Robert D. Bunning

Low-Energy Femoral Fractures Associated With Long-Term Bisphosphonate Use in a Rehabilitation Setting: A Case Series

Bisphosphonate therapy for the treatment of postmenopausal osteoporosis is common, with more than 22 million prescriptions for alendronate (Merck) alone in 2005. The safety of this class of medications has been supported by long-term trials [1,2]. However, during the last several years multiple small case series link the long-term use of bisphosphonates to unusual complications such as avascular necrosis of the jaw and low-energy nonvertebral fractures that in some cases surprisingly demonstrate severely suppressed bone turnover [3] .I t may be that the suppressed turnover prevents effective repair of stress fractures. Recently reported cases of nonvertebral fractures include multiple small series describing an unusual fracture of the femur, either subtrochanteric or diaphyseal, in patients taking long-term alendronate [4-7]. This fracture may be preceded by vague complaints of pain in the thigh in the setting of “low or no trauma.” There may be local cortical thickening and a fracture pattern that is simple and horizontally situated [4]. Biopsies in some of these patients have demonstrated a frozen bone pattern [3]. This pattern reveals depression of bone formation. At the authors’ freestanding rehabilitation hospital in the last 7 years, 1 male and 3 postmenopausal female patients with 5 atypical low-impact or no-impact femoral fractures were identified. One was subtrochanteric and 4 were diaphyseal. Two of these patients were receiving extended alendronate therapy; one had received zoledronic acid infusions as an adjunctive therapy for multiple myeloma. One patient was found to be hypogonadal and osteopenic. These cases add to the data that suggest the long-term use of bisphosphonates is associated with a risk of low-energy femoral fractures. CASE 1 A 53-year-old white man with a history of osteoporosis, hypertension, coronary artery disease, gastroesophageal reflux, asthma, psoriatic arthritis, and obsessive-compulsive disorder complained of right-sided hip and knee pain. While walking, he felt a sudden pain in his right leg and fell to the floor. He was taken for immediate plain radiographs, which revealed a right transverse mid-femur fracture. He underwent an intramedullary nailing. He was transferred to acute inpatient rehabilitation and then discharged home without an assistive device. Endocrine consultation revealed a testosterone level of less than 50 ng/dL (normal 212-755 ng/dL) and a luteinizing hormone level of less than 0.1 mIU/mL (normal 20-140 U/mL). He was diagnosed with hypogonadism, which was thought to contribute to his insufficiency fracture. He was treated with topical androgen (Solvay) for his hypogonadism and alendronate for his osteopenia. A DEXA scan obtained at the time of the fracture had a T score of the spine of 0.98, and the hip T score was 0.3 (the lower limit of normal). This fracture did not achieve a primary union, and required a reoperation to achieve a union.

Two Cases of Metallosis from Metal-on-Polyethylene Total Hips: An Emerging Problem

This report describes 2 cases of metallosis from metal‐on‐polyethylene total hip replacements. Case 1 involved a Stryker rejuvenate implant, which has since been recalled. This patient had minimal symptoms, an elevated cobalt level, and loosening. The patient in case 2 had a Dupuys Pinnacle system, with symptoms of weakness, rash, and hip pain. Abnormal laboratory values include elevated sedimentation rate, C‐reactive protein, creatinine, cobalt, and decreased hematocrit. Magnetic resonance imaging revealed synovial thickening and extracapsular edema. Although metallosis is a well‐established complication of metal‐on‐metal implants, emerging data reveal that it also may be a problem in non–metal‐on‐metal implants such as either metal‐on‐polyethylene or ceramic‐on‐polyethylene implants, perhaps related to modular corrosion.

Poster 21: Screening for Lead Toxicity after Gun Shot Wound in a Rehabilitation Setting

Objective: To analyze factors associated with patients’ risk for transfer from IRF back to acute care. Design: Retrospective chart review Setting: Free-Standing IRF Participants: Patients admitted to IRF from October 01, 2014, to December 31, 2015. Interventions: The data from each rehabilitation impairment categories (RIC) were analyzed using chi-square for categorical variables, independent t-test for interval variables, and logistic regression. The seven most common RICs were selected for this study. Main Outcome Measures: RIC, acute hospital length of stay (LOS), admission functional independence measure (FIM), age at admission, comorbidities, gender, race, marital status, and Tier categories. Results: 10,251 total patients were subdivided into stroke, brain injury, spinal cord injury, neurological disorder, joint replacements, orthopedics, and cardiopulmonary. The study included 5,919 and 4,332 male and female patients, respectively. 5,428 and 4,823 patients had less than and more than ten comorbidities, respectively. Tier 0, 1, 2, and 3 had 7,368, 145, 1,527, and 2,211 patients, respectively. The average admission FIM was 60.8 (range 17-104). The average admission motor and cognitive FIM was 36.45 (range 12-71) and 24.23 (range 5-35), respectively. 715 total patients (7%) were transferred to an acute care hospital during their stay. Presence of 10 or more comorbidities was associated with increased risk of transfer; gender, race, or marital status had no effect. The independent t-test revealed patients with a longer acute care LOS prior to admission were more likely to be transferred back. Also, motor and cognitive FIM scores were lower at admission in patients who were transferred. The logistic regression confirms the impact of these variables. The LR identified that 13% of the variance was associated with these variables. Thesefindingswereconsistent for eachof theRICgroups. Conclusions: Approximately 7% of acute rehabilitation patients were transferred back to an acute care hospital for medical complications. This information is especially significant from an administrative perspective. Level of Evidence: Level III

Quadriparesis Caused by Lead Poisoning Nine Years After a Gunshot Wound With Retained Bullet Fragments: A Case Report

Lead toxicity in adults is characterized by nonspecific symptoms of abdominal pain, vomiting, constipation, fatigue, and weight loss. We present a case of severe lead toxicity that developed subacutely, causing quadriparesis 9 years after a gunshot wound with retained bullet fragments. The onset of symptoms may have been related to the development of a pseudocyst. The long interval between the gunshot wound and the onset of symptoms contributed to a delay in suspecting that the retained bullet was a source of lead toxicity. The patients symptoms gradually improved after chelation therapy, removal of the bullet fragment, and an extended program of acute inpatient rehabilitation.

Poster 97 Statin-Induced Rhabdomyolysis Triggered by Concomitant Colchicine Administration: A Case Report.

physicians sampled avoid referring patients for rehab with a life expectancy of less than 3 months and 1 month. Conclusions: Even though medical oncology specialists have some knowledge that rehabilitation is beneficial for their patients, there continues to be a low referral pattern among oncologists, describing poor access, lack of information about cancer rehabilitation and economic difficulties as barriers. Further efforts should be undertaken to emphasize the importance of integrating rehabilitation techniques in the care of cancer patients. Level of Evidence: Level II

Poster 59 Acute Diffuse Tendinopathy Causing Systemic Weakness and Pain Secondary to Ciprofloxacin Use: A Case Report

Case/Program Description: The patient had 1/5 (Medical Research Council scale) strength in his right hand intrinsic muscles and 5/5 strength on his contralateral side. His entire right hand was significantly atrophied while his left hand had normal muscle bulk. Bilateral ulnar nerve conduction studies were performed to the first dorsal interosseous muscle (FDI). Setting: Tertiary care hospital. Results: The compound muscle action potential (CMAP) amplitude on the rightwas 5.2mV, compared to 13.4mVon the left. CMAPduration and latencywere 5.5msand 5.4ms, respectively, on the right, and 5.1ms and 4.8 ms, respectively, on the left. Both ulnar nerves were stimulated with 48.2 mA, which was the supramaximal stimulus to the right FDI. Discussion: Multiple studies have attempted to correlate CMAP amplitudes with muscle grade and were met with mixed results. In this patient, the amplitude of the affected side was 39% that of the contralateral side. However, his strength reflected a far greater difference. The amplitude of the affected side was larger than anticipated due to the electrical manifestations of motor neuron loss and subsequent atrophy. With fewer supplying axons, there may be reduced phase cancellation, which occurs upon stimulation of multiple axons in normal nerves. Atrophy of other hand intrinsic muscles also decreased the likelihood of far volume conduction contributing to lowering of CMAP amplitude. Additionally, the lack of muscle mass diminished the high frequency filtering ordinarily seen with normal muscle bulk, which could also increase the CMAP amplitude. Conclusions: One must be cautious when interpreting CMAP amplitudes, especially in the setting of axon loss and muscle atrophy. CMAP amplitudes can be greatly influenced by axon density, muscle mass, and other factors, and often do not correlate with muscle grade. Level of Evidence: Level V

Poster 377 Two Rare Complications of CCP+ RF + Rheumatoid Arthritis While on Anti-TNF Therapy

Results or Clinical Course: A Spearman’s correlation was run to determine the side-to-side relationship of EMG activity for each lower extremity muscle tested during the double leg squat in FAI and control groups. Bonferroni correction was used to determine the P value equal to .004. The two groups demonstrated different patterns of correlated side-to-side EMG activity in 4 muscles. Control group had statistically significantly correlation in tibialis anterior (r1⁄40.5597, P1⁄4.0001) and FAI group did not (r1⁄40.1749, P1⁄4.3224). Whereas FAI group had statistically significant side-to-side correlation with gluteus medius, soleus and medial/lateral gastrocs (r1⁄40.6608, P1⁄4.0000; r1⁄40.8151, P1⁄4.0000; r1⁄40.4129, P1⁄4.0123; r1⁄40.6330, P1⁄4.0000) and the control group did not. (r1⁄40.2811, P1⁄4.0968; r1⁄40.4129, P1⁄4.0123; r1⁄40.2952, P1⁄4.0804; r1⁄4-0.1498, P1⁄4.3832) Conclusion: Individuals with FAI appear to utilize different motor control strategies than healthy controls when asked to perform a double leg squat.

Atypical Presentation of Hip Pain and Fever: A Case Report

weakness was noted in right-sided hip abduction, foot inversion, plantarflexion, and toe extension. Right medial ankle and foot arch were atrophied. Linear hyperpigmentation with associated induration was present from the medial groin down to the medial foot arch and the first toe. Setting: Sports Medicine Clinic. Results or Clinical Course: Right foot MRI revealed mild medial muscle atrophy and edema. Bilateral thigh MRI was normal. EMG study showed no foot muscle denervation. ANA and doublestranded DNA antibodies were positive. Dermatology was consulted, and a right medial thigh skin biopsy showed histopathologic evidence of morphea. Discussion: Morphea is a self-limited, localized scleroderma characterized by excessive collagen deposition, leading to dermal and subcutaneous tissue thickening. Considerable morbidity develops from growth interference, joint contractions, limb length discrepancy, and prominent atrophy. Therapy aims to reduce inflammation in early disease. Limited disease can be managed with topical or phototherapy, but disabling linear morphea requires more aggressive therapy with methotrexate, corticosteroids, or TNF-alpha inhibitors. By initiating TNF-alpha therapy for CD, our patient was unknowingly also treating undiagnosed linear morphea. Although this arrested disease progression, years of delayed diagnosis had already resulted in chronic disability. Conclusions: This case shows the importance of considering morphea in the differential diagnosis of a patient with focal atrophy, stiffness, and pain with abnormal skin findings, as earlier treatment may have altered her functional outcome.

Poster 127 Brachial Artery Pseudoaneurysm Contributing to Nerve Symptoms in the Hand: A Case Report

reflexes and upper motor neuron tests were normal. Setting: County public hospital, PM&R EMG Clinic. Results or Clinical Course: Motor nerve conduction studies (NCS) of the median and ulnar nerves demonstrated significantly decreased amplitudes, prolonged distal latencies, and decreased conduction velocities bilaterally, right side more affected than left. Sensory NCS of the median and ulnar nerves and lower extremity NCS were normal. Needle electromyography (EMG) of the bilateral upper extremity revealed signs of early reinnervation in all muscles (polyphasic motor units, slightly increased amplitude, and reduced recruitment) in addition to ongoing denervation in distal muscles. Proximally, it revealed reinnervation featuring polyphasia with decreased recruitment. The findings were consistent with multilevel, bilateral cervical radiculopathy. The patient was referred for magnetic resonance imaging (MRI) of the spine which showed extensive cervical and thoracic syringohydromyelia with enlargement of the spinal cord and small, ribbonlike spinal cord tissue remaining along the periphery of the cavity. Discussion: The clinical and EDx findings in this patient are consistent with those found in patients with syringomyelia. These findings include decreased compound muscle action potential amplitudes and normal sensory nerve action potentials on NCS. EMG findings include spontaneous activity such as fibrillations and positive sharp waves. However, these abnormalities are also found in motor neuron disease, poliomyelitis, and radiculopathy. MRI is an important tool to distinguish syringomyelia from these other conditions. Conclusions: This case report illustrates the role of EDx in diagnosing syringomyelia in a patient who presented with bilateral hand weakness and numbness with no other symptoms of spinal cord involvement.

Poster 162 Sonographically Assisted Diagnosis of Left Rectus Femoris Tendon Tear in a Patient with a Total Knee Arthroplasty: A Case Report

Childhood Experience (ACE) Module asks about abuse (physical, sexual, emotional) and family dysfunction (exposure to domestic violence, living with mentally ill, substance abusing, or incarcerated family member). Setting: Six U.S. States: Arkansas, Louisiana, New Mexico, Tennessee, Washington, Wisconsin. Participants: Community-dwelling adults ages 18 (n 30,059). Interventions: Not Applicable. Main Outcome Measures: Self-reported musculoskeletal (MSK) disorder prevalence; MSK-disorderrelated disability measured as: activity limitations, work and social participation restrictions. Results: The prevalence of any ACE was 59% and of 4 ACEs was 15%. The age-adjusted MSK-disorder prevalence increased from 21% for those with no ACEs to 36% for those with 4 ACEs. In those with MSK-disorders (n 9354), the percent reporting activity limitations increased from 46% (no ACEs) to 59% (4 ACEs.). The percent reporting work and social restrictions increased from 25% (no ACEs) to 44% (4 ACEs) and from 40% (no ACEs) to 57% (4 ACEs) respectively. In logistic regression analyses adjusting for demographic factors (sex, age, education, marital status, income), those reporting 1, 2, 3, and 4 ACEs had an increased OR (95% confidence interval) of MSK disorders of 1.14 (1.05-1.24), 1.53 (1.33-1.76), 1.84 (1.58-2.13), 2.43 (2.15-2.74) respectively, compared to those reporting no ACEs. Those with MSK-disorders and 4 ACEs also had an increased adjusted odds of MSK-related activity limitations [1.6 (1.4-2.0)], work [1.9 (1.5-2.4)] and social [1.6 (1.3-2.0)] participation restrictions compared to those with no ACEs. Conclusions: Adverse childhood experiences have a graded effect on musculoskeletal disorder prevalence and also magnify the disability associated with these disorders. A better understanding of this link will help physicians improve functioning in those affected by childhood adversity and musculoskeletal disorders.