Hip Pelvis.  2017 Dec;29(4):286-290. 10.5371/hp.2017.29.4.286.

Acetabular Insufficiency Fracture Following Prolonged Alendronate Use and the Failure of Total Hip Arthroplasty in “Frozen” Bone: Two Cases Report

• Kwak SJ
• Cho YJ
• Jung GY
• Lee JH
• Chun YS
• Rhyu KH

• KMID: 2424256
• DOI: http://doi.org/10.5371/hp.2017.29.4.286

Abstract

Atypical insufficiency fracture of the femur following prolonged bisphosphonate use is well described. Regardless of the cause, insufficiency fracture of the acetabulum is extremely rare, and no reports have described insufficiency fractures of the acetabulum that are associated with prolonged bisphosphonate use. This report demonstrates the possibility of insufficiency fracture at the acetabulum following long-term alendronate use and the necessity of particular care in managing insufficiency fractures in "frozen" bone. We describe two cases of insufficiency fracture of the acetabulum following 6 years of alendronate use. Given the patients' medical histories and bone biopsy findings, these insufficiency fractures were thought to be attributable to alendronate use. One case involved the left hip and the presence of pelvic fractures on the opposite side. The patient was treated using cementless total hip arthroplasty (THA), which failed 1 year after surgery. The hip was revised with a massive bone graft and a supportive wire mesh. The other case was managed via THA with a Ganz reinforcement ring due to concerns regarding the use of a cementless implant.

Keyword

Total hip replacement; Alendronate; Acetabulum; Insufficiency fracture

MeSH Terms

Acetabulum*
Alendronate*
Arthroplasty, Replacement, Hip*
Biopsy
Femur
Fractures, Stress*
Hip
Humans
Transplants
Alendronate

Figure

• 

  Fig. 1 Radiographic and histological images of case 1. (A) Initial anteroposterior (AP) pelvis radiograph, showing axial migration of the left femoral head into a protruding acetabulum with disruption of the medial wall. Concomitant fractures were found at ala of right sacrum and right pubis (arrows). (B) Histological findings of fractured fragmented bone from the patents of case 1, showing dead bone with empty lacunas and without any lining osteoblasts (H&E stain, ×100). (C) Postoperative AP pelvis radiograph, showing internal fixation with cannulated screw at ala of right sacrum and pubis. Left acetabular fracture was managed by internal fixation using a reconstructive plate on the posterior wall and wiring following total hip arthroplasty with primary cementless cup. (D) AP pelvis radiograph at 1 year after operation, revealing loosening failure of cementless acetabular cup. (E) Left acetabulum was reconstructed by impaction morselised bone graft on the wire mesh support.

• 

  Fig. 2 Radiographic and pathologic images of case 2. (A) Initial plain radiograph of pelvis at the time with left hip pain, revealing axial migration of the left femoral head into a protruding acetabulum with disruption of the roof. (B) Biopsy of trabecular bone (H&E stain, ×100), showing very thin, fragmented lamella bone and absence of surface osteoid, osteoclasts, and osteoblastslooks like dead bone. (C) Anteroposterior pelvis radiograph taken 6 months after surgery with total hip arthroplasty using Ganz reinforcement ring and allogenous bone graft.

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