Atypical femoral fracture in a bisphosphonate-naïve patient on denosumab for osteoporosis,Archives of Osteoporosis

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Atypical femoral fracture in a bisphosphonate-naïve patient on denosumab for osteoporosis
Archives of Osteoporosis ( IF 3.1 ) Pub Date : 2022-10-01 , DOI: 10.1007/s11657-022-01166-x
Shejil Kumar _{1,

2} , Ruby Chang ₁ , Michael Reyes ₁ , Terrence Diamond ₁

Affiliation

Summary

A post-menopausal Caucasian woman sustained an atypical femoral fracture (AFF) after 5-years continuous denosumab for osteoporosis without prior bisphosphonate exposure. This is only the fifth case reported of AFF in a bisphosphonate-naïve patient receiving denosumab for osteoporosis. Although rare, physicians should consider AFF in patients taking denosumab even without prior bisphosphonate exposure.

Introduction

Denosumab has demonstrated overwhelmingly favourable skeletal benefit/risk profile in managing post-menopausal osteoporosis with up to 10-year exposure in the extension of the pivotal FREEDOM randomised placebo-controlled trial. Four previous cases of atypical femoral fracture have been reported in bisphosphonate-naïve patients receiving denosumab for osteoporosis.

Methods

We present an 85-year-old Caucasian post-menopausal woman without prior fragility fracture who sustained unilateral atypical femoral fracture after 5-years continuous subcutaneous denosumab for osteoporosis. She had no prior bisphosphonate or glucocorticoid exposure and had known chronic kidney disease.

Results

X-ray scan demonstrated complete, non-comminuted left proximal femoral shaft fracture meeting radiographic criteria for an atypical femoral fracture. Computed tomography (CT) scan lower limbs revealed unusual side-by-side appearance of proximal and distal fragments of left proximal femur. DXA BMD was artefactually elevated at lumbar spine (1.504 g/cm², T-score + 2.5) and low-normal at right femoral neck (0.856 g/cm², T-score -1.0). Serum biochemistry showed renal impairment at baseline (eGFR 30 mL/min/1.73m²). Low-normal serum C telopeptide of type 1 collagen (CTX) (230 ng/L) indicated therapeutic suppression of bone resorption.

Conclusion

The patient underwent intramedullary nailing of the femur and denosumab was ceased. This is only the fifth case reported of atypical femoral fracture in a bisphosphonate-naïve patient receiving denosumab for osteoporosis. Although rare, physicians should maintain a high index of suspicion for atypical femoral fracture in a patient taking denosumab even without prior bisphosphonate exposure.

中文翻译：

非典型股骨骨折，双膦酸盐初治患者骨质疏松症地诺单抗

概括

一名绝经后白人女性在连续 5 年连续地诺单抗治疗骨质疏松症后发生了非典型股骨骨折 (AFF)，之前没有接触过双膦酸盐。这只是第 5 例因骨质疏松症而接受地诺单抗治疗的双膦酸盐初治患者发生 AFF 的报道。尽管很少见，但对于服用狄诺塞麦的患者，即使既往未接触过双膦酸盐，医生也应考虑 AFF。

介绍

在关键的 FREEDOM 随机安慰剂对照试验的扩展中，狄诺塞麦在长达 10 年的暴露期中，已证明在管理绝经后骨质疏松症方面具有压倒性的良好骨骼益处/风险状况。在接受狄诺塞麦治疗骨质疏松症的双膦酸盐初治患者中，已有四例非典型股骨骨折的报道。

方法

我们介绍了一位 85 岁的绝经后白人女性，之前没有发生过脆性骨折，她在连续 5 年皮下注射狄诺塞麦治疗骨质疏松症后发生了单侧非典型股骨骨折。她既往未接触过双膦酸盐或糖皮质激素，并且已知患有慢性肾病。

结果

X 射线扫描显示完全的、非粉碎性左侧近端股骨干骨折符合非典型股骨骨折的影像学标准。计算机断层扫描 (CT) 扫描下肢显示左股骨近端的近端和远端碎片异常并排出现。DXA BMD 在腰椎处人为升高（1.504 g/cm ²，T 分数 + 2.5），在右股骨颈处低于正常水平（0.856 g/cm ²，T 分数 -1.0）。血清生化显示基线肾功能损害（eGFR 30 mL/min/1.73m ²）。1 型胶原 (CTX) 的低正常血清 C 端肽 (230 ng/L) 表明治疗性抑制骨吸收。