A Case of an Unusual Subtrochanteric Fracture in a Patient Receiving Denosumab

ObjectiveBisphosphonates are the most common class of medications used to treat osteoporosis. Their widespread use has uncovered rare complications, including atypical femoral fractures (AFF). The pathogenesis of AFF is incompletely understood; however, if oversuppression of bone remodeling contributes to AFF, it is plausible that other potent antiresorptive agents, such as denosumab, could be associated with AFF as well.MethodsWe report a case of an 81-year-old woman with densitometric osteopenia, chronic kidney disease, and hyperparathyroidism, who was initiated on denosumab for elevated fracture risk. Approximately 6 months after her initial denosumab injection, she developed severe right groin and thigh pain without prior trauma.ResultsA femoral radiograph was normal, without cortical thickening, but a magnetic resonance imaging revealed a transverse subtrochanteric insufficiency fracture with a medial defect involving 25% of the femoral cortex. She did not receive any further doses of denosumab. Bone turnover markers did not suggest oversuppression. Her fracture was treated conservatively with nonweight bearing status with resultant full recovery.ConclusionThis fracture does not meet the current definition of an AFF as, for that definition, a lateral femoral location is required. This case does not provide conclusive evidence for a causal relationship between treatment with denosumab and this unusual fracture. It clearly illustrates, however, the occurrence of an unusual, nontraumatic subtrochanteric fracture in a patient treated with the potent antiresorptive agent denosumab with many features in common with bisphosphonate-associated AFF. (Endocr. Pract. 2013;19:e64-e68)     

Subungual Exostosis in an Osteoporotic Patient Treated with Teriparatide

ObjectiveTo report an unusual case of subungual exostosis in a patient on teriparatide.MethodsWe describe the presentation and symptoms of the patient and review of the relevant literature.ResultsTeriparatide is used for the treatment of osteoporosis. Rat studies using 3-60x the approved human dose have shown an association between teriparatide and an increased risk of osteosarcoma. Subungual exostosis, to our knowledge, has not been reported. We report the case of a 54-year-old female who presented with a 4-month history of pain and swelling in the medial side of her right thumb with no preceding trauma. The patient had history of severe osteoporosis with multiple fractures and was on teriparatide for 16 months. On examination, the right thumb was swollen and tender with no superficial erythema or signs of an infection. X-ray imaging revealed a trabecular bony overgrowth consistent with subungual exostosis. The patient was treated with subungual excision. Pathology showed endochondral bone formation with reactive atypia, consistent with osteocartilaginous exostosis.ConclusionTo our knowledge, this is the first case hypothesizing an association between teriparatide and subungual exostosis. Subungual exostosis is a benign growth of bone that arises in the distal phalanx, under or adjacent to the nail bed. The pathophysiology is not clearly understood, but the lesion has base of trabecular bone with a proliferating fibrocartilaginous cap. Teriparatide can stimulate the trabecular bone formation. Hence, an association between the use of teriparatide and the development of subungal exostosis cannot be excluded. Further studies delineating this relationship are needed. (Endocr. Pract. 2013;19:e115-e117)     

Teriparatide as a Systemic Treatment for Lower Extremity Nonunion Fractures: A Case Series

ObjectiveTo investigate the effect of teriparatide (parathyroid hormone [1-34]) on the healing of long bone nonunion fractures.MethodsWe performed a retrospective chart review of patients with fracture nonunion, aged 10 to 99 years who were treated with teriparatide at the Children’s Hospital of Philadelphia or the Hospital of the University of Pennsylvania between November 2002 and January 2013. The primary endpoints were radiographic evidence of callus formation and fracture union, ability to bear weight without affected limb limp, and normal range of motion and strength.ResultsSix patients aged 19 to 64 years with tibial or femoral fractures that had not healed for 3 to 36 months were treated with teriparatide 20 μg/day. Accelerated healing of fracture nonunion was confirmed in 5 of 6 patients with time to complete union of 3 to 9 months. The shortest time to recovery was observed in younger patients without comorbidities. Treatment was well tolerated.ConclusionTeriparatide is a promising treatment for nonunion fractures, but its response depends on associated comorbidities. The potential benefit of teriparatide as an adjunct to treat nonunion justifies randomized placebo-controlled trials to determine its efficacy and safety in broader populations. (Endocr Pract. 2015;21:136-142)     

Adult Hypophosphatasia Treated with Teriparatide: Report of 2 Patients and Review of the Literature

Objective: Hypophosphatasia (HPP) is a rare inherited metabolic bone disease from deficient activity of the tissue-nonspecific isoenzyme of alkaline phosphatase (TNSALP). Reportedly, teriparatide (parathyroid hormone 1–34) can benefit the adult form of HPP, including fracture healing. We studied 2 women with adult HPP given teripa-ratide and reviewed the reports of 6 additional patients.Methods: A 68-year-old black woman (patient 1) described low-trauma fractures and had subnormal serum alkaline phosphatase (ALP) activity. Biochemical findings were consistent with HPP. Mutation analysis revealed a heterozygous defect in exon 10 of TNSALP (ALPL). Teriparatide was injected daily for 2 years. Four years later, she fractured her right hip. Treatment was resumed for 8 months without further fractures. A 53-year-old white woman (patient 2) reported low-trauma fractures and had subnormal serum ALP. Mutation analysis revealed a heterozygous defect in exon 8 of TNSALP. She injected teriparatide daily for 2 years. One year later, bone mineral density (BMD) declined and treatment was resumed for 3 months. When she sustained a sacral fracture, teriparatide was administered for a further 18 months.Results: Patient 1's serum ALP increased while receiving teriparatide and returned to baseline after its discontinuation. BMD remained unchanged, but no fractures were sustained. Patient 2's serum ALP increased, but the improvement was not sustained. Femoral neck BMD increased significantly during the first cycle, declined significantly afterwards, and was regained during course of teriparatide.Conclusion: Teriparatide shows some benefit for adult HPP.Abbreviations:ALP = alkaline phosphataseBMD = bone mineral densityBSAP = bone-specific alkaline phosphataseCTX = C-telopeptideDXA = dual-energy X-ray absorptiometryFN = femoral neckHPP = hypophosphatasiaLS = lumbar spinePEA = phosphoethanolaminePLP = pyridoxal 5′-phosphatePTH = parathyroid hormoneSQ = subcutaneousTNSALP = tissue-nonspecific isoenzyme of alkaline phosphataseTPTD = teriparatide     

Mortality Risk After Atypical Femoral Fracture: A Systematic Review and Meta-analysis

ObjectiveTo summarize all available data using systematic review and meta-analysis to estimate the 1-year mortality risk after atypical femoral fracture (AFF) and risk ratio of mortality after AFF versus typical femoral fracture (TFF).MethodsPotentially eligible studies were identified from MEDLINE and Embase databases from inception to February 2022 using a search strategy that comprised the terms for “atypical femoral fracture” and “mortality.” An eligible study must consist of a cohort of patients with AFF. Then, the study must report the 1-year mortality rate after the AFF or report effect estimates with 95% confidence intervals, comparing the incident mortality between patients with AFF and TFF. Point estimates with standard errors were retrieved from each study and combined using the generic inverse variance method.ResultsA total of 8967 articles were identified. After 2 rounds of independent review by 3 investigators, we identified 7 studies reporting the 1-year mortality rate of AFFs and 3 studies comparing the mortality rate of AFF with that of TFF. Pooled analysis revealed a pooled 1-year mortality rate after an AFF of 0.10 (95% confidence interval, 0.05-0.16; I² = 93.3%). Two studies compared the mortality risks of AFF with those of TFF and revealed conflicting results.ConclusionThe 1-year mortality rate after an AFF was approximately 10%. However, evidence is insufficient to conclude whether there was a difference in mortality risk between AFF and TFF.     

髓腔内固定联合低强度脉冲超声对兔股骨中段骨折愈合作用研究

摘要 目的：针对髓腔内固定联合低强度脉冲超声对兔股骨中段骨折愈合作用进行研究。方法：选择成年兔股骨中段骨折40只,作为本次的研究对象,将其平均分为对照组和观察组。所有兔子,在手术前禁水、禁食,对其右后肢进行备皮,称重、麻醉,对照组实施髓腔内固定治疗,观察组实施髓腔内固定联合低强度脉冲超声治疗。治疗后1、2、3、4周对兔子的骨折部位进行影像学检查确定兔子的骨折线模糊情况,并在各周采集样品进行组织学检查。治疗4周后对骨折愈合情况进行检查。结果：观察组愈合程度I级、II级、II级比例均低于对照组相应比例,差异具有统计学意义（P＜0.05）,观察组IV级、V级比例分别为35.0 %、55.0 %,均高于对照组的5.0 %、5.0 %,差异具有统计学意义（P＜0.05）;观察组兔子的在1 w、2 w、3 w、4 w骨折线模糊程度评分高于对照组相应时间评分,差异具有统计学意义（P＜0.05）。结论：在兔股骨中断骨折治疗中,实施髓腔内固定联合低强度脉冲超声,可以提高骨折的愈合速度,加速骨折修复,整体治疗效果显著,可以在临床上进行推广实施。     

An Interesting Case of Peripheral Vascular Disease,Vascular Reperfusion,and Subsequent Development of Pain Due to Paget's Disease of Bone

ObjectiveTo present a case of Paget’s disease of bone that was unmasked after vascular reperfusion.MethodsIn this case study, we review the presentation, evaluation, diagnosis, and management of a patient with Paget’s disease and peripheral vascular disease.ResultsA 79-year-old-woman with a history of coronary artery heart disease and recent finding of a T5 compression fracture was hospitalized for evaluation of right lower extremity claudication. Angiography demonstrated a focal complete occlusion of the distal right femoral and popliteal arteries. A self-expanding stent was placed in the distal femoral and popliteal arteries. Approximately 48 hours after the procedure, the patient developed severe, right lower leg pain. On endocrine evaluation, the patient was found to have clinical signs suggesting Paget’s disease of bone, which was subsequently confirmed by imaging.ConclusionThis patient’s development of severe pain following reperfusion of distal femoral and popliteal arteries is in keeping with the known and aforementioned hypervascularity of pagetic bone. The finding of increased warmth over an area of skeletal deformation should always raise the possibility of Paget’s disease of bone.(Endocr Pract. 2013;19:e61-e63)     

Iatrogenic Osteoporosis,Bilateral Hip Osteonecrosis,and Secondary Adrenal Suppression in an Hiv-Infected Man Receiving Inhaled Corticosteroids and Ritonavir-Boosted Highly Active Antiretroviral Therapy

ObjectiveTo report the first case of severe osteoporosis associated with a vertebral pathologic fracture and osteonecrosis of femoral heads in an HIV-infected man receiving inhaled corticosteroids and ritonavir-boosted antiretroviral therapy.MethodsWe describe an HIV-infected man with severe osteoporosis, bilateral hip osteonecrosis, and secondary adrenal suppression, including detailed clinical, laboratory, and radiographic data, and review the related literature.ResultsA 60-year-old man with a 15-year history of HIV infection and a medical history of long-standing bronchiectasis treated with inhaled corticosteroids and hypogonadism treated with testosterone was referred to the endocrinology clinic after experiencing an osteoporotic vertebral fracture. He was taking ritonavir-boosted antiretroviral therapy. Osteonecrosis of both hips was also diagnosed, which required total hip replacement therapy.Laboratory evaluation revealed adrenal insufficiency due to increased effect of exogenous inhaled steroids and no other secondary causes of osteoporosis. A bone densitometry study showed osteoporosis of both hips and the lumbar spine. He was treated with intravenous pamidronate. During treatment, he developed bilateral femoral fractures after minor trauma.ConclusionsGiven the potential for increased serum levels of inhaled corticosteroids in patients taking ritonavirboosted highly active antiretroviral therapy, attention must be paid to the risk of bone loss in HIV-infected patients taking inhaled corticosteroids. Prescribing calcium and vitamin D supplementation and considering early osteoporosis screening are reasonable measures for this patient population. Interaction between inhaled corticosteroids and ritonavir may increase risk of hypothalamus-pituitary-adrenal axis suppression. (Endocr Pract. 2011;17:74-78)     

Treatment of Adult Hypophosphatasia with Teriparatide

ObjectiveTo describe the effects of 24 months of teriparatide therapy in an adult with hypophosphatasia, which thus far has no established medical treatment.MethodsA 75-year-old woman with hypophosphatasia was treated with ergocalciferol and calcium supplements for 2 years. She had sustained multiple spontaneous and low-trauma fractures since she was 10 years old. Baseline biochemical values (and reference ranges) were as follows: serum total alkaline phosphatase ranged from 14 to 17 U/L (30 to 110), bone-specific alkaline phosphatase (BSALP) was 5 U/L (14 to 43), serum phosphorus was elevated at 5.4 mg/dL (2.6 to 4.4), and pyridoxal 5′-phosphate was high at 250 ng/mL (5 to 30). At baseline, she had mild secondary hyperparathyroidism (intact parathyroid hormone, 76 pg/mL; reference range, 10 to 65), which was corrected by the calcium supplementation and vitamin D therapy. Dual-energy x-ray absorptiometry (DXA) scanning in 2003 showed L1-L4 bone mineral density (BMD) of 0.786 g/cm², T score of -3.3, and Z score of -1.7; DXA also showed femoral neck BMD of 0.740 g/cm², T score of -2.5, and Z score of -0.5. During walking, the patient sustained a low-trauma fracture in a metatarsal. Teriparatide, synthetic parathyroid hormone(1-34), in a dosage of 20 μg subcutaneously was given daily from April 2004 until June 2006.ResultsAfter about 1.5 years of teriparatide therapy, BSALP reached the lower end of the reference range at 16 U/L, and after 24 months of continuous teriparatide treatment, both serum total alkaline phosphatase and BSALP normalized at 30 U/L and 18 U/L, respectively. Pyridoxal 5′-phosphate declined from a baseline of 250 to 188 ng/mL after 17 months of treatment. Urinary N-telopeptide increased from a baseline of < 6 to 19 after 17 months and to 70 bone collagen equivalents/mmol creatinine after 24 months of anabolic therapy. Repeated DXA scanning showed a substantial improvement in lumbar spine BMD and stability in hip BMD. The patient experienced no clinical fractures or adverse events during teriparatide therapy.ConclusionIn one woman with adult hypophosphatasia, 2 years of teriparatide treatment improved bio-chemical markers of bone remodeling and increased skeletal mineralization. Teriparatide may prove to be a viable treatment for adult hypophosphatasia; thus, this intervention warrants further evaluation. (Endocr Pract. 2008;14:204-208)     

A Case of Hypercalcemia Associated with Castleman Disease

ObjectiveTo present a case of hypercalcemia associated with Castleman disease.MethodsThe details of case presentation, evaluation, diagnosis, and treatment are reviewed in a 25-year-old woman with severe hypercalcemia, joint pain, conjunctival injection, and lymphadenopathy.ResultsEndocrinopathies such as primary hyperparathyroidism were ruled out. Infectious and rheumatologic laboratory evaluations revealed normal results. On a whole-body scan, the patient was noted to have diffusely increased osseous uptake in conjunction with increased periarticular uptake, consistent with a metabolic superscan. After extensive evaluation, the patient underwent a right axillary lymph node biopsy and was found to have multicentric Castleman disease. She was treated with high-dose corticosteroids and eventually immunomodulators to help control her disease.ConclusionTo the best of our knowledge, this is the first published case report demonstrating hypercalcemia in association with Castleman disease. The pathologic mechanism is likely bone turnover mediated by cytokines such as interleukin-6. (Endocr Pract. 2010;16:1007-1011)     

Efficacy of Teriparatide in Patients with Resolved Secondary Hyperparathyroidism due to Vitamin D Deficiency

ObjectiveTo determine the efficacy of at least 1 year of teriparatide therapy on bone mineral density (BMD), T-scores, and rates of occurrence of fractures in patients with a history of resolved secondary hyperparathyroidism due to vitamin D deficiency and to compare its efficacy with that in patients without a history of resolved secondary hyperparathyroidism.MethodsIn this retrospective study based on a search of electronic medical records, we collected the following data: patient demographics, doses of calcium and vitamin D supplementation, duration of teriparatide treatment, history and treatment of secondary hyperparathyroidism, BMD information, T-scores, and any history of fractures. Paired and unpaired t tests, the Fisher exact test, and the Wilcoxon rank sum test were used for statistical analysis.ResultsNinety-five patients (7 with a history of resolved secondary hyperparathyroidism due to vitamin D deficiency and 88 without such a history) fulfilled the study inclusion criteria. Baseline characteristics (demographics, median calcium and vitamin D supplementation doses, mean BMD, mean T-scores, and fracture rates before Submitted for publication July 31, 2010 Accepted for publication January 13, 2011 teriparatide therapy) were similar between the 2 groups. In comparison with baseline data, after a mean of 21 months of teriparatide therapy: (1) hip BMD and T-scores did not change in either study group (with no significant differences between the 2 groups), (2) spine BMD and T-scores significantly improved in both study groups (with no significant differences between them), and (3) wrist T-scores significantly worsened in both study groups (with wrist BMD significantly lower in patients without a history of secondary hyperparathyroidism). No patients with a history of secondary hyperparathyroidism sustained a fracture while receiving teriparatide therapy versus 6 of 88 patients without a history of secondary hyperparathyroidism (P = .624).ConclusionPatients with a history of resolved secondary hyperparathyroidism attributable to vitamin D deficiency responded to teriparatide therapy in a fashion similar to patients without such a history. (Endocr Pract. 2011;17:568-573)     

Osteoporosis in Men

ObjectiveTo review information pertinent to bone health and osteoporosis in men.MethodsA review of pertinent literature was conducted.ResultsOsteoporosis affects approximately 2 million men in the US and accounts for an estimated 600,000 fractures each year. There are significant differences in skeletal size and structure between men and women that account for differences in fracture incidence, location, and outcomes. Bone density testing is appropriate for men age 70 and older and younger men (50-69) who have risk factors for osteoporosis. Lifestyle management, including adequate calcium and vitamin D intake, appropriate physical activity, and avoidance of tobacco and heavy alcohol use, is appropriate for all men. Pharmacologic therapy to reduce fracture risk is advisable for men with a clinical diagnosis of osteoporosis (a spine or hip fracture) or a T-score of −2.5 or below in the spine, femoral neck, total hip or 1/3 radius; however, the majority of men at high risk will only be identified using a fracture risk assessment tool, such as FRAX. Alendronate, risedronate, zoledronic acid, denosumab, and teriparatide are Food and Drug Administration (FDA)-approved therapeutic options.ConclusionOsteoporosis in men presents an important public health problem with significant morbidity and mortality. There are recommended strategies for identifying men at high risk of fracture, and effective agents are available for treatment. (Endocr Pract. 2013;19:834-838)     

Graves Ophthalmopathy After Radiation Treatment of Thyroid Cancer

ObjectiveTo describe a patient with metastatic thyroid cancer who developed Graves ophthalmopathy after treatment with radioiodine (I 131) and external beam radiation.MethodsWe present a case report that includes clinical, laboratory, and radiologic findings and a brief review of the literature.ResultsA 49-year-old woman who had had a total thyroidectomy and neck dissection followed by I 131 treatment 5 years earlier for papillary thyroid cancer presented for follow-up management after recent neck dissection for recurrent disease. Because she had thyroglobulin antibodies, she was again treated with I 131 after preparation with recombinant human thyroid-stimulating hormone. A post-treatment scan revealed uptake in the right iliac crest. A fludeoxyglucose F 18 positron emission tomography/computed tomography fusion scan revealed osseous metastases in the right pelvis, and external beam radiotherapy was delivered to this area. Approximately 5 months later, she developed periocular swelling and excessive tearing. Magnetic resonance imaging of the orbits revealed enlargement of the extraocular muscles. Serum thyroid-stimulating immunoglobulins were greatly elevated.ConclusionThis case corroborates an earlier report to suggest that radiation-associated thyroid injury in a patient with thyroid cancer may be followed by Graves ophthalmopathy and appearance of thyroid-stimulating immune-globulins in the serum. (Endocr Pract. 2008;14:419-421)     

AN 18-Month Open-Label Trial of Teriparatide in Patients with Previous Parathyroidectomy at Continued Risk for Osteoporotic Fractures: An Exploratory Study

ObjectiveTo determine whether teriparatide increases lumbar spine bone mineral density (BMD) in patients who have undergone parathyroidectomy for primary hyperparathyroidism (PHPT) and are at continued risk for fracture.MethodsThis open-label, nonrandomized, uncontrolled exploratory design study included patients who had undergone parathyroidectomy for PHPT and were judged to be at continued risk for fracture according to National Osteoporosis Foundation criteria. Patients were administered teriparatide subcutaneously, 20 mcg daily, for 18 months after they satisfactorily completed the screening period to ensure their eligibility for study participation. BMD was assessed by dual-energy x-ray absorptiometry at baseline, 6 months, 12 months, and 18 months. Secondary objectives included efficacy of teriparatide on increasing hip BMD, incidence of fractures, and safety measurements.ResultsSeven women and 3 men were included. Change in mean lumbar spine BMD was 0.059 gm/cm², which is a 7.1% increase (P = .005). Change in mean femoral neck BMD was 0.019 gm/cm², which is a nonsignificant increase of 3.3% (P = .49). There was no incidence of fractures. There were no significant changes in the safety measurements.ConclusionsThe use of teriparatide in patients with PHPT who have undergone parathyroidectomy and are still at risk for fracture is effective in improving lumbar spine BMD without deleterious effects on safety. Teriparatide should therefore be considered as a viable alternative for the treatment of these patients, as it may help in the prevention of fractures and their complications. (Endocr Pract. 2011;17:377-383)     

对侧皮质锁定螺钉与锁定螺钉治疗股骨远端骨折疗效比较

目的:比较对侧皮质锁定螺钉与锁定螺钉治疗股骨远端骨折的临床疗效。方法:回顾性分析自2013年5月至2016年8月诊治的52例股骨远端骨折患者,采用对侧皮质锁定螺钉+NCB接骨板内固定治疗26例(A组:对侧皮质锁定组),采用锁定螺钉+NCB接骨板内固定治疗26例(B组:锁定螺钉组)。记录两组手术出血量和手术时间、切口长度、内固定治疗后骨折愈合时间、内固定治疗后完全负重时间、内固定治疗后并发症发生率等,在每个随访节点对每位患者进行患肢的正侧位X线平片检查,末次随访时对患肢进行膝关节功能评分,采用美国特种外科医院膝关节评分标准评定患肢功能。骨折愈合的定义为活动时骨折处无痛且在骨折正侧位X线平片上可见到断端骨皮质骨痂连接。术后并发症包括:关节僵硬、内固定断裂、骨不连以及感染等。结果:本研究52例骨折均获得至少12个月的随访。两组在手术相关指标及切口愈合等方面均无明显差异(P均0.05)。在骨折愈合以及完全负重时间方面,A组均显著短于B组(P均0.05)。末次随访时52例患者患肢膝关节功能:A组:优18例,良5例,差4例,优良率88.5%;B组:优15例,良6例,中4例,差1例,优良率80.8%。两组对比A组优良率显著高于B组(P0.05)。两组并发症对比无明显差异:A组发生骨不连2例,骨折内固定断裂2例。B组发生骨不连3例,畸形愈合2例。结论:与传统锁定螺钉相比,对侧皮质锁定螺钉在骨折愈合时间、完全负重时间、术后患肢功能优良率方面具有优势,但在并发症发生率方面没有明显差异。对侧皮质锁定螺钉的治疗指征及自身强度还有待大样本、多中心的临床研究进一步明确。     

Switching to Denosumab or Bisphosphonates After Completion of Teriparatide Treatment in Women With Severe Postmenopausal Osteoporosis

ObjectiveTo compare bone mineral density (BMD) changes after 12 months of treatment with denosumab or bisphosphonates in postmenopausal women with severe osteoporosis after stopping teriparatide therapy.MethodsWe retrospectively analyzed 140 postmenopausal women (mean age, 74.2 years) with severe osteoporosis who had been treated with teriparatide for 18 to 24 months at our outpatient clinic in a tertiary endocrine center between 2006 and 2015. After stopping teriparatide therapy, they continued treatment with a bisphosphonate (alendronate, risedronate, ibandronate, or zoledronic acid) or denosumab while receiving daily vitamin D and calcium. BMD at the lumbar spine (LS), total hip (TH), and femoral neck (FN) was measured by dual energy x-ray absorptiometry when teriparatide therapy was discontinued (baseline) and after 12 months of further treatment. Multivariate linear regression models were used to identify the predictors of BMD gain.ResultsAfter stopping teriparatide therapy, 70 women continued treatment with bisphosphonates and 70 received denosumab. LS, but not TH or FN, BMD gain was significantly greater in the denosumab group than in the bisphosphonates group at 12 months. Multivariate analysis showed that BMD gain at the LS was negatively associated with bisphosphonate versus denosumab treatment and positively associated with baseline serum total procollagen type I N-terminal propeptide. BMD gains at the FN were predicted by higher baseline serum urate levels. BMD gains at the TH and FN were negatively associated with pretreatment BMD gains at the same site.ConclusionTwelve months after stopping teriparatide therapy, sequential denosumab treatment appeared to yield higher additional LS BMD gain on average compared with bisphosphonates treatment.     

Slipped Capital Femoral Epiphysis In a Patient With Turner Syndrome Receiving Growth Hormone Therapy

ObjectiveTo report a case of slipped capital femoral epiphysis in a young patient with Turner syndrome (TS) receiving growth hormone therapy and to emphasize the importance of keeping this orthopedic condition in mind during management of this patient group.MethodsClinical, laboratory, and radiographic findings are presented, and risk factors for slipped capital femoral epiphysis are discussed.ResultsA child with TS presented for medical assessment because of a limp but with no history of trauma or febrile illness. Growth hormone therapy had been administered for 1 year because of her short stature. Physical examination and pelvic radiography of the patient showed the presence of bilateral slipped capital femoral epiphysis. She underwent bilateral pinning in situ, and growth hormone therapy was terminated. At follow-up after more than 2 years, no sequelae were noted.ConclusionPatients with TS are at high risk for developing certain orthopedic conditions, such as slipped capital femoral epiphysis. Furthermore, slipped capital femoral epiphysis is a known complication of growth hormone therapy in growing children. A limp, hip pain, knee pain, or thigh pain might be a symptom of slipped capital femoral epiphysis in patients with TS, especially those receiving growth hormone therapy. Prompt recognition and treatment of this condition are important for prevention of sequelae. (Endocr Pract. 2012;18:e135-e137)     

Osteogenic Sarcoma of the Sella After Radiation Treatment of a Pituitary Adenoma

ObjectiveTo report an uncommon case of osteogenic sarcoma of the sella turcica after radiation treatment of a pituitary adenoma.MethodsWe present the clinical history, physical findings, laboratory data, imaging studies, and pathologic findings in a patient found to have osteogenic sarcoma of the sella after radiation therapy for a nonfunctioning pituitary adenoma.ResultsSix years after transsphenoidal resection and postoperative fractionated radiation therapy for a nonfunctioning pituitary adenoma that extended to the cavernous sinus, a 45-year-old man presented with a sinus infection, diplopia, and ophthalmoplegia of the right eye. A computed tomographic scan of the head showed a mass in the sella with involvement of the optic chiasm and right cavernous sinus. Transsphenoidal resection and debulking of the tumor revealed an osteogenic sarcoma. The patient was discharged from the hospital with residual diplopia and ophthalmoplegia. He was treated with levothyroxine, testosterone, and hydrocortisone. Six weeks later, the patient was readmitted after he was found unresponsive, and computed tomographic scans disclosed a massive cerebrovascular accident. He died a few days later.ConclusionOsteogenic sarcoma is a rare, late complication of radiation treatment of pituitary adenoma. Although radiotherapy remains an effective adjunctive treatment in patients with pituitary adenomas, particularly those with residual or recurrent tumor, potential complications must be acknowledged. (Endocr Pract. 2004;10: 335-338)     

Teriparatide (1-34 human PTH) regulation of osterix during fracture repair

Based on remarkable success of PTH as an anabolic drug for osteoporosis, case reports of off-label use of teriparatide (1-34 PTH) in patients with complicated fractures and non-unions are emerging. We investigated the mechanisms underlying PTH accelerated fracture repair. Bone marrow cells from 7 days 40 microg/kg of teriparatide treated or saline control mice were cultured and Osx and osteoblast phenotypic gene expression assessed by real-time RT-PCR in these cells. Fractured animals injected daily with either saline or 40 microg/kg of teriparatide for up to 21 days were X-rayed and histological assessment performed, as well as immunohistochemical analyses of the Osx expression in the fracture callus. Osx, Runx2 and osteoblast or chondrocyte phenotypic gene expression was also assessed in fracture calluses. Our data shows that Osx and Runx2 are up-regulated in marrow-derived MSCs isolated from mice systemically treated with teriparatide. Furthermore, these MSCs undergo accelerated osteoblast maturation compared to saline injected controls. Systemic teriparatide treatments also accelerated fracture healing in these mice concomitantly with increased Osx expression in the PTH treated fracture calluses compared to controls. Collectively, these data suggest a mechanism for teriparatide mediated fracture healing possibly via Osx induction in MSCs.     

"F"型置钉与FNS固定术对成人创伤性Pauwels III型股骨颈骨折患者疗效、骨折愈合状况及髋关节功能的影响

摘要 目的：探讨"F"型置钉与新型股骨颈内固定系统（FNS）固定术对成人创伤性Pauwels III型股骨颈骨折疗效、骨折愈合状况及髋关节功能的影响。方法：选取2019年1月-2021年12月我院收治的78例成人创伤性Pauwels III型股骨颈骨折患者作为研究对象,采用随机数字表法将患者分为对照组及研究组,各36例。对照组采用FNS进行治疗,观察组采用"F"型置钉内固定术进行治疗。观察并比较两组患者治疗疗效、术后情况、骨折愈合情况、髋关节功能、骨折复位质量及并发症发生情况。结果：观察组治疗总有效率80.56%高于对照组52.78%（P<0.05）。观察组住院时间、下地行走时间及完全负重时间均短于对照组（P<0.05）。观察组骨折愈合状况优于对照组（P<0.05）。两组患者Harris评分随时间发展而逐渐升高,且观察组术后1个月、术后3个月及术后6个月评分均高于对照组（P<0.05）。观察组骨折复位率77.78%高于对照组41.67%（P<0.05）。观察组并发症发生率低于对照组（P<0.05）。结论："F"型置钉及FNS固定术均可以治疗成人创伤性Pauwels III型股骨颈骨折患者,但"F"型置钉治疗疗效更好,并且力学稳定性能更好,术后并发症较少,利于患者术后恢复,值得在临床治疗中推广使用。