instrument that measures health-related quality of life in osteoporotic women with back pain due to vertebral compression fracture. At two weeks, two months, and six months postoperatively, all patients completed a validated extraction of the Osteoporosis Quality of Life Questionnaire. The minimal, clinically important difference in this 7-point scale is 0.5 unit per question. To assess pain, a visual analog scale (ranging from 1 to 10) was completed preoperatively, one day postoperatively, and at each evaluation thereafter. RESULTS Forty-six consecutive patients (thirty-two women and fourteen men) underwent forty-nine percutaneous vertebroplasty procedures for the treatment of sixty-six vertebral compression fractures. The mean age of the patients was 74.3 years. The mean fracture age was 2.5 months. The mean pain rating decreased from 7.7 preoperatively to 2.8 one day after the vertebroplasty (p < 0.001), and it remained substantially improved at two weeks, two months, and six months postoperatively (p < 0.001). All five domains of the Osteoporosis Quality of Life Questionnaire were improved at two weeks postoperatively and remained improved at each evaluation point through six months (p </= 0.007). Multivariate analysis demonstrated no consistent correlation between postoperative pain relief or any postoperative Osteoporosis Quality of Life Questionnaire domain score and gender, smoking history, previous or current steroid use, bone mineral density, dynamic mobility, or the presence of an intravertebral cleft. Immediate postoperative pain relief was weakly and positively associated with age (p < 0.03). Four incident vertebral compression fractures occurred in three (6.5%) of the forty-six patients, and five patients died within six months after the vertebroplasty. No deaths or serious adverse events appeared to be related to vertebroplasty. CONCLUSIONS Rapid and substantial relief of pain and improvement in the quality of life are observed following percutaneous vertebroplasty, and these improvements are maintained for at least six months. Percutaneous vertebroplasty can be performed safely in frail, elderly patients, with no apparent increase in the incidence of fractures postoperatively. LEVEL OF EVIDENCE Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Reporting height restoration in vertebral compression fractures

Study Design. Prospective radiographic analysis of vertebral compression fractures (VCFs) that underwent vertebroplasty. Objective. Illustrate the variability in apparent magnitude of vertebral height restoration when this outcome is reported by four different methods commonly used in the vertebroplasty literature. Propose a consensus method for reporting vertebral height restoration. Summary of Background Data. Measuring and reporting height restoration of fractured vertebrae presupposes a consensus of method that does not exist. Lack of consensus makes the interpretation of reports and comparison of outcomes of interventions that claim vertebral height restoration difficult. Materials and Methods. Preoperative and postoperative standing lateral radiographs of 65 VCFs in 41 patients were compared to assess operative vertebral height restoration. Restorations of vertebral height occurred in 23 instances and were reported by each of the following commonly used methods: (1) absolute restoration in millimeters; (2) percent restoration relative to initial fracture height; (3) percent restoration relative to lost vertebral height; and (4) percent restoration relative to referent vertebral height. Results. Apparent magnitude of height restoration varied nearly four-fold depending on initial fracture severity and reporting method. Conclusions. Substantial apparent variability in the reported magnitude of identical height restorations demonstrates the need for a consensus method for measuring, reporting, and interpreting this outcome. Rationale is presented to support the recommendation that reports of vertebral height restoration should: include all index vertebral height dimensions (posterior (Hp), middle (Hm) and anterior (Ha) vertebral height); include absolute measurements of all referent vertebral heights; be reported relative to a referent normative height; include a correction for inter-radiographic measurement error; take into consideration the dynamic mobility of some osteoporotic VCFs; and include the calculated precision error for all measurements.

Calling all vertebral fractures classification of vertebral compression fractures: a consensus for comparison of treatment and outcome.

OSTEOPOROSIS IS a disease characterized by low bone mass, microarchitectural deterioration of bone tissue, and the propensity to low-energy fracture. The most frequent osteoporotic fracture is the vertebral compression fracture (VCF) of which only one in three manifests as an acutely painful event. Thus, prevalent radiographic VCFs outnumber clinical fractures. Several fracture definition schemes exist but all are essentially binary decisions (i.e., fracture vs. no fracture) based on that degree of vertebral height reduction that results in disease prevalence and incidence most accurately reflecting the problem of osteoporosis in the general population. Vertebral fractures serve as sentinel markers for the epidemiological study of osteoporosis and are the benchmark by which efficacy of new osteoporosis therapies is established. Therefore, consensus on vertebral fracture definition is extremely important because small changes in fracture definition might potentially result in profound alterations in fracture epidemiology, diagnostic strategies, and treatment outcomes. On the other hand, vertebral fracture morphology is descriptive (i.e., wedge, crush, and biconcave), unstandardized, and of uncertain clinical relevance. Vertebral fractures, whether clinically apparent or not, are associated with an increased risk of recurrent vertebral fracture, future nonvertebral osteoporotic fracture, and future hospitalization and mortality. Prevalent VCFs predict decreased pulmonary capacity and increased risk of pulmonary death. The number and severity of prevalent compression fractures correlates with frailty and poor functional status by multiple validated quality of life instruments. Severely painful VCF may initiate the frustrating cascade of impaired mobility, physical deconditioning, accelerated bone loss, and further frailty. Longterm consequences of VCF include postural deformity, chronic back pain, abdominal crowding, altered body image, social withdrawal, fear of future fracture, and depression. Thus, fracture-prevention strategies and interventions that promote postural and functional recovery from acute VCFs are welcome. Conventional treatment of painful VCFs has been supportive, rehabilitative, and, heretofore, rarely surgical. Previous surgical interventions for VCF have resulted in significant morbidity and poor surgical outcomes because of the insufficient material properties of osteoporotic bone and the advanced age and multiple medical comorbidities of this patient population. Therefore, the emergence of percutaneous vertebral augmentation (PVA) is a hopeful option for managing the pain and sequelae of vertebral fractures in osteoporotic patients. PVA refers primarily to vertebroplasty, the percutaneous fixation of fractured vertebrae with polymethylmethacrylate (PMMA). Kyphoplasty, a proprietary derivative of vertebroplasty, is the PMMA fixation of fractured vertebrae after purported vertebral end plate elevation using a percutaneous inflatable balloon tamp. Both procedures claim to relieve vertebral fracture pain, quickly restore functional capacity, and abort the cascade of accelerating frailty previously described. The accessibility and perceived technical simplicity of vertebral augmentation, the desire to relieve suffering, the recent assignment of current proceThe authors have no conflict of interest.

A Simple Gait-Stabilizing Device Reduces Outdoor Falls and Nonserious Injurious Falls in Fall-Prone Older People During the Winter

Objectives: To determine whether Yaktrax Walker (YW), a nonmedical gait‐stabilizing device, prevents outdoor falls and injurious falls in fall‐prone older people during the winter.

Does Vertebral Height Restoration Achieved at Vertebroplasty Matter

PURPOSE Altered vertebral and spinal configuration after osteoporotic vertebral compression fracture (VCF) is believed to contribute to postfracture morbidity. The objective of this study was to determine whether patients in whom partial vertebral height restoration (VHR) was achieved at percutaneous vertebroplasty had greater pain relief or improved quality of life compared with patients in whom no anatomic restoration was achieved. MATERIALS AND METHODS Consecutive subjects undergoing percutaneous vertebroplasty for painful osteoporotic VCFs completed the Osteoporosis Quality of Life Questionnaire (OQLQ) a validated, disease specific instrument that measures health related quality of life in women with osteoporosis with back pain caused by VCF. At postoperative week 2, month 2, and month 6, all subjects completed the mini-OQLQ, a validated extraction of OQLQ. Pain was rated with a standard visual analogue scale (VAS). Radiographs were manually digitized and evaluated for the presence of dynamic mobility and VHR. The relationship between VHR achieved at percutaneous vertebroplasty and postoperative pain relief and quality of life outcome was examined by multivariate analysis. RESULTS Forty-six subjects (32 women) underwent 49 percutaneous vertebroplasty procedures to treat 66 painful VCFs. Mean patient age was 74.3 years+/-10.9. Mean fracture age was 2.5 months+/-2.1. Pain rating fell from 7.7+/-1.8 to 2.8+/-1.8 within 1 day of percutaneous vertebroplasty and remained improved through month 6 (P<.001). All OQLQ domains improved substantially at week 2 (P<.02) and remained improved through month 6 (P<or=.007). Preoperative dynamic mobility ranged -2.9 to 19.9 mm (average, 5.5 mm). Postoperative VHR in mobile VCFs ranged -2.1 to 9.6 mm (average, 2.9 mm). At all postoperative time points up to 6 months, pain and OQLQ domain scores were similar in patients who achieved partial VHR at percutaneous vertebroplasty compared with those in whom no VHR was achieved. CONCLUSION Partial vertebral height restoration achieved at percutaneous vertebroplasty did not result in additional pain relief or improved quality of life beyond cement fixation alone.

Musculoskeletal manifestations of mild osteogenesis imperfecta in the adult

The musculoskeletal manifestations of mild forms of osteogenesis imperfecta are not well defined in the adult. The aim of this study was to characterize the musculoskeletal manifestations and resulting impairments reported by adults with mild osteogenesis imperfecta. For this task a survey of musculoskeletal symptoms and impairments was hosted on the Osteogenesis Imperfecta Foundation web site for 6 weeks. Survey responses are reported herein. There were 111 unduplicated, adult respondents (78 female). Mean age was 40.8 years. More than one-quarter of 3,410 lifetime fractures occurred in adulthood. Nearly half of respondents reported an established diagnosis of “arthritis” (usually osteoarthritis), and the majority of these reported some degree of impairment attributable to arthritis. Articular pain, stiffness and instability were dominant in the large, weight-bearing joints of the lower extremities. Back pain and scoliosis were common. Of the respondents, 15% required assistance with light physical tasks and personal care. Two-thirds reported joint hyper-mobility, and one-third reported a previous tendon rupture. Complex regional pain syndrome was rare. Respondents reported frequent use of medications known to have potential adverse skeletal effects. In spite of these concerns the majority rated their overall physical health as good or excellent. Adults with mild osteogenesis imperfecta continue to sustain fractures into adulthood, and the majority reports some functional impairment due to musculoskeletal issues. Significant impairment is not rare.

Clinical and Radiographic Findings in Adults With Persistent Hypophosphatasemia

A serum alkaline phosphatase value below the age‐adjusted lower limits of normal (hypophosphatasemia) is uncommonly encountered in clinical practice. The electronic and paper medical records of 885,165 patients treated between 2002 and 2012 at a large, rural, multispecialty health clinic were interrogated to estimate the prevalence and characterize the clinical and radiographic findings of adults whose serum alkaline phosphatase was almost always low (persistent hypophosphatasemia). We hypothesized that some of these patients might harbor previously unrecognized hypophosphatasia, a rare, inherited condition of impaired mineralization of bones and teeth. Persistent hypophosphatasemia (serum alkaline phosphatase ≤30 IU/L) was found in 1 of 1544 adult patients. These adult patients had more crystalline arthritis, orthopedic surgery, chondrocalcinosis, calcific periarthritis, enthesopathy, and diffuse idiopathic skeletal hyperostosis than a general adult patient population. A gender effect was observed. The clinical and radiographic findings of adult patients with persistent hypophosphatasemia resemble those of the adult form of hypophosphatasia. Clinicians should take notice of persistent hypophosphatasemia, consider the diagnosis of hypophosphatasia, and be cautious when considering potent anti‐remodeling therapy in these adults. This population warrants further evaluation.