J Korean Fract Soc.  2018 Oct;31(4):159-164. 10.12671/jkfs.2018.31.4.159.

Atypical Femoral Fractures: What Do We Know about Them?

• Lee BS
• Lee YK
• Won H
• Kim H
• Koo KH

• KMID: 2422898
• DOI: http://doi.org/10.12671/jkfs.2018.31.4.159

Abstract

Recently, atypical femoral fractures (AFFs) have been found in patients who were prescribed bisphosphonate to prevent osteoporotic fractures. Although the occurrence of AFF is rare, there are some concerns, such as a higher risk of delayed or non-union of AFF. This paper reviews the treatment of AFF and suggests some considerations during surgery.

Keyword

Fractures stress; Fracture fixation intramedullary; Teriparatide; Osteoporosis

MeSH Terms

Femoral Fractures*
Humans
Osteoporosis
Osteoporotic Fractures
Teriparatide
Teriparatide

Figure

• 

  Fig. 1 Typical femoral fracture and atypical femoral fracture.

• 

  Fig. 2 Treatment of an atypical femoral fracture. IM: intramedullary.

Reference

1. Odvina CV, Zerwekh JE, Rao DS, Maalouf N, Gottschalk FA, Pak CY. Severely suppressed bone turnover: a potential complication of alendronate therapy. J Clin Endocrinol Metab. 2005; 90:1294–1301.

2. Shane E, Burr D, Ebeling PR, et al. Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2010; 25:2267–2294.

3. Park-Wyllie LY, Mamdani MM, Juurlink DN, et al. Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women. JAMA. 2011; 305:783–789.

4. Abrahamsen B, Einhorn TA. Beyond a reasonable doubt? Bisphosphonates and atypical femur fractures. Bone. 2012; 50:1196–1200.

5. Abrahamsen B, Eiken P, Eastell R. Cumulative alendronate dose and the long-term absolute risk of subtrochanteric and diaphyseal femur fractures: a register-based national cohort analysis. J Clin Endocrinol Metab. 2010; 95:5258–5265.

6. Shane E, Burr D, Abrahamsen B, et al. Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2014; 29:1–23.

7. Im GI, Jeong SH. Pathogenesis, management and prevention of atypical femoral fractures. J Bone Metab. 2015; 22:1–8.

8. Kwek EB, Goh SK, Koh JS, Png MA, Howe TS. An emerging pattern of subtrochanteric stress fractures: a long-term complication of alendronate therapy? Injury. 2008; 39:224–231.

9. 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.

10. Schilcher J, Aspenberg P. Incidence of stress fractures of the femoral shaft in women treated with bisphosphonate. Acta Orthop. 2009; 80:413–415.

11. Koh JH, Myong JP, Jung SM, et al. Atypical femoral fracture in rheumatoid arthritis patients treated with bisphosphonates: a nested case-control study. Arthritis Rheumatol. 2016; 68:77–82.

12. Sato H, Kondo N, Wada Y, et al. The cumulative incidence of and risk factors for latent beaking in patients with autoimmune diseases taking long-term glucocorticoids and bisphosphonates. Osteoporos Int. 2016; 27:1217–1225.

13. Lenart BA, Neviaser AS, Lyman S, et al. Association of low-energy femoral fractures with prolonged bisphosphonate use: a case control study. Osteoporos Int. 2009; 20:1353–1362.

14. Lee YK, Ha YC, Park C, Yoo JJ, Shin CS, Koo KH. Bisphosphonate use and increased incidence of subtrochanteric fracture in South Korea: results from the national claim registry. Osteoporos Int. 2013; 24:707–711.

15. Vestergaard P, Schwartz F, Rejnmark L, Mosekilde L. Risk of femoral shaft and subtrochanteric fractures among users of bisphosphonates and raloxifene. Osteoporos Int. 2011; 22:993–1001.

16. Wang Z, Ward MM, Chan L, Bhattacharyya T. Adherence to oral bisphosphonates and the risk of subtrochanteric and femoral shaft fractures among female medicare beneficiaries. Osteoporos Int. 2014; 25:2109–2116.

17. Wang Z, Bhattacharyya T. Trends in incidence of subtrochanteric fragility fractures and bisphosphonate use among the US elderly, 1996–2007. J Bone Miner Res. 2011; 26:553–560.

18. Abrahamsen B, Eiken P, Eastell R. Subtrochanteric and diaphyseal femur fractures in patients treated with alendronate: a register-based national cohort study. J Bone Miner Res. 2009; 24:1095–1102.

19. Swiontkowski MF. Oral bisphosphonates and risk of subtrochanteric or diaphyseal femur fractures in a population-based cohort. v. 2012. Yearbook of Orthopedics. New York: Elsevier Health Science;2012. p. 45–48.

20. Rose PS. Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women. v. 2012. Yearbook of Orthopedics. New York: Elsevier Health Science;2012. p. 355–357.

21. Meier RP, Perneger TV, Stern R, Rizzoli R, Peter RE. Increasing occurrence of atypical femoral fractures associated with bisphosphonate use. Arch Intern Med. 2012; 172:930–936.

22. Schilcher J, Michaëlsson K, Aspenberg P. Bisphosphonate use and atypical fractures of the femoral shaft. N Engl J Med. 2011; 364:1728–1737.

23. Dell RM, Adams AL, Greene DF, et al. Incidence of atypical nontraumatic diaphyseal fractures of the femur. J Bone Miner Res. 2012; 27:2544–2550.

24. Clarke BL. Bisphosphonates and fractures of the subtrochanteric or diaphyseal femur. v. 2011. Yearbook of Endocrinology. New York: Elsevier Health Science;2011. p. 197–199.

25. Beaudouin-Bazire C, Dalmas N, Bourgeois J, et al. Real frequency of ordinary and atypical sub-trochanteric and diaphyseal fractures in France based on X-rays and medical file analysis. Joint Bone Spine. 2013; 80:201–205.

26. LeBlanc ES, Rosales AG, Black DM, et al. Evaluating atypical features of femur fractures: how change in radiological criteria influenced incidence and demography of atypical femur fractures in a community setting. J Bone Miner Res. 2017; 32:2304–2314.

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

28. Neviaser AS, Lane JM, Lenart BA, Edobor-Osula F, Lorich DG. Low-energy femoral shaft fractures associated with alendronate use. J Orthop Trauma. 2008; 22:346–350.

29. Prasarn ML, Ahn J, Helfet DL, Lane JM, Lorich DG. Bisphosphonate-associated femur fractures have high complication rates with operative fixation. Clin Orthop Relat Res. 2012; 470:2295–2301.

30. Weil YA, Rivkin G, Safran O, Liebergall M, Foldes AJ. The outcome of surgically treated femur fractures associated with long-term bisphosphonate use. J Trauma. 2011; 71:186–190.

31. Lim HS, Kim CK, Park YS, Moon YW, Lim SJ, Kim SM. Factors associated with increased healing time in complete femoral fractures after long-term bisphosphonate therapy. J Bone Joint Surg Am. 2016; 98:1978–1987.

32. Lee KJ, Yoo JJ, Oh KJ, et al. Surgical outcome of intramedullary nailing in patients with complete atypical femoral fracture: a multicenter retrospective study. Injury. 2017; 48:941–945.

33. Tosounidis TH, Lampropoulou-Adamidou K, Kanakaris NK. Intramedullary nailing of sequential bilateral atypical subtrochanteric fractures and the management of distal femoral intraoperative fracture. J Orthop Trauma. 2015; [epub]. DOI: 10.1097/BOT.0000000000000370.

34. Kim JW, Kim H, Oh CW, et al. Surgical outcomes of intramedullary nailing for diaphyseal atypical femur fractures: is it safe to modify a nail entry in bowed femur? Arch Orthop Trauma Surg. 2017; 137:1515–1522.

35. Park YC, Song HK, Zheng XL, Yang KH. Intramedullary nailing for atypical femoral fracture with excessive anterolateral bowing. J Bone Joint Surg Am. 2017; 99:726–735.

36. Molvik H, Khan W. Bisphosphonates and their influence on fracture healing: a systematic review. Osteoporos Int. 2015; 26:1251–1260.

37. Yue B, Ng A, Tang H, Joseph S, Richardson M. Delayed healing of lower limb fractures with bisphosphonate therapy. Ann R Coll Surg Engl. 2015; 97:333–338.

38. Bogdan Y, Tornetta P 3rd, Einhorn TA, et al. Healing time and complications in operatively treated atypical femur fractures associated with bisphosphonate use: a multicenter retrospective cohort. J Orthop Trauma. 2016; 30:177–181.

39. Min BW, Koo KH, Park YS, et al. Scoring system for identifying impending complete fractures in incomplete atypical femoral fractures. J Clin Endocrinol Metab. 2017; 102:545–550.

40. Lee YK, Ha YC, Kang BJ, Chang JS, Koo KH. Predicting need for fixation of atypical femoral fracture. J Clin Endocrinol Metab. 2013; 98:2742–2745.

41. Unnanuntana A, Saleh A, Mensah KA, Kleimeyer JP, Lane JM. Atypical femoral fractures: what do we know about them?: AAOS exhibit selection. J Bone Joint Surg Am. 2013; 95:e81–13.

42. Murphy CM, Schindeler A, Cantrill LC, Mikulec K, Peacock L, Little DG. PTH(1-34) treatment increases bisphosphonate turnover in fracture repair in rats. J Bone Miner Res. 2015; 30:1022–1029.

43. Lee YK, Ha YC, Koo KH. Teriparatide, a nonsurgical solution for femoral nonunion? A report of three cases. Osteoporos Int. 2012; 23:2897–2900.

44. Pietrogrande L, Raimondo E. Teriparatide in the treatment of non-unions: scientific and clinical evidences. Injury. 2013; 44:Suppl 1. S54–S57.

45. Watts NB, Aggers D, McCarthy EF, et al. Responses to treatment with teriparatide in patients with atypical femur fractures previously treated with bisphosphonates. J Bone Miner Res. 2017; 32:1027–1033.

46. Chiang CY, Zebaze RM, Ghasem-Zadeh A, Iuliano-Burns S, Hardidge A, Seeman E. Teriparatide improves bone quality and healing of atypical femoral fractures associated with bisphosphonate therapy. Bone. 2013; 52:360–365.