Subtrochanteric insufficiency fractures in patients on alendronate therapy

Abstract

We carried out a retrospective review over ten months of patients who had presented with a low-energy subtrochanteric fracture. We identified 13 women of whom nine were on long-term alendronate therapy and four were not. The patients treated with alendronate were younger, with a mean age of 66.9 years (55 to 82) vs 80.3 years (64 to 92) and were more socially active. The fractures sustained by the patients in the alendronate group were mainly at the femoral metaphyseal-diaphyseal junction and many had occurred after minimal trauma. Five of these patients had prodromal pain in the affected hip in the months preceding the fall, and three demonstrated a stress reaction in the cortex in the contralateral femur. Our study suggests that prolonged suppression of bone remodelling with alendronate may be associated with a new form of insufficiency fracture of the femur. We believe that this finding is important and indicates the need for caution in the long-term use of alendronate in the treatment of osteoporosis.

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

“…(10)(11)(12)(13) A relatively large proportion of patients also has taken GCs in addition to BPs. GCs reduce osteoblast activity, increase osteoblast apoptosis, (14)(15)(16) and are also associated with osteonecrosis of the femoral head.…”

“…The bone marrow was hypercellular, but there was no evidence of inflammation, malignancy, or myelosclerosis. Goh and colleagues (10) performed qualitative histology on biopsies removed intraoperatively during repair of subtrochanteric fractures in 5 alendronate-treated patients, but they simply reported that there was no evidence of neoplasia.…”

“…A femoral fracture must be ruled out. (10,12,93,100,110,115,124,159) Anteroposterior and lateral plain radiographs of the hip, including the full diaphysis of the femur, should be performed. If the radiograph is negative and the level of clinical suspicion is high, a technetium bone scan or MRI of the femur should be performed to detect a periosteal stress reaction.…”

“…Orthopedic management includes stabilizing the fracture and addressing the medical management (10,12,93,100,110,115,124,159) (see below). Since BPs inhibit osteoclastic remodeling, endochondral fracture repair is the preferred method of treatment.…”

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

“…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.…”