Rev. bras. ortop. vol.49 número5

r e v b r a s o r t o p . 2014;49(5):540–542

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Case

Report

Bilateral

spontaneous

fracturing

of

the

femoral

neck

in

a

patient

with

renal

osteodystrophy

夽

,

夽夽

Flavio

Luís

Garcia

,

Renato

Bellini

Dalio

,

Arthur

Tomotaka

Sugo

,

Celso

Hermínio

Ferraz

Picado

a_{RibeirãoPretoMedicalSchool,UniversidadedeSãoPaulo(USP),RibeirãoPreto,SP,Brazil}

b_{HospitaldasClínicas,RibeirãoPretoMedicalSchool,UniversidadedeSãoPaulo(USP),RibeirãoPreto,SP,Brazil}

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Articlehistory: Received4July2013 Accepted19July2013 Availableonline22July2014

Keywords:

Fracturesofthefemoralneck Renalosteodystrophy Fracturefixation

a

b

s

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c

t

Wereportacaseofbilateralfracturingofthefemoralneckinapatientwithrenal osteodys-trophywhowastreatedbymeansofosteosynthesis.Inthistypeofpatient,thereisaneedto remainwatchfulforthepossibilityofoccurrencesofspontaneousfracturingofthefemoral neck,eveniftheinitialradiographicexaminationisnormal.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Fratura

espontânea

bilateral

do

colo

femoral

em

paciente

com

osteodistrofia

renal

Palavras-chave:

Fraturasdocolofemoral Osteodistrofiarenal Fixac¸ãodefratura

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e

s

u

m

o

Relatamosumcasodefraturabilateraldocolofemoralempacientecomosteodistrofiarenal tratadacomosteossíntese.Nessetipodepaciente,énecessárioestaratentoàpossibilidade deocorrênciadefraturasespontâneasdocolofemoral,mesmocomexameradiográfico inicialnormal.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora Ltda.Todososdireitosreservados.

夽

Pleasecitethisarticleas:GarciaFL,DalioRB,SugoAT,PicadoCHF.Fraturaespontâneabilateraldocolofemoralempacientecom osteodistrofiarenal.RevBrasOrtop.2014;49(5):540-2.

夽夽

WorkdevelopedatHospitaldasClínicas,RibeirãoPretoMedicalSchool,UniversidadedeSãoPaulo(USP),RibeirãoPreto,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](F.L.Garcia).

http://dx.doi.org/10.1016/j.rboe.2014.07.004

rev bras ortop.2014;49(5):540–542

541

Introduction

Pathological bilateral fractures of the femoral neck have alreadybeenwelldescribedintheliterature,1,2_butcases

relat-ingspecificallytorenalosteodystrophyarerare.3_Wereporta

caseofanadultpatientwithchronickidneyfailureandrenal osteodystrophywhopresentedspontaneousbilateral fractur-ingofthefemoralneck,whichwastreatedbymeansof inter-nalfixation.Thepatient’sinitialradiographswerenormal.

Case

report

The patient was a 43-year-old woman who was admitted tohospitalforasecond kidney transplantation. Shehad a historyofchronicrenalfailurethathadoccurred9years ear-lier,ofunknownetiology,andsheunderwentherfirstkidney transplantation8yearsbeforethe presentcase.This trans-plantedkidneyfailedbecauseofstenosisoftherenalartery. Itwas removed 4months afterwards and, since then,the patient had been living under hemodialysis. She also pre-sentedcongestiveheartfailure,whichwasbeingtreatedwith antihypertensives and diuretics. During the month before hospitaladmission,shewasalsodiagnosedaspresenting sec-ondaryhyperparathyroidism,withhypocalcemia(7.1mg/dL; normalrange:8.4–10.5mg/dL)andextremelyhigh parathor-monelevels(>2500pg/mL;normalrange:10–69pg/mL).Oral calcitrioltherapywasstarted:threedosesof7␮gperweek).

Threeweeksafterthesecondkidneytransplantation,while stillatthehospital,thepatientcomplainedofsudden contin-uouspaininherlefthip,withoutanytrauma,whichprevented herfromwalking.Shepresentedacompleterangeofmotion, albeitpainfulinthat hip,butwithout requiringpainkillers. Thephysical examinationon her right hip showed that it wascompletelynormal.Radiographsproducedatthattime showedthattherewasareductioninthemaingroupof ten-sionedtrabecularboneintheproximalfemur(Singhindex grade4),diffusebonerarefaction,thickeningofthe perios-teuminthefemoralcorticalboneandacetabularprotrusion. Thesefindingsrelatedtorenalosteodystrophy,butnofracture lineswerepresent(Fig.1).Wesuspectedthattheremightbe anoccultfractureintheleftfemoralneck,andmagnetic reso-nanceimaging(MRI)wasrequested.Thepatientwasadvised toremainrestinginbeduntiltheexamination.

Fivedaysafterthisfirstevaluation,thepatientpresented paininherrighthipandworseningofthepaininherlefthip. Newradiographswererequestedandthesedemonstratedan incompletefractureoftheuppersurfaceofthefemoralneck, bilaterally(Fig.2).TheMRIwasthencanceled.

Twodaysafterthisdiagnosiswasmade,thepatient under-wentosteosynthesis.Shewaspositionedinhorizontaldorsal decubitusonaradiotransparenttableandimagesofthehips were obtainedbymeans ofanimageintensifier.Wemade astraight incisionoflength4cminthelateralfaceofeach hip,immediatelydistaltothemostprominentregionofthe greatertrochanter.Guidewireswereintroducedandthe frac-tureswerefixedusingcannulatedscrews.Weonlyusedtwo 7mmcannulated screwsineachhip, ashad beenplanned preoperatively,giventhatthefemoralneckwasverynarrow.

Fig.1–Initialanteroposteriorradiographonthepelvis.No fracturewasidentified.

Thepatientwasdischargedfromhospitaltwoweeksafter theosteosynthesis,withoutpainandwithanalmostcomplete rangeofhipmotion.Shewaskeptwithoutbearingweighton herlowerlimbs,and wasevaluatedclinicallyand radiogra-phicallyonceamonthonanoutpatientbasis,untilthefifth monthafterosteosynthesis,when the radiographs demon-stratedthatcompleteboneconsolidationhadbeenattained (Fig.3).Atthisevaluation,5monthsaftertheoperation,the patientwasadvisedtouseawalkingframe,andinthe subse-quentevaluation,shewasauthorizedtowalkbearingherown fullweight,withoutexternalsupport.Shewasseenforthelast time1yearaftertheosteosynthesis,anddidnotpresentany complaints.

Discussion

Renalosteodystrophyisarelativelycommonconditionandis oneofthebiggestcauses ofmorbidityinpatients undergo-ingdialysistreatmentforkidneyfailureorevenafterkidney transplantation.

ChronicazotemiahasamarkedeffectonvitaminD, cal-cium and phosphorus metabolism and on parathormone

542

Fig.3–Anteroposteriorradiographonthepelvis,5months aftertheosteosynthesis,showingconsolidationofthe fractures.

secretion, and all these metabolic alterations lead to the pathological bone remodeling that is observed in renal osteodystrophy.4 _{Contrarytotheosteopeniaand}

osteoporo-sisobservedinthesepatients,pathologicalfractures ofthe femoralneck are generally symptomatic.5 _{Several cases of}

femoralneckfracturesinpatientswithrenalosteodystrophy havenowbeenreported,1,3,6,7_{butbilateralcasesarerare.}3

Althoughincomplete fractures of the femoral neckcan betreatedconservatively,wechosetouseosteosynthesisin ordertoreducethepossibilityofdisplacementofthese frac-tures.Thisconsequentlyreducedtheneedformoreextensive andmorecomplexsurgery,giventhatseveralauthors have reportedhighratesofcomplications,andevendeaths,among patientswhorequirehip arthroplastywhiletheyareunder dialysistreatmentforchronickidneyfailure.8,9_Theprolonged

timetakentoachieveboneconsolidationinthepresentcase (5months)waspossiblyconsequenttothedeficientbone min-eralizationthatpatientswithrenalosteodystrophypresent.10

There are very fewreports inthe literatureon bilateral osteosynthesis of the femoral neck in patients with renal osteodystrophy.10_{Ourintentionisthatthecasereportedhere}

mightservetoalertorthopediststothe possibilityof bilat-eral fractures of the femoral neck in patients with renal

osteodystrophywhopresentsuddenspontaneouspain,even iftheinitialradiographswerenormal.Ahighdegreeof suspi-cionisnecessaryamongthesepatients,sothatnon-deviated fracturescanbeidentifiedandtreatedearlyon,thusavoiding surgeryofgreatercomplexityandexpense,andreducingthe riskofcomplications.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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2.VossL,DaSilvaM,TraftonPG.Bilateralfemoralneckstress fracturesinanamenorrheicathlete.AmJOrthop(BelleMead NJ).1997;26(11):789–92.

3.KarapinarH,OzdemirM,AkyolS,UlküO.Spontaneous bilateralfemoralneckfracturesinayoungadultwithchronic renalfailure.ActaOrthopBelg.2003;69(1):82–5.

4.MankinHJ.Ricketsosteomalaciaandrenalosteodystrophy. Anupdate.OrthopClinNorthAm.1990;21(1):81–96.

5.SinghM,NagrathAR,MainiPS.Changesintrabecularpattern oftheupperendofthefemurasanindexofosteoporosis.J BoneJointSurgAm.1970;52(3):457–67.

6.SchaabPC,MurphyG,TzamaloukasAH,HaysMB,MerlinTL, EisenbergB,etal.Femoralneckfracturesinpatientsreceiving long-termdialysis.ClinOrthopRelatRes.1990;260:224–31.

7.TaylorLJ,GrantSC.Bilateralfractureofthefemoralneck duringahypocalcaemicconvulsion.Acasereport.JBone JointSurgBr.1985;67(4):536–7.

8.SundayJM,GuilleJT,TorgJS.Complicationsofjoint arthroplastyinpatientswithend-stagerenaldiseaseon hemodialysis.ClinOrthopRelatRes.2002;397:350–5.

9.SakalkaleDP,HozackWJ,RothmanRH.Totalhiparthroplasty inpatientsonlong-termrenaldialysis.JArthroplasty. 1999;14(5):571–5.