Clin Orthop Surg.  2016 Dec;8(4):437-443. 10.4055/cios.2016.8.4.437.

Influence of Early Bisphosphonate Administration for Fracture Healing in Patients with Osteoporotic Proximal Humerus Fractures

• Seo JB
• Yoo JS
• Ryu JW
• Yu KW

• KMID: 2412327
• DOI: http://doi.org/10.4055/cios.2016.8.4.437

Abstract

BACKGROUND
Bisphosphonates are generally known to adversely affect fracture healing because they inhibit osteoclastic bone resorption. However, some authors argue that bisphosphonates have no adverse effect on the restoration of the mechanical integrity of long bones after fractures. It is unclear whether bisphosphonates can be initiated safely in patients with acute proximal humerus fractures. The aim of this study was to determine whether the early use of a bisphosphonate affects healing and outcomes of osteoporotic proximal humerus fractures treated with a locking compression plate.
METHODS
Between August 2004 and June 2013, a total of 82 osteoporotic patients who underwent locking plate fixation of proximal humerus fractures were enrolled retrospectively. The patients were divided into two groups according to the timing of the commencement of treatment with alendronate after surgery: group A (n = 34, initiation of the bisphosphonate treatment within two weeks after surgery) and group B (n = 48, control group, initiation of the treatment three months after surgery). Patients were assessed for radiographic union at 2, 6, 10, and 16 weeks, 6 months, and 1 year after surgery. Clinical assessments were performed using the Constant score and American Shoulder and Elbow Surgeons (ASES) score at 1 year after surgery.
RESULTS
No significant differences were observed between the two groups with respect to radiographic and clinical outcomes after locking plate fixation. All patients obtained fracture union, and the mean time to radiographic union was similar in group A and group B (6.3 and 6.6 weeks, respectively; p = 0.67).
CONCLUSIONS
This study shows that the early initiation of bisphosphonate treatment does not affect bone union or clinical outcomes in patients with an osteoporotic proximal humerus fracture treated by locking compression plate fixation.

Keyword

Proximal humeral fracture; Osteoporosis; Bisphosphonate

MeSH Terms

Aged
Diphosphonates/administration & dosage/*pharmacology/*therapeutic use
Female
Fracture Healing/*drug effects
Humans
Male
Middle Aged
Osteoporotic Fractures/*drug therapy
Retrospective Studies
Shoulder Fractures/*drug therapy
Diphosphonates

Figure

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  Fig. 1 Immediate postoperative radiographs. (A) Anteroposterior view. (B) Axillary view.

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  Fig. 2 Radiographs taken at 6 weeks after operation showing union of the proximal humerus fracture. (A) Anteroposterior view to confirm the medial and lateral cortices. (B) Axillary view to confirm the anterior and posterior cortices.

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  Fig. 3 Measurement of the cervicodiaphyseal angle.

Reference

1. Consensus development conference: prophylaxis and treatment of osteoporosis. Osteoporos Int. 1991; 1(2):114–117.

2. Johnell O, Kanis J. Epidemiology of osteoporotic fractures. Osteoporos Int. 2005; 16:Suppl 2. S3–S7.

3. Johnell O, Kanis JA, Oden A, et al. Mortality after osteoporotic fractures. Osteoporos Int. 2004; 15(1):38–42.

4. Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. 2006; 17(12):1726–1733.

5. Helmy N, Hintermann B. New trends in the treatment of proximal humerus fractures. Clin Orthop Relat Res. 2006; 442:100–108.

6. Baron JA, Barrett JA, Karagas MR. The epidemiology of peripheral fractures. Bone. 1996; 18:3 Suppl. 209S–213S.

7. Silverman S, Christiansen C. Individualizing osteoporosis therapy. Osteoporos Int. 2012; 23(3):797–809.

8. Reginster JY, Burlet N. Osteoporosis: a still increasing prevalence. Bone. 2006; 38:2 Suppl 1. S4–S9.

9. Osugi K, Miwa S, Marukawa S, Marukawa K, Kawaguchi Y, Nakato S. Diaphyseal femoral fatigue fracture associated with bisphosphonate therapy: 3 more cases. Acta Orthop. 2011; 82(1):112–113.

10. Li C, Mori S, Li J, et al. Long-term effect of incadronate disodium (YM-175) on fracture healing of femoral shaft in growing rats. J Bone Miner Res. 2001; 16(3):429–436.

11. Cao Y, Mori S, Mashiba T, et al. Raloxifene, estrogen, and alendronate affect the processes of fracture repair differently in ovariectomized rats. J Bone Miner Res. 2002; 17(12):2237–2246.

12. Kim TY, Ha YC, Kang BJ, Lee YK, Koo KH. Does early administration of bisphosphonate affect fracture healing in patients with intertrochanteric fractures? J Bone Joint Surg Br. 2012; 94(7):956–960.

13. Gong HS, Song CH, Lee YH, Rhee SH, Lee HJ, Baek GH. Early initiation of bisphosphonate does not affect healing and outcomes of volar plate fixation of osteoporotic distal radial fractures. J Bone Joint Surg Am. 2012; 94(19):1729–1736.

14. Li YT, Cai HF, Zhang ZL. Timing of the initiation of bisphosphonates after surgery for fracture healing: a systematic review and meta-analysis of randomized controlled trials. Osteoporos Int. 2015; 26(2):431–441.

15. Neer CS 2nd. Displaced proximal humeral fractures: I. classification and evaluation. J Bone Joint Surg Am. 1970; 52(6):1077–1089.

16. Neer CS 2nd. Displaced proximal humeral fractures: II. treatment of three-part and four-part displacement. J Bone Joint Surg Am. 1970; 52(6):1090–1103.

17. Constant CR, Gerber C, Emery RJ, Sojbjerg JO, Gohlke F, Boileau P. A review of the Constant score: modifications and guidelines for its use. J Shoulder Elbow Surg. 2008; 17(2):355–361.

18. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977; 33(1):159–174.

19. Eriksen EF, Lyles KW, Colon-Emeric CS, et al. Antifracture efficacy and reduction of mortality in relation to timing of the first dose of zoledronic acid after hip fracture. J Bone Miner Res. 2009; 24(7):1308–1313.

20. Dirschl DR, Henderson RC, Oakley WC. Accelerated bone mineral loss following a hip fracture: a prospective longitudinal study. Bone. 1997; 21(1):79–82.

21. Beaupre LA, Morrish DW, Hanley DA, et al. Oral bisphosphonates are associated with reduced mortality after hip fracture. Osteoporos Int. 2011; 22(3):983–991.

22. Harrington JT, Ste-Marie LG, Brandi ML, et al. Risedronate rapidly reduces the risk for nonvertebral fractures in women with postmenopausal osteoporosis. Calcif Tissue Int. 2004; 74(2):129–135.

23. Li J, Mori S, Kaji Y, Mashiba T, Kawanishi J, Norimatsu H. Effect of bisphosphonate (incadronate) on fracture healing of long bones in rats. J Bone Miner Res. 1999; 14(6):969–979.

24. Odvina CV, Zerwekh JE, Rao DS, Maalouf N, Gottschalk FA, Pak CY. Severely suppressed bone turnover: a potential complication of alendronate therapy. J Clin Endocrinol Metab. 2005; 90(3):1294–1301.

25. Rozental TD, Vazquez MA, Chacko AT, Ayogu N, Bouxsein ML. Comparison of radiographic fracture healing in the distal radius for patients on and off bisphosphonate therapy. J Hand Surg Am. 2009; 34(4):595–602.

26. Amanat N, McDonald M, Godfrey C, Bilston L, Little D. Optimal timing of a single dose of zoledronic acid to increase strength in rat fracture repair. J Bone Miner Res. 2007; 22(6):867–876.

27. Fleisch H. Can bisphosphonates be given to patients with fractures? J Bone Miner Res. 2001; 16(3):437–440.

28. Bindra RP. Basic pathology of the hand, wrist, and forearm: bone and joint. In : Berger RA, Weiss AP, editors. Hand surgery. Philadelphia, PA: Lippincott Williams & Wilkins;2004. p. 1–21.