Department of Orthopaedic Surgery, Toranomon Hospital, 1-3-1 Kajigaya, Takatu-ku, Kawasaki-shi, Kanagawa, 213-8587, Japan.
Department of Nephrology Center, Toranomon Hospital, 1-3-1, Takatsu, Kawasaki, Kanagawa, 212-0015, Japan.
Arch Osteoporos. 2020 Nov 12;15(1):179. doi: 10.1007/s11657-020-00849-7.
Currently, there are no reports of diaphyseal femoral fracture equivalent to atypical femoral fractures (AFFs) in patients receiving long-term hemodialysis (HD).
A 56-year-old Japanese man receiving long-term HD for 34 years was admitted to our hospital due to a delay in postoperative healing. The patient began maintenance hemodialysis at 22 years of age. The patient then underwent surgical parathyroidectomy (PTX) for secondary hyperparathyroidism at 43 years of age, which resulted in decreased levels of parathyroid hormone (PTH). Thereafter, this patient's serum 1,25(OH) D level was very low because active vitamin D derivative was not administered. At 54 years of age, a transverse fracture of the femoral shaft equivalent to AFF occurred. Surgery with open reduction and internal fixation using intramedullary nailing was performed; however, the delay of postoperative healing continued for 16 months. A left iliac crest bone biopsy was performed and showed osteoid-like lesion and an increase of woven bone. The patient received active vitamin D derivative and recombinant human PTH (1-34) derivative. Twenty-nine months after the first surgery, a reoperation was performed. Simultaneously, a right iliac crest bone biopsy was performed. Bone morphometrical improvement was confirmed. Six months after resurgery, the bone union was achieved. Severe vitamin D deficiency and decreased levels of PTH may induce a higher osteoid state and an increase of woven bone, which may then attribute to the development of diaphyseal femoral fracture and impairment of postoperative bone healing. It is hypothesized that treatment with active vitamin D and teriparatide acetate may be a therapeutic option via the accelerated formation of lamellar bone for refractory diaphyseal femoral fracture of long-term dialysis.
目前，在接受长期血液透析（HD）治疗的患者中，尚未有报告出现类似于非典型股骨骨折（AFF）的骨干股骨骨折。
一名 56 岁的日本男性，因术后愈合延迟而入住我院。他在 22 岁时开始接受长期 HD 治疗。该患者在 43 岁时因继发性甲状旁腺功能亢进症接受甲状旁腺切除术（PTX），导致甲状旁腺激素（PTH）水平降低。此后，由于未给予活性维生素 D 衍生物，该患者的血清 1,25(OH)D 水平非常低。54 岁时，发生了类似于 AFF 的股骨干横形骨折。采用髓内钉进行切开复位内固定手术；然而，术后愈合延迟持续了 16 个月。进行了左侧髂嵴骨活检，显示类骨质样病变和编织骨增加。患者接受了活性维生素 D 衍生物和重组人 PTH（1-34）衍生物治疗。第一次手术后 29 个月，再次进行了手术。同时进行了右侧髂嵴骨活检。证实了骨形态计量学的改善。再次手术后 6 个月，骨折愈合。严重的维生素 D 缺乏和 PTH 水平降低可能导致更高的类骨质状态和编织骨增加，从而导致骨干股骨骨折和术后骨愈合受损。据推测，通过加速形成板层骨，使用活性维生素 D 和特立帕肽治疗可能是治疗长期透析难治性骨干股骨骨折的一种选择。
