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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

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Abstract

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.

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Author information

Authors and Affiliations

  1. Health Administration Center, Niigata University, 2-8050 Ikarashi, Nishiku, Niigata City, 950-2181, Japan

    H. Sato, T. Kuroda & Y. Suzuki

  2. Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuoku, Niigata City, 951-8510, Japan

    H. Sato, T. Nakatsue, Y. Wada & I. Narita

  3. Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuoku, Niigata City, 951-8510, Japan

    N. Kondo, J. Fujisawa & N. Endo

  4. Department of Nephrology and Hypertention, Fukushima Medical University, 1 Hikariga-oka, Fukushima City, 960-1295, Japan

    J. J. Kazama

  5. Department of Medical Technology, School of Health Sciences, Faculty of Medicine, Niigata University, 2-746 Asahimachi-Dori, Chuoku, Niigata City, 951-8518, Japan

    M. Nakano

Authors
  1. H. Sato
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  2. N. Kondo
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  3. T. Nakatsue
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  4. Y. Wada
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  5. J. Fujisawa
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  6. J. J. Kazama
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  7. T. Kuroda
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  8. Y. Suzuki
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  9. M. Nakano
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  10. N. Endo
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  11. I. Narita
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Corresponding author

Correspondence to H. Sato.

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The study protocol was approved by the ethics committee of Niigata University Hospital and executed according to all relevant tenets of the Declaration of Helsinki.

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Sato, H., Kondo, N., Nakatsue, T. et al. 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. Osteoporos Int 28, 2367–2376 (2017). https://doi.org/10.1007/s00198-017-4038-8

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  • DOI: https://doi.org/10.1007/s00198-017-4038-8

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