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Cumulative incidence of femoral localized periosteal thickening (beaking) preceding atypical femoral fractures in patients with rheumatoid arthritis

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Abstract

Summary

The incidence of localized periosteal thickening (LPT, also termed beaking) of the lateral cortex that often precedes an atypical femoral fracture (AFF) was not high in patients with rheumatoid arthritis (RA) but incomplete AFFs developed in two patients. Higher-dose prednisolone was a significant risk factor for LPT in patients with RA.

Introduction

Atypical femoral fractures (AFFs) are stress fractures; bisphosphonate (BP) use is a major risk factor for the development of such fractures. Localized periosteal thickening (LPT, also termed beaking) of the lateral cortex often precedes a complete or incomplete AFF. We evaluated the incidence of latent LPT in patients with rheumatoid arthritis (RA), to evaluate LPT progression, and to define LPT risk factors.

Methods

A total of 254 patients with RA were included; all underwent annual X-ray evaluation, dual-energy X-ray absorptiometry, and analyses of serum and bone metabolic markers for 2–3 years. LPT of the lateral cortex was sought in femoral X-rays.

Results

The incidence of LPT was 2.4% (6/254). Among patients on both BP and prednisolone (PSL) at enrollment, the incidence was 2.3% (3/131). Two femurs of two patients with LPT developed incomplete AFFs; LPT was extensive and associated with endosteal thickening. One patient had been on BP and PSL and microscopic polyangiitis was comorbidity. The other was on a selective estrogen receptor modulator and PSL. A daily PSL dose >5 mg (OR 11.4; 95%CI 2.15–60.2; p = 0.004) and higher-dose methotrexate (OR 1.22; 95%CI 1.01–1.49; p = 0.043) were significant risk factors for LPT.

Conclusions

The incidence of latent LPT was not high (2.4%) but incomplete AFFs developed in two RA patients. Higher-dose PSL because of a comorbid disease requiring glucocorticoid treatment other than RA or refractory RA were risk factors for LPT; X-ray screening for latent LPT would usefully prevent complete AFFs.

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Acknowledgments

We are grateful to Drs. A. Murasawa and K. Nakazono (Niigata Rheumatic Center) for helpful discussion and advice. We thank A. Seino (Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences) for expert technical help.

Funding

This work was supported by the Lilly Research Grant Program for Bone & Mineral Research (grant to HS).

Author information

Authors and Affiliations

  1. Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Honcho, Shibata City, 957-0054, Japan

    H. Sato, C. Takai, A. Abe, S. Ito & H. Ishikawa

  2. Health Administration Center, Niigata University, 2-8050 Ikarashi, Nishi-ku, Niigata City, 950-2181, Japan

    H. Sato, T. Kuroda & Y. Suzuki

  3. Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan

    N. Kondo

  4. Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan

    Y. Kurosawa, E. Hasegawa, A. Wakamatsu, D. Kobayashi, T. Nakatsue & I. Narita

  5. Department of Nephrology and Hypertension, Fukushima Medical University, 1 Hikariga-oka, Fukushima City, 960-1295, Japan

    J. J. Kazama

  6. Division of Orthopedic Surgery, Tsubame Rosai Hospital, 633, Sawatari, Tsubame City, 959-1228, Japan

    N. Endo

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  1. H. Sato
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  2. C. Takai
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  9. A. Abe
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Corresponding author

Correspondence to H. Sato.

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The study protocol was approved by the ethics committee of the Niigata Rheumatic Center and the work was performed in accordance with the Declaration of Helsinki.

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Sato, H., Takai, C., Kondo, N. et al. Cumulative incidence of femoral localized periosteal thickening (beaking) preceding atypical femoral fractures in patients with rheumatoid arthritis. Osteoporos Int 32, 363–375 (2021). https://doi.org/10.1007/s00198-020-05601-y

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