Abstract
Background
There is increasing evidence suggesting a high incidence of low-energy fractures of the diaphysis or the proximal femur in patients receiving bisphosphonates for a long time. Bisphosphonate-related femoral fractures occur after low-energy trauma and have a typical simple transverse or oblique radiographic pattern, with focal or generalized increased cortical thickness, cortical beaking, and medial spiking.
Materials and methods
This article presents six female patients who experienced seven transverse femoral diaphysis and subtrochanteric fractures with cortical thickening and beaking; all patients had alendronate treatment for 4–10 years (average, 9 years) before their fracture.
Results
The typical radiographic findings, long-term administration of alendronate, low-energy mechanism of fracture, and related literature support the fact that the fractures in the patients presented in this series should be related to alendronate treatment.
Conclusion
Until definite evidence is available, alendronate treatment in patients with osteoporosis is not now prohibited by the healthcare authorities, probably because its beneficial influence outweighs the adverse effects. However, this adverse effect deserves attention of medical practitioners; physicians should be alert on alendronate’s possible suppressive effect on bone turnover, which in turn may be responsible for the occurrence of femoral fractures.
Similar content being viewed by others
References
Black DM, Thompson DE, Bauer DC et al (2000) Fracture risk reduction with alendronate in women with osteoporosis: the fracture intervention trial. J Clin Endocrinol Metab 85:4118–4124
Neviaser AS, Lane JM, Lenart BA, Edobor-Osula F, Lorich DG (2008) Low-energy femoral shaft fractures associated with alendronate use. J Orthop Trauma 22:346–350
Kwek EB, Goh SK, Koh JS, Png MA, Howe TS (2008) An emerging pattern of subtrochanteric stress fractures: a long-term complication of alendronate therapy? Injury 39:224–231
Goh SK, Yang KY, Koh JS et al (2007) Subtrochanteric insufficiency fractures in patients on alendronate therapy: a caution. J Bone Joint Surg Br 89:349–353
Abrahamsen B, Eiken P, Eastell R (2009) Subtrochanteric and diaphyseal femur fractures in patients treated with alendronate: a register-based national cohort study. J Bone Miner Res 24:1095–1102
Odvina CV, Levy S, Rao S, Zerwekh JE, Rao DS (2010) Unusual mid-shaft fractures during long-term bisphosphonate therapy. Clin Endocrinol (Oxf) 72(2):161–168
Ward WG Jr, Carter CL, Wilson SC, Emory CL (2012) Femoral stress fractures associated with long-term bisphosphonate treatment. Clin Orthop Relat Res 470(3):759–765
Glennon DA (2009) Subtrochanteric stress fractures in six patients on long-term bisphosphonate therapy: a case series. Bone 44(Suppl 1):S77–S78
Schilcher J, Aspenberg P (2009) Incidence of stress fractures of the femoral shaft in women treated with bisphosphonate. Acta Orthop 80(4):413–415
Capeci CM, Tejwani NC (2009) Bilateral low-energy simultaneous or sequential femoral fractures in patients on long-term alendronate therapy. J Bone Joint Surg Am 91:2556–2561
Cermak K, Shumelinsky F, Alexiou J, Gebhart MJ (2010) Case reports: subtrochanteric femoral stress fractures after prolonged alendronate therapy. Clin Orthop Relat Res 468(7):1991–1996
Ha YC, Cho MR, Park KH, Kim SY, Koo KH (2010) Is surgery necessary for femoral insufficiency fractures after long-term bisphosphonate therapy? Clin Orthop Relat Res 468(12):3393–3398
Goddard MS, Reid KR, Johnston JC, Khanuja HS (2009) Atraumatic bilateral femur fracture in long-term bisphosphonate use. Orthopedics 32(8)
Mashiba T, Hirano T, Turner CH, Forwood MR, Johnston CC, Burr DB (2000) Suppressed bone turnover by bisphosphonates increases microdamage accumulation and reduces biomechanical properties in dog rib. J Bone Miner Res 15:613–620
Nancollas GH, Tang R, Phipps RJ et al (2006) Novel insights into actions of bisphosphonates on bone: differences in interactions with hydroxyapatite. Bone 38(5):617–627
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
Armamento-Villareal R, Napoli N, Diemer K et al (2009) Bone turnover in bone biopsies of patients with low-energy cortical fractures receiving bisphosphonates: a case series. Calcif Tissue Int 85:37–44
Cosman F, Curtis JR, Dell R et al (2010) American Society for Bone and Mineral Research. 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(11):2267–2294
Shane E, Ebeling PR, Abrahamsen B, et al (2013) 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. doi:10.1002/jbmr.1998. (Epub ahead of print)
Lo JC, Huang SY, Lee GA, Khandewal S, Provus J, Ettinger B, Gonzalez JR, Hui RL, Grimsrud CD (2012) Clinical correlates of atypical femoral fracture. Bone 51(1):181–184
Conflict of interest
None of the authors had any financial or personal relationships with other people or organizations that could inappropriately influence (bias) their work.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Ballas, E.G., Mavrogenis, A.F., Karamanis, E. et al. Low-energy femoral shaft fractures after long-term alendronate therapy: report of seven cases. Eur J Orthop Surg Traumatol 25, 181–187 (2015). https://doi.org/10.1007/s00590-014-1443-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00590-014-1443-y