J Bone Metab.  2012 Nov;19(2):129-132. 10.11005/jbm.2012.19.2.129.

Is It a Simple Stress Fracture or Bisphosphonate-related Atypical Fracture?

• Kang SY
• Baek JH
• Kang BJ
• Kim MK
• Lee HJ

• KMID: 1975986
• DOI: http://doi.org/10.11005/jbm.2012.19.2.129

Abstract

A number of reports regarding atypical fractures of the femur have raised questions concerning the possible correlation between long-term bisphosphonate treatment and the occurrence of insufficiency fractures in the proximal femur. However, clinically, it is often confused whether is it a fatigue fracture because of implant induced stress concentration or a bisphosphonate-related atypical fracture, especially in a patient with a subtrochanteric fracture who receive bisphosphonate therapy after open reduction and internal fixation, such as dynamic hip screw (DHS) fixation for previous ipsilateral femoral neck or intertrochanteric fracture. The authors experienced a case of a progressive femoral insufficiency fracture in a woman who had been on Fosamax (Alendronic acid with Vitamin D; Merck & Co. Inc, NJ, USA) therapy for four years after ipsilateral femoral neck fracture treated with a two hole DHS system. Despite a high suspicion of an insufficiency femoral subtrochanteric fracture by bone scan, the occult fracture progressed to a displaced femoral subtrochanteric fracture one year after. The fracture site was fixed with a 6 hole DHS plate, and six months after reoperation the patient had no symptoms and the fracture site had united without any complication.

Keyword

Bisphosphonate; Early diagnosis; Femoral fractures; Fractures stress; Osteoporosis

MeSH Terms

Alendronate
Early Diagnosis
Female
Femoral Fractures
Femoral Neck Fractures
Femur
Femur Neck
Fractures, Closed
Fractures, Stress
Hip
Humans
Osteoporosis
Reoperation
Vitamins
Alendronate
Vitamins

Figure

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  Fig. 1 A 76-year old woman complained of left thigh pain, (A) Pelvic plain radiograph and (B) Computed tomography image showing the absence of cortical hypertrophy and of a transverse fracture line. However, (C) a bone scan revealed hot uptake in the lateral cortex area below the end of the plate.

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  Fig. 2 (A) Plain radiography shows characteristic radiographic finding of atypical femoral fracture such as transverse fracture, lateral cortex thickness, and medical spike. (B) Anteroposterior pelvic radiograph of patient taken 6 months postoperatively shows callus formation without complications.

Reference

1. Odvina CV, Zerwekh JE, Rao DS, et al. Severely suppressed bone turnover: a potential complication of alendronate therapy. J Clin Endocrinol Metab. 2005. 90:1294–1301.

2. Goh SK, Yang KY, Koh JS, et al. Subtrochanteric insufficiency fractures in patients on alendronate therapy: a caution. J Bone Joint Surg Br. 2007. 89:349–353.

3. Kwek EB, Goh SK, Koh JS, et al. An emerging pattern of subtrochanteric stress fractures: a long-term complication of alendronate therapy? Injury. 2008. 39:224–231.

4. Capeci CM, Tejwani NC. Bilateral low-energy simultaneous or sequential femoral fractures in patients on long-term alendronate therapy. J Bone Joint Surg Am. 2009. 91:2556–2561.

5. Ha YC, Cho MR, Park KH, et al. Is surgery necessary for femoral insufficiency fractures after long-term bisphosphonate therapy? Clin Orthop Relat Res. 2010. 468:3393–3398.

6. Visekruna M, Wilson D, McKiernan FE. Severely suppressed bone turnover and atypical skeletal fragility. J Clin Endocrinol Metab. 2008. 93:2948–2952.

7. McKiernan FE, Hocking J, Cournoyer S, et al. A long femur scan field does not alter proximal femur bone mineral density measurements by dual-energy X-ray absorptiometry. J Clin Densitom. 2011. 14:354–358.

8. Puah KL, Tan MH. Bisphosphonate-associated atypical fracture of the femur: Spontaneous healing with drug holiday and re-appearance after resumed drug therapy with bilateral simultaneous displaced fractures--a case report. Acta Orthop. 2011. 82:380–382.