Hip Pelvis.  2018 Jun;30(2):109-114. 10.5371/hp.2018.30.2.109.

An Uncommon Case of Bilateral Pathologic Hip Fractures: Antiviral Drug-induced Osteomalacia in a Patient with Hepatitis B

• Moon NH
• Shin WC
• Do MU
• Cho HJ
• Suh KT

• KMID: 2412692
• DOI: http://doi.org/10.5371/hp.2018.30.2.109

Abstract

The long-term use of adefovir and tenofovir-antiviral medications commonly used to treat chronic hepatitis B-can be associated with proximal renal tubular dysfunction resulting in significant hypophosphatemic osteomalacia. However, there have been few reports about pathological fractures requiring surgical stabilization in cases of antiviral drug-induced hypophosphatemic osteomalacia. We present the case of a 51-year-old man who sustained bilateral pathological hip fractures associated with antiviral drug-induced hypophosphatemic osteomalacia. To treat a lamivudine-resistant hepatitis-B viral infection, the patient received adefovir for 7 years followed by tenofovir for the subsequent 3 years. He had suffered from polyarthralgia and generalized weakness for 2 years prior to presentation at our clinic. Misdiagnosis and inadequate management of his condition accelerated weakness of the bone matrix and ultimately induced pathological fractures. The patient was managed via cementless total hip arthroplasty on the left hip and internal fixation on the right hip. This case highlights that orthopaedic surgeons should consider the possibility of hypophosphatemic osteomalacia if patients receiving antiviral drugs complain of polyarthralgia and generalized weakness.

Keyword

Antiviral agents; Hypophosphatemic osteomalacia; Pathological fracture

MeSH Terms

Antiviral Agents
Arthralgia
Arthroplasty, Replacement, Hip
Bone Matrix
Diagnostic Errors
Fanconi Syndrome
Fractures, Spontaneous
Hepatitis B*
Hepatitis*
Hepatitis, Chronic
Hip Fractures*
Hip*
Humans
Middle Aged
Osteomalacia*
Surgeons
Tenofovir
Antiviral Agents
Tenofovir

Figure

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  Fig. 1 Anteroposterior plain radiograph of both hip joints shows a displaced femoral neck fracture on the left side (arrow head) and a vertical crack across the intertrochanteric area (white arrow) on the right side.

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  Fig. 2 Coronal views of (A, B) computed tomography and (C, D) T1-weighted magnetic resonance images demonstrate a vertical crack in the right hip joint extending to the femoral neck and the subtrochanteric area.

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  Fig. 3 Postoperative anteroposterior radiograph of both hip joints shows total hip arthroplasty on the left side and internal fixation with an intramedullary device on the right side.

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  Fig. 4 (A) Whole-body bone scintigraphy demonstrates multiple foci of increased radiotracer uptake in multiple ribs, bilateral distal femurs, bilateral proximal and distal tibias, and right calcaneus. (B) Plain radiograph of both knee joints shows radiopaque transverse lines (white arrows) involving the left proximal femur and distal tibia suggestive of an insufficiency fracture. (C) Coronal T1-weighted magnetic resonance image of the left knee reveals incomplete fracture lines involving both distal femurs and the proximal tibial metaphysis. (D) Plain radiograph of the left ankle joint shows radiopaque transverse lines (arrow head) involving the left distal tibial metaphysis.

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