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Clinical Practice Article

Osteopetrosis and fracture: planning and management

[version 1; peer review: 1 approved with reservations]
PUBLISHED 19 Mar 2025
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Abstract

Introduction

Osteopetrosis (OP) is a rare genetic disorder characterized by increased bone density. Monitoring is the only alternative in these patients because of bone fragility, which is a source of frequent complications.

This study aimed to describe the fracture profile, possible complications, and management in this group of patients.

Material and methods

We conducted a retrospective, descriptive study including 21 fractures in 8 OP patients managed in our department between 1996 and 2022, with a minimum follow-up of 2 years. Patient data included age, sex, history of surgery, fractures, intraoperative difficulties encountered, and complications.

Results

All of our patients were young adults with a mean age of 28.4 years and an M/F ratio of 3:1. A total of 21 fractures (8 patients with OP) were managed in our department. The femur was the most frequent fracture site. The management of these fractures is surgical. Plate osteosynthesis is the most common indication. Three fractures were treated by orthopaedics. There were high rates of intraoperative and post-operative complications.

Discussion

Fractures in patients with OP often involve the long bones. As this is a rare disease, there are few studies on the appropriate management of fractures in this population. Most studies are case series with a small number of cases. Osteosynthesis is the recommended treatment for these fractures despite the risk of failure. Therefore, effective preoperative planning is essential. Great care must be taken when synthesizing these fractures to avoid intraoperative complications.

Conclusion

Fractures in patients with osteopetrosis present a challenge to orthopaedic surgeons. Planned surgery enables the appropriate synthesis of fractures. Long-term follow-up is essential for these patients to detect complications at an early stage.

Keywords

Osteopetrosis, Fracture, Fracture management

Introduction

Osteopetrosis (OP), or marble bone disease, is a rare inherited genetic disorder characterized by increased bone density.1 This is due to defects in the development and function of osteoclasts.1 Osteopetrosis occurs in approximately 1 in 300.000 births.2

To date, there has been no definitive cure for OP.3 For most patients, the treatment involves complications, such as fractures, which are observed in 75% of patients.3 Treatment of these fractures is difficult and associated with a high rate of complications.4

We aimed to describe the fracture profile, possible complications, and difficulty of management in patients with osteopetrosis.

Methods

This was a retrospective, descriptive study including patients followed for OP and managed for fractures at our institute over a 27-year period between 1996 and 2022, with a minimum 2-year follow-up. We excluded patients with a follow-up of less than 2 years and those with missing data.

The diagnosis of OP was either already known and for which patients were regularly followed up or made following multiple fracture consultations and confirmed by radiological assessment. Patient data included age, sex, history of surgery, and fracture characteristics (type, site, and number).

Indications for the management of patients with osteopetrosis and intraoperative challenges have been reported. We also recorded all the complications encountered.

Clinical and radiological follow-up was carried out systematically in all patients at the second, sixth, and twelfth weeks postoperatively and at the final follow-up.

Data were analyzed using SPSS software version 26.0.

Patient anonymity was maintained during data collection. Written informed consent was obtained from all the participants.

The various parties involved in this work declare that they have no conflict of interest.

Results

Based on these criteria, 21 fractures in eight patients with OP were included in our study. All patients were young adults in their second to fourth decade of life, with a mean age of 28.4 years, 17–42 years). They were predominantly male with an M/F ratio of 3:1. Four patients had a history of orthopaedic treatment for childhood fractures.

A kinship was present in our series. Two patients had brothers. For the others, we found no family ties, but on questioning, four patients reported a fairly high rate of fractures in certain members of their families and were not followed up at our institute.

The majority of fractures involved the femur (17 fractures), followed by both leg bones (3 fractures). Upper-limb involvement is rare. We report a single case of supra- and intercondylar fracture of the left elbow.

The management of these fractures is surgical. Initial plate osteosynthesis was the most common indication (16 fractures), with a Dynamic Compression Plate (DCP) of 4.5 mm for diaphyseal fractures and a Dynamic Hip Screw (DHS) for subtrochanteric fractures ( Figure 1 and Figure 2).

73af2242-f4b6-4d98-a5f6-12663ddd6538_figure1.gif

Figure 1. 5 surgically treated femur fractures (over a 16-year period).

73af2242-f4b6-4d98-a5f6-12663ddd6538_figure2.gif

Figure 2. Subtrochanteric fracture, right and left, 7 years apart.

Only one patient was treated with an external fixator for an open fracture of the two leg bones, and another patient was treated with intramedullary pinning with a poor radiological result, necessitating repeat surgery ( Figure 3). Three fractures (one femoral and two 2-leg fractures) were initially treated orthopaedically.

73af2242-f4b6-4d98-a5f6-12663ddd6538_figure3.gif

Figure 3. Subtrochanteric fracture treated with intramedullary pinning; canal narrowness required revision with plate osteosynthesis.

Owing to the hardness of the bone, there was a high rate of intraoperative incidents involving broken instruments and implants, especially drill bits. However, tapping is difficult. The tap broke twice. We also reported breakage of intraosseous screws ( Figure 4).

73af2242-f4b6-4d98-a5f6-12663ddd6538_figure4.gif

Figure 4. Intraosseous fracture of proximal screws.

Given the hardness of the bone, we used certain devices to perforate the bone, such as tungsten drill bits, square points, burs, and taps.

Intraoperative bleeding was significant in most patients. Surgery in one patient was complicated by hemorrhagic shock, requiring transfusion of 6 packed red blood cells and a stay in the surgical intensive care unit.

Post-operative complications were mainly represented by:

  • Early complications:

    • - Early sepsis requiring two washouts.

    • - Hemorrhagic shock due to significant blood loss.

  • Late complications:

    • - Fractures above or below the osteosynthesis material in four patients ( Figure 5).

    • - Two cases of plate breakage ( Figure 5).

    • - One case of delayed consolidation.

    • - Pseudarthrosis in two cases ( Figure 5).

      Iterative fracture case

    • - One case of late plate sepsis requiring drainage and plate removal.

73af2242-f4b6-4d98-a5f6-12663ddd6538_figure5.gif

Figure 5. Plate fracture treated with removal and replacement with a longer plate, complicated by pseudarthrosis.

A summary of the management of each patient is given in Table 1.

Table 1. Summary of patient management and complications.

GenderAge at fractureFractureTreatmentEvolution/Complications
1st case Male ( Figure 1,3,5)23Fracture of proximal 1/3 of right femurIntramedullary pinning with a single pin, given the impossibility of inserting another pinPoor radiological result; Revision by removal of the pin and insertion of a 7-hole plate
Subplate fracture at 4 months post-op; 9-hole anterior plate inserted without removing lateral plate; consolidation after 6 months
30Mid-diaphyseal fracture of left femurSynthesis with 7-hole lateral plateFracture under plate at 2 years post-op; Removal of old plate and synthesis with longer plate (9 holes)
Plate fracture at 4 months post-op with no notion of trauma; Removal of plate and synthesis with 12-hole plate
Pseudarthrosis; Cancellous contribution and insertion of a new plate; consolidation after 9 months
2nd case Male ( Figure 2)25Right subtrochanteric fracture4-hole nail-plate Early sepsis; Drainage washed 2 times; Consolidation with hip ankylosis after 4 mouths.
33Left subtrochanteric fractureDHS 4-holePseudarthrosis and plate fracture; therapeutic abstention
42Left supra- and inter-condylar elbow fracture2 external and internal platesConsolidation after 3 months with elbow stiffness and mobility of 20/90
3rd case male21Isolated tibia fractureCastIterative fracture at 10 months post-trauma; synthesis with 9-hole external plate; consolidation after 4 months
4th case female17Right femur fractureOrthopaedic treatment with splintConsolidation after 4 months
41Subtrochanteric fractureDHS 6 holesSignificant bleeding with hemorrhagic shock and stay in intensive care unit; consolidation after 6 months
5th case female ( Figure 4)21Fracture 1/3 proximal right femur8-hole external plateBreakage of 2 screws proximally
Fracture under the plate at 2 years post-operatively; Synthesis with 12-hole anterior plate with consolidation at 9 months post-operatively
27Mid-diaphyseal fracture of left femurSynthesis with 12-hole lateral plateDelayed consolidation + plate breakage; Functional treatment with consolidation at 1 year postoperatively
29Open fracture of 2 leg bonesExternal tibio-tibial fixatorDelayed consolidation; Walking boot cast then consolidation at 6 months post-op.
6th case male18Mid-diaphyseal fracture of left femur10-hole lateral plate fixationConsolidation at 9 months post-op.
24Mid-diaphyseal fracture of right femurSynthesis with lateral plateFracture above plate at 4 years post-operatively following mild trauma; plate removed and synthesis with 12-hole plate; consolidation at 6 months post-operatively
7th case female34Diaphyseal leg fractureCastConsolidation at 6 months with callus vicus
8th case male29Mid-diaphyseal fracture of the left femur8-hole lateral plate fixationConsolidation at 1-year post-op
31Mid-diaphyseal fracture of right femurSynthesis with 12-hole lateral plateLate sepsis at 18 months post-op; Drainage and plate removal

Discussion

Osteopetrosis is a rare disease characterized by increased bone deposition in unresorbed calcified cartilage or primary spongiosis.5 Its incidence is approximately 1 in 300.000 births.2 The condition is diagnosed based on radiographic findings of generalized osteosclerosis, mainly affecting the axial skeleton and long bones without involvement of the medullary canal.5 Brittle sclerotic bones are susceptible to severe fractures following relatively minor trauma, which would not result in fractures in healthy individuals.5

Few studies have focused on this subject. Indeed, the majority of publications were case reports.6

A personal history of fractures, as well as a family history, must be carefully considered. The diagnosis is often not made during the first consultation.7 Standard X-rays can guide the diagnosis, showing sclerosis in the long bones, skull, pelvis, and spine, associated with a characteristic “Erlenmeyer flask” appearance of the distal femur, or a “bone-in-bone” appearance in the spine and phalanges.8

Orthopaedic treatment is part of the therapeutic arsenal for these fractures. Indeed, cases of femoral fractures treated with casts and traction have been reported in the literature.9 However, longer recovery periods are required, with immobilization averaging three months and reduction difficult to maintain.5 This treatment can only be considered for diaphyseal fractures of long bones that are only slightly displaced, particularly in children.9

Osteosynthesis is the recommended treatment, despite the risk of failure; however, good preoperative planning and great care during surgery are required to avoid intraoperative incidents.6

Conventional plate fixation has shown limited success.5,6 This could be explained by two factors.

Screw holes and plate ends create stress zones, increasing the risk of fractures.

Plates are prone to fracture because of the high stress they are subjected to during consolidation, which is generally delayed.

Locked titanium plates are a good alternative, as they are less rigid implant systems and therefore less susceptible to damage.5

With regard to drilling, some studies have recommended the use of a high-density metal drill bit, a diamond drill bit or a tungsten carbide drill bit considered to be reliable high-density drill.10 Dawar et al.11 reported the use of multiple drill bits of progressive sizes and introduced the use of powerful high-speed motors to avoid back-and-forth drilling with continuous saline irrigation, thus preventing the problem of thermal necrosis. In addition, self-tapping screws minimize the risk of instrument breakage, eliminating the need for an additional tapping step.5

Plate fractures are generally caused by a short plate applied to the proximal femur.6,12 Because stresses through the proximal femur are very high, any implant that terminates in this region creates stresses at the end of the plate.12 Most authors recommend the use of longer plates to cover the entire bone.6 Table 2 summarizes the difficulties encountered in managing patients with OP and their solutions.

Table 2. Difficulties encountered in managing patients with osteopetrosis and their solutions.

ProblemsSuggested solution
Broken/deformed drill bitMultiple drill bits, diamond drill bits, use of progressive-size drill bits.
Hard boneLow-speed, high-torque electric motors; clean drilling grooves.
Bone overheatingFrequent cooling with saline solution; drilling pauses.
Narrow, hard medullary canalDrill patiently under fluoroscopy; use hand drill to mark entry point.
Fragile bonesAvoid excessive force and the use of a hammer.
Difficulty while screw insertionAlways use a tap prior to insertion of a cortical screw; always check for the required size with measuring device.
Extremely difficult to exchange a screw if the wrong size is inserted.
Screw breakageWhile insertion use a screw with a larger core diameter; avoid cancellous screw which has a lesser core diameter and might break while insertion.
Brittle Bone – How to avoid fracture around the plateThe last screw should be a unicortical screw, or should be inserted at an obtuse angle directed away from the fracture site to distribute the stress at the terminal end of the plate.

Few authors have described the results of intramedullary pinning in the literature, but they are associated with a high rate of revision surgery.7 Ding et al.4 recommended predrilling the pin under fluoroscopic control.

Intramedullary nailing is recommended to achieve long-term strength. However, it is very difficult to locate the medullary canal in long osteopetrotic bone.13 The procedure is laborious and involves opening the canal using drills and reamers adapted to this bone.13

Bone consolidation takes longer in patients with OP; therefore, the ban on weight-bearing must be prolonged. The time required for bone consolidation on the femoral shaft in these patients is approximately one year.7

Complications associated with fixation in patients with osteopetrosis should be considered when managing these fractures. Early complications consist mainly of significant blood loss, which can lead to hemorrhagic shock due to laborious synthesis and early sepsis of the material due to prolonged operating time.14 Late complications are fairly frequent, mainly delayed consolidation or pseudarthrosis due to the nature of the bone,15 fracture above or below the plate due to the biomechanical constraints imposed by the implant,5 and plate fracture due mainly to pseudarthrosis.12 A less frequent complication is chronic sepsis, explained by some authors as a result of frequent haematological disorders in these patients, leading to disruption of the local vascularization of the bone and, hence, to poor resistance to infection.7 The reoperation rate reported in the literature is 29%.5,16

The limitations of our study lie in its retrospective nature and small sample size; however, this is a rare pathology, with a small series in the literature. A multicenter study would enable better generalization of the results and could potentially lead to a consensus regarding fracture management in patients with OP.

Currently, there is no specific curative treatment for fractures in OP.1 However, a better understanding of the pathology could eventually lead to the development of less invasive treatments with fewer complications.

Conclusion

OP fractures are a challenge for orthopaedic surgeons. Long-term follow-up is essential for the early detection of possible complications.

Orthopaedic treatment may be indicated for fractures of the long bones that are only slightly displaced, particularly in children. In all other cases, surgical treatment with plates remains the gold standard treatment. However, this surgery is lengthy and difficult. The prolonged duration of the operation and risk of infection must be clearly explained to the patient.

Good preoperative planning is essential to anticipate intraoperative technical difficulties. The risks and benefits of each fixation modality must be considered during planning.

Consent to publish

Written informed consent was obtained from all participants (or their legal guardians) for publication of this study, including relevant clinical details and accompanying images.

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CHABCHOUB A, Meddeb M, TRIKI MA et al. Osteopetrosis and fracture: planning and management [version 1; peer review: 1 approved with reservations]. F1000Research 2025, 14:308 (https://doi.org/10.12688/f1000research.161715.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
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Reviewer Report 22 Aug 2025
Martine Cohen-Solal, Universite Paris Cite, Paris, Île-de-France, France 
Approved with Reservations
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This paper describes the fracture profile of a cohort of osteopetrosis. Eight patients with 21 fractures were analyzed and the report includes a 2 year-follow-up. This is an interesting report since few cases reported the complications that may occur in ... Continue reading
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Cohen-Solal M. Reviewer Report For: Osteopetrosis and fracture: planning and management [version 1; peer review: 1 approved with reservations]. F1000Research 2025, 14:308 (https://doi.org/10.5256/f1000research.177787.r399148)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

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Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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