Osteonecrosis of the jaw (ONJ) and atypical femoral fracture (AFF) are rare potential adverse effects of bisphosphonates and RANKL antibody therapy. The pathogenic mechanisms of both conditions are known to be independent of each other. Here, we report both conditions sequentially occurring in the same patient.An 81-year-old, obese, diabetic, female was admitted due to hypertensive urgency and persistent jaw pain after tooth extraction. The patient has postmenopausal osteoporosis for fourteen years and was on intermittent, unsupervised treatment with alendronate, denosumab and ibandronate. Upon presentation, the patient was noted with tenderness intraorally of tooth number 35 periapical region. This was associated with elevated erythrocyte sedimentation rate and C-reactive protein. Imaging study showed presence of bony sclerosis which represent a sequestrum in the molar area of the left hemi-mandible. Antibiotic infusion and excision and debridement of left posterior mandible were done. Histopathologic finding was consistent with a diagnosis of osteonecrosis of the jaw. The same patient, upon review, had suffered sequential fracture of both femurs during the eighth and eleventh year of treatment with antiresorptive agents. The fractures were transverse, non-comminuted, at the proximal femoral shaft. Each occurred after a minor trauma and was managed with open reduction and internal fixation. Both fractures were consistent with atypical femoral fractures.ONJ and AFF can occur both in the same patient during prolonged treatment with bisphosphonates and denosumab and may suggest a common pathogenic mechanism.
Osteoporosis

OBJECTIVE: To review cases of adult patients who develop Hungry Bone Syndrome (HBS) after parathyroidectomy for Primary Hyperparathyroidism (PHPT) in a tertiary care center in the Philippines and describe the clinical features, pre-operative preventive measures done and risk factors for HBS.
METHODS:
Design: Retrospective Case Note Review
Setting: Tertiary Private Hospital
Participants: Chart review of adult Filipino patients who underwent parathyroidectomy for PHPT at Makati Medical Center from January 2011 to December 2016 was conducted and evaluated according to the inclusion and exclusion criteria. Medical information obtained included clinical parameters, biochemical results, operation performed, pathology, length of hospital stay and complications if with any.
RESULTS: From among 20 adult Filipino patients (mean age 55 years; 13, 65% female) who underwent parathyroidectomy for PHPT, HBS was found in 7 (35%). Most common pre-operative symptoms of hypercalcemia were musculoskeletal complaints. To prevent HBS, all were hydrated prior to surgery while some were given bisphosphonates and diuretics. The most common parathyroid gland imaging used for pre-procedure localization was Tc 99m Sestamibi scan with single photon emission computed tomography (SPECT) and 19 (95%) had parathyroid adenoma on post-operative histopathologic report. Among biochemical and clinical factors that may be risk factors for HBS, those with HBS had significantly lower pre-operative 25-hydroxyvitamin D, higher BUN, phosphate and alkaline phosphatase (ALP) than those without HBS. Of these, only ALP showed significant association with HBS (OR = 107.17, p = <0.0001). Length of hospital stay was longer among those with HBS although not statistically significant.
CONCLUSION: Knowledge on post-parathyroidectomy HBS for PHPT may aid clinicians on preoperative prevention and post-operative monitoring. Thirty-five percent (7) of our patients presented with HBS post-parathyroidectomy for PHPT from 2011 to 2016. An abnormal ALP level pre-operatively may be a risk factor in developing HBS post-parathyroidectomy for PHPT

Human ; Male ; Female ; Middle Aged ; Adult ; Hyperparathyroidism, Primary ; Parathyroidectomy ; Parathyroid Neoplasms ; Alkaline Phosphatase ; Parathyroid Glands ; Hypercalcemia ; Diphosphonates ; Diuretics ; Blood Urea Nitrogen ; Calcifediol ; 25-hydroxyvitamin D ; Vitamin D

Introduction: Endoscopic trans-sphenoidal surgeries are mainly the procedure of choice in pituitary adenomas with favorable results and varied outcomes arise from these techniques. The study aims to report the postoperative complications, and if these complications may have an impact on hospital stay. Methods: This is a retrospective cross-sectional study. 47 patients were involved ages 19 years old and above who had trans-sphenoidal surgery (TSS) from January 2011 to December 2016. Data collected were focused on preoperative diagnosis and post-operative complications (prolonged intubation, post-operative vomiting, CSF leak, post-operative bleeding, adrenal insufficiency, diabetes insipidus, electrolyte imbalance). Chi-square and independent T-tests were used in this study. Results: Most of the cases reported were nonfunctioning pituitary macroadenoma, prolactinoma and acromegaly. The study showed that the average length of stay of a patient who had undergone TSS is about seven days. Mean age of patients was 47 years old and 59% are males. The five most common complications while at hospital stay were headache (46%), throat irritation (38%), electrolyte imbalance (27%), SIRS (25%), and diabetes insipidus (10%). No sufficient evidence was appreciated with these complications comparing to the length of hospital stay. Conclusion Headache is the most common complication of post TSS. Comparing post-operative complications, it did not dictate the length of hospital stay.
Length of Stay