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

Lee, Seung Hyun; Lee, Young Han

doi:10.2214/ajr.17.17938

Cited by 12 publications

(11 citation statements)

References 25 publications

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“…In cases with normal radiographs on the contralateral side, but where there is still clinical suspicion, computed tomography (CT) should be considered, since fracture lines, not visible on radiographs, might be diagnosed. Lee et al 36 have shown that patients with a subsequent AFF have a thicker lateral cortex in the subtrochanteric region of the femur on CT before the fracture event, than bisphosphonate (BP) users who did not sustain a femoral fracture, and than BP-naïve patients. Thus, CT might be used for the early detection of AFF in long-term BP users.…”

Section: Evaluation and Diagnosismentioning

confidence: 99%

“…Quantitative CT analyses are able to show that long-term users of bisphosphonates with a subsequent fracture have a thicker subtrochanteric lateral cortex with a higher bone mineral density compared with patients who did not sustain a femoral fracture. 36 This is associated with a higher lateral femoral bowing angle with a vertex located at the site of the later subtrochanteric fracture. 37 …”

Section: Evaluation and Diagnosismentioning

confidence: 99%

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The enigma of atypical femoral fractures

Larsen

Schmal

2018

EFORT Open Reviews

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Atypical femoral fractures (AFF) are stress or ‘insufficiency’ fractures, often complicated by the use of bisphosphonates or other bone turnover inhibitors. While these drugs are beneficial for the intact osteoporotic bone, they probably prevent a stress fracture from healing which thus progresses to a complete fracture.Key features of atypical femoral fractures, essential for the diagnosis, are: location in the subtrochanteric region and diaphysis; lack of trauma history and comminution; and a transverse or short oblique configuration.The relative risk of patients developing an atypical femoral fracture when taking bisphosphonates is high; however, the absolute risk of these fractures in patients on bisphosphonates is low, ranging from 3.2 to 50 cases per 100,000 person-years.Treatment strategy in patients with AFF involves: radiograph of the contralateral side (computed tomography and magnetic resonance imaging should also be considered); dietary calcium and vitamin D supplementation should be prescribed following assessment; bisphosphonates or other potent antiresorptive agents should be discontinued; prophylactic surgical treatment of incomplete AFF with cephalomedullary nail, unless pain free; cephalomedullary nailing for surgical fixation of complete fractures; avoidance of gaps in the lateral and anterior cortex; avoidance of varus malreduction.Cite this article: EFORT Open Rev 2018;3:494-500. DOI: 10.1302/2058-5241.3.170070.

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Section: Evaluation and Diagnosismentioning

confidence: 99%

Section: Evaluation and Diagnosismentioning

confidence: 99%

The enigma of atypical femoral fractures

Larsen

Schmal

2018

EFORT Open Reviews

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“…It is "atypical" because osteoporotic fractures rarely involve the lateral femoral cortex. Due to poor healing potential and risk for fracture completion, patients may undergo prophylactic surgical fixation [24].…”

Section: Atypical Femoral Fracturementioning

confidence: 99%

“…Bilateral femoral radiographs may demonstrate asymptomatic contralateral fracture requiring prophylactic fixation. When radiographs are negative, CT and MR improve fracture detection in symptomatic patients on bisphosphonate therapy [23,24]. Similar to other tensile-sided stress fractures, healing is delayed [22].…”

Section: Atypical Femoral Fracturementioning

confidence: 99%

Glossary of terms for musculoskeletal radiology

et al. 2020

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

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“…A "beaking" or "flaring" phenomenon of localized periosteal or endosteal thickening of the lateral cortex often precedes an AFF, and this may aid in early detection. 29 Standard imaging modalities such as magnetic resonance imaging or computed tomography can visualize beaking, bone heterogeneity, the fracture line, and associated bone marrow edema. 10 Although less specific, radionuclide bone scans may detect hyperemia suggestive of AFF.…”

Section: Definition and Diagnosismentioning

confidence: 99%

The limitations of today’s clinical guidance: Atypical femoral fracture and long-term bone-modifying agents in the oncology setting

Cheung

Borno

2020

J Oncol Pharm Pract

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While bone-modifying agents such as bisphosphonates and denosumab are crucial to preventing skeletal-related events in patients with bone metastases, the optimal duration remains undefined. Extended duration may be associated with adverse effects such as osteonecrosis of the jaw and atypical femoral fracture. Although uncommon, atypical femoral fracture represents a serious consequence of prolonged bone-modifying agent use and are characterized by a prodrome and distinct radiographic findings. The oncology setting encompasses a unique set of atypical femoral fracture risk factors and considerations, with hormonal therapy in early stage disease, bone metastases in the advanced setting, and new targeted agents that may affect bone homeostasis. As outcomes in cancer treatment continue to improve, the questions of risks versus benefits of long-term bone-modifying agents and how to mitigate atypical femoral fracture risk become increasingly pertinent.

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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

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

Cited by 12 publications

References 25 publications

The enigma of atypical femoral fractures

The enigma of atypical femoral fractures

Glossary of terms for musculoskeletal radiology

The limitations of today’s clinical guidance: Atypical femoral fracture and long-term bone-modifying agents in the oncology setting

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