Richard M. Dell

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.

Incidence of atypical nontraumatic diaphyseal fractures of the femur

Bisphosphonates reduce the rate of osteoporotic fractures in clinical trials and community practice. “Atypical” nontraumatic fractures of the diaphyseal (subtrochanteric or shaft) part of the femur have been observed in patients taking bisphosphonates. We calculated the incidence of these fractures within a defined population and examined the incidence rates according to duration of bisphosphonate use. We identified all femur fractures from January 1, 2007 until December 31, 2011 in 1,835,116 patients older than 45 years who were enrolled in the Healthy Bones Program at Kaiser Southern California, an integrated health care provider. Potential atypical fractures were identified by diagnostic or procedure codes and adjudicated by examination of radiographs. Bisphosphonate exposure was derived from internal pharmacy records. The results showed that 142 patients had atypical fractures; of these, 128 had bisphosphonate exposure. There was no significant correlation between duration of use (5.5 ± 3.4 years) and age (69.3 ± 8.6 years) or bone density (T‐score −2.1 ± 1.0). There were 188,814 patients who had used bisphosphonates. The age‐adjusted incidence rates for an atypical fracture were 1.78/100,000/year (95% confidence interval [CI], 1.5–2.0) with exposure from 0.1 to 1.9 years, and increased to 113.1/100,000/year (95% CI, 69.3–156.8) with exposure from 8 to 9.9 years. We conclude that the incidence of atypical fractures of the femur increases with longer duration of bisphosphonate use. The rate is much lower than the expected rate of devastating hip fractures in elderly osteoporotic patients. Patients at risk for osteoporotic fractures should not be discouraged from initiating bisphosphonates, because clinical trials have documented that these medicines can substantially reduce the incidence of typical hip fractures. The increased risk of atypical fractures should be taken into consideration when continuing bisphosphonates beyond 5 years.

Osteoporosis Disease Management: The Role of the Orthopaedic Surgeon

Osteoporosis is a major medical problem affecting 8 million women and 2 million men in the United States. An additional 34 million Americans have low bone mass. Each year, an estimated 1.5 million people in the United States experience a fragility fracture secondary to osteoporosis, resulting in an annual cost of

Incidence and demography of femur fractures with and without atypical features.

18 billion1. The problem of osteoporosis is now reaching epidemic proportions with the rapidly aging population2. One-half of all women and one-third of all men will sustain a fragility fracture in their lifetime3. There is a huge cost associated with osteoporosis in terms of morbidity, mortality, and the financial impact on society4. The most devastating complication of osteoporosis is a hip fracture. According to the most recent statistics published in the 2004 United States Surgeon Generals report on osteoporosis, of the 325,000 patients who sustain a hip fracture each year, 24% end up in nursing homes, 50% never reach their previous functional capacity, and 25% die within the first year after the fracture2. The first-year mortality rate after a hip fracture is almost twice as high in men as in women (30% compared with 17%)5. The mortality rate due to osteoporosis-related fractures is greater than the rates for breast cancer and cervical cancer combined6. Only 20% of patients with a previous hip or other fragility fracture receive treatment for osteoporosis7-12. For example, in one study, between 12% and 25% of patients with a hip fracture had testing of bone density, fewer than 25% were given calcium and vitamin-D supplements, and fewer than 10% were treated with effective anti-osteoporosis medications13. There are certainly many missed opportunities for fracture prevention. The World Health Organization now has a tool to assess a …

Risk of Fractures Requiring Hospitalization After an Initial Prescription for Zolpidem, Alprazolam, Lorazepam, or Diazepam in Older Adults

The case definition, community incidence, and characteristics of atypical femoral shaft fractures (FSFs) are poorly understood. This retrospective study utilized electronic medical records and radiograph review among women ≥50 years of age and men ≥65 years of age from January 1996 to June 2009 at Kaiser Permanente Northwest to describe the incidence rates and characteristics of subgroups of femur fractures. Fractures were categorized based on the American Society for Bone and Mineral Research (ASBMR) as atypical fracture major features (AFMs) (low force, shaft location, transverse or short oblique, noncomminuted) and AFMs with additional minor radiograph features (AFMms) (beaking, cortical thickening, or stress fracture). There were 5034 fractures in the study. The incidence rates of FSFs (without atypical features) and AFMs appeared flat (cumulative incidence: 18.2 per 100,000 person‐years, 95% CI = 16.0–20.7; 5.9 per 100,000 person‐years, 95% CI = 4.6–7.4; respectively) with 1,271,575 person‐years observed. The proportion of AFMs that were AFMms increased over time. Thirty percent of AFMs had any dispensing of a bisphosphonate prior to the fracture, compared to 15.8% of the non‐atypical FSFs. Years of oral glucocorticosteroid dispensing appeared highest in AFM and AFMm fractures. Those with AFMs only were older and had a lower frequency of bisphosphonate dispensing compared to those with AFMms. We conclude that rates of FSFs, with and without atypia, were low and stable over 13.5 years. Patients with only AFMs appear to be different from those with AFMms; it may be that only the latter group is atypical. There appear to be multiple associated risk factors for AFMm fractures.

Hip fracture in postmenopausal women after cessation of hormone therapy: Results from a prospective study in a large health management organization

To determine whether zolpidem is a safer alternative to benzodiazepines.

Osteoporosis Disease Management: What Every Orthopaedic Surgeon Should Know

Objective:Millions of women in the United States and across the globe abruptly discontinued postmenopausal hormone therapy (HT) after the initial Womens Health Initiative trial publication. Few data describing the effects of HT cessation on hip fracture incidence in the general population are available. We evaluated the impact of HT cessation on hip fracture incidence in a large cohort from the Southern California Kaiser Permanente health management organization. Methods:In this longitudinal observational study, 80,955 postmenopausal women using HT as of July 2002 were followed up through December 2008. Data on HT use after July 2002, antiosteoporotic medication use, and occurrence of hip fracture were collected from the electronic medical record system. Bone mineral density (BMD) was assessed in 54,209 women once during the study period using the dual-energy x-ray absorptiometry scan. Results:After 6.5 years of follow-up, age- and race-adjusted Cox proportional hazard models showed that women who discontinued HT were at 55% greater risk of hip fracture compared with those who continued using HT (hazard ratio, 1.55; 95% CI, 1.36-1.77). Hip fracture risk increased as early as 2 years after cessation of HT (hazard ratio, 1.52; 95% CI, 1.26-1.84), and the risk incrementally increased with longer duration of cessation (P for trend < 0.0001). Longer duration of HT cessation was linearly correlated with lower BMD (&bgr; estimate [SE]) = −0.13 [0.003] T-score SD unit per year of HT cessation; P < 0.0001). Conclusions:Women who discontinued postmenopausal HT had significantly increased risk of hip fracture and lower BMD compared with women who continued taking HT. The protective association of HT with hip fracture disappeared within 2 years of cessation of HT. These results have public health implications with regard to morbidity and mortality from hip fracture.

Fracture prevention in Kaiser Permanente Southern California

According to recent information from the National Osteoporosis Foundation1 and the Office of the Surgeon General2, osteoporosis is a major medical problem. The disease currently affects 8 million women and 2 million men in the United States. An additional 34 million Americans have low bone mass. Each year, an estimated 1.5 million individuals in the United States experience a fragility fracture secondary to osteoporosis, resulting in an annual cost of 18 billion dollars. With the rapidly aging U.S. population, the problem of osteoporosis is now reaching epidemic proportions. There are 75 million baby boomers entering the stage in their lives when they are most at risk for osteoporosis. One-half of all women and one-third of all men will sustain a fragility fracture during their lifetime. There is a huge cost associated with osteoporosis in terms of morbidity, mortality, and the financial impact on society. The most devastating complication of osteoporosis is a hip fracture. According to the most recent statistics published in the United States Surgeon Generals 2004 report on osteoporosis, of the 325,000 patients who sustain a hip fracture each year, 25% will find it necessary to enter a nursing home, 50% will never reach their previous functional capacity, and 25% will die within the first year after the fracture2. The first-year mortality rate after a hip fracture is almost twice as high in men as it is in women (30% compared with 17%). The mortality rate associated with osteoporosis-related fractures is greater than the rates associated with breast cancer and cervical cancer combined1-6. Only 20% of patients who have had a previous hip fracture or other fragility fracture receive treatment for osteoporosis7-13. There are certainly many missed opportunities for fracture prevention14. To achieve …

Ten-year hip fracture incidence rate trends in a large California population, 1997-2006

The Kaiser Permanente Healthy Bones Program has used a systematic approach to address the osteoporosis/fracture care gaps. The article discusses the ten-step processes that utilize information technology and care managers to identify, risk stratify, treat, and then track our patients with care gaps. This program has led to 40+% reduction in the expected number of hip fractures in 2009 that we attribute to the increase in DXA screening followed by appropriate osteoporosis treatment.

Is Osteoporosis Disease Management Cost Effective

SummaryHip fractures are a large public health problem with significant negative impact on an individual’s overall health and survival. But while the total numbers of persons affected by hip fractures may be anticipated to increase, incidence rates appear to be declining.IntroductionTo describe annual hip fracture incidence rate trends in an integrated health-care organization over 1997–2006, during which a proactive bone health program was initiated program-wide and other secular trends occurred in the population.MethodsFor this ecologic trend study, we identified all men and women ≥45 years old as of January 1 of each year. Incident fractures for each year were identified using ICD-9 diagnosis codes 820–820.9, excluding all subjects who had fractures in prior years. Annual person-time at risk for hip fracture was determined from enrollment data. Sex- and age-specific and adjusted annual incidence rates were calculated.ResultsThe overall annual hip fracture incidence rate for men declined from 1.52/1,000 person-years in 1997 to 1.29/1,000 person-years in 2006, a 15.3% (95% confidence interval [CI]=6.2–24.5) decrease. For women, incidence declined from 2.65/1,000 person-years in 1997 to 2.24/1,000 person-years in 2006, a 15.3% (95% CI=8.7–21.9) decrease. Among subjects aged 85 years or older, incidence rates for men declined from 27.0/1,000 to 18.9/1,000 person-years, and for women they declined from 32.7/1,000 to 27.1/1,000 person-years.ConclusionHip fracture incidence has been declining in all age groups over the past 10 years. While many factors may contribute to this decline, the results are consistent with a potential benefit of the active bone health intervention.