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SICOT e-Newsletter

Issue No. 66 - March 2014

Worldwide News

Effect of early administration of alendronate after surgery for distal radius fragility fracture on radiological fracture healing time
S. Uchiyama, T. Itsubo, K. Nakamura, Y. Fujinaga, N. Sato, T. Imaeda, M. Kadoya, H. Kato
Bone Joint Journal 2013;95-B:1544–50.


Abstract

Background: This multicentre prospective clinical trial aimed to determine whether early administration of alendronate (ALN) delays fracture healing after surgical treatment of fractures of the distal radius.

Patients and Method: The study population comprised 80 patients (four men and 76 women) with a mean age of 70 years (52 to 86) with acute fragility fractures of the distal radius requiring open reduction and internal fixation with a volar locking plate and screws. Two groups of 40 patients each were randomly allocated either to receive once weekly oral ALN administration (35 mg) within a few days after surgery and continued for six months, or oral ALN administration delayed until four months after surgery. Postero-anterior and lateral radiographs of the affected wrist were taken monthly for six months after surgery.

Results: No differences between groups were observed with regard to gender (p = 1.0), age (p = 0.916), fracture classification (p = 0.274) or bone mineral density measured at the spine (p = 0.714). Three independent assessors assessed the radiographs. There were no significant differences in the mean time to complete cortical bridging observed between the ALN group (3.5 months (SE 0.16)) and the no-ALN group (3.1 months (SE 0.15)) (p = 0.068). All the fractures healed in both groups by the last follow-up. Improvement of the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, grip strength, wrist range of movement, and tenderness over the fracture site did not differ between the groups over the six-month period.

Summary: Based on our results, early administration of ALN after surgery for distal radius fracture did not appear to delay fracture-healing times either radiologically or clinically.

Comment by Syah Bahari

This is a very well-designed randomised control study that highlighted the issue on optimising the care for osteoporotic related distal radius fractures specifically and osteoporotic related fractures generally.

The authors acknowledged the concern of starting antiresorptive therapy for the patient right after the fracture due to the effect of antiresorptive medication on bone remodelling. Although the initiation of antiresorptive therapy after osteoporotic vertebral and hip fracture has been better received, the use of antiresorptive therapy for osteoporotic distal radius fractures is still not widely accepted. I agree that the distal radius fracture is usually the first fragility fracture sustained by osteoporotic patients, thus early intervention will likely prevent future fragility fractures.

The take home message from this study was that the primary outcome of cortical bridging across the fracture site was not significant between the treated group and the control. The secondary outcome such as functional outcome I believe is related to the use of the locking plate for fracture fixation. This also begs the question on whether the conclusion from this study can be used for conservative treatment or closed reduction and percutaneous wire fixation of distal radius fractures.

Another issue is that the dose of alendronate used in this study was 35mg weekly, instead of the recommended dose of 70mg weekly. The authors did acknowledge this in their discussion. However, the question is whether the recommended dose of 70mg weekly may affect bone remodelling?

Overall, I think this study provides satisfactory evidence to support early initiation of antiresorptive therapy for osteoporotic distal radius fracture.