Cumulative incidence of femoral localized periosteal thickening (beaking) preceding atypical femoral fractures in patien
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ORIGINAL ARTICLE
Cumulative incidence of femoral localized periosteal thickening (beaking) preceding atypical femoral fractures in patients with rheumatoid arthritis H. Sato 1,2 & C. Takai 1 & N. Kondo 3 & Y. Kurosawa 4 & E. Hasegawa 4 & A. Wakamatsu 4 & D. Kobayashi 4 & T. Nakatsue 4 & A. Abe 1 & S. Ito 1 & H. Ishikawa 1 & J. J. Kazama 5 & T. Kuroda 2 & Y. Suzuki 2 & N. Endo 6 & I. Narita 4 Received: 28 May 2020 / Accepted: 12 August 2020 # International Osteoporosis Foundation and National Osteoporosis Foundation 2020
Abstract Summary The incidence of localized periosteal thickening (LPT, also termed beaking) of the lateral cortex that often precedes an atypical femoral fracture (AFF) was not high in patients with rheumatoid arthritis (RA) but incomplete AFFs developed in two patients. Higher-dose prednisolone was a significant risk factor for LPT in patients with RA. Introduction Atypical femoral fractures (AFFs) are stress fractures; bisphosphonate (BP) use is a major risk factor for the development of such fractures. Localized periosteal thickening (LPT, also termed beaking) of the lateral cortex often precedes a complete or incomplete AFF. We evaluated the incidence of latent LPT in patients with rheumatoid arthritis (RA), to evaluate LPT progression, and to define LPT risk factors. Methods A total of 254 patients with RA were included; all underwent annual X-ray evaluation, dual-energy X-ray absorptiometry, and analyses of serum and bone metabolic markers for 2–3 years. LPT of the lateral cortex was sought in femoral X-rays. Results The incidence of LPT was 2.4% (6/254). Among patients on both BP and prednisolone (PSL) at enrollment, the incidence was 2.3% (3/131). Two femurs of two patients with LPT developed incomplete AFFs; LPT was extensive and associated with endosteal thickening. One patient had been on BP and PSL and microscopic polyangiitis was comorbidity. The other was on a selective estrogen receptor modulator and PSL. A daily PSL dose >5 mg (OR 11.4; 95%CI 2.15–60.2; p = 0.004) and higher-dose methotrexate (OR 1.22; 95%CI 1.01–1.49; p = 0.043) were significant risk factors for LPT. Conclusions The incidence of latent LPT was not high (2.4%) but incomplete AFFs developed in two RA patients. Higher-dose PSL because of a comorbid disease requiring glucocorticoid treatment other than RA or refractory RA were risk factors for LPT; X-ray screening for latent LPT would usefully prevent complete AFFs. Keywords Atypical femoral fracture . Beaking . Bisphosphonate . Femoral localized periosteal thickening . Glucocorticoid . Rheumatoid arthritis
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00198-020-05601-y) contains supplementary material, which is available to authorized users. * H. Sato [email protected] 1
Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Honcho, Shibata City 957-0054, Japan
2
Health Administration Center, Niigata University, 2-8050 Ikarashi, Nishi-ku, Niigata City 950-2181, Japan
3
Division of Orthopedic Surger
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