Atypical Femoral Fractures: What Do We Know About Them?

Unnanuntana, Aasis; Saleh, Anas; Mensah, Kofi A.; Kleimeyer, John P.; Lane, Joseph M.

doi:10.2106/jbjs.l.00568

Cited by 81 publications

(94 citation statements)

References 2 publications

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“…An additional finding in our case was a concomitant medial cortical hypertrophy, which has not been described for AFF (but a medial spike is common with a complete AFF). 10 Although prophylactic nailing seems to be the treatment of choice for these impending AFFs, progression of the fracture after nailing is not expected, as happened in our case. We are aware of only two other reports where bisphosphonate-related AFF progressed even after intramedullary nailing (Table 1).…”

Section: Discussionmentioning

confidence: 49%

“…2,3,9 The predominant hypothesis regarding the pathophysiology of atypical femur fracture is that bisphosphonate induced suppression of bone turnover leads to the accumulation of bone microdamage, a reduction in matrix heterogeneity, and an increase in advanced glycation endproducts, leading to impaired stress fracture healing, and the development of an insufficiency fracture at the point of maximal, weight-bearing stress, namely at the subtrochanteric or diaphyseal femur. 10,11 In spite of history of myeloma, we still believe that our case was an AFF rather than a myeloma-related pathologic or stress fracture as there was a typical AFF like beaking, absence of a typical myeloma lytic lesion at the beaking site, and over 4 years of prior bisphosphonate use. Moreover, the fracture progressed after adequate fixation (the stress fracture should have healed not progressed after nailing).…”

Section: Discussionmentioning

confidence: 78%

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Progression of bisphosphonate-associated impending atypical femoral fracture despite prophylactic cephalomedullary nailing: A case report and review of literature

Maheshwari

Yarmis

Tsai

et al. 2016

Journal of Clinical Orthopaedics and Trauma

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Section: Discussionmentioning

confidence: 49%

Section: Discussionmentioning

confidence: 78%

Progression of bisphosphonate-associated impending atypical femoral fracture despite prophylactic cephalomedullary nailing: A case report and review of literature

Maheshwari

Yarmis

Tsai

et al. 2016

Journal of Clinical Orthopaedics and Trauma

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“…hypophosphatasia, pycnodysostosis and osteopetrosis) and these conditions should be kept in mind in the differential diagnosis. However, their bilaterality as well as prodromal pain are the distinguishing clinical features of AFF (8,10).…”

Section: ) Generalized Increase In Cortical Thickness Of the Femoralmentioning

confidence: 99%

“…Prophylactic nail fixation is recommended for incomplete fractures (with cortical lucency) accompanied by pain. If the patient has minimal pain, conservative therapy with limited weight-bearing through the use of crutches or a walker may be considered (8,10).…”

Section: ) Generalized Increase In Cortical Thickness Of the Femoralmentioning

confidence: 99%

“…Generalized suppression of remodeling as a consequence of BP therapy does not negatively affect periosteal and endosteal callus formation. BPs localize in areas developing stress fractures and, suppression of intracortical remodeling at the site of an AFF could impair the process by which stress fractures normally heal (8,10). The risk difference between ethnical groups suggests that the lower limb geometry contributes to AFF formation.…”

Section: Introductionmentioning

confidence: 99%

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Bilateral Incomplete Atypical Femoral Fracture due to Long-Term Bisphosphonate Use: A Case Report

Başaran¹,

Benlidayı²,

Akın³

et al. 2017

meandros

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Although the overall safety profile of bisphosphonates (BP) is favorable, adverse effects associated with long-term use have came up during recent years. In this report, a case of bilateral incomplete atypical femoral fracture (AFF) due to prolonged BP use was presented. A 69-year-old patient, who has been in surgical menopause for 20 years and was started on BP following vertebral fracture almost 10 years ago, was admitted with thigh pain, which was increased two weeks ago. On physical examination, she had antalgic gait, increased thoracic kyphosis and tenderness to percussion over the thoracolumbar region. Lateral cortical thickness in the subtrochanteric region of both femurs and cortical radiolucency on the left femur were observed on plain radiography. Loss of height in L3 and L4 vertebrae was detected on vertebral radiography. Serum 25-hydroxy vitamin D [25(OH) D], parathyroid hormone, alkaline phosphatase and calcium levels, along with osteoporosis markers were all within the normal ranges. As the patient was diagnosed with AFF, BP therapy was terminated and vitamin D-calcium supplementation was continued. Since she did not have severe pain, conservative management (limited weight bearing, using a walking stick) was recommended for 3 months. Teriparatide therapy was started and she was discharged with recommendations. AFF, which is a rare disorder, should be kept in mind in patients on long-term BP treatment who are admitted with thigh pain and, necessary interventions should be tailored before the occurrence of complete fracture.Bifosfonatların (BP) güvenlik profili genel olarak iyi olmakla birlikte son zamanlarda uzun süreli kullanımları ile ilişkilendirilebilen yan etkiler gündeme gelmeye başlamıştır. Bu olgu raporunda uzun süre BP kullanımına bağlı olarak gelişen bilateral inkomplet atipik femur fraktürü (AFF) olgusu sunulmuştur. Yirmi yıldır cerrahi menapozda olup, 10 yıl kadar önce vertebra kırığı sonrasında BP tedavisi başlanan 69 yaşındaki hasta, 6 ay önce başlayan ve 2 haftadır artış gösteren uyluk ağrısı nedeniyle başvurdu. Fizik muayenesinde antaljik yürüyüşü mevcuttu. Torakal kifozu artmıştı. Künt perküsyonla torakolomber vertebral hassasiyeti mevcuttu. Direkt grafilerinde her iki femurda subtrokanterik bölgede lateral kortekste kalınlaşma ve solda kortekste radyolusen görünüm tespit edildi. Vertebra grafilerinde ise L3 ve L4 vertebralarda yükseklik kaybı mevcuttu. Serum 25-hidroksi vitamin D [25(OH)D], parathormon, alkalen fosfataz ve kalsiyum düzeyleri ile osteoporoz markerları normal sınırlardaydı. AFF olarak değerlendirilen hastanın BP tedavisi kesilerek kalsiyum ve vitamin D takviyesine

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Bisphosphonate‐Associated Atypical Femur Fracture

Nguyen

Sinnollareddy

2014

Pharmacy Practice and Res

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Background Bisphosphonate therapies have long been reported to decrease the risk of typical low trauma fractures in the elderly population and are commonly prescribed for this indication. In recent literature, case reports of atypical sub‐trochanteric and femoral shaft fractures have been documented in patients treated with bisphosphonates. Clinical details Herein we report on an 81‐year‐old woman with postmenopausal osteoporosis who presented with an atypical femoral sub‐trochanteric fracture on plain film X‐ray following approximately 5 months for query left hip bursitis after having received risedronate and alendronate therapy for >5 years. Outcomes The patient was transferred to a hospital closer to home for further rehabilitation 10 days after surgery. Her bisphosphonate therapy was ceased with advice for her general practitioner (GP) to undertake annual bone mineral density testing, as well as regular calcium and vitamin D levels. It was also recommended that the patient be referred to a bone health clinic. Conclusion The burden of atypical fractures is significant both for the healthcare system and, more importantly, patients. There are now clear radiological changes to bone scans that give rise to the possibility of bisphosphonate‐associated atypical fractures; therefore, it is recommended that patients on long‐term bisphosphonate therapy for osteoporosis be reviewed every 5 years. In addition, GPs should be informed of the need for surveillance for prodromal symptoms and the possibility of atypical and minimal trauma fractures associated with long‐term bisphosphonate use.

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Atypical Femoral Fractures: What Do We Know About Them?

Cited by 81 publications

References 2 publications

Progression of bisphosphonate-associated impending atypical femoral fracture despite prophylactic cephalomedullary nailing: A case report and review of literature

Progression of bisphosphonate-associated impending atypical femoral fracture despite prophylactic cephalomedullary nailing: A case report and review of literature

Bilateral Incomplete Atypical Femoral Fracture due to Long-Term Bisphosphonate Use: A Case Report

Bisphosphonate‐Associated Atypical Femur Fracture

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