March/April - West Virginia State Medical Association

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Scientific Article | Table 1. Summary of characteristics in patients with atypical femoral fractures associated with bisphosphonate therapy. mean mean yrs. n gluco- n delayed n prodromal n contralateral n* age treatment corticoid healing symptoms cortical reaction Reference duration therapy or fracture 11 5 60.2 5.6 2 4 N/A † 2 12 9 66.9 4.2 2 N/A 5 N/A 13 1 82 10 0 N/A 1 1 14 1 73 7 0 1 1 1 15 19 69.4 6.2 N/A N/A N/A N/A 16 17 66 4.8 2 N/A 13 9 17 3 62.6 8.3 3 2 2 3 18 3 63.3 7 N/A N/A 2 2 19 1 76 8 1 1 1 1 20 1 60 6 1 N/A 1 1 21 7 55.1 6.5 3 3 N/A 2 22 8 66.9 5.4 4 2 2 4 23 4 66.3 8.4 0 2 3 1 24 7 61 8.6 0 0 4 7 Unpublished 3 76 7.3 1 1 3 2 *= Numbers of patients presented with specific characteristic in each report. † = Information not available in reports. most but not all studies; however, no reduction in nonvertebral fractures was observed. Interestingly, one trial conducted over one year did not find impaired fracture healing in individuals receiving glucocorticoids and bisphosphonates. 33 No trials of longer duration (e.g., five or more years) exist to provide evidence whether longer treatment with bisphosphonates in patients on glucocorticoids have an increased susceptibility of these atypical fractures. These atypical fractures have only been retrospectively linked to bisphosphonate therapy. Furthermore, population-based studies have not been able to validate this association. A Danish registry cohort observational study found that fractures in the subtrochanteric and diaphyseal locations were no more frequent in patients receiving alendronate. 34 However, the average age of patients with fractures in these locations were 12 years older than those in our review, and the authors were unable to access records to determine whether atypical x-ray patterns were present similar to the reported cases. An Australian study after reviewing hip fractures from the previous year found that atypical femoral fractures were rare and no more common in patients who were treated with bisphosphonates. 35 Furthermore, a report reviewing three large randomized trials also found these fractures to be quite rare and not significantly increased even in patients who received bisphosphonates for as long as 10 years. These authors, however, were not able to view all images of atypical fractures. Conclusion Physicians should continue to prescribe bisphosphonates for the treatment of osteoporosis. The occurrence of atypical fractures in the femur with minimal or no trauma in patients receiving longterm bisphosphonates appears to be rare and the evidence linking bisphosphonates as a cause has not been strongly substantiated. A prospective observational study viewing radiographic images along with clinical symptoms would help to verify the population-based studies. New onset of thigh pain in a patient receiving long-term bisphosphonates warrants imaging of the femur. Individuals receiving concomitant glucocorticoids or other agents which suppress bone turnover should also raise awareness of the possibility of these fractures. Acknowledgements The authors acknowledge the following persons: Brittain McJunkin, MD and Robert Cagna, JD for assistance in manuscript review; 10 West Virginia Medical Journal
| Scientific Article Figure 1. A 91 year old lady who had taken alendronate for 10 years and intermittent glucocorticoids for chronic obstructive lung disease experienced right thigh pain for nine months. Cortical thickening (a) was noted before experiencing a femoral transverse fracture with a unicortical spike (b). Healing was noted at 3 months (c) as well as contralateral thickening (d). The patient has been receiving teriparatide for recovery. Faculty Position Academic Internist West Virginia University - Charleston Division Robert C. Byrd Health Sciences Center Charleston Division Available November 1, 2010 The Department of Internal Medicine is seeking an Academic Internist for a full-time position at the Robert C. Byrd Health Sciences Center, West Virginia University, Charleston Division, available November 1, 2010. The position will provide academic support to a dually accredited residency program sponsored by Charleston Area Medical Center, an 838-bed tertiary hospital located in the capital city of Charleston, West Virginia. The affiliation between West Virginia University and Charleston Area Medical Center, which is the oldest regional medical campus in the nation, offers a clinical training environment for more than 80 medical students, 150 residents and other health professions. The candidate must be Board Certified or Board Eligible. The position requires a significant commitment to resident and medical student education in Internal Medicine and participation in appropriate academic, clinical research or other scholarly activity as may be required of clinical faculty. West Virginia University offers a flexible job description with both inpatient and outpatient opportunities available. Enjoy the beautiful outdoors in a culturally rich area with highly desirable residential communities and outstanding school systems. Our compensation package is extremely competitive and commensurate with qualifications and experience. The search will remain open until a suitable candidate is identified. This position is not qualified for J-1 Visa. Please submit letter of interest and curriculum vitae to: Gregory Rosencrance, MD, FACP Professor and Chairman Department of Internal Medicine West Virginia University Charleston Division 3110 MacCorkle Avenue, SE Charleston, WV 25304 Fax: (304) 347-1344 Office: (304) 347-1254 E-mail: grosencrance@hsc.wvu.edu Women and minorities are encouraged to apply. West Virginia University is an Affirmative Action Equal Employment Opportunity Employer 22554-J10 March/April 2011 | Vol. 107 11
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