Commentary and Perspective
In their well-designed randomized trial, Gong et al. concluded that early initiation of bisphosphonate treatment has no effect on the clinical or radiographic outcomes of distal radial fractures treated with volar plate fixation. Bisphosphonates are currently the most commonly used anti-resorptive medications, and their primary mechanism of action involves inhibition of osteoclastic bone resorption. Because bisphosphonates cause a pronounced suppression of both bone resorption and bone formation, it has been suggested that treatment can interfere with normal fracture-healing. Animal studies, however, have provided controversial evidence1,2, and randomized clinical trials of bisphosphonates have not demonstrated any adverse events associated with fracture-healing.
The majority of patients with a distal radial fracture have low bone mineral density at the time of injury and benefit from treatment with anti-resorptive therapy. This study is unique in that it directly examined bisphosphonate treatment in the setting of fracture-healing. By showing that bisphosphonates can safely be started in the postoperative period, the authors ensure that orthopaedic surgeons do not miss a valuable opportunity to initiate treatment for osteoporosis immediately after a fracture occurs. The reader should be aware that the definition of fracture-healing continues to be controversial. The authors of some studies have categorized it as radiographic evidence of healing while others have focused on clinical factors. The study by Gong et al. is further strengthened by the authors’ adoption of a comprehensive definition of fracture-healing, including both radiographic parameters and clinical outcomes scores.
The study weaknesses include relatively small numbers and a short follow-up period that did not allow a full assessment of complications. The time intervals selected for follow-up may not have allowed the detection of more subtle differences between groups, particularly given the presence of implants, which makes the interpretation of radiographs more challenging. Finally, the authors only included patients with a known diagnosis of osteoporosis. Prior work has demonstrated that patients with a distal radial fracture are most commonly osteopenic as demonstrated by dual x-ray absorptiometry (DXA) scanning3. Arguably, these patients would benefit the most from aggressive screening and treatment before losing additional bone mass and becoming osteoporotic. The study thus falls short in providing guidelines for treatment in the most common patient population: those with fractures of the distal part of the radius and underlying osteopenia. Despite these limitations, this trial reveals that bisphosphonates are safe with regard to fracture-healing after volar plate fixation of distal radial fractures, and orthopaedic surgeons should consider initiating medical osteoporosis treatment in the immediate postoperative period.
This article was chosen to appear electronically on August 22, 2012, in advance of publication in a regularly scheduled issue.
1. Li C, Mori S, Li J, Kaji Y, Akiyama T, Kawanishi J, Norimatsu H . Long-term effect of incadronate disodium (YM-175) on fracture healing of femoral shaft in growing rats. J Bone Miner Res. 2001 Mar;16(3):429-36.
2. Amanat N, Brown R, Bilston LE, Little DG . A single systemic dose of pamidronate improves bone mineral content and accelerates restoration of strength in a rat model of fracture repair. J Orthop Res. 2005 Sep;23(5):1029-34. Epub 2005 Apr 19.
3. Rozental TD, Makhni EC, Day CS, Bouxsein ML . Improving evaluation and treatment for osteoporosis following distal radial fractures. A prospective randomized intervention. J Bone Joint Surg Am. 2008 May;90(5):953-61.
Disclosure: The author received no payments or services, either directly or indirectly (i.e., via her institution), from a third party in support of any aspect of this work. Neither the author nor her institution has had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, the author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.