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Lau A, Prout T, Malabanan A, Szalat A, Krueger D, Tanner SB, Rosen H, Shuhart C. Reporting of Full-Length Femur Imaging to Detect Incomplete Atypical Femur Fractures: 2023 Official Positions of the International Society for Clinical Densitometry. J Clin Densitom 2024; 27:101439. [PMID: 38000921 DOI: 10.1016/j.jocd.2023.101439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Incomplete atypical femur fractures (iAFFs) are associated with the long-term use of anti-resorptive therapies. Although X-rays are typically used to screen for iAFFs, images from dual-energy X-ray absorptiometry (DXA) offer an alternate method for detecting iAFFs. Although a previous 2019 ISCD Official Position on this subject exists, our task force aimed to update the literature review and to propose recommendations on reporting findings related to iAFFs that may be observed on DXA images. The task force recommended that full-length femur imaging (FFI) from DXA can be used as a screening tool for iAFFs. The presence of focal lateral cortical thickening and transverse lucencies should be reported, if identified on the FFI. This task force proposed a classification system to determine the likelihood of an iAFF, based on radiographic features seen on the FFI. Lastly, the task force recommended that the clinical assessment of prodromal symptoms (pain) is not required for the assessment of FFI.
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Affiliation(s)
- Adrian Lau
- Division of Endocrinology and Metabolism, Department of Medicine, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Tyler Prout
- Radiology Department, University of Wisconsin, Madison, WI, United States
| | - Alan Malabanan
- Bone Health Clinic, Boston Medical Center, Boston, MA, United States
| | - Auryan Szalat
- Osteoporosis Center, Internal Medicine Ward, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Diane Krueger
- School of Medicine and Public Health, Osteoporosis Clinical Research Program, University of Wisconsin-Madison, Madison, WI, United States
| | - S Bobo Tanner
- Department of Medicine, Divisions of Rheumatology, Allergy & Immunology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Harold Rosen
- Osteoporosis Prevention and Treatment Center, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Christopher Shuhart
- Bone Health and Osteoporosis Center, Swedish Medical Group, Seattle, WA, United States
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Sakuda T, Omoto O, Hamasaki T, Okimoto N, Adachi N. Incomplete Atypical Femoral Fracture Treated by Prophylactic Intramedullary Nail Fixation: A Case Series. Cureus 2022; 14:e22725. [PMID: 35386143 PMCID: PMC8968090 DOI: 10.7759/cureus.22725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 11/15/2022] Open
Abstract
Long-term bisphosphonate use may be associated with atypical femoral fractures. In this report, we describe three cases of bisphosphonate-associated incomplete atypical femoral fracture, treated by prophylactic intramedullary nail fixation. Patients with long-term intake of bisphosphonates must be carefully monitored; atypical femoral fracture should be suspected in the presence of symptoms such as thigh pain. Its early identification is important to avoid a complete fracture and invasive surgery, and prophylactic fixation is recommended for incomplete atypical femoral fractures.
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Ota S, Tokizaki T, Sugimoto M, Ochiai R, Haruyama T, Ishihara M, Natsume M, Fukasawa Y, Sakamoto T, Tanzawa S, Usui R, Honda T, Ichikawa Y, Watanabe K, Kawano H, Seki N. Importance and Difficulty of Differentiating BMA-induced AFF Prodromal Symptoms from Hormonal Therapy-related Femoral Pain. Intern Med 2020; 59:855-857. [PMID: 31761883 PMCID: PMC7118384 DOI: 10.2169/internalmedicine.3157-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
We herein report a case of breast cancer in a 74-year-old woman treated with exemestane as fourth-line hormonal therapy and bone-modifying agents for long time. She suddenly developed a right femoral shaft fracture during treatment. Her femoral fracture had a beaking sign on radiogram. Given this finding, her fracture was ultimately diagnosed as atypical femoral fracture (AFF). In this case, it was difficult to recognize the difference between groin pain as a prodromal symptom of AFF and that due to an adverse reaction to hormonal therapy. Therefore, clinicians should recognize the difficulty of this differentiation and consider the situation with caution.
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Affiliation(s)
- Shuji Ota
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Toru Tokizaki
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Japan
| | | | - Ryosuke Ochiai
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Terunobu Haruyama
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Masashi Ishihara
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Maika Natsume
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yoko Fukasawa
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Takahiko Sakamoto
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shigeru Tanzawa
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Ryo Usui
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Takeshi Honda
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yasuko Ichikawa
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Kiyotaka Watanabe
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Hirotaka Kawano
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Japan
| | - Nobuhiko Seki
- Division of Medical Oncology, Department of Internal Medicine, Teikyo University School of Medicine, Japan
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Pedrazzoni M, Giusti A, Girasole G, Abbate B, Verzicco I, Cervellin G. Atypical femoral fractures in Italy: a retrospective analysis in a large urban emergency department during a 7-year period (2007-2013). J Bone Miner Metab 2017; 35:562-570. [PMID: 27830385 DOI: 10.1007/s00774-016-0790-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 09/20/2016] [Indexed: 10/20/2022]
Abstract
The aim of this study was to determine the incidence of atypical femoral fractures (AFFs) seen in a large emergency department in Italy. It was a retrospective study of all men and women aged 40 years or older admitted to the Emergency Department of Parma University Hospital for a femoral fracture. Cases were identified in the hospital database with use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 820 or 821 or text strings. All the radiographic images of fractures not clearly identified as proximal or condylar were retrieved and evaluated by three independent reviewers. Fractures were considered as atypical if all three reviewers agreed on at least four of five major features defined by the 2013 American Society for Bone and Mineral Research criteria. In the 7-year period (2007-2013), with a total follow-up of 1,383,154 patient-years, we found 22 AFFs in 21 patients, accounting for 7.1% of low-trauma subtrochanteric/femoral shaft fractures and 0.6% of all femoral fractures. The incidence was very low (1.6 in 100,000 patient-years in both sexes combined). In contrast, the incidence of classic fractures of the proximal end of the femur was at least two orders of magnitude higher (typical/atypical rate ratio 152). Bisphosphonate use was reported in 13 patients (62%; mean treatment duration 9 years; range 5-14 years). Among 286 patients with typical subtrochanteric/femoral shaft fractures, 20 were being treated with bisphosphonate (7%; odds ratio 22; 95% confidence interval 8-58; p < 0.001). This study confirms the very low incidence of AFFs in the largest Italian cohort of patients to date. Even though the risk is higher in patients treated with bisphosphonates, AFFs are very rare, and typical femoral fractures are at least 100-fold more frequent.
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Affiliation(s)
- Mario Pedrazzoni
- Department of Clinical and Experimental Medicine, University of Parma, Via Gramsci 14, 43126, Parma, Italy.
| | - Andrea Giusti
- Bone Clinic, Department of Geriatric Care, Ortho-Geriatrics and Rehabilitation, Galliera Hospital, Genoa, Italy
| | | | - Barbara Abbate
- Department of Clinical and Experimental Medicine, University of Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Ignazio Verzicco
- Department of Clinical and Experimental Medicine, University of Parma, Via Gramsci 14, 43126, Parma, Italy
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Phillips HK, Harrison SJ, Akrawi H, Sidhom SA. Retrospective review of patients with atypical bisphosphonate related proximal femoral fractures. Injury 2017; 48:1159-1164. [PMID: 28410753 DOI: 10.1016/j.injury.2017.03.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 03/07/2017] [Accepted: 03/21/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Patients may be at an increased risk of atypical proximal femoral fractures with prolonged bisphosphonate use. PATIENTS AND METHODS This was a retrospective review of patients who sustained a subtrochanteric fracture of the femur in our department between April 2009 and March 2014. The radiographs were reviewed for features of atypical femoral fractures as described by the American Society of Bone Mineral Research. RESULTS 185 patients were coded according to the National Hip Fracture Database as having sustained a subtrochanteric fracture of the femur. Of these, 26 patients had radiographic findings consistent with an atypical subtrochanteric fracture. 5 patients were excluded as their histology confirmed malignancy. 12 patients were taking bisphosphonates on admission. All 12 patients were females taking alendronic acid on admission, who sustained the fracture as the result of minimal or no trauma and underwent long gamma nail fixation. The mean age was 71.6 years (range 62-79 years). The mean length of time on bisphosphonates prior to admission was 8.33 years (range 3-25 years). 9/12 patients had pre-existing symptoms for between 5days and 2 years prior to admission. 1 patient sustained a broken gamma nail 14 weeks post-operatively requiring revision. The mean time to discharge from theatre was 16days (range 5-57days). The mean time to radiological union in the patients in whom there was evidence was 24 weeks. CONCLUSIONS In this small group of patients, management of this fracture pattern can be complex with the potential for delayed or non-union and prodromal symptoms are common.
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Affiliation(s)
- H K Phillips
- Department of Trauma and Orthopaedics, Calderdale and Huddersfield NHS FoundationTrust, Huddersfield Royal Infirmary, Acre Street, Lindley, Huddersfield, HD3 3EA, United Kingdom.
| | - S J Harrison
- Department of Trauma and Orthopaedics, Calderdale and Huddersfield NHS FoundationTrust, Huddersfield Royal Infirmary, Acre Street, Lindley, Huddersfield, HD3 3EA, United Kingdom
| | - H Akrawi
- Department of Trauma and Orthopaedics, Calderdale and Huddersfield NHS FoundationTrust, Huddersfield Royal Infirmary, Acre Street, Lindley, Huddersfield, HD3 3EA, United Kingdom
| | - S A Sidhom
- Department of Trauma and Orthopaedics, Calderdale and Huddersfield NHS FoundationTrust, Huddersfield Royal Infirmary, Acre Street, Lindley, Huddersfield, HD3 3EA, United Kingdom
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Qiu S, Divine GW, Palnitkar S, Kulkarni P, Guthrie TS, Honasoge M, Rao SD. Bone Structure and Turnover Status in Postmenopausal Women with Atypical Femur Fracture After Prolonged Bisphosphonate Therapy. Calcif Tissue Int 2017; 100:235-243. [PMID: 28013363 PMCID: PMC5315598 DOI: 10.1007/s00223-016-0223-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 12/16/2016] [Indexed: 12/31/2022]
Abstract
Atypical femur fracture (AFF), a serious complication of long-term bisphosphonate therapy, is usually preceded by an incomplete fracture appearing on the lateral femur. AFF is most likely the result of severely suppressed bone turnover (SSBT). However, the differences in bone structure and turnover between patients with incomplete and complete AFF remain unknown. We examined trans-iliac bone biopsies from 12 white postmenopausal women with AFF (incomplete = 5; complete = 7) on BP therapy of >5 years and 43 healthy white premenopausal women. Histomorphometric measurements were performed separately in cancellous, intracortical and endosteal envelopes. Of the 43 histomorphometric measurements on 3 difference bone surfaces (cancellous, intracortical and endosteal), only 2 bone resorption variables (Oc.S/BS and Oc.S/NOS) on the endosteal surface were significantly lower in patients with complete AFF than those with incomplete AFF. Compared to healthy premenopausal women, the trabecular bone volume, thickness and number were all significantly lower in patients with AFF. The dynamic bone formation variables in patients with AFF were significantly reduced on all bone surfaces. The likelihood of a biopsy with no tetracycline labeling was significantly higher in AFF patients than in healthy premenopausal women. Based on these results, we conclude that there are no significant differences in bone turnover between patients with incomplete and complete AFF, suggesting that the suppression of bone turnover had already existed in the femur with incomplete AFF. Compared to healthy premenopausal women, bone turnover is similarly suppressed in patients with either type of AFF.
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Affiliation(s)
- Shijing Qiu
- Bone and Mineral Research Laboratory, Henry Ford Hospital, Detroit, MI, USA.
| | - George W Divine
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, MI, USA
| | - Saroj Palnitkar
- Bone and Mineral Research Laboratory, Henry Ford Hospital, Detroit, MI, USA
| | - Pooja Kulkarni
- Bone and Mineral Research Laboratory, Henry Ford Hospital, Detroit, MI, USA
| | - Trent S Guthrie
- Department of Orthopedic Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Mahalakshmi Honasoge
- Division of Endocrinology, Diabetes, and Bone and Mineral Disorders, Henry Ford Hospital, Detroit, MI, USA
| | - Sudhaker D Rao
- Bone and Mineral Research Laboratory, Henry Ford Hospital, Detroit, MI, USA
- Division of Endocrinology, Diabetes, and Bone and Mineral Disorders, Henry Ford Hospital, Detroit, MI, USA
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Min BW, Koo KH, Park YS, Oh CW, Lim SJ, Kim JW, Lee KJ, Lee YK. Scoring System for Identifying Impending Complete Fractures in Incomplete Atypical Femoral Fractures. J Clin Endocrinol Metab 2017; 102:545-550. [PMID: 27802096 DOI: 10.1210/jc.2016-2787] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 10/26/2016] [Indexed: 01/22/2023]
Abstract
CONTEXT Although impending incomplete atypical femoral fractures (AFFs) require prophylactic fixation, there is still a lack of study on predicting complete fracture among the incomplete AFFs. OBJECTIVE Our purposes are to develop a scoring system to predict progression into complete fracture and to evaluate its reliability and validity. DESIGN, SETTING, AND PATIENTS We reviewed 46 incomplete AFFs in 44 patients who did not undergo prophylactic fixation. A weighted scoring system, including four identified risk factors (the site, severity of pain, status of the contralateral femur, and the extent of radiolucent line), was developed. We evaluated its interobserver reliability by using intraclass correlation coefficiency (ICC) and its accuracy using receiver operator characteristic (ROC) curve. The validity of the scoring system was tested in a different cohort. INTERVENTION Observational study. MAIN OUTCOME MEASURE Progression to complete fracture within 6 months. RESULTS Among 46 incomplete fractures, 13 developed a complete fracture within 6 months. The probability of complete fracture increased abruptly when the score was 8 points or more. The proposed scoring system showed an almost perfect reliability (ICC, 0.997; 95% confidence interval, 0.995 to 0.998) and higher accuracy than any single risk factor in ROC curve. In the different series, the positive predictive value was 100% and the sensitivity was 75%, when cutoff value was 8 points. CONCLUSION The progression to complete fracture could be predicted by using our scoring system. Incomplete AFF with scores <8 points can be treated conservatively, whereas lesions with scores ≥8 require prophylactic fixation.
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Affiliation(s)
- Byung-Woo Min
- Department of Orthopaedic Surgery, Keimyung University, Dongsan Medical Center, Daegu 41931, South Korea
| | - Kyung-Hoi Koo
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam 13620, South Korea
| | - Youn-Soo Park
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul 06351, South Korea; and
| | - Chang-Wug Oh
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, Daegu 41944, South Korea
| | - Seung-Jae Lim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul 06351, South Korea; and
| | - Joon-Woo Kim
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, Daegu 41944, South Korea
| | - Kyung-Jae Lee
- Department of Orthopaedic Surgery, Keimyung University, Dongsan Medical Center, Daegu 41931, South Korea
| | - Young-Kyun Lee
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam 13620, South Korea
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Abstract
The use of bisphosphonates in treatment of osteoporosis declined significantly over the past decade. There is currently great concern, among patients and physicians, about two potential skeletal adverse effects associated with bisphosphonates- jaw osteonecrosis and atypical femur fractures. This has become a major public health issue since untreated osteoporosis carries a significant burden in terms of fracture-related morbidity and mortality, and bisphosphonates, considered first-line therapy for osteoporosis, have established efficacy in fracture and mortality reduction. Areas covered: In this review we discuss current literature on osteonecrosis of the jaw and atypical femur fractures in patients with osteoporosis treated with bisphosphonates, including case definition, pathogenesis, epidemiology, risk factors, clinical presentation, management and prevention. We conducted a literature search using PubMed and PubMed Central, using the search terms 'bisphosphonates', 'osteonecrosis of the jaw', and 'atypical fractures'. We selected relevant articles including meta-analyses, clinical trials, observational studies, and major society guidelines published between 2010 and 2016, to be included in this review. A few articles published prior to 2010 were also included as references. Expert commentary: The rare skeletal side effects of bisphosphonates should not preclude their use in patients with osteoporosis and high fracture risk, as benefits significantly outweigh the risks.
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Affiliation(s)
- Zeina A Habib
- a Department of Internal Medicine, Division of Endocrinology , Central Michigan University Medical Education Partners
- b Central Michigan University College of Medicine , Saginaw , MI , USA
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Mahjoub Z, Jean S, Leclerc JT, Brown JP, Boulet D, Pelet S, Grondin C, Dumont J, Belzile ÉL, Michou L. Incidence and Characteristics of Atypical Femoral Fractures: Clinical and Geometrical Data. J Bone Miner Res 2016; 31:767-76. [PMID: 26588590 DOI: 10.1002/jbmr.2748] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 11/13/2015] [Accepted: 11/17/2015] [Indexed: 11/09/2022]
Abstract
Despite the multitude of studies published on atypical femoral fractures (AFFs), a profile for patients at risk does not exist. This study aimed first at estimating AFF incidence over a 19-month-period in Quebec City using the ASBMR Task force criteria to define AFF. The medical records of patients hospitalized for hip or femoral fracture between June 1, 2009, and December 31, 2010, were reviewed. Thirty-six cases of atypical fractures were identified during the 19-month period, representing an AFF incidence of 7.0 (range, 4.7 to 9.3) cases per 100,000 person-years. In the second part of the study, data regarding the characteristics suspected of increasing the risks of AFF were collected from medical and pharmacological records, proximal femur radiographs, and patient interviews. The data regarding each patient with an AFF during years 2008-2011 were compared to two controls with a hip or femoral fragility fracture or a traumatic fracture, paired for age and sex. Twenty patients with AFF were added to the 36 patients with AFF selected in the first part, thereby 56 patients with AFF were investigated. The association between the occurrence of AFF and bisphosphonates (BPs) use was proven statistically significant in multivariate analysis, odds ratio (OR) = 10.39 (95% CI, 2.22 to 48.58; p = 0.0029). Compared to controls, patients with AFF had excessive femoral offset (43.1 mm versus 38.3 mm, p = 0.0007), proximal femoral neck angle in varus (128.9 degrees versus 134.0 degrees, p < 0.0001), and had greater proximal cortical thickness. This retrospective study confirms the low incidence of AFF, confirms its significant association with exposure to BPs, and reveals the possible contribution of proximal femoral geometry in AFF occurrence.
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Affiliation(s)
- Zeineb Mahjoub
- Department of Rheumatology, CHU de Québec-Université Laval, Québec, Québec, Canada
| | - Sonia Jean
- Institut National de Santé Publique du Québec, Québec, Québec, Canada.,Department of Medicine, Université Laval, Québec, Québec, Canada
| | - Jean-Thomas Leclerc
- Department of Orthopedic Surgery, Centre hospitalier universitaire (CHU) de Québec-Université Laval, Québec, Québec, Canada.,Division of Orthopedic Surgery, Department of Surgery, Université Laval, Québec, Québec, Canada
| | - Jacques P Brown
- Department of Rheumatology, CHU de Québec-Université Laval, Québec, Québec, Canada.,Department of Medicine, Université Laval, Québec, Québec, Canada.,Centre hospitalier universitaire (CHU) de Québec Research Centre, Québec, Québec, Canada
| | - Dominic Boulet
- Division of Orthopedic Surgery, Department of Surgery, Université Laval, Québec, Québec, Canada
| | - Stéphane Pelet
- Department of Orthopedic Surgery, Centre hospitalier universitaire (CHU) de Québec-Université Laval, Québec, Québec, Canada.,Division of Orthopedic Surgery, Department of Surgery, Université Laval, Québec, Québec, Canada
| | - Charlotte Grondin
- Department of Rheumatology, CHU de Québec-Université Laval, Québec, Québec, Canada
| | - Jeannette Dumont
- Centre hospitalier universitaire (CHU) de Québec Research Centre, Québec, Québec, Canada
| | - Étienne L Belzile
- Department of Orthopedic Surgery, Centre hospitalier universitaire (CHU) de Québec-Université Laval, Québec, Québec, Canada.,Division of Orthopedic Surgery, Department of Surgery, Université Laval, Québec, Québec, Canada
| | - Laetitia Michou
- Department of Rheumatology, CHU de Québec-Université Laval, Québec, Québec, Canada.,Department of Medicine, Université Laval, Québec, Québec, Canada.,Centre hospitalier universitaire (CHU) de Québec Research Centre, Québec, Québec, Canada
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Kharazmi M, Hallberg P, Schilcher J, Aspenberg P, Michaëlsson K. Mortality After Atypical Femoral Fractures: A Cohort Study. J Bone Miner Res 2016; 31:491-7. [PMID: 26676878 DOI: 10.1002/jbmr.2767] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 11/19/2015] [Accepted: 12/11/2015] [Indexed: 11/06/2022]
Abstract
Although osteoporotic fracture rates can be reduced by bisphosphonates, prolonged therapy is associated with higher risk of atypical femoral fractures. Ordinary fragility fractures are linked to high mortality rates. We aimed to determine whether atypical femoral fractures also confer excess mortality. Radiographs were reviewed for all patients aged ≥55 years who had experienced a subtrochanteric or femoral shaft fracture in Sweden in 2008 to 2010. The fractures were classified as either atypical or ordinary. Data on medication use, coexisting conditions, and date of death were obtained from national registers. We estimated multivariable-adjusted relative risks of death after atypical femoral fractures compared with ordinary subtrochanteric or femoral shaft fractures and calculated age- and sex-standardized mortality ratios (SMRs) for atypical and ordinary fractures compared with the population average. During a mean of 4 years of follow-up, 39 of 172 (23%) patients with an atypical fracture had died compared with 588 of 952 (62%) with an ordinary fracture, corresponding to a relative risk of 0.51 (95% confidence interval [CI] 0.38-0.68). The lower risk was evident in both users and nonusers of bisphosphonates. No patient with atypical fracture died in the first year after fracture. Individuals with an ordinary fracture had a higher mortality risk than the general population (SMR = 1.82; 95% CI 1.69-1.99), but no excess risk was found in patients with atypical fracture (SMR = 0.92; 95% CI 0.65-1.26). We conclude that in contrast to ordinary subtrochanteric and femoral shaft fractures, atypical femoral fractures are not associated with excess mortality.
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Affiliation(s)
- Mohammad Kharazmi
- Section of Orthopedics, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Pär Hallberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Jörg Schilcher
- Section of Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - Per Aspenberg
- Section of Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - Karl Michaëlsson
- Section of Orthopedics, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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11
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The atypical femoral fracture. CURRENT ORTHOPAEDIC PRACTICE 2016. [DOI: 10.1097/bco.0000000000000326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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13
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Schilcher J, Koeppen V, Aspenberg P, Michaëlsson K. Risk of atypical femoral fracture during and after bisphosphonate use. Acta Orthop 2015; 86:100-7. [PMID: 25582459 PMCID: PMC4366670 DOI: 10.3109/17453674.2015.1004149] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Use of bisphosphonates in women is associated with higher risk of atypical femoral fractures. The risk in terms of timing of use and type of bisphosphonate, and in men, remains unclear. PATIENTS AND METHODS We reviewed radiographs of 5,342 Swedish women and men aged 55 years or more who had had a fracture of the femoral shaft in the 3-year period 2008-2010 (97% of those eligible), and found 172 patients with atypical fractures (93% of them women). We obtained data on medication and comorbidity. The risk of atypical fracture associated with bisphosphonate use was estimated in a nationwide cohort analysis. In addition, we performed a case-control analysis with comparison to 952 patients with ordinary shaft fractures. A short report of the findings has recently been presented (Schilcher et al. 2014a). Here we provide full details. RESULTS The age-adjusted relative risk (RR) of atypical fracture associated with bisphosphonate use was 55 (95% CI: 39-79) in women and 54 (CI: 15-192) in men. In bisphosphonate users, women had a 3-fold higher risk than men (RR = 3.1, CI: 1.1-8.4). Alendronate users had higher risk than risedronate users (RR = 1.9, CI: 1.1-3.3). The RR after 4 years or more of use reached 126 (CI: 55-288), with a corresponding absolute risk of 11 (CI: 7-14) fractures per 10,000 person-years of use. The risk decreased by 70% per year since last use. INTERPRETATION Women have a higher risk of atypical femoral fracture than men. The type of bisphosphonate used may affect risk estimates and the risk decreases rapidly after cessation.
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Affiliation(s)
- Jörg Schilcher
- Orthopedics Section, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping
| | - Veronika Koeppen
- Orthopedics Section, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping
| | - Per Aspenberg
- Orthopedics Section, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping
| | - Karl Michaëlsson
- Orthopedics Section, Department of Surgical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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