Is surgery necessary for femoral insufficiency fractures after long-term bisphosphonate therapy?

The effect of teriparatide on patients with atypical femur fractures: a systematic review and meta-analysis

INTRODUCTION

Bisphosphonates (BPs) are one of the most often used drugs to lower fracture risk in osteoporosis patients; nonetheless, BPs have been linked to atypical femoral fracture (AFF). Teriparatide (TPTD) is a parathyroid hormone analogue and anabolic drug that may accelerate fracture repair. TPTD has been considered as a possible treatment for AFF, particularly those caused by BP use. We evaluate the effect of TPTD on AFF in this systematic review and meta-analysis.

MATERIALS AND METHODS

A thorough search of: Web of Science, Scopus, PubMed, and Cochrane was conducted on August 2, 2023. Trials evaluating the effect of TPTD on the incidence of: complete bone healing, non-union, early and delayed bone union, progression of incomplete AFF to complete AFF, and time to bone union were included. Using Review Manager (RevMan) version 5.4, the risk ratio (RR) and mean difference (MD) with the corresponding 95% confidence interval (CI) were estimated for dichotomous and continuous outcomes, respectively. The Newcastle-Ottawa Scale was used to assess the quality of studies.

RESULTS

Eight studies met the eligibility criteria and were included in our analysis. TPTD significantly increased the incidence of early bone union (RR = 1.45, 95% CI [1.13, 1.87], P = 0.004) and time to bone union (MD = -1.56, 95% CI [-2.86, -0.26], P = 0.02) compared to the control group. No significant differences were observed in terms of complete bone healing (RR = 1.09, 95% CI [0.99, 1.13], P = 0.12), non-union (RR = 0.48, 95% CI [0.22, 1.04], P = 0.06), and progression of incomplete AFF to complete AFF (RR = 0.27, 95% CI [0.04, 1.97], P = 0.19).

CONCLUSIONS

TPTD is an effective therapy for enhancing and hastening healing following AFF, particularly in postoperative settings. Future large randomized clinical trials are needed to confirm or dispute the results.

Importance of Whole-Body Scintigraphy or Positron Emission Tomography for Early Detection of Femoral Lesions in Breast Cancer Patients Treated with Bisphosphonates

Background

We hypothesized that most of the atypical femoral fractures (AFFs) associated with bisphosphonate treatment for breast cancer (BC) could be found before the fracture event in another radiological examination already performed by breast surgeons, rather than on simple radiographs (SRs).

Methods

We thoroughly inspected the clinical charts of BC patients treated at our institute between 2008 and 2017. In total, 228 patients were categorized into three groups based on SRs: complete AFF on at least one side (group 1); incomplete fracture on at least one side, but not any complete fracture (group 2); and no suspicious lesion (group X) on either femur. Then, we inspected whole-body scintigraphy (WBS) and positron emission tomography (PET)-computed tomography (CT) images in all groups. For group X, patients with radiological clues from at least one femur were categorized, ultimately, into final group 3 and the rest made up the normal group.

Results

About 35% of the patients showed AFFs (complete or incomplete) or suspicious lesions as AFFs, associated with the side effect of Bisphosphonate. In group 1, bilateral lesions (complete or incomplete fractures) were more frequently seen on SRs than unilateral lesions (p = 0.008). The initially identified findings in WBS and PET-CT for the respective complete and incomplete fractures on SRs of groups 1 and 2 were seen at a mean of 7 months previously. SRs did not reveal the lesions in group 3 until 5 months after the initial identification of the lesions in WBS and PET-CT.

Conclusions

Even before incomplete AFFs were detectable on SRs, they could be found at check-ups using WBS and PET-CT that had been previously examined by breast surgeons and radiologists for metastasis surveillance. Awareness of the lesions creates an opportunity for prophylactic surgery before complete fractures occur.

Position Statement: Atypical Femoral Fracture from the Korean Society for Bone and Mineral Research in 2023

As the aging population increases, the number of patients with osteoporosis is gradually rising. Osteoporosis is a metabolic bone disease characterized by low bone mass and the microarchitectural deterioration of bone tissue, resulting in reduced bone strength and an increased risk of low-energy or fragility fractures. Thus, the use of anti-resorptive agents, such as bisphosphonates (BPs), to prevent osteoporotic fractures is growing annually. BPs are effective in reducing hip and other fractures. However, the longer a patient takes BPs, the higher the risk of an atypical femoral fracture (AFF). The exact mechanism by which long-term BP use affects the development of AFFs has not yet been clarified. However, several theories have been suggested to explain the pathogenesis of AFFs, such as suppressed bone remodeling, impaired bone healing, altered bone quality, and femoral morphology. The management of AFFs requires both medical and surgical approaches. BPs therapy should be discontinued immediately, and calcium and vitamin D levels should be evaluated and supplemented if insufficient. Teriparatide can be used for AFFs. Intramedullary nailing is the primary treatment for complete AFFs, and prophylactic femoral nailing is recommended if signs of an impending fracture are detected.

Persistence of Atypical Femoral Fracture 14 Years After Initial Diagnosis: A Case Report

CASE

A 75-year-old woman presented with left thigh pain 14 years after initial diagnosis of bilateral atypical femoral fractures secondary to chronic bisphosphonate use. New radiographic imaging and magnetic resonance imaging demonstrated bilateral incomplete femur fractures with surrounding marrow edema, cortical remodeling, and periosteal edema in a manner similar to that found 14 years earlier upon original diagnosis.

CONCLUSION

Recurrence of pain 14 years after initial diagnosis supports consideration of initial surgical management of atypical femur fractures (AFFs), even in patients with nonoperative symptom improvement. Patients who decline surgical intervention should be informed that incomplete AFFs may become a chronic medical condition moving forward.

Surgical strategy of the treatment of atypical femoral fractures

The atypical femoral fracture (AFF) has been attracting significant attention because of its increasing incidence; additionally, its treatment is challenging from biological and mechanical aspects. Although surgery is often required to manage complete AFFs, clear guidelines for the surgical treatment of AFFs are currently sparse. We reviewed and described the surgical treatment of AFFs and the surveillance of the contralateral femur. For complete AFFs, cephalomedullary intramedullary nailing spanning the entire length of the femur can be used. Various surgical techniques to overcome the femoral bowing common in AFFs include a lateral entry point, external rotation of the nail, and the use of a nail with a small radius of curvature, or a contralateral nail. In the case of a narrow medullary canal, severe femoral bowing, or pre-existing implants, plate fixation may be considered as an alternative. For incomplete AFFs, prophylactic fixation depends on several risk factors, such as a subtrochanteric location, presence of a radiolucent line, functional pain, and condition of the contralateral femur; the same surgical principles as those in complete AFFs can be applied. Finally, once AFF is diagnosed, clinicians should recognize the increased risk of contralateral AFFs, and close surveillance of the contralateral femur is recommended.

Bilateral Atypical Femoral Fractures after Bisphosphonate Treatment for Osteoporosis: A Literature Review

INTRODUCTION

This literature review aimed to investigate the incidence, anatomical concerns, etiology, symptoms, diagnostic tools, management, and prognosis of bisphosphonate (BP)-associated bilateral atypical femoral fractures (AFFs).

METHODS

The PubMed, Cochrane Library, Web of Sciences, and CINAHL databases were searched up to 20 March 2022. All cases of bilateral AFFs were included, excluding those without any bisphosphonate treatment information and those in which the femoral fracture did not precisely fit into the diagnostic criteria for AFF.

RESULTS

We identified 43 patients with bilateral AFFs associated with BP use and conducted a comprehensive analysis. Among 43 patients, 29 (67%) had prodromal symptoms. Regarding the simultaneity of fracture, 21 cases (49%) occurred simultaneously, and 22 cases (51%) occurred sequentially. Alendronate was the most commonly used BP treatment (59%). Regardless of the medication type, BP intake duration was more than 5 years in 77%. The initial diagnosis was performed using X-rays in all cases. A total of 53% of patients had complete fractures, and all patients underwent surgical treatment. Among the remaining patients with incomplete fractures, 18% and 29% received surgical and medical treatments, respectively. After BP discontinuation, teriparatide was most commonly used (63%).

CONCLUSIONS

The careful evaluation of relevant imaging findings in patients with thigh/groin pain allows the identification of early incomplete fractures and timely management. Since the rate of contralateral side fractures is also high, imaging studies should be performed on the asymptomatic contralateral side.

Functional and Radiological Outcome in Atypical Subtrochanteric Femur Fracture After Surgical Fixation: A Retrospective Observational Study

Background: Treatment for osteoporosis can have catastrophic side effects, including the uncommon fracture known as an atypical femur fracture (AFF), which is related to the long-term usage of antiresorptive agents. Bisphosphonate therapy may lead to significant and chronic suppression of bone turnover, impairing the bone's remodelling property and finally leading to incomplete or complete atypical femur fracture. AFF was defined by the American Society for Bone and Mineral Research (ASBMR) Task Force in 2010 and is far less prevalent than proximal femur (hip) fracture, with an incidence of 2 to 78 per 100,000 patients per year following two to eight years of bisphosphonate therapy, respectively. Due to the rarity of the fracture, it is still not clear what the functional and radiological outcome will be after surgery.

Aim: To identify the functional and radiological outcomes of surgical fixation of atypical femur fractures.

Methods: The study was conducted in a tertiary healthcare centre after scientific and ethical clearance from the competent authority. Between January 2018 and December 2021, individuals who were diagnosed with an atypical subtrochanteric femoral fracture associated with the use of bisphosphonates and treated surgically were retrospectively evaluated. The study's inclusion and exclusion criteria were used to include 20 patients. The features of an atypical subtrochanteric fracture were congruent with the radiographic findings. Most of the patients were treated with internal fixation with intramedullary osteosynthesis in standard with or without plate osteosynthesis. They were then followed up for a year to look at the functional and radiological outcomes.

Results: All of the 20 patients who were included had an atypical subtrochanteric fracture, with 15 of them being female and 5 of them being male. The patients' mean age at surgery was 65.12 (range 49 to 82) years, and their average history of bisphosphonate use was 3 (range 2.5 to 5) years. All patients were treated surgically. We found that five months was the mean period for bone union (p = 0.990). Within six months, bone union was achieved in 11 patients (55 %) (p = 0.884). Five patients (about 25%) had implant failure and non-union, requiring two to three revision surgeries. At three, six, and nine months, the mean visual analogue score (VAS) was 4.14, 3.12, and 1.85, respectively. The modified Hip Harris Score had a mean of 72.66 and 15 patients (about 75% of them) could walk normally again after a fracture. The mean of the modified HHS was 72.66, and the VAS at three, six, and nine months was 4.14, 3.12, and 1.85, respectively.

Conclusion: AFFs are rare fractures that must be treated effectively, and most of them require surgery. Successful treatment of AFF is possible by the use of intramedullary fixation, which enhances axial stability, serves as an internal splint, and lessens the likelihood of implant failure. A good functional and radiological prognosis can come from a stable fixation and a fracture that has been reduced anatomically.

Atypical femur fractures associated with bisphosphonate therapy: post-operative outcomes

PURPOSE

Bisphosphonates are commonly used medication for the treatment of osteoporosis, and a well-established complication of this medication is bisphosphonate-associated atypical femur fractures (BAAFFs). The aim of this study was to assess the post-operative functional and radiographic outcomes of surgically treated BAAFFs.

METHODS

An analysis of patients treated at a university-affiliated institution was performed. Patients who had undergone surgical fixation for a subtrochanteric or shaft of femur fracture which had been classified as atypical and treated with bisphosphonate therapy at the time of fracture were included. The outcome measures assessed included post-operative complications, length of stay, discharge destination, post-operative function, independence in activities of daily living (ADLs) and fracture union.

RESULTS

Twenty patients were included in this study with a mean age of 75.2 years. The cohort was predominantly female. The average duration of bisphosphonate therapy was 7.35 years. Nine patients had contralateral bisphosphonate-related stress reactions at the time of their initial fracture and underwent prophylactic surgical intervention. The majority of patients received cephalomedullary nail fixation (95%) with more than half (65.0%) of the cohort experiencing one or more post-operative complications. The median length of stay was 6.5 days and 50% of the cohort required inpatient rehabilitation. At final review, independent mobilisation was recorded in only 10.0% of patients, and 70% of patients were dependent with their ADLs at their latest follow-up. Average follow-up was 8 months, and only six cases demonstrated union at the six-month review, with delayed union between 9 and 12 months being common.

CONCLUSION

Patients with BAAFFs experience high rates of complications, record poor post-operative functional outcomes, and demonstrate a delayed time to union. Nearly half of our cohort had radiographic evidence of bilateral pathology.

Radiological Reversibility of Incomplete Atypical Femoral Fracture with Cessation of Bisphosphonate: Including an Early Stage of Incomplete Fracture

BACKGROUND

We found some important early findings in simple radiographs under the bisphosphonate (BP) treatment through a retrospective study. Here, we report the degree of reversibility of the early findings before overt fracture and analyze the factors affecting the differences through a retrospective case-control study.

METHODS

We retrospectively inspected the clinical charts of patients diagnosed with atypical femoral fracture (AFF) at our institute between March 2006 and September 2018. Among the 209 screened patients, 102 patients were ultimately divided into 3 categories: Category 1 was described as endosteal diffuse flaring (EDF, early IAFF); category 2 was typical IAFF, with a tiny/partial crack that was limited to less than half of the thickness of the cortex; and category 3 was IAFF with a crack through the entire cortex. Demographics, clinical factors, and three categories of incomplete atypical femoral fracture (IAFF) were analyzed to determine whether their radiological condition "improved" or "progressed" after cessation of BP via univariate and multivariate analyses.

RESULTS

Thirty-three, 53, and 16 were classified as categories 1, 2, and 3, respectively. Groups 1 and 2 consisted of 79 patients whose IAFF on the side of interest improved and 23 patients whose IAFF progressed, respectively. The uni/multivariate analyses of the groups demonstrated that the total period of BP (odds ratio [OR] = 1.49) and period of cessation of BP (OR = 0.24) were significant variables. In addition, prophylactic treatment for a contralateral IAFF was a strong factor for progression of the incomplete lesion on the side of interest (OR = 25.99). The rate of progression was significantly higher in patients with a mean treatment period of 43 months or longer, and in those with a mean cessation period shorter than 1.2 months.

CONCLUSION

Early-stage IAFF was found to be a unique finding in simple radiographs before the typical features of AFF. This EDF (category 1) was definitively reversible to normal bone when administration of BP was stopped. In addition, a long period of BP treatment and recent cessation of BP adversely affected IAFF with respect to spontaneous healing.

LEVEL OF EVIDENCE

Level III, a retrospective case-control study.

Revision osteosynthesis after primary treatment of atypical ulnar fractures associated with bisphosphonate usage - Nonunion after ordinary open reduction and internal fixation

BACKGROUND

We performed revision surgeries to treat nonunion of bisphosphonate-associated ulnar fractures that had originally been treated, after misdiagnosis, using the typical open reduction/internal fixation (ORIF).

METHODS

Of nine cases of ulnar nonunion initially treated at other institutions, we performed revision surgeries on four that met our inclusion/exclusion criteria. All previous implants were removed; the areas of nonunion were resected, and strut bone grafts were inserted and fixed with locking plates. Radiological assessments were performed monthly for 3 months after surgery and then every 3 months for 1 year.

RESULTS

All patients were female, with a mean age of 71.8 years. All patients had been taking bisphosphonate for a mean of 7.2 years. The primary fixation methods used at other institutions were intra-medullary nailing (n = 1) and placement of 3.5-mm locking plates (n = 3). In one patient (patient 1), the contralateral (right) ulna developed a new fracture at 1 month after revision surgery on the left ulna. Another patient (patient 3) exhibited an incomplete fracture in the contralateral (right) ulna. All four patients exhibited hip fractures (bilateral in three). All revisions resulted in final union at a mean of 4.8 months postoperatively.

CONCLUSION

Atypical ulnar fractures should be suspected in elderly women on long-term bisphosphonate treatment. Union will fail with standard ORIF for atypical ulnar fractures, because the fracture occurred due to compromised normal bone metabolism as reflected in the bone resorption, remodeling, and healing processes. Revision osteosynthesis using a locking plate with callus resection and strut/cancellous bone graft provided satisfactory results.

LEVEL OF EVIDENCE

Therapeutic level IV.

Risk factors for atypical forearm fractures associated with bisphosphonate usage

BACKGROUND

The purpose of this study was to find the diagnostic factors for atypical forearm fractures additional to atypical femur fractures, via a retrospective case-control study. Thus, our authors performed a complete enumeration survey for patients under the treatment of bisphosphonate (BP).

METHODS

We identified 53 patients that met the following inclusion criteria between March 2009 and February 2019: a BP therapy history or ongoing administration of at least 1 year, presence of simple radiographs of bilateral femurs and forearms, and availability of complete medical records and radiological data. The patients were divided into two groups: those with any lesion of atypical fractures of ulna or radius, regardless of the displacement of at least one side extremity in simple radiographs (group 1, 20 patients); and those without any lesions of pathognomonic finding or fractures in either forearm in simple radiographs (group 2, 33 patients).

RESULTS

Univariate analyses of basic demographic characteristic such as age, smoking, comorbidity of diabetes mellitus or any connective tissue disease needing steroid treatment, and BMD showed no significant differences between the groups (P > 0.05). The co-morbidity of malignant cancer inevitably needing BP usage was not different between the two groups. Multivariate analyses of the several variables that differed significantly between the two groups in univariate analyses demonstrated that total period and single prescribing physician/surgeon were significantly associated with forearm fractures. A cut-off value of 65 months for the total period predicted the presence atypical forearm fractures.

CONCLUSIONS

Atypical forearm fractures are probably more common than reported in the literature to date, and all forearm lesions were accompanied by preceding atypical femur fractures. The period of BP administration had the main effect on the occurrence of atypical forearm fractures, particularly if more than 65 months. Also, the prescription by multiple physician was predicting factor for forearms lesion additionally to AFFs, however, more evidence-based study is needed to understand the effects of cancer-related BP usage on the forearm.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Evaluation and management of atypical femoral fractures: an update of current knowledge

Atypical femoral fractures are often attributed to the use of anti-resorptive medications such as bisphosphonates (BP). Whilst they have proven effects on fragility fracture prevention, clinical and laboratory evidence is evolving linking BP-related suppression of bone remodelling to the development of atypical stress-related sub-trochanteric fractures (Shane et al. in JBMR 29:1-23, 2014; Odvina et al. in JCEM 90:1294-301, 2005; Durchschlag et al. in JBMR 21(10):1581-1590, 2006; Donnelly et al. in JBMR 27:672-678, 2012; Mashiba et al. in Bone 28(5):524-531, 2001; Dell et al. in JBMR 27(12):2544-2550, 2012; Black et al. in Lancet 348:1535-1541, 1996; Black et al. in NEJM 356:1809-1822, 2007; Black et al. in JAMA 296:2927-2938, 2006; Schwartz et al. in JBMR 25:976-82, 2010). Injuries may present asymptomatically or with prodromal thigh pain and most can be successfully managed with cephalomedullary nailing and discontinuation of BP therapy. Such injuries exhibit a prolonged time to fracture union with high rates of non-union and metal-work failure when compared to typical subtrochanteric osteoporotic femoral fractures. Despite emerging literature on AFFs, their management continues to pose a challenge to the orthopaedic and extended multi-disciplinary team. The purpose of this review includes evaluation of the current evidence supporting the management of AFFs, clinical and radiological features associated with their presentation and a review of reported surgical strategies to treat and prevent these devastating injures.

Multiple ipsilateral femoral stress fractures in a patient taking denosumab for osteoporosis-a case report

This is the first report describing three ipsilateral femoral stress fractures in a patient taking denosumab.

INTRODUCTION

Multiple reports of atypical femur fractures (AFF) in patients receiving denosumab have emerged recently. Denosumab is an anti-resorptive agent approved for treatment of osteoporosis. It is a human monoclonal antibody which blocks osteoclast activation, maturation, and function.

METHODS

This is a case report of a 74-year-old female patient who sustained three stress fractures of her left femur.

RESULTS

The patient healed her fractures after intramedullary nailing of the femur and was able to return to her activities.

CONCLUSIONS

High index of suspicion is needed in any patient with osteoporosis on denosumab complaining of thigh or groin pain. Careful examination and radiographic studies of both femurs are warranted if AFF is discovered.

Post-operative Rehabilitation of Atypical Femoral Fracture in a Single Center

Objective:

Increasing numbers of reports have described atypical femoral fracture (AFF) in patients being treated with oral bone resorption inhibitors, such as bisphosphonates. Most AFF patients undergo surgical treatment. However, there is little information about post-operative rehabilitation and patient activity levels after surgery for such fractures. Here we report the outcome of surgical treatment and postoperative rehabilitation for AFF at a single center in Japan.

Methods:

We retrospectively reviewed 13 patients (14 AFFs) who underwent surgery at Nagano Matsushiro General Hospital between January 2013 and December 2016. The clinical backgrounds of the patients were evaluated.

Results:

The patients comprised 1 man (1 AFF) and 12 women (13 AFFs). The mean age at surgery was 77.7±7.1 years (mean±SD). Before AFF occurred, 12 of the 13 patients had used bisphosphonates for osteoporosis. An intramedullary nail was inserted in all patients. Partial weight bearing was started on average 2 weeks after surgery, and full weight-bearing gait was permitted on average 3 weeks after surgery. The average time to bone union was 9.9±6.1 months, ranging from 3 to 23 months. None of the patients required additional surgical procedures, including revision surgery for pseudoarthrosis (nonunion) or delayed union. Before AFF, 12 patients walked independently, and 1 patient walked with a single cane. At the final follow-up (mean duration: 34.5±15.7 months), 8 patients could walk independently and 5 patients walked with a single cane.

Conclusions:

We recognized that rigid fixation for AFF supported early weight-bearing gait after surgery.

Detection and management of atypical femur fractures

PURPOSE OF REVIEW

This article summarizes the risk factors for atypical femur fractures (AFF), discusses current and emerging imaging modalities for early identification of AFF, and offers recommendations for prevention and management of AFFs based on the current concepts.

RECENT FINDINGS

Antiresorptive therapies are widely recommended for prevention and treatment of osteoporosis. Despite their well established effectiveness to reduce fracture risk, emerging concerns related to potential adverse effects have led to a substantial decline in the use of bisphosphonates. Although, the pathogenesis of AFF has not yet been elucidated, the bulk of evidence supports that the well known therapeutic benefits of bisphosphonate far outweigh the relatively low risk of AFFs. Recommendations for early identification of patients at risk for AFF using radiographic imaging have been established. Consensus on the management of AFF and osteoporosis in patients with AFF needs to be formulated.

SUMMARY

AFF is a rare event associated with long-term bisphosphonate therapy, which represents an apparent paradox in the management of osteoporosis. Improved understanding of pathogenetic mechanisms will be helpful in further refining of screening guidelines and standardization of management and treatment strategies.

Natural history of incomplete atypical femoral fractures in patients after a prolonged and variable course of bisphosphonate therapy-a long-term radiological follow-up

Understanding the natural history of lateral femoral stress fractures helps to guide their management. Improvement in their radiographic characteristics is rare. Progression was generally sequential, most developing an incomplete fracture line before fracture displacement. Stopping bisphosphonates decreased the fracture rate, a feasible management option for lesions without incomplete fracture lines.

INTRODUCTION

Retrospective study evaluating the natural history of lateral femoral stress fractures (FSF) by serial radiography over a variable period of time in a cohort of patients treated for some time with bisphosphonates for osteoporosis, whilst also identifying the fracture response in cases where bisphosphonates were discontinued.

METHODS

The radiographs of 76 consecutive patients (92 femurs) with 161 FSF were reviewed to document their change over time. Femurs were classified into the following: A-normal, B-focal cortical thickening, C-dreaded black line and D-displaced fracture. Bisphosphonate history was recorded.

RESULTS

66.5% FSF showed group stability between the first and last radiographs: group B (79.1%), group C (45.7%). 28.6% progressed, mostly following an ordered sequence starting from group A, progressing to B, then C, before culminating in D. Progression rate was as follows: A-100% (11/11), B-18.3% (21/115), C-40% (14/35). Regression in FSF was uncommon-5.6% (8/161). 34.8% (32/92) sustained displaced fractures. Kaplan-Meier analysis showed statistically significant difference between the groups; median survival (95% CI): A-4189 (-), B-3383.0 (-), C-1807 (0.0-3788.6) and progression to displaced fracture when bisphosphonate had been stopped for at least 6 months. The group without recent bisphosphonates had a lower group progression rate (17.1%, 12/70). Nevertheless, 10.9% (5/46) progressed to displaced fracture. This group also had the highest proportion of stable (77.1%, 54/70) and regressive lesions (5.7%, 4/70).

CONCLUSIONS

In FSF, there is natural progression from normal bone, to focal cortical thickening, to dreaded black line and eventually to displaced fracture. Most lesions persist, remaining static or progressing, especially if a dreaded black line is present and bisphosphonates are continued. Regression is uncommon and more frequent when bisphosphonates are discontinued. Despite stopping bisphosphonates, there remains a 10.9% risk of progression to displaced fracture.

Different surgical outcomes in a patient with bilateral atypical femoral fracture related to bisphosphonate use with or without teriparatide treatment

Bisphosphonates (BPs) are first-line drugs for the treatment of osteoporotic fractures, but long-term use of BP reduces bone turnover and is associated with atypical femur fractures (AFFs). Additionally, BP treatment may cause delayed fracture healing or nonunion, which makes AFF treatment difficult. The incidence of AFF is generally low. In fact, there are only a few clinical reports of AFF and there is no controlled study on AFF treatment. Herein, we report a case of multiple osteoporotic fractures. After 5 years of BP treatment, left and right AFFs occurred within 2 years. The fracture types and surgical operations were the same, but the level of bone metabolism and drug treatment were different. The right AFF healed well following teriparatide initiation compared with non-healed left AFF with BP continuation; thus, our case can be considered a self-controlled study. Furthermore, we have reviewed the diagnosis and treatment of this case in detail and analyzed and investigated the potential causes of the different outcomes of AFFs between the two sides to inform the clinical treatment of atypical fractures. Mini Abstract We report a case of bilateral AFFs. The surgical treatments were the same, but the final treatment outcomes were different with or without teriparatide treatment. We investigated the potential causes of the different outcomes of AFFs between the two sides to inform the clinical treatment of AFFs.

Intramedullary Nailing: Definitive as well as Prophylactic Fixation Method in a Case of Bilateral Atypical Femoral Fractures - A Case Report

Introduction:

Atypical femoral fractures(AFF) are rare. To get more knowledge, these cases are being reported at an increasing rate in recent literature. Surgical treatment in these fractures is controversial.

Case Report:

A 73-year-old lady, known rheumatoid and osteoporotic with a history of long-term bisphosphonate intake, presented with sudden onset right thigh pain after trivial trauma. We diagnosed a complete atypical femoral fracture, treated with closed intramedullary nailing. 4 months later, she presented with dull aching left thigh pain for 2 weeks. Radiographic features suggested an incomplete atypical femoral fracture, treated with prophylactic insitu intramedullary nailing. At 1 year follow-up, lady was walking well with stick support.

Conclusion:

Our case highlights two important points. Intramedullary nailing is a minimally invasive treatment option for incomplete and complete AFF. We should have a high index of suspicion in diagnosing and recognizing warning signs of incomplete fractures such as prodromal thigh pain and isolated focal lateral cortical thickening, thereby preventing further progression and treatment with prophylactic nailing at an early stage.

A Periprosthetic Femoral Fracture with Characteristics of Atypical Femoral Fracture

Although the definition of atypical femoral fracture (AFF) excludes periprosthetic femoral fracture (PFF), the number of reports about PFF with characteristics of AFF is increasing. We present the case of such a fracture in this report. An 87-year-old woman who underwent bipolar hip arthroplasty for a femoral neck fracture 38 months prior reported left thigh pain with no history of trauma. Radiographs showed a simple transverse fracture at the level of the stem distal end with features of AFF: periosteal thickening of the lateral cortex, a medial spike, and a noncomminuted fracture. She presented other features resembling AFF: history of bisphosphonate use, prodromal symptoms, no associated trauma, and lateral bowing of the contralateral femur. The fracture showed nonunion after the initial osteosynthesis, and a revision surgery of the arthroplasty and osteosynthesis was performed. Nine months after the surgery, bony union was achieved and she regained the ability to walk. It is supposed that the fracture was influenced by a stress force related to implants and lateral bowing concentrating on the fracture site as a mechanical factor in addition to bisphosphonates as a biological factor. It would be important to recognize that AFF could occur at the peri-implant location, and early detection and treatment are essential.

Atypical Femur Fractures: Review of Epidemiology, Relationship to Bisphosphonates, Prevention, and Clinical Management

Bisphosphonates (BPs) are highly effective in treating osteoporosis and reducing hip, vertebral, and other fractures by as much as 50% to 70%. However, since 2006, atypical femur fractures (AFFs) emerged as potential side effects of BPs and other treatments. These fractures have unusual radiologic features and occur with little trauma. Public concern has led to a >50% decrease in BP usage. AFFs are rare: for each AFF, >1200 fractures, including 135 hip fractures, are prevented. Case definition criteria were updated by the American Society of Bone and Mineral Research in 2014. Many epidemiologic studies have been reported, and although methodologically challenging, generally support a BP-AFF association. However, the magnitude of the association between BPs and AFFs is uncertain: estimates of relative risk for AFFs among BP users vs nonusers range from 1 to 65 with a meta-analysis estimate of 1.7. Although mechanistic studies have proposed several hypotheses explaining how BPs might decrease bone strength, AFF pathogenesis remains uncertain and cannot explain the paradox of efficacy of reduction of common fractures while increasing risk for rare fractures at one site. There are several consistent risk factors, including Asian race (in North America), femoral bowing, and glucocorticoid use, whereas others remain unclear. Consensus is emerging about strategies to prevent AFFs in BP users (including drug holidays after 5 years' use in some patients). In conclusion, AFFs can be devastating, but even under the most pessimistic assumptions, the benefit/risk ratio is highly positive for BPs, particularly during 3 to 5 years of use. As understanding of AFFs increases, it is becoming increasingly possible to maximize BP benefits while minimizing AFF risk.

Spontaneous Insufficiency Fractures

Spontaneous insufficiency fractures are caused by normal or physiological stress on weakened bone. The leading cause of insufficiency fractures is osteoporosis which has a propensity to affect older patients. Other causes or associated factors are disorders which affect bone metabolism, collagen formation, bone remodelling and medications such as bisphosphonates and glucocorticoids. Pathological fractures and abuse are important causes of unexplained fractures which warrant careful consideration. Spontaneous fractures of the long bones affect on average 1% of nursing home residents per year and tend to occur in patients who are bed-bound with joint contractures. Preventative measures for spontaneous insufficiency fractures include optimising nutrition to include an adequate intake of protein, calcium and vitamin D, maintaining mobility and preventing long periods of bed-rest and treatment of underlying pre-disposing conditions.

Surgical Treatment of the Atypical Femoral Fracture: Overcoming Femoral Bowing

Atypical femoral fractures differ from ordinary femoral diaphyseal or subtrochanteric fractures in several aspects. Although several authors have reported the results of surgical treatment for atypical femoral fractures, the rate of complications (e.g., delayed union, nonunion, fixation failure, and reoperation) is still high. Therefore, we reviewed principles of surgical treatment and describe useful methods for overcoming femoral bowing in these high-risk patients.

Atypical femur fracture in a woman with osteogenesis imperfecta and multiple myeloma

Use of intravenous bisphosphonates has been demonstrated to improve clinical outcomes in children with osteogenesis imperfecta (OI). However, efficacy and safety of bisphosphonates in adults with OI remains unclear. Atypical femur fractures (AFF) are rare insufficiency fractures associated with long-term bisphosphonate use. We report on a 56 year old woman with OI type 1 and long-term bisphosphonate use who was diagnosed with multiple myeloma (MM) following a severe vertebral fracture. During workup, an asymptomatic incomplete AFF of the left femur diaphysis was noted. Multiple factors may have contributed to the occurrence of AFF, including bisphosphonate exposure, bowing of the proximal femur, as well as the intrinsic collagen defect of OI. To reduce the risk of skeletal complications from MM, intravenous pamidronate was administered in addition to chemotherapy, though in reduced dose and frequency. Orthopedic consultant recommended against prophylactic surgery for the AFF. Follow-up radiograph showed no progression of the AFF, though delayed healing was present. This case highlights the importance of close monitoring of patients on long-term bisphosphonate therapy who have additional risk factors for developing AFF, such as underlying genetic bone disorders or lower limb deformities. A multidisciplinary approach is recommended for optimal management of such complex patients.

Current Understanding of Epidemiology, Pathophysiology, and Management of Atypical Femur Fractures

PURPOSE OF REVIEW

To summarize reports published since the 2013 American Society of Bone and Mineral Research Task Force Report on atypical femoral fractures (AFF).

RECENT FINDINGS

The absolute incidence of AFFs remains low. AFFs are primarily associated with prolonged bisphosphonate (BP) exposure, but have also been reported in unexposed patients and those receiving denosumab for osteoporosis and metastatic bone disease. Asians may be more susceptible to AFFs. Lateral femoral bowing and varus hip geometry, which increase loading forces on the lateral femoral cortex, may increase AFF risk. Altered bone material properties associated with BP therapy may predispose to AFFs by permitting initiation and increasing propagation of micro-cracks. Relevant genetic mutations have been reported in patients with AFFs. Single X-ray absorptiometry femur scans permit early detection of incomplete and/or asymptomatic AFFs. Orthopedists recommend intramedullary rods for complete AFFs and for incomplete, radiologically advanced AFFs associated with pain and/or marrow edema on MRI. Teriparatide may advance AFF healing but few data support its efficacy. Greater understanding of biological and genetic predisposition to AFF may allow characterization of individual risk prior to initiating osteoporosis therapy and help allay fear in those at low risk for this complication, which remains rare in comparison to the osteoporotic fractures prevented by antiresorptive therapy.

Low Positive Predictive Value of Bone Scan to Predict Impending Complete Fracture among Incomplete Atypical Femoral Fracture

BACKGROUND

Although bone scan might be useful to detect incomplete atypical femoral fractures (AFFs) earlier than radiographs, there is no study on predicting further progression to a complete fracture among incomplete AFFs. Our purposes are to determine whether bone scan detects impending complete fracture among incomplete AFFs.

METHODS

We reviewed 18 patients (20 AFFs) who underwent bone scan at the diagnosis of incomplete AFF and were not treated with prophylactic fixation. A diagnosis of impending complete fracture was made, when the femur completely fractured within 6 months after the scan. We correlated radioisotope uptake with the impending complete fracture to calculate sensitivity, specificity, positive predictive value and negative predictive value of bone scan.

RESULTS

Thirteen AFFs (65%, 13/20) showed a positive uptake in bone scan. Among the 13, only one femur was completely fractured within 6 months. None of the 7 femurs without uptake in bone scan fractured. In diagnosing impending complete fracture, the sensitivity of bone scan was 100% and negative predictive value was 100%. However, the specificity (36.8%) and positive predictive value (7.7%) were quite low.

CONCLUSION

Bone scan has no significant role in detecting the impending complete fracture, and a positive uptake does not mean the necessity of prophylactic fixation of incomplete AFF.

Biologically synthesized titanium oxide nanostructures combined with morphogenetic protein as wound healing agent in the femoral fracture after surgery

The aim of the present study is to develop novel approach for the green synthesis of titanium oxide nanoparticles (TiO₂ NPs) using Eichhornia crassipes extract and calcined at different temperatures for evaluate the wound healing activity in the femoral fracture. The synthesized TiO₂ are formed different (plate and rod-like) nanostructures at various calcination temperatures. These samples were characterized by X-ray diffraction (XRD), Fourier transform-infrared spectroscopy (FTIR), Field emission scanning electron microscope (FE-SEM) and transmission electron microscope (TEM). Microscopic studies of TiO₂ NPs revealed that the synthesized TiO₂ NPs are formed well-defined rod-like structures at 400 °C with size ranged from 200 nm to 500 nm. The characterized plate and rod-like TiO₂ NPs are combined with human morphogenetic protein (HbMP) to improving its wound healing activity and osteoblast properties on femoral fractures. The biocompatibility was tested by using human bone marrow mesenchymal stem cells (BMSC) cells and antibacterial efficacy analyzed using human pathogenica bacteria Staphylococcus aureus and Escherichia coli through agar well diffusion assay. The green synthesized rod-like TiO₂ NPs combined with HbMP has been exhibited effective bone fusion behaviors with biomechanical properties and also improved antibacterial activity against pathogenic bacteria. From this study results, it is suggested that green synthesized TiO₂NPs could be used effectively in biomedical application.

Atypical fractures: An issue of concern or a myth?

Atypical Femoral Fractures (AFF) represent fractures located between the lesser trochanter and the supracondylar flare of a femur. An increasing pool of evidence supports their association with the prolonged use of bisphosphonates, even though a direct correlation is yet to be proved. The purpose of this review is to encapsulate the current evidence associating bisphosphonate use and the development of AFFs, the clinical features related to their presentation, as well as to report the armamentarium of strategies available in the prevention and treatment of AFFs. Based on these evidence, we propose a management algorithm for AFFs, that can serve as a guide for patients presenting with this condition.

Lateral fixation: an alternative surgical approach in the prevention of complete atypical femoral fractures

Little evidence is available on how to treat incomplete atypical fractures of the femur. When surgery is chosen, intramedullary nailing is the most common invasive technique. However, this approach is adopted from the treatment of other types of ordinary femoral fracture and does not aim to prevent the impending complete fracture by interrupting the mechanism underlying the pathology. We suggest a different surgical approach that intends to counteract the underlying biomechanical conditions leading to a complete atypical fracture and thus could be better suited in selected cases. Here, we share an alternative surgical approach and present two cases treated accordingly.

Lateral Cortical Thickening and Bone Heterogeneity of the Subtrochanteric Femur Measured With Quantitative CT as Indicators for Early Detection of Atypical Femoral Fractures in Long-Term Bisphosphonate Users

OBJECTIVE

The objective of our study was to compare subtrochanteric femur bone mineral density (BMD) and bone quality of long-term bisphosphonate (BP) users who sustained an atypical femoral fracture (AFF) with BP users who did not sustain a femoral fracture and BP-naïve patients with no history of femoral fracture using quantitative CT (QCT).

MATERIALS AND METHODS

Fourteen female BP users with an AFF (mean age, 72.6 years; mean duration of BP use, 6.2 years; mean body mass index, 21.9) who had undergone QCT before fracture events were sex-, age-, BP use duration-, and body mass index-matched to 14 BP users who did not sustain a fracture and 14 BP-naïve patients. The lateral cortical thickness index (CTI) and the mean BMD (BMD_mean) and SD of the BMD (BMD_SD) within the lateral cortex and within the entire cross-sectional area of the subtrochanteric femur were measured on axial QCT. Femoral neck-shaft angles were measured on the QCT scout image. Parameters were analyzed using the Kruskal-Wallis test.

RESULTS

Lateral CTIs were greater in the BP users with an AFF (median, 0.28) than in the BP users without a femoral fracture (median, 0.21) (p = 0.038) and the BP-naïve group (median, 0.21) (p = 0.009). The lateral cortex BMD_SD was significantly higher in the BP users with an AFF (median, 59.59 mg/cm³) than the BP users without a femoral fracture (median, 39.27 mg/cm³; p = 0.049) and the BP-naïve group (median, 31.02 mg/cm³; p = 0.037). There was no significant difference among groups in lateral cortex BMD_mean, BMD_mean and BMD_SD of the entire cross-sectional area, and femoral neck-shaft angle.

CONCLUSION

Long-term BP users with a subsequent AFF had a thicker lateral cortex and higher lateral cortex BMD_SD at the subtrochanteric area before the fracture on QCT than BP users who did not sustain a femoral fracture and BP-naïve patients.

Undisturbed local bone formation capacity in patients with atypical femoral fractures: a case series

We excised the fracture site in 8 patients with incomplete atypical femoral fractures by drilling an 11-mm-diameter hole. New bone formation could be seen in the hole within a normal time frame. Delayed healing of these fractures might be unrelated to an impaired capacity to form bone.

INTRODUCTION

Incomplete atypical femoral fractures (undisplaced cracks) heal slowly or not at all, and often progress to a complete fracture with minimal trauma. The impaired healing has been attributed to an impaired biologic healing capacity related to bisphosphonate use, or, alternatively, to the mechanical environment within the fracture crack. This study aimed to investigate the capacity for bone formation after resection of the fracture site.

METHODS

Between 2008 and 2014, we recruited eight patients with incomplete atypical femoral fractures. All used oral bisphosphonates before the fracture for on average 8 years (range 4 to 15) and complained of thigh pain. The fractures were stabilized with reamed cephalomedullary nails. During surgery, the fracture site in the lateral cortex was resected with a cylindrical drill (diameter 11.5 mm). The cylindrical cortical defect allowed radiographic evaluation of new bone formation, and the patients were followed clinically and radiologically for 24 months (range 15 to 92).

RESULTS

After 3 months, newly formed bone could be seen in the cortical defects in all patients. After 13-26 months, the previous defects showed continuous cortical bone. At final follow-up, all patients reported full recovery of pre-surgical complaints. No complications occurred and no reoperations were performed.

CONCLUSIONS

New bone formation occurred within a time frame that appears normal for healing of cortical bone defects. This suggests that the capacity to form new bone is intact.

Atypical femoral fractures related to bisphosphonate treatment: issues and controversies related to their surgical management

AIMS

Treatment guidelines for atypical femoral fractures associated with bisphosphonates have not been established. We conducted a systematic review of the treatment of atypical femoral fractures first, to evaluate the outcomes of surgical fixation of complete atypical fractures and secondly, to assess whether prophylactic surgery is necessary for incomplete atypical fractures.

MATERIALS AND METHODS

Case reports and series were identified from the PubMed database and were included if they described the treatment of atypical femoral fractures. In total, 77 publications met our inclusion criteria and 733 patients with 834 atypical complete or incomplete femoral fractures were identified.

RESULTS

For complete fractures, internal fixation was predominantly achieved by intramedullary nailing. The mean time to healing post-operatively was 7.3 months (2 to 31). Revision surgery for nonunion or implant failure was needed in 77 fractures (12.6%). A greater percentage of fractures treated with plate fixation (31.3%) required revision surgery than those treated with intramedullary nailing (12.9%) (p < 0.01). Non-operative treatment of incomplete fractures failed and surgery was eventually needed in nearly half of the patients (47%), whereas prophylactic surgery was successful and achieved a 97% rate of healing.

CONCLUSION

Intramedullary nailing is the first-line treatment for a complete fracture, although the risk of delayed healing and revision surgery seems to be higher than with a typical femoral fracture. Non-operative treatment does not appear to be a reliable way of treating an incomplete fracture: prophylactic intramedullary nailing should be considered if the patient is in intractable pain. Radiographs of the opposite side should be obtained routinely looking for an asymptomatic fracture. Bisphosphonates must be discontinued but ongoing metabolic management in the form of calcium and/or vitamin D supplements is advisable. Teriparatide therapy can be considered as an alternative treatment. Cite this article: Bone Joint J 2017;99-B:295-302.

Scoring System for Identifying Impending Complete Fractures in Incomplete Atypical Femoral Fractures

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.

A new contralateral atypical femoral fracture despite sequential therapy with teriparatide and strontium ranelate.Bone Rep. 2017;6:34-37. [PMID: 28377979 DOI: 10.1016/j.bonr.2017.01.002]

Atypical femoral fractures (AFFs) are a rare association of anti-resorptive therapy for osteoporosis. Limited evidence-based management guidelines on their optimal treatment exist, with observational studies suggesting a role for teriparatide (TPTD) in AFF healing. We report a case of a 65-year-old woman with postmenopausal osteoporosis who sustained an AFF following long-term bisphosphonate therapy, and who subsequently developed a new contralateral AFF after completion of TPTD therapy and initiation of strontium ranelate (SR) treatment. The sequence of events in this case report showed that TPTD and SR did not prevent the development of a new AFF, and questions the optimal treatment of these stress fractures.

•

A patient sustained a bisphosphonate-associated atypical femoral fracture (AFF).

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A contralateral AFF occurred despite sequential therapy with teriparatide and strontium ranelate.

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The role of teriparatide in the treatment of AFF remains uncertain.

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The use of strontium ranelate following an AFF is cautioned.

Insufficiency Fracture Occurring 3 Years After Union of an Intertrochanteric Hip Fracture: A Case Report

CASE

We present a rare case of insufficiency fracture at the level of the distal interlocking screw following union of an intertrochanteric hip fracture. A 74-year-old woman reported chronic thigh pain for 1 month. She had a history of an osteoporotic stable intertrochanteric fracture that was successfully treated with a short intramedullary nail 3.5 years prior. However, after union, the neck-shaft angle of the femur changed from 125° to 117°. She had been on alendronic acid therapy to prevent a secondary osteoporotic fracture. A recent radiograph and bone scan suggested an insufficiency fracture around the level of the distal interlocking screw. Revision surgery with a long intramedullary nail was performed, and complete union was observed 1 year postoperatively.

CONCLUSION

This case suggests that subsequent insufficiency fracture can occur after complete union of an intertrochanteric hip fracture. Physicians should be aware of the possibility of a stress fracture when a patient has thigh pain after an intertrochanteric fracture has healed following repair with a short intramedullary nail.

Atypical femoral fracture after receiving antiresorptive drugs in breast cancer patients with bone metastasis

Background

Atypical femoral fracture (AFF) occurs with minor trauma in patients receiving antiresorptive drugs such as bisphosphonate and denosumab. We hypothesized that patients with bone metastasis who receive higher doses of antiresorptive drugs tend to experience AFF more frequently. This study aimed to investigate the prevalence rate of AFF in patients receiving antiresorptive drugs for bone metastasis of breast cancer.

Methods

Based on the database from our hospital, patients with breast cancer between March and September 2014 were investigated. Thirty-two patients with bone metastasis who received higher doses of antiresorptive drugs were included for analysis and defined as the metastasis (M) group. For the control (C) group, 32 patients in the same period with breast cancer without bone metastasis who did not undergo antiresorptive drug therapy were included. We evaluated the localized periosteal thickening of the lateral cortex (beaking) and femoral neck-shaft angle in CT scout view, the periods from induction of antiresorptive drugs to the appearance of beaking, and the occurrence rate of complete fracture. The 2 groups were compared.

Results

Of the 64 limbs in 32 patients of the M group, 8 limbs in 6 patients showed beaking at the subtrochanteric area (12.5%). After the occurrence of beaking, 5 limbs in 3 patients eventually had a complete fracture with minor trauma (7.8%). On the other hand, no beaking was observed in the C group.

Conclusions

The frequency of AFF in patients with breast cancer receiving bisphosphonate and/or denosumab for bone metastasis was high. More attention should be paid to the occurrence of AFF in these patients than osteoporotic patients.

Total Hip Arthroplasty for Implant Rupture after Surgery for Atypical Subtrochanteric Femoral Fracture

Treatment methods for delayed union and nonunion of atypical femoral fracture are still controversial. Moreover, no treatment method has been established for implant rupture caused by delayed union and nonunion. We encountered a 74-year-old female in whom nonunion-induced implant rupture occurred after treatment of atypical subtrochanteric femoral fracture with internal fixation using a long femoral nail. It was unlikely that sufficient fixation could be obtained by repeating osteosynthesis alone. Moreover, the patient was elderly and early weight-bearing activity was essential for early recovery of ADL. Based on these reasons, we selected one-stage surgery with total hip arthroplasty and osteosynthesis with inverted condylar locking plate as salvage procedures. Bone union was achieved at 6 months after surgery. This case illustrated that osteosynthesis-combined one-staged total hip arthroplasty could be considered as one of the options for nonunion-induced implant rupture of atypical femoral subtrochanteric fracture.

Clinical features of atypical femur fracture

Objectives

We aim to elucidate the clinical outcomes of bisphosphonate-associated atypical femoral fracture and the clinical results depending on the bisphosphonate therapy period.

Methods

Twenty cases involving 15 patients who had been diagnosed with atypical femoral facture between 2004 and 2014 and who had been followed up for at least 12 months were retrospectively analyzed. The control group was composed of 15 typical femoral facture patients. We used plain radiography and physical examinations to determine the period of time required for fracture healing as well as complication occurrence. We investigated the bisphosphonate administration status and duration and the names of its components, bilateral fracture occurrence status, the period of time required for bone union, and reoperation or bone graft status due to nonunion.

Results

Revision surgery involving a bone graft was performed due to nonunion in 1 out of 15 cases. Except in one revision case, the duration of the union was 11.9 months on average in 14 cases of atypical fracture patients, and 4.3 months on average in the control group. This difference was statistically significant (p < 0.05). The bisphosphonate administration duration was positively correlated with the union period (p < 0.05). In contrast, there was no statistically significant correlation between the bisphosphonate administration duration and the incidence of bilateral atypical fractures (p > 0.05).

Conclusions

Atypical femoral fractures required more time for bone union than typical ones and prolonged bisphosphonate administration led to a longer period of time required for bone union.

Does the Time of Postoperative Bisphosphonate Administration Affect the Bone Union in Osteoporotic Intertrochanteric Fracture of Femur?

Purpose

This study was designed to investigate the effect of bisphosphonate administration starting time on bone healing and to identify the best administration time following surgical treatment of osteoporotic intertrochanteric fractures.

Materials and Methods

Two hundreds and eighty four patients (284 hips; 52 males, 232 females) who underwent surgery following osteoporotic intertrochanteric fracture from December 2002 to December 2012 were retrospectively analyzed. The average follow-up period was 68.4 months. The patients were divided into three groups according to the time of bisphosphonate administration after operation: 1 week (group A; n=102), 1 month (group B; n=89), and 3 months (group C; n=93). Koval scores and change of Koval scores 1 year after operation were used for clinical evaluation. For radiologic evaluation, the time of callus appearance across the fracture line on sagittal and coronal radiographs and the time to absence of pain during hip motion was judged as the time of bone union.

Results

Koval scores one year after surgery for groups A, B, and C were 2.44, 2.36, and 2.43 (P=0.895), respectively. The mean time of union was 12.4, 11.9, and 12.3 weeks after operation in the three groups (P=0.883), respectively. There were zero cases of nonunion. There were 3, 5, and 7 cases of fixative displacement in the three groups, respectively, but the distribution showed no significant difference (P>0.472).

Conclusion

The initiating time of bisphosphonate administration following surgery does not affect the clinical outcomes in patients with osteoporotic intertrochanteric fracture.

Trochanteric Stress Fracture in a Female Window Cleaner

Stress fractures may occur at various sites in the femur including the head, neck, shaft, supracondylar and condylar regions. To the best of our knowledge, stress fracture occurring in the trochanteric region has not been previously reported. We report here a case of trochanteric stress fracture in a 53-year-old female window cleaner treated with hip nailing without adverse consequences. Careful consideration of this entity is needed when evaluating patients who have repetitive jumping up and down.

Management of atypical femoral fracture: a scoping review and comprehensive algorithm

BACKGROUND

Atypical femoral fractures (AFF) are a rare type of femoral stress fracture recently described, potentially associated with prolonged bisphosphonate therapy. Evidence-based recommendations regarding diagnosis and management of these fractures are scarce. The purpose of this study is to propose an algorithm for the diagnosis and management of AFF.

METHODS

We performed a PubMed search of the last ten years using the keywords "atypical femoral fractures" and identified further articles through an evaluation of the publications cited in these articles. Relevant studies were included by agreement between researchers, depending on their specialization. Pertinent points of debate were discussed based on the available literature, allowing for consensus regarding the proposed management algorithm.

RESULTS

Using a systematic approach we performed a scoping review that included a total of 137 articles.

CONCLUSIONS

A practical guide for diagnosis and management of AFF based on the current concepts is proposed. In spite of the impressive large volume of published literature available since AFF were initially identified, the level of evidence is mostly poor, in particular regarding treatment choice. Therefore, further studies are required.

Radiology of Osteoporosis

The radiologist has a number of roles not only in diagnosing but also in treating osteoporosis. Radiologists diagnose fragility fractures with all imaging modalities, which includes magnetic resonance imaging (MRI) demonstrating radiologically occult insufficiency fractures, but also lateral chest radiographs showing asymptomatic vertebral fractures. In particular MRI fragility fractures may have a nonspecific appearance and the radiologists needs to be familiar with the typical locations and findings, to differentiate these fractures from neoplastic lesions. It should be noted that radiologists do not simply need to diagnose fractures related to osteoporosis but also to diagnose those fractures which are complications of osteoporosis related pharmacotherapy. In addition to using standard radiological techniques radiologists also use dual-energy x-ray absorptiometry (DXA) and quantitative computed tomography (QCT) to quantitatively assess bone mineral density for diagnosing osteoporosis or osteopenia as well as to monitor therapy. DXA measurements of the femoral neck are also used to calculate osteoporotic fracture risk based on the Fracture Risk Assessment Tool (FRAX) score, which is universally available. Some of the new technologies such as high-resolution peripheral computed tomography (HR-pQCT) and MR spectroscopy allow assessment of bone architecture and bone marrow composition to characterize fracture risk. Finally radiologists are also involved in the therapy of osteoporotic fractures by using vertebroplasty, kyphoplasty, and sacroplasty. This review article will focus on standard techniques and new concepts in diagnosing and managing osteoporosis.

Caveats of bisphosphonate abuse

BACKGROUND

Bisphosphonates (BPs) are the common drugs used for the treatment of postmenopausal osteoporosis. Short term benefits of the BPs are well known. However, there are concerns regarding their long term use. The aim of the study was to analyze the association between atypical femoral fractures and BP misuse/abuse as well as study the outcome of management of these fractures.

MATERIALS AND METHODS

A retrospective study of a prospectively studied patients who presented with atypical femoral fractures between January 2010 and August 2012 and were followed up upto June 2014. The cohort consisted of nine female patients (12 fractures) with an average age of 71 years (range 58-85 years). Analysis was done for the indications, duration of BP use, configuration of associated fractures and method of treatment.

RESULTS

The mean duration of BP use was 6.6 years (range 4-10 years). BP treatment was initiated without sufficient indication and continued without proper review and followup in most cases. Most patients did not followup and continued to consume BPs without any review by the doctors. All patients had prodromal thigh pain of various duration, which was inadequately investigated and managed before the presentation. Two cases with an incomplete fracture and no thigh pain were managed successfully with conservative treatment. The rest were treated by surgery with intramedullary nailing. The average union time was longer and two fractures went into nonunion which required further surgical intervention.

CONCLUSION

Atypical femoral fractures appear to be strongly related to abuse of BPs. Great care is to be exercised at initiation as well as the continuation of BP therapy, and regular review is required. There is a need for improved awareness among physicians about the possibility of such fractures, and interpretation of thigh pain and radiological findings, especially if the patient has been on BPs therapy. Internal fixation for complete fractures and for incomplete fractures with thigh pain is needed. Delayed union is common.

Delayed healing of lower limb fractures with bisphosphonate therapy

INTRODUCTION

Bisphosphonate therapy (BT) is used commonly in the management of osteoporosis. A systematic review was conducted investigating delayed union of lower limb, long bone fractures in patients on BT. We specifically assessed whether BT increases the risk of delayed union or non-union in lower limb, long bone fractures.

METHODS

A literature search was conducted in the PubMed and Embase™ on 4 November 2014. Articles that investigated lower limb fractures, history of BT and fracture union were included in the review.

RESULTS

A total of 9,809 papers were retrieved and 14 were deemed suitable for this review. The mean time to union in patients on BT was 8.5 months. A longer time to union was reported in a study investigating BT users versus controls (6.5 vs 4.8 months respectively). The mean rate of delayed or non-union for BT associated atypical fractures was 20% per fracture. Specifically in one study, delayed union was more common in the cohort with more than three years of BT (67%) than in the group with less than three years of BT (26%). Surgical fixation was associated with improved outcomes compared with non-operative management.

CONCLUSIONS

BT has been described to be associated with multiple adverse outcomes related to atypical fractures. Current evidence recommends operative management for this patient group. Further investigation is required to evaluate the exact effects of BT on lower limb fractures, in particular typical femoral fractures.

Periprosthetic Atypical Femoral Fracture-like Fracture after Hip Arthroplasty: A Report of Three Cases

Atypical femoral fractures are stress or insufficient fractures induced by low energy trauma or no trauma and have specific X-ray findings. Although the American Society for Bone and Mineral Research has excluded periprosthetic fractures from the definition of an atypical femoral fracture in 2013, this is still a matter of controversy because some authors report periprosthetic fractures showing specific features of atypical fractures around a well-fixed femoral stem. We report 3 cases of periprosthetic femur fractures that had specific radiographic features of atypical femoral fractures in patients with a history of prolonged bisphosphonate use; we also review relevant literature.

Periprosthetic Insufficiency Fracture around Radiographically Loose Cemented Stem: A Report of Two Cases

As the osteoporotic patient population grows, various periprosthetic fractures that cannot be classified appropriately can occur around the femur after hip arthroplasty. We experienced two cases of periprosthetic insufficiency fractures at subtrochanteric area of the femurs around radiographically loose cemented femoral stems. The ages of the patients were 75 years and 83 years. Both patients could not recall any history of trauma before the onset of pain. Both were treated non-operatively. Both healed uneventfully and did not recur after two years of follow up. When the osteoporotic patient with cemented stem showed sudden hip or thigh pain without a history of trauma, great attention should be focused to find this lesion.

Atypical femoral fracture due to chronic use of bisphosphonates: case report

The causal relationship between chronic use of bisphosphonates and occurrences of atypical femoral fractures has not yet been established. Nonetheless, it is known that their chronic use is more related to fractures with a pattern differing from that of classical osteoporotic fractures. Atypical fractures are still rare events and the benefit from using bisphosphonates remains greater for prevention and treatment of osteoporosis. There are few studies guiding the diagnosis and management of these fractures, thus making it difficult to achieve better results. In this report, we present the case of an elderly patient with an atypical femoral fracture that was managed in accordance with guidance from the American Society for Bone and Mineral Research.