High and pointed type of femoral localized reaction frequently extends to complete and incomplete atypical femoral fracture in patients with autoimmune diseases on long-term glucocorticoids and bisphosphonates

• Published in: Osteoporosis international 2017-08, Vol.28 (8), p.2367-2376
• Main Authors: Sato, H., Kondo, N., Nakatsue, T., Wada, Y., Fujisawa, J., Kazama, J. J., Kuroda, T., Suzuki, Y., Nakano, M., Endo, N., Narita, I.
• Format: Article
• Language: English
• Subjects: Adult; Aged; Autoimmune diseases; Autoimmune Diseases - drug therapy; Biomarkers - metabolism; Bisphosphonates; Bone and Bones - metabolism; Bone Density Conservation Agents - administration & dosage; Bone Density Conservation Agents - adverse effects; Bone Density Conservation Agents - therapeutic use; Diphosphonates - administration & dosage; Diphosphonates - adverse effects; Diphosphonates - therapeutic use; Drug Administration Schedule; Endocrinology; Female; Femoral Fractures - chemically induced; Femoral Fractures - diagnostic imaging; Femoral Fractures - pathology; Femur; Fractures; Fractures, Stress - chemically induced; Fractures, Stress - diagnostic imaging; Fractures, Stress - pathology; Glucocorticoids; Glucocorticoids - administration & dosage; Glucocorticoids - adverse effects; Glucocorticoids - therapeutic use; Humans; Medicine; Medicine & Public Health; Middle Aged; Original Article; Orthopedics; Pain; Parathyroid hormone; Radiography; Retrospective Studies; Rheumatology; Supplements; Vitamin D
• ISSN: 0937-941X; 1433-2965
• DOI: 10.1007/s00198-017-4038-8

Summary Once a localized reaction (beaking) was detected, discontinuation of bisphosphonates (BPs) and switching to vitamin D supplementation or teriparatide therapy effectively improved its shape. When the localized reaction was high, of the pointed type, and/or accompanied by prodromal pain, the risks of complete and incomplete atypical femoral fracture increased and consideration of prophylactic fixation for such patients was required. Introduction Femoral localized reaction (localized periosteal thickening of the lateral cortex, beaking) is reported to precede atypical femoral fractures (AFFs) and to develop in 8–10% of patients with autoimmune diseases taking BPs and glucocorticoids. The aims of the present study were to retrospectively investigate the shapes of localized reaction to consider how to manage the condition. Methods Twenty femora of 12 patients with autoimmune diseases who were on BPs and glucocorticoids exhibited femoral localized reaction. The heights of localized reaction were measured and the shapes classified as pointed, arched, and other. Localized reaction changes were divided into three categories: deterioration, no change, and improvement. A severe form of localized reaction was defined; this was associated with prodromal pain, de novo complete AFF, or incomplete AFF with a fracture line at the localized reaction. Results The mean height of localized reaction was 2.3 ± 0.8 mm (range, 1.0–3.7 mm) and the pointed type was 35%. Localized reaction was significantly higher (3.3 ± 0.8 vs. 2.1 ± 0.7 mm; p  = 0.003) and the pointed type more common (78 vs. 27%; p  = 0.035) in those with the severe form of localized reaction. Seven patients with localized reactions discontinued BPs just after localized reaction was detected, but five continued on BPs for 2 years. Localized reaction deterioration was more common in patients who continued than discontinued BPs (100 vs. 29%; p  = 0.027). After 2 years, all patients had discontinued BPs and localized reaction did not deteriorate further in any patient. Conclusions Once a localized reaction was detected, discontinuation of BPs and switching to vitamin D supplementation or teriparatide therapy effectively improved it. When the localized reaction was high, of the pointed type, and/or accompanied by prodromal pain, the risks of complete and incomplete AFF increased and consideration of prophylactic fixation for such patients was required.