Cases reported "Osteoporosis"

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1/40. Eighteen fractures in a man with profound mental retardation.

    A 39-year-old man with generalized tonic clonic epilepsy and profound mental retardation sustained 18 fractures (15 in appendicular and 3 in axial bones) during 19 years. Both femoral necks were fractured, requiring surgical repair. Although he had been on antiepileptic drugs for 35 years, he had no radiographic or biochemical sign of osteomalacia. He had a very low bone mineral density, suggesting osteoporosis. This case illustrates an important medical problem affecting people with developmental disability and a management challenge for their caretakers.
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2/40. Severe anorexia nervosa associated with osteoporotic-linked femural neck fracture and pulmonary tuberculosis: a case report.

    We report a case study of a 38-year-old woman who had been suffering from anorexia nervosa (AN) since the age of 26. Before admittance to our clinic, she weighed 23.8 kg (at a height of 164 cm, 8.8 body mass index [BMI]) but still carried out strenuous physical activities. After good psychotherapeutic response and weight gain (34.4 kg), she accidentally fell and broke her femoral neck-favored as it was by osteoporosis. The X-ray taken before dynamic hip screw implantation coincidentally showed signs of pulmonary tuberculosis (TB), which could then be proven by computed tomography (CT) scans and cultures from a bronchoscopy. Other than lack of appetite and loss of weight, which we attributed to AN, there were no other clinical or biochemical indicators which could have pointed to an earlier TB diagnosis. As a result, the need for screening procedures is discussed. The manifestation of TB during the first weight gain after 12 years of severe malnutrition, during which there were no serious infections, seems to endorse former observations that AN patients appear to be "resistant" to some extent against infectious diseases, a "protection" which may be lost with convalescence and weight gain.
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3/40. Subcapital femoral neck fracture after closed reduction and internal fixation of an intertrochanteric hip fracture: a case report and review of the literature.

    A subcapital femoral neck fracture in a healed intertrochanteric fracture treated by an open reduction and internal fixation is a rare, but catastrophic, event. We present the case of an 86-year-old woman, a community ambulator, who sustained a displaced right intertrochanteric hip fracture during a fall. She was treated with closed reduction and internal fixation with a dynamic compression hip screw and side plate. Four months later, she was noted to have a displaced subcapital femoral neck fracture and underwent hip screw and side plate hardware removal and cemented bipolar hemiarthroplasty. Both postoperative recoveries were uncomplicated, and she was discharged to a rehabilitation facility able to ambulate with minimal assistance. This devastating complication in patients with osteoporosis may be prevented by deeper placement of the dynamic hip compression lag screw to within 5 mm to 8 mm of the subchondral bone, which may decrease the stress forces in the subcapital femoral neck.
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4/40. Transient osteoporosis of the hip.

    We report four cases of transient hip osteoporosis studied between 1995 and 1997. All patients were men. The diagnosis was based on clinical symptoms, absence of abnormal laboratory tests, increased uptake in the femoral head and neck on Tc-99 bone scans and magnetic resonance imaging showing Oedema of the bone marrow. In three patients radiographs showed osteopenia of the head and neck of the involved femur, whereas no major radiographic changes were seen in the fourth patient. The clinical symptoms lasted 7 months and there was no recurrence after 8-24 months' follow-up.
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5/40. Transient osteoporosis of the hip during pregnancy.

    We report the clinical features of and MRI findings in transient osteoporosis of the hip during pregnancy. The study population consisted of 4 patients with a mean age of 33 years. The mean gestational age at onset was 31 weeks (range: 27 to 35 weeks). The main symptoms consisted of a weight-bearing pain in the hip and gait disturbance. The pain occurred suddenly and was of unknown cause and became severe within 2 to 3 weeks. X-ray examinations showed diffuse osteoporosis in the femoral head and neck. Moreover in 3 patients, similar lesions were also found in the lumbar spine or the knee. MRI obtained from 3 patients revealed a mottled low-signal lesion extending from the femoral head and neck on T1-weighted images and a high-signal lesion in the bone marrow suggesting edema on T2-weighted images. Mild elevation of C- reactive protein was shown in 2 patients. Conservative treatments with the limitation of weight bearing and bed rest were performed for all patients, and nonsteroidal anti-inflammatory drugs were given to 3 patients. The hip pain began to decline from 8 to 14 weeks after the onset, and completely disappeared from 14 to 24 weeks. X-ray examinations showed that osteoporotic lesions tended to improve at 10 to 14 weeks, on MRI, a high-signal lesion suggesting bone marrow edema resolved together with relief of the pain. No recurrence was found in any patients at mean follow-up of 70.8 months.
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6/40. Anterior cervical spine fusion using RABEA-Titan-Cages avoiding iliac crest spongiosa: first experiences and results.

    INTRODUCTION: In cervical discectomy using the ventral approach both, the necessity of replacement of the removed disc space itself as well as the material of the graft, if used, is still a matter of discussion. New approaches are titan-cages, usually filled with autologeous spongiosa. We present in the following study our first experiences using the hollow RABEA-Titan-Cages without filling with spongiosa to avoid the iliac crest complications. MATERIAL AND methods: 63 patients (33 male, 30 female, age 25-79 years, mean 52 years) were operated on a degenerative cervical disc herniation by ventral discectomy and replacement of the disc by the cage for fusion. The mean follow-up was 8 months. The preoperative symptoms were radiculopathies (n = 43) and myelopathies (n = 20). The diagnosis was confirmed by CT, MRI, myelography/CT and functional plain x-ray examination excluding instability. Level of the disc herniation: C3/4 n = 3, C4/5 n = 4, C5/6 n = 21, C6/7 n = 23, C7/Th1 n = 5, and 7 cases with 2 levels. In 30 cases we found hard discs, in 13 cases soft discs and in 20 patients combined lesions. All patients were intra- and postoperatively controlled by x-ray examination. RESULTS: Free of complaints were 17 patients, a marked improvement was found in 33 cases, a minor improvement in 10 cases, from those 4 patients additionally suffered from depression or alcoholism and 1 patient had a trauma in the history. 3 patients showed no change. Minor neck pain was reported in 5 cases. The mean postoperative hospitalisation was 8 days. Surgery related complications: temporary radicular palsies n = 5, hoarseness/problems with swallowing n = 5. In 2 cases (3%) with osteoporosis surgical revision of the cage was necessary (one case with ventral dislocation and one case with recurrent nerve root compression). In all other cases the x-ray control proved the correct placement of the cages intra- and postoperatively on discharge. CONCLUSION: For the anterior cervical fusion, the hollow RABEA-Titan-Cages present good clinical results and help to avoid complications from the iliac crest donor site. For long-term results, a longer follow-up and a increased number of patients is required.
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7/40. The use of methylmethacrylate as an adjunct in the internal fixation of unstable comminuted intertrochanteric fractures in osteoporotic patients.

    Forty-two unstable, four-part intertrochanteric fractures in forty-one patients (seventy-one to 104 years old) with severe osteoporosis were treated by open reduction and internal fixation (Jewett nail or compression screw-plate) supplemented with methylmethacrylate packed into the curetted medullary space. One patient was lost to follow-up, one died of a myocardial infarction at six weeks, and one was excluded because of an unsuspected myeloma found at the fracture site. All patients were sitting up in a chair the day after operation. Full weight-bearing on the limb was started within three weeks by thirty patients and at an average of 118 days by six who had very comminuted fractures. Three patients, non-ambulatory preoperatively, did not walk after operation. Of the thirty-eight fractures followed for from nine to thirty-seven months, thirty-seven healed with no loss of position. One fracture which had been fixed with the nail and cement not extending far enough into the head and neck displaced, and the operation had to be repeated, this time with a successful result. The fractures healed by periosteal new-bone formation. There was no evidence of avascular necrosis or wound complications.
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8/40. Recovery from severe glucocorticoid-induced osteoporosis in an adolescent boy.

    An 18-yr-old boy presented with extreme back pain as the result of multiple vertebral fractures. At age 16 he had developed a tumor of the mesencephalon. A ventriculoperitoneal shunt was established surgically. One year later, he developed progressive neurologic deficits in his upper and lower limbs with an increase in the size of the tumor. He was treated by irradiation and high doses of glucocorticoids. Although the neurologic deficits progressively improved, he developed severe back pain resulting in complete immobilization for 3 mo in spite of neurologic recovery. Multiple vertebral fractures were diagnosed by X-ray. bone density was extremely low (Z-score of -5.5 in the spine and -3.1 in the femoral neck). The patient was treated with calcium and vitamin d, calcitonin, bisphosphonates, physiotherapy, and progressive mobilization. glucocorticoids were decreased and could be stopped as the neurologic deficits fully recovered. After 1 yr of treatment with intermittent i.v. pamidronate, bone density had increased by 40% in the spine and by 25% in the femoral neck despite growth arrest. He progressively recovered from back pain and is now, at age 20, fully ambulant, studying mechanical engineering, without neurologic sequelaes and free of glucocorticoids. magnetic resonance imaging revealed that the tumor had disappeared. This case proves that treatment of symptomatic glucocorticoid-induced osteoporosis during puberty can be rewarding, even when multiple and invalidating vertebral fractures already exist.
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9/40. Neglected bilateral femoral neck fractures in a patient with end-stage renal disease before chronic dialysis.

    Bilateral femoral neck fractures are rarely reported in patients with end-stage renal disease before chronic dialysis. We report on a 39-year-old woman with neglected bilateral femoral neck fractures, who presented with severe uremic complications prior to chronic dialysis. Three years before admission, she had injured herself in a trivial slip with subsequent bilateral hip pain. She had progressively waddled since then. Pelvic X-ray taken after admission revealed bilateral femoral neck fractures. Bilateral hip hemiarthroplasties were subsequently performed. Displaced femoral neck fractures were found intraoperatively. Pathologic findings and results of examinations supported the coexistence of osteoporosis and high turnover renal osteodystrophy, rendering this woman at high risk of bilateral femoral neck fractures. Therefore, preventing a simple fall or trivial accident and treating renal osteodystrophy and osteoporosis are paramount in patients with chronic renal failure even before the start of dialysis therapy. We also emphasize the need to seek any possible underlying metabolic bone disease once a patient presents with unusual fractures.
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10/40. Transient osteoporosis with bilateral fracture of the neck of the femur during pregnancy: a case report.

    A case of bilateral non-nion of femoral neck fracture during the last trimester of pregnancy was reported. Bilateral hemiarthroplasty with bipolar prosthesis was performed in May, 2000. The result after one year follow-up was excellent.
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