Skip to main content

Advertisement

SpringerLink
Log in

Differences in subtrochanteric and diaphyseal atypical femoral fractures in a super-aging prefectural area: YamaCAFe Study

  • Original Article
  • Published:
Journal of Bone and Mineral Metabolism Aims and scope Submit manuscript

Abstract

Introduction

Atypical femoral fractures (AFFs) have been correlated with long-term use of bisphosphonates (BPs), glucocorticoids (GCs), and femoral geometry. We investigated the incidence and characteristics of subtrochanteric (ST) and diaphyseal (DP) AFFs in all institutes in a super-aging prefectural area.

Materials and methods

We performed a blinded analysis of radiographic data in 87 patients with 98 AFFs in all institutes in Yamagata prefectural area from 2009 to 2014. Among the 98 AFFs, 57 AFFs comprising 11 ST fractures in 9 patients and 46 DP fractures in 41 patients with adequate medical records and X-rays were surveyed for time to bone healing and geometry.

Results

Of the 87 patients, 67 received BPs/denosumab (77%) and 10 received GCs (11%). Surgery was performed in 94 AFFs. Among 4 AFFs with conservative therapy, 3 required additional surgery. In univariate regression analyses for ST group versus DP group, male-to-female ratio was 2/7 versus 1/40, mean age at fracture was 58.2 (37–75) versus 78 (60–89) years, rheumatic diseases affected 55.5% (5/9) versus 4.9% (2/41), femoral lateral bowing angle was 1.7 (0–6) versus 11.8 (0.8–24)°, GC usage was 67% (6/9) versus 4.9% (2/41), and bone healing time was 12.1 (6–20) versus 8.1 (3–38) months (p < 0.05). In multivariate analyses, higher male-to-female ratio, younger age, greater proportion affected by rheumatic diseases, and higher GC usage remained significant (p < 0.05).

Conclusions

The incidence of AFFs in our prefectural area was 1.43 cases/100,000 persons/year. This study suggests that the onset of ST AFFs have greater correlation with the worse bone quality, vice versa, the onset of DP AFFs correlated with the bone geometry. The developmental mechanisms of AFFs may differ significantly between ST and DP fractures.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

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

    Article  Google Scholar 

  2. Schilcher J, Michaelsson K, Aspenberg P (2011) Bisphosphonate use and atypical fractures of the femoral shaft. N Engl J Med 364:1728–1737

    Article  CAS  Google Scholar 

  3. Schilcher J, Koeppen V, Aspenberg P, Michaelsson K (2014) Risk of atypical femoral fracture during and after bisphosphonate use. N Engl J Med 371:974–976

    Article  Google Scholar 

  4. Black DM, Delmas PD, Eastell R, Reid IR, Boonen S et al (2007) Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med 356:1809–1822

    Article  CAS  Google Scholar 

  5. Hyodo K, Nishino T, Kamada H, Nozawa D, Mishima H, Yamazaki M (2017) Location of fractures and the characteristics of patients with atypical femoral fractures: analyses of 38 Japanese cases. J Bone Miner Metab 35:209–214

    Article  Google Scholar 

  6. Kondo N, Fukuhara T, Watanabe Y, Miyasaka D, Yamamoto N, Sato H, Wada Y, Nakatsue T, Fujisawa J, Sakuma M, Imai N, Yoda T, Narita I, Endo N (2017) Bone formation parameters of the biopsied ilium differ between subtrochanteric and diaphyseal atypical femoral fractures in bisphosphonate-treated patients. Tohoku J Exp Med 243:247–254

    Article  CAS  Google Scholar 

  7. Oh Y, Wakabayashi Y, Kurosa Y, Fujita K, Okawa A (2014) Potential pathogenic mechanism for stress fractures of the bowed femoral shaft in the elderly: Mechanical analysis by the CT-based finite element method. Injury 45:1764–1771

    Article  Google Scholar 

  8. van de Laarschot DM, McKenna MJ, Abrahamsen B, Langdahl B, Cohen-Solal M, Guañabens N, Eastell R, Ralston SH, Zillikens MC (2020) Medical management of patients after atypical femur fractures: a systematic review and recommendations from the European Calcified Tissue Society. J Clin Endocrinol Metab 1:105

    Google Scholar 

  9. De Das S, Setiobudi T, Shen L, De Das S (2010) A rational approach to management of alendronate-related subtrochanteric fractures. J Bone Joint Surg Br 92:679–686

    Article  Google Scholar 

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

    Article  CAS  Google Scholar 

  11. Dell RM, Adams AL, Greene DF, Funahashi TT, Silverman SL, Eisemon EO, Zhou H, Burchette RJ, Ott SM (2012) Incidence of atypical nontraumatic diaphyseal fractures of the femur. J Bone Miner Res 27:2544–2550

    Article  Google Scholar 

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

    PubMed  Google Scholar 

  13. Ettinger B, Burr DB, Ritchie RO (2013) Proposed pathogenesis for atypical femoral fractures: lessons from materials research. Bone 55:495–500

    Article  CAS  Google Scholar 

  14. Nakamura T, Turner CH, Yoshikawa T, Slemenda CW, Peacock M, Burr DB, Mizuno Y, Orimo H, Ouchi Y, Johnston CC Jr (1994) Do variations in hip geometry explain differences in hip fracture risk between Japanese and white Americans? J Bone Miner Res 9:1071–1076

    Article  CAS  Google Scholar 

  15. Shane E, Burr D, Abrahamsen B, Adler RA, Brown TD et al (2014) 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 29:1–23

    Article  Google Scholar 

  16. Lo JC, Hui RL, Grimsrud CD, Chandra M, Neugebauer RS, Gonzalez JR, Budayr A, Lau G, Ettinger B (2016) The association of race/ethnicity and risk of atypical femur fracture among older women receiving oral bisphosphonate therapy. Bone 85:142–147

    Article  Google Scholar 

  17. Markman LH, Allison MB, Rosenberg ZS, Vieira RL, Babb JS, Tejwani NC, Im SA, Peck V (2013) A retrospective review of patients with atypical femoral fractures while on long-term bisphosphonates: including pertinent biochemical and imaging studies. Endocr Pract 19:456–461

    Article  Google Scholar 

  18. National Institute of Population and Social Security Research. Japanese Mortality Database (2014) http://www.ipss.go.jp/

  19. Yamagata prefecture government, Health and longevity Promotion Section. Rate of elderly people in Yamagata prefecture (2014) http://www.pref.yamagata.jp/ou/kikakushinko/020052/tokei/jinkel.html (in Japanese).

  20. Takakubo Y, Ohta D, Ishi M, Ito J, Oki H et al (2017) The incidence of atypical femoral fractures in patients with rheumatic disease: Yamagata Prefectural Committee of Atypical Femoral Fractures (YamaCAFe) Study. Tohoku J Exp Med 242:327–334

    Article  Google Scholar 

  21. Hagen JE, Miller AN, Ott SM, Gardner M, Morshed S, Jeray K, Alton TB, Ren D, Abblitt WP, Krieg JC (2014) Association of atypical femoral fractures with bisphosphonate use by patients with varus hip geometry. J Bone Joint Surg Am 96:1905–1909

    Article  Google Scholar 

  22. Cooper C, Cole ZA, Holroyd CR, Earl SC, Harvey NC, Dennison EM, Melton LJ, Cummings SR, Kanis JA, IOF CSA Working Group on Fracture (2011) Secular trends in the incidence of hip and other osteoporotic fractures. Osteoporos Int 22:1277–1288

    Article  CAS  Google Scholar 

  23. Bawa HS, Weick J, Dirschl DR (2015) Anti-osteoporotic therapy after fragility fracture lowers rate of subsequent fracture: Analysis of a large population sample. J Bone Joint Surg Am 97:1555–1562

    Article  Google Scholar 

  24. Tamaki J, Fujimori K, Ikehara S, Kamiya K, Nakatoh S, Okimoto N, Ogawa S, Ishii S, Iki M, Working Group of Japan Osteoporosis Foundation (2019) Estimates of hip fracture incidence in Japan using the National Health Insurance Claim Database in 2012–2015. Osteoporos Int 30:975–983

    Article  CAS  Google Scholar 

  25. Kishimoto H, Maehara M (2015) Compliance and persistence with daily, weekly, and monthly bisphosphonates for osteoporosis in Japan: analysis of data from the CISA. Arch Osteoporos 10:231

    Article  Google Scholar 

  26. Lee KJ, Yoo JJ, Oh KJ, Yoo JH, Rhyu KH, Nam KW, Suh DH (2017) Surgical outcome of intramedullary nailing in patients with complete atypical femoral fracture: a multicenter retrospective study. Injury 48:941–945

    Article  Google Scholar 

  27. Park YC, Yoon SP, Yang KH (2019) Localization of atypical femoral fracture on straight and bowed femurs. J Bone Metab 26:123–131

    Article  Google Scholar 

  28. Cho YJ, Kang KC, Chun YS, Rhyu KH, Kim SJ, Jang TS (2018) Critical differences between subtrochanteric and diaphyseal atypical femoral fractures: analyses of 51 cases at a single institution in Korean population. Arch Osteoporos 13:53

    Article  Google Scholar 

  29. Giusti A, Hamdy NA, Papapoulos SE (2010) Atypical fractures of the femur and bisphosphonate therapy: A systematic review of case/case series studies. Bone 47:169–180

    Article  CAS  Google Scholar 

  30. Saita Y, Ishijima M, Mogami A, Kubota M, Baba T et al (2015) The incidence of and risk factors for developing atypical femoral fractures in Japan. J Bone Miner Metab 33:311–318

    Article  CAS  Google Scholar 

  31. Sato H, Kondo N, Wada Y, Nakatsue T, Iguchi S, Fujisawa J, Kazama JJ, Kuroda T, Nakano M, Endo N, Narita I (2016) The cumulative incidence of and risk factors for latent beaking in patients with autoimmune diseases taking long-term glucocorticoids and bisphosphonates. Osteoporos Int 27:1217–1225

    Article  CAS  Google Scholar 

  32. Banffy MB, Vrahas MS, Ready JE, Abraham JA (2011) Nonoperative versus prophylactic treatment of bisphosphonate-associated femoral stress fractures. Clin Orthop Relat Res 469:2028–2034

    Article  Google Scholar 

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

    CAS  PubMed  Google Scholar 

  34. Schilcher J (2015) High revision rate but good healing capacity of atypical femoral fractures. A comparison with common shaft fractures. Injury 46:2468–2473

    Article  Google Scholar 

  35. Miyakoshi N, Aizawa T, Sasaki S, Ando S, Maekawa S, Aonuma H, Tsuchie H, Sasaki H, Kasukawa Y, Shimada Y (2015) Healing of bisphosphonate-associated atypical femoral fractures in patients with osteoporosis: a comparison between treatment with and without teriparatide. J Bone Miner Metab 33:553–559

    Article  CAS  Google Scholar 

Download references

Acknowledgements

The authors thank a lot for all members of YamaCAFe study, Ms. Itsuho Tomuro and Ms. Emi Arai for their great supports, and Dr. Alison Sherwin, PhD, from Edanz Group, and American Journal Experts for editing a draft of this manuscript.

Author information

Authors and Affiliations

  1. Faculty of Orthopaedic Surgery & Rehabilitation, Yamagata University, Yamagata, Japan

    Yuya Takakubo

  2. Faculty of Orthopaedic surgery, Yamagata University, Yamagata, Japan

    Takahiro Miyaji, Daichi Ohta, Juji Ito, Ryosuke Momma, Ryusuke Honma, Takeru Akabane, Tomohiro Uno, Yang Suran, Takaaki Nagase, Hanqing Huang & Michiaki Takagi

  3. Faculty of Orthopaedic surgery, Yamagata Saisei Hospital, Yamagata, Japan

    Hiroharu Oki, Akiko Sasaki, Kan Sasaki & Masaji Ishi

  4. Faculty of Orthopaedic surgery, Yamagata Prefectural Central Hospital, Yamagata, Japan

    Yasushi Naganuma

  5. Faculty of Orthopaedic surgery, Okitama Public General Hospital, Yamagata, Japan

    Katsuyuki Dairaku

  6. Faculty of Orthopaedic surgery, Tsuruoka Municipal Shonai Hospital, Yamagata, Japan

    Shinichi Goto

  7. Faculty of Orthopaedic surgery, Sagae City Hospital, Yamagata, Japan

    Yasuo Goto

  8. Faculty of Orthopaedic surgery, Yamagata Prefectural Kahoku Hospital, Yamagata, Japan

    Yumiko Kanauchi

  9. Faculty of Orthopaedic surgery, Shiseido General Hospital, Yamagata, Japan

    Shinji Kobayashi

  10. Faculty of Orthopaedic surgery, Sanyudo Hospital, Yamagata, Japan

    Taku Nakajima

  11. Faculty of Orthopaedic surgery, Tohoku Central Hospital, Yamagata, Japan

    Michiharu Matsuda

  12. Faculty of Orthopaedic surgery, Yamagata City Hospital, Yamagata, Japan

    Keiji Masuda & Atsushi Noro

  13. Faculty of Orthopaedic surgery, Yoshioka Hospital, Yamagata, Japan

    Nariyuki Mura & Takashi Furukawa

  14. Faculty of Orthopaedic surgery, Kitamurayama Hospital, Yamagata, Japan

    Kenji Takenouchi

  15. Faculty of Orthopaedic surgery, Miyuki social medical corporation, Miyukikai Hospital, Yamagata, Japan

    Hiroyuki Tsuchida

  16. Faculty of Orthopaedic surgery, Yamagata Tokusyukai Hospital, Yamagata, Japan

    Yasushi Onuma

  17. Faculty of Orthopaedic surgery, Yamagata Prefectural Shinjo Hospital, Yamagata, Japan

    Junichirou Shibuya

  18. Faculty of Orthopaedic surgery, Sinoda General Hospital, Yamagata, Japan

    Osamu Yamaguchi

  19. Faculty of Orthopaedic surgery, Mamurogawa Town Hospital, Yamagata, Japan

    Yasuhiro Urayama

  20. Faculty of Orthopaedic surgery, Nihonkai General Hospital, Yamagata, Japan

    Shouta Okuda

  21. Faculty of Orthopaedic surgery, Yonezawa City Hospital & Ogura Orthopaedic Clinic, Yamagata & Sendai, Japan

    Ken Ogura

  22. Faculty of Orthopaedic surgery, Funayama Hospital, Yamagata, Japan

    Takeshi Nakamura

Authors
  1. Yuya Takakubo
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Takahiro Miyaji
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Daichi Ohta
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Juji Ito
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Hiroharu Oki
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ryosuke Momma
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Yasushi Naganuma
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Ryusuke Honma
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Takeru Akabane
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Tomohiro Uno
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Akiko Sasaki
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Yang Suran
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Katsuyuki Dairaku
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Shinichi Goto
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Yasuo Goto
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. Yumiko Kanauchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  17. Shinji Kobayashi
    View author publications

    You can also search for this author in PubMed Google Scholar

  18. Taku Nakajima
    View author publications

    You can also search for this author in PubMed Google Scholar

  19. Michiharu Matsuda
    View author publications

    You can also search for this author in PubMed Google Scholar

  20. Keiji Masuda
    View author publications

    You can also search for this author in PubMed Google Scholar

  21. Nariyuki Mura
    View author publications

    You can also search for this author in PubMed Google Scholar

  22. Kenji Takenouchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  23. Hiroyuki Tsuchida
    View author publications

    You can also search for this author in PubMed Google Scholar

  24. Yasushi Onuma
    View author publications

    You can also search for this author in PubMed Google Scholar

  25. Junichirou Shibuya
    View author publications

    You can also search for this author in PubMed Google Scholar

  26. Takaaki Nagase
    View author publications

    You can also search for this author in PubMed Google Scholar

  27. Osamu Yamaguchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  28. Yasuhiro Urayama
    View author publications

    You can also search for this author in PubMed Google Scholar

  29. Takashi Furukawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  30. Shouta Okuda
    View author publications

    You can also search for this author in PubMed Google Scholar

  31. Hanqing Huang
    View author publications

    You can also search for this author in PubMed Google Scholar

  32. Atsushi Noro
    View author publications

    You can also search for this author in PubMed Google Scholar

  33. Ken Ogura
    View author publications

    You can also search for this author in PubMed Google Scholar

  34. Takeshi Nakamura
    View author publications

    You can also search for this author in PubMed Google Scholar

  35. Kan Sasaki
    View author publications

    You can also search for this author in PubMed Google Scholar

  36. Masaji Ishi
    View author publications

    You can also search for this author in PubMed Google Scholar

  37. Michiaki Takagi
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Yuya Takakubo.

Ethics declarations

Conflict of interest

All authors have no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Takakubo, Y., Miyaji, T., Ohta, D. et al. Differences in subtrochanteric and diaphyseal atypical femoral fractures in a super-aging prefectural area: YamaCAFe Study. J Bone Miner Metab 39, 700–711 (2021). https://doi.org/10.1007/s00774-021-01215-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00774-021-01215-4

Keywords

Search

Navigation