, Volume 23, Issue 12, pp 2901-2902
Date: 31 Jan 2012

Comment on Compston: Pathophysiology of atypical femoral fractures and osteonecrosis of the jaw

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In the review on atypical subtrochanteric fractures and ONJ [1], Professor Compston concludes that bisphosphonates “whilst not a prerequisite for the development of atypical femoral fractures, may contribute to their development in some cases.” Although an excellent overview, we think this conclusion is an understatement.

In our study with radiographic adjudication of femoral shaft fractures in Sweden during 2008, we found a 47 times higher risk of atypical femoral fractures for patients taking bisphosphonates [2]. This high relative risk together with the absence of any dependence on other drugs or co-morbidities, and the time dependence with bisphosponate use, speak for a clear relation. Although results from observational studies are claimed not to allow conclusions about causality, we believe this is as close as one can get. As a comparison, the association between smoking and lung cancer is less strong (relative risk, 20) [3]. Still, most researchers agree that smoking is an import ...