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Femoral cortical stress lesions in long-term bisphosphonate therapy: a herald of impending fracture?

Abstract：

OBJECTIVE:Lateral cortical stress reactions have been documented to precede femoral insufficiency fractures after long-term bisphosphonate therapy. We studied the natural history of femoral stress lesions associated with long-term bisphosphonate therapy. DESIGN AND SETTING:A retrospective clinical and radiologic review of all patients with radiologically documented femoral stress lesions associated with bisphosphonate therapy was carried out in a tertiary center involved with geriatric trauma care. PATIENTS:Of 1463 geriatric hip fractures occurring from May 1, 2004, to July 31, 2008, 33 were of a distinct metaphyseal-diaphyseal configuration. Thirty-two were on prior bisphosphonate therapy. Sixteen femurs showed a lateral cortical thickening either on prefracture radiographs (four femurs) or on radiographs of the contralateral femur (12 femurs). MAIN OUTCOME MEASURES:Features that predispose to complete stress fractures were determined. The intact femurs were followed up for symptomatic and radiologic progression and occurrence of new lesions. RESULTS:All four cases that fractured had a "dreaded black line" in the lesion, whereas only 1 of 12 patients had this fracture in femurs which remained intact (100% versus 8.3%, P = 0.003). All patients who fractured reported thigh discomfort over 1 month (range, 0.1-9.0 months; standard deviation, 4.0 months), whereas three of 12 patients who did not fracture reported thigh discomfort (100% versus 25%, P = 0.019). In the remaining patients, eight patients were asymptomatic, two patients had reduced symptoms, and one patient had persistent thigh pain at 23.0 months (range, 5-35 months; standard deviation, 10.2 months). One patient was too demented for symptomatic assessment. No patient developed a new lesion. Radiologic stabilization of the lateral cortical thickening was evident on follow-up radiographs. CONCLUSION:Cortical stress reactions associated with prolonged antiresorptive therapy, in the presence of pain and the "dreaded black line," have an increased risk for complete stress fractures.

journal_name

J Orthop Trauma

journal_title

Journal of orthopaedic trauma

authors

Koh JS,Goh SK,Png MA,Kwek EB,Howe TS

doi

10.1097/BOT.0b013e3181b6499b

subject

Has Abstract

pub_date

2010-02-01 00:00:00

pages

75-81

issue

eissn

0890-5339

issn

1531-2291

pii

00005131-201002000-00002

journal_volume

pub_type

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Femoral cortical stress lesions in long-term bisphosphonate therapy: a herald of impending fracture?