Long-term radiographic follow-up of bisphosphonate-associated atypical femur fractures

Medical Management of Patients After Atypical Femur Fractures: a Systematic Review and Recommendations From the European Calcified Tissue Society

CONTEXT

Atypical femur fractures (AFFs) are serious adverse events associated with bisphosphonates and often show poor healing.

EVIDENCE ACQUISITION

We performed a systematic review to evaluate effects of teriparatide, raloxifene, and denosumab on healing and occurrence of AFF.

EVIDENCE SYNTHESIS

We retrieved 910 references and reviewed 67 papers, including 31 case reports, 9 retrospective and 3 prospective studies on teriparatide. There were no RCTs. We pooled data on fracture union (n = 98 AFFs on teriparatide) and found that radiological healing occurred within 6 months of teriparatide in 13 of 30 (43%) conservatively managed incomplete AFFs, 9 of 10 (90%) incomplete AFFs with surgical intervention, and 44 of 58 (75%) complete AFFs. In 9 of 30 (30%) nonoperated incomplete AFFs, no union was achieved after 12 months and 4 (13%) fractures became complete on teriparatide. Eight patients had new AFFs during or after teriparatide. AFF on denosumab was reported in 22 patients, including 11 patients treated for bone metastases and 8 without bisphosphonate exposure. Denosumab after AFF was associated with recurrent incomplete AFFs in 1 patient and 2 patients of contralateral complete AFF. Eight patients had used raloxifene before AFF occurred, including 1 bisphosphonate-naïve patient.

CONCLUSIONS

There is no evidence-based indication in patients with AFF for teriparatide apart from reducing the risk of typical fragility fractures, although observational data suggest that teriparatide might result in faster healing of surgically treated AFFs. Awaiting further evidence, we formulate recommendations for treatment after an AFF based on expert opinion.

Glossary of terms for musculoskeletal radiology

Members of the International Skeletal Society compiled a glossary of terms for musculoskeletal radiology. The authors also represent national radiology or pathology societies in Asia, Australia, Europe, and the USA. We provide brief descriptions of musculoskeletal structures, disease processes, and syndromes and address their imaging features. Given the abundance of musculoskeletal disorders and derangements, we chose to omit most terms relating to neoplasm, spine, intervention, and pediatrics. Consensus agreement was obtained from 19 musculoskeletal radiology societies worldwide.

Surgical Management of Atypical Femur Fractures Associated With Bisphosphonate Therapy

Atypical femur fractures associated with long-term bisphosphonate use can be challenging injuries to manage. Not only do they have a prolonged healing time and increased rate of nonunion as compared to typical femur fractures, intraoperative complications are not infrequent and can be catastrophic. Given the pathologic nature of these fractures, a multidisciplinary approach to the patient's care is necessary. Treatment begins with medical optimization and careful surgical planning. Radiographic characteristics of the fracture and femoral osteology dictate reduction strategy, adjunctive surgical techniques, and implant choice. Intraoperative complications including malreduction, iatrogenic fracture, and fracture propagation can be avoided with thoughtful planning. The purpose of this article is to discuss the technical aspects of surgical management of atypical femur fractures. We also discuss management of intraoperative complications and treatment failure. Finally, we provide an update on recommendations for postoperative medical treatment and management of the contralateral femur.

Skeletal Radiology: the year in review 2016

A look back at Skeletal Radiology in 2016 reveals a sizable number of publications that significantly advanced the state of knowledge about diseases of the musculoskeletal system. This review summarizes the content of some of the most intriguing papers of the year.