Clinical Orthopaedics and Related Research®

, Volume 468, Issue 12, pp 3384–3392

Femoral Insufficiency Fractures Associated with Prolonged Bisphosphonate Therapy

  • Joseph D. Isaacs
  • Louis Shidiak
  • Ian A. Harris
  • Zoltan L. Szomor
Clinical Research

DOI: 10.1007/s11999-010-1535-x

Cite this article as:
Isaacs, J.D., Shidiak, L., Harris, I.A. et al. Clin Orthop Relat Res (2010) 468: 3384. doi:10.1007/s11999-010-1535-x

Abstract

Background

Emerging evidence has linked the long-term use of bisphosphonates with femoral insufficiency fractures. It has been suggested that the prolonged effect on bone remodeling leads to the accumulation of microfractures and weakening of bone.

Questions/purposes

We investigated the association between bisphosphonate use and femoral insufficiency fractures.

Methods

We evaluated 100 patients with low-energy femoral shaft fractures before and after bisphosphonates became available for use. Twenty-one consecutive patients who presented between January 1995 and February 1997 were compared with 79 consecutive patients who presented between January 2007 and February 2009. The radiographs of all 100 patients were examined for evidence of preexisting insufficiency fractures. We identified insufficiency fractures by a transverse fracture line on the tension side of the femur with lateral cortical thickening immediately adjacent to the fracture. Relevant details from the history were recorded.

Results

Forty-one patients had an underlying femoral insufficiency fracture, all of whom had been receiving bisphosphonate therapy. Among the 21 patients with low-energy femoral fractures before the availability of bisphosphonates, none had insufficiency fractures. Of the 41 patients with insufficiency fractures, 29 (71%) had prodromal pain and 18 (44%) had bilateral insufficiency fractures. Bisphosphonate use was associated (odds ratio greater than 1000) with insufficiency fracture. The mean duration of bisphosphonate use in patients with insufficiency fractures was longer than in patients without fractures (7.1 versus 3.2 years).

Conclusion

Long-term bisphosphonate use is associated with insufficiency fractures of the femoral shaft, which commonly present with prodromal thigh pain and may be bilateral. These fractures were not seen before bisphosphonates became available for use.

Level of Evidence

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Copyright information

© The Association of Bone and Joint Surgeons® 2010

Authors and Affiliations

  • Joseph D. Isaacs
    • 1
    • 3
  • Louis Shidiak
    • 1
    • 3
  • Ian A. Harris
    • 2
  • Zoltan L. Szomor
    • 1
    • 4
  1. 1.The St George and Sutherland Hospital Orthopaedic DepartmentsSydneyAustralia
  2. 2.Department of Orthopaedic SurgeryThe University of New South Wales, South West Sydney Clinical School, Liverpool HospitalLiverpoolAustralia
  3. 3.Department of Orthopaedic SurgeryThe University of New South Wales, The St George HospitalSydneyAustralia
  4. 4.Department of Orthopaedic SurgeryThe University of New South WalesSydneyAustralia

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