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Is Bisphosphonate Therapy Safe After Wrist Fractures?

Posted on: 11/14/2012
Older adults who have osteoporosis (brittle bones) are more likely to fracture their wrists when they reach out their hand(s) to catch themselves during a fall. Surgeons are faced with an interesting dilemma when treating these folks. Should they put them on a bisphosphonate during the healing process? If so, how soon should bisphosphonate therapy begin?

Bisphosphonates are a group of drugs that inhibits (prevents) bone-resorption. In the normal day-to-day life of our bones, there are certain bone cells called osteoclasts that break down bone, allowing it to be absorbed by the body. But at the same time, there are also osteoblasts that build bone back up with new, healthy, strong bone cells.

The effects of osteoporosis can be slowed down by preventing osteoclasts from breaking down bone so rapidly. That's important in preventing complications of osteoporosis like bone fractures. However, after a fracture, the normal healing process involves osteoclasts coming in and clearing away the bone fragments and debris in preparation for fracture healing (new bone coming in and filling in the gaps).

The question arises: If an older adult who has osteoporosis fractures a bone and is given a bisphosphonate to help slow the osteoporosis process, will this drug treatment also slow the fracture healing process?

To find out, 50 women aged 51 and older who had a wrist fracture and surgery to stabilize the fracture were divided into two groups. The first group was put on a bisphosphonate (alendronate/Fosamax) two weeks after surgery. Group two had the same fracture, got the same surgery (volar locking plates), and then started taking the same bisphosphonate three months later.

Results between the two groups were compared using X-rays to compare fracture healing (union versus nonunion) after two, six, 10, 16, and 24 weeks (six months). Other measures of outcomes compared between the two groups included wrist motion, grip strength, and hand function.

There was no difference between the two groups -- either radiographically or clinically. Everyone healed up nicely in about the same amount of time (six weeks). Healing did not seem to be hampered by the presence of osteoporosis. The authors offer two possible explanations for this surprising finding.

One: maybe surgery using the rigid plate to hold the bone together stabilized the fracture enough that only a one-step process of healing between the bone fragments was required. Without stabilization, the fracture might require the addition of bone crossing the fracture lines, a process called bridging. And two: the site of these fractures (wrist) is an area where there is extra room between all the bones. This "spacious environment" (as they refer to it) allows for more new bone to form, thus balancing the resorption process.

The authors of this study were well aware of the ways their research may have fallen short and point to the need for further future studies. At the end of the article, they mention five areas considered limitations of the study. These included:

1) The patients in this study had not been taking bisphosphonates before their fall, fracture, and surgery; results might be different if that were the case.

2) Only one type of bisphosphonate medication was used by their patients (alendronate/Fosamax); results might be different for different drugs

3) Number of women in the study was small; some factors such as complications could not be assessed unless there were more people in the study

4) Only women (no men) were in the group; future studies are needed that do include the response in men

5) This was a short-term study: patients were only followed for six months; more information might be gained if long-term studies are conducted

In summary, medications such as bisphosphonates can be given to patients with osteoporosis who have not been on a bisphosphonate and then suffer a wrist fracture. Taking these medications (designed to slow down bone resorption) does not appear to hinder fracture healing. Treating the osteoporosis is important to prevent future fractures.

In this group of patients, it didn't matter how severe the osteoporosis was or the type of fracture present. The fact that there was no delay in bone healing may be because the fractures were fixed (held in place) by a metal plate. As you can see by the authors' own list of potential limits of their study, there is much room for further investigation regarding the use of bisphosphonates after fractures in patients with osteoporosis (both those individuals who have already been taking these medications before the fracture and those who haven't).

References:
Hyun Sik Gong, MD, PhD, et al. Early Initiation of Bisphosphonates Does Not Affect Healing and Outcomes of Volar Plate Fixation of Osteoporotic Distal Radial Fractures. In The Journal of Bone and Joint Surgery. October 3, 2012. Vol. 94-A. No. 19. Pp. 1729-1736.

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