Bisphosphonates (BPs) and denosumab reduce the risk of spine and nonspine fractures. Atypical femur fractures (AFFs) located in the subtrochanteric region and diaphysis of the femur have been reported in patients taking BPs and in patients on denosumab, but they also occur in patients with no exposure to these drugs. In this report, we review studies on the epidemiology, pathogenesis, and medical management of AFFs, published since 2010. This newer evidence suggests that AFFs are stress or insufficiency fractures. The original case definition was revised to highlight radiographic features that distinguish AFFs from ordinary osteoporotic femoral diaphyseal fractures and to provide guidance on the importance of their transverse orientation. The requirement that fractures be noncomminuted was relaxed to include minimal comminution. The periosteal stress reaction at the fracture site was changed from a minor to a major feature. The association with specific diseases and drug exposures was removed from the minor features, because it was considered that these associations should be sought rather than be included in the case definition. Studies with radiographic review consistently report significant associations between AFFs and BP use, although the strength of associations and magnitude of effect vary. Although the relative risk of patients with AFFs taking BPs is high, the absolute risk of AFFs in patients on BPs is low, ranging from 3.2 to 50 cases per 100,000 person-years. However, long-term use may be associated with higher risk ($100 per 100,000 personyears). BPs localize in areas that are developing stress fractures; suppression of targeted intracortical remodeling at the site of an AFF could impair the processes by which stress fractures normally heal. When BPs are stopped, risk of an AFF may decline. Lower limb geometry and Asian ethnicity may contribute to the risk of AFFs. There is inconsistent evidence that teriparatide may advance healing of AFFs.

The metabolic benefits from bariatric surgery, including the changes in BCAA profile, are comparable between SG and GB. The reduction in BCAAs and improvement in the AC profiles after bariatric surgery persists up to 12 months after surgery and may not be surgical related but is influenced primarily by the amount of weight loss, in particular the reduction in visceral adiposity.

Objectives: To investigate the relationship between thyroid function and short-term outcomes in elderly patients undergoing surgery for hip fracture. Methods: Patients aged >60 years admitted from July 2009 to June 2010 who underwent surgical fixation of low-energy hip fracture, excluding those with pathological or periprosthetic fracture, were enrolled in a retrospective observational cohort study. Patients were classified as having biochemically overt or subclinical hyperthyroidism or hypothyroidism, normal thyroid function, or nonclassifiable state based on preoperative thyroid-stimulating hormone and free thyroxine values. Outcome data were collected from hospital records. Biochemical thyroid dysfunction was not systematically treated. Outcomes measured were length of stay (LOS), 30-day postoperative complications, readmissions, and mortality. Results: A total of 254 patients were analyzed; 64 (25.2%) were male and mean age was 77.8 years. There were 128 (50.4%) patients with euthyroid, 68 (26.8%) nonclassifiable, 13 (5.1%) overtly hyperthyroid, 20 (7.9%) subclinically hyperthyroid, 4 (1.6%) overtly hypothyroid, and 21 (8.3%) subclinically hypothyroid. The 30-day postoperative complication rate was 38% (96 patients). The most common complication was urinary tract infection (12.6%), followed by cardiac events (8.3%) and delirium (5.5%). Patients with overt hyperthyroidism had an increased risk of complications in multivariate analysis (odds ratio 3.75, 95% confidence interval 1.10-12.84). Complications in this group were similar to those in the overall cohort. Thyroid function did not predict LOS, readmissions, or mortality. Conclusion: Older patients frequently develop complications following surgery for hip fractures. This risk appears to be increased by preoperative biochemically overt hyperthyroidism. Further study is warranted to confirm this finding and to determine whether preoperative treatment improves outcomes.

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We report a case of an 86-year-old woman with an atypical femoral fracture (AFF) who was treated with intramedullary nailing followed by lateral femoral plating. She developed a second femoral shaft fracture distal to the intramedullary nail which required a second operation. Biopsy of the periosteum overlying the site of the initial proximal AFF was sent for pathogen analysis. Using the Ibis T5000 platform and the BAC plate assay, a polymicrobial infection was diagnosed consisting of Bifidobacterium subtile and Pseudomonas mendocina. This raises the possibility that bacterial infections may play some role in atypical fractures of the femur.