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Case contributed by Dato’ Dr Lim Boon Ping, Consultant Orthopaedic Surgeon, Subang Jaya Medical Centre, Malaysia
Patient information
Age: 87 years
Sex: Female
Underlying Disease: Hypertension, On tablet Amlodipine 5 mg OD since 2010
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History
Presenting complaint
- The patient had an accidental fall while hanging clothes on a clothesline at home on 26th February 2020, 6 hours prior to presentation.
- Upon X-ray of hip, patient was diagnosed with left neck of femur fracture with osteoporotic bones
- Cementless bipolar hip replacement was done one day after the fall.
- 4 years later, on 22nd Jan 2024, the patient had another fall and sustained a left femur osteoporotic periprosthetic fracture.
Left neck of femur fracture
Left femur osteoporotic periprosthetic fracture 4 years later
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Physical Examination
Weight: 52 kg
Height: 152 cm
BMI: 22.5 kg/m2
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Investigation
Blood investigations
Full blood count: Normal
Renal profile: Normal
Liver function test: Normal
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Treatment
Surgical
- Cementless bipolar hip replacement done on 27th February 2020 (1 day after fall)
Pharmacological
- Subcutaneous Denosumab 60 mg, started on 28th February 2020 (post-operation day 1)
- Started on Romosozumab on 24th January 2024, after sustaining 2nd fracture
Non-pharmacological
- Compression stockings
- Physiotherapy
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Follow Up
1st fracture
- DXA scan for BMD was not done at the time of first fracture
- Patient did not continue pharmacological treatment for osteoporosis after first dose of Denosumab
2 years after 1st fracture
- Patient was walking well. X-ray left hip was done on 13th October 2022.
- Additionally, patient was diagnosed with osteoarthritis grade 4 of left knee. However, patient was not keen on surgery
- Following that, patient defaulted follow-up
2nd fracture (4 years after first fracture)
- Patient had an accidental fall in bathroom on 22nd January 2024
- She sustained a left femur osteoporotic periprosthetic fracture. Patient was also found to have osteoarthritis of left knee with effusion and lumbar spondylosis
- She had undergone plating with circlage wiring of left femur on 23rd January 2024
Patient was started on Romosozumab on 24th January 2024, in alignment with the Malaysia CPG on Management of Osteoporosis (2022, 3rd edition):1
- A recent fracture (within the past two years) is a stronger predictor of fracture in the following two years (imminent fracture risk) than is an older fracture (>5 years) history.
- In patients with very high risk of fractures, anabolic agents (teriparatide and romosozumab) are most appropriate to promptly reduce fracture risk. Anabolic agents should be followed by an anti-resorptive agent to maintain anti-fracture efficacy.
BMD was done on 26th January 2024 and it showed severe osteoporosis
4 months after 2nd fracture
- Patient was walking well
- X-ray showed fully united left femur periprosthetic fracture*
- Hypertension was well controlled
- No cardiac event
- Patient has been on Romosozumab since 24th January 2024, with subsequent doses given monthly thereafter
- The treatment plan is to continue Romosozumab therapy for 1 year and then transition to Denosumab
*Currently available efficacy data do not support the use of romosozumab as an adjuvant therapy to promote fracture healing. Kindly refer to the local prescribing information for the approved indication of romosozumab.
Fully united left femur periprosthetic fracture
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Results- DXA Scan
26th January 2024
Right Hip
Lumbar Spine
Right Wrist
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Summary
- 1st fracture: 26th February 2020
- Started on Denosumab after 1st fracture but patient discontinued after 1st dose
- 13th October 2022, patient came back to the clinic. Repeat X-ray of left hip was done. She had defaulted follow-up since then
- 2nd fracture: 22nd January 2024
- Started on Romosozumab: 24th January 2024
- 1st DXA: 26th January 2024
- Treatment plan is to continue Romosozumab therapy for 1 year and then transition to Denosumab
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References
1. Malaysia CPG on Management of Osteoporosis 2022, 3rd Edition.
2. Malaysia Pack Insert for Romosozumab.
Abbreviations
BMD, bone mineral density; DXA, dual-energy X-ray absorptiometry; THR, total hip replacement BMI, body mass index; BMD, bone mineral density; DXA, dual-energy X-ray absorptiometry; OD, once-daily, L1, first lumbar vertebrae; L2, second lumbar vertebrae; L3, third lumbar vertebrae; L4, fourth lumbar vertebrae
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Important Safety Information:Osteoporosis Case BinderThis curated collection of patient case studies aims to provide healthcare practitioners in the area of bone health, with a comprehensive understanding of risk-based treatment approach in the long-term management of patients living with osteoporosis.The patient cases were contributed by bone health experts from respective clinical setting, incorporating evidence-based discussions, guidelines and clinical considerations in the individualised treatment sequencing plans of different real-world scenarios..Please review full product information before prescribingFor Healthcare Professionals Only.Please refer to full prescribing information prior to administrationFor information on Amgen products or to report an adverse event involving an Amgen product, please contact Medical Information at 1800 818 227 or medinfo.JAPAC@amgen.comSC-MAL-CP-00128-0425Endorsed By:
