Low‐Energy Femoral Fractures Associated With Long‐Term Bisphosphonate Use in a Rehabilitation Setting: A Case Series

Bunning, Robert D.; Rentfro, Robert J.; Jelinek, James S.

doi:10.1016/j.pmrj.2009.11.007

Cited by 16 publications

(12 citation statements)

References 11 publications

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“…It is also important to note that atypical fractures have been reported in patients who have not been exposed to BPs. This occurred in 3 of the 8 patients with atypical fragility fractures of the femur reported by Schilcher and colleagues, (101) in 1 of 20 patients in the Neviaser case series, (100) in 5 of 102 patients reported by Dell and colleagues, (99) in 1 of 4 patients reported by Bunning and colleagues, (102) and in 3 of 26 patients in the Lenart study, (93) as well as in patients with hypophosphatasia. (2,103) Epidemiologic studies show that fractures of the subtrochanteric region of the femur and the femoral shaft follow an age and sex distribution similar to osteoporotic fractures.…”

Section: Epidemiology Of Subtrochanteric and Femoral Shaft Fracturesmentioning

confidence: 84%

Atypical subtrochanteric and diaphyseal femoral fractures: Report of a task force of the american society for bone and mineral Research

Shane

Burr

Ebeling

et al. 2010

Journal of Bone and Mineral Research

999

679

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Reports linking long-term use of bisphosphonates (BPs) with atypical fractures of the femur led the leadership of the American Society for Bone and Mineral Research (ASBMR) to appoint a task force to address key questions related to this problem. A multidisciplinary expert group reviewed pertinent published reports concerning atypical femur fractures, as well as preclinical studies that could provide insight into their pathogenesis. A case definition was developed so that subsequent studies report on the same condition. The task force defined major and minor features of complete and incomplete atypical femoral fractures and recommends that all major features, including their location in the subtrochanteric region and femoral shaft, transverse or short oblique orientation, minimal or no associated trauma, a medial spike when the fracture is complete, and absence of comminution, be present to designate a femoral fracture as atypical. Minor features include their association with cortical thickening, a periosteal reaction of the lateral cortex, prodromal pain, bilaterality, delayed healing, comorbid conditions, and concomitant drug exposures, including BPs, other antiresorptive agents, glucocorticoids, and proton pump inhibitors. Preclinical data evaluating the effects of BPs on collagen cross-linking and maturation, accumulation of microdamage and advanced glycation end products, mineralization, remodeling, vascularity, and angiogenesis lend biologic plausibility to a potential association with long-term BP use. Based on published and unpublished data and the widespread use of BPs, the incidence of atypical femoral fractures associated with BP therapy for osteoporosis appears to be very low, particularly compared with the number of vertebral, hip, and other fractures that are prevented by BPs. Moreover, a causal association between BPs and atypical fractures has not been established. However, recent observations suggest that the risk rises with increasing duration of exposure, and there is concern that lack of awareness and underreporting may mask the true incidence of the problem. Given the relative rarity of atypical femoral fractures, the task force recommends that specific diagnostic and procedural codes be created and that an international registry be established to facilitate studies of the clinical and genetic risk factors and optimal surgical and medical management of these fractures. Physicians and patients should be made aware of the possibility of atypical femoral fractures and of the potential for bilaterality through a change in labeling of BPs. Research directions should include development of animal models, increased surveillance, and additional epidemiologic and clinical data to establish the true incidence of and risk factors for this condition and to inform orthopedic and medical management. ß

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Section: Epidemiology Of Subtrochanteric and Femoral Shaft Fracturesmentioning

confidence: 84%

Atypical subtrochanteric and diaphyseal femoral fractures: Report of a task force of the american society for bone and mineral Research

Shane

Burr

Ebeling

et al. 2010

Journal of Bone and Mineral Research

999

679

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“…Interest in these fractures has increased recently, as many reports have been published suggesting that the distinction between typical and atypical fractures may be related to long-term bisphosphonate use. (1)(2)(3)(4)(5)(6)(7)(8) However, the increased risk of ST/FS fractures in patients taking bisphosphonates long term has not been clearly established and might be related to fragility fractures. (9)(10)(11)(12) Although the incidence of hip fractures has been well characterized, the incidence of ST/FS fractures has only recently been reported.…”

Section: Introductionmentioning

confidence: 99%

Subtrochanteric/femoral shaft Versus hip fractures: Incidences and identification of risk factors

Maravic¹,

Ostertag

Cohen‐Solal

2011

Journal of Bone and Mineral Research

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Subtrochanteric and femoral shaft (ST/FS) fractures are now considered to be fragility fractures in osteoporotic patients. Although rare, there is growing evidence of the burden that they constitute. Little is known about the change over time in incidence of ST/FS fractures. We assessed the incidence of ST/FS fractures and the associated risk factors from 2002 to 2009 compared with those of hip fractures. Data were obtained from the French National Database, which includes all hospital discharge codes from acute care facilities. Hospitalizations for primary surgical management of neck/trochanteric (hip) and ST/FS fractures in patients aged above 50 years were selected and described for different age groups. Incidences per million populations were calculated using the estimated French population adjusted for each year, age, and gender. We studied the change for each fracture site. The comorbidity factors related to these fractures were assessed in 2009 using multivariate logistic regression. From 2002 to 2009, the adjusted incidence of hip fractures decreased continuously from 4368 to 3662 in women ( p < 0.0001), and a mild increase from 1476 to 1384 in men ( p < 0.0001) after an initial decrease. In contrast, the incidence of ST/FS increased significantly in both genders (from 353 to 395 in women, from 146 to 159 in men).

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“…14,15 Recent articles and case reports in the literature have detailed several additional negative effects, such as osteonecrosis of the jaw and low-energy nonvertebral fractures. 16 The latter has become heavily focused on because the incidence of bisphosphonate-related femur fractures continues to increase. This association is interesting, as subtrochanteric or femoral shaft fractures are relatively uncommon and only represent 10%-30% of all hip and femur fractures.…”

Section: Discussionmentioning

confidence: 99%

“…This association is interesting, as subtrochanteric or femoral shaft fractures are relatively uncommon and only represent 10%-30% of all hip and femur fractures. 16 Furthermore, although increased risk of fractures is commonly associated with osteoporosis, the atypical femoral fractures sustained by osteoporotic patients who have been treated with bisphosphonates occur spontaneously or with minimal trauma. 17 In a study of nonoperative versus prophylactic treatment of bisphosphonate-associated femoral stress fractures, Banffy et al 18 emphasized the importance of orthopaedic surgeons recognizing incomplete bisphosphonate-related femur fractures.…”

Section: Discussionmentioning

confidence: 99%

Surgical Treatment Improves Clinical and Functional Outcomes for Patients Who Sustain Incomplete Bisphosphonate-Related Femur Fractures

Egol

Park

Prensky

et al. 2013

Journal of Orthopaedic Trauma

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Low‐Energy Femoral Fractures Associated With Long‐Term Bisphosphonate Use in a Rehabilitation Setting: A Case Series

Cited by 16 publications

References 11 publications

Atypical subtrochanteric and diaphyseal femoral fractures: Report of a task force of the american society for bone and mineral Research

Atypical subtrochanteric and diaphyseal femoral fractures: Report of a task force of the american society for bone and mineral Research

Subtrochanteric/femoral shaft Versus hip fractures: Incidences and identification of risk factors

Surgical Treatment Improves Clinical and Functional Outcomes for Patients Who Sustain Incomplete Bisphosphonate-Related Femur Fractures

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