Skip to main content
SpringerLink
Log in

Atypical Femoral Fracture (AFF)

  • Chapter
  • First Online:
The Art of Intramedullary Nailing for Femoral Fracture

  • 262 Accesses

Abstract

To satisfy the case definition of AFF, the fracture must be located along the femoral diaphysis from just distal to the lesser trochanter to just proximal to the supracondylar flare. In addition, at least four of five Major Features must be present. A long-term intake of BP has been regarded as a major cause of atypical femoral fracture since its first report mentioned above. Early detection of AFF usually starts from the prodromal symptoms of the patient. The patient complains of dull thigh or groin pain which leads to the hip and thigh radiographic examination. When the suspicious lesion is detected on the lateral cortex of the femur, further examinations, such as bone scan and MRI, are required. The primary healing rate after cephalomedullary nailing of bisphosphonate-associated complete subtrochanteric AFF was 68.7%. The margin of errors is narrow compared to the common subtrochanteric femoral nailing.

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

Access this chapter

Log in via an institution
eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Koh JS, Goh SK, Png MA, Kwek EB, Howe TS. Femoral cortical stress lesions in long-term bisphosphonate therapy: a herald of impending fracture? J Orthop Trauma. 2010;24(2):75–81.

    Article  PubMed  Google Scholar 

  2. Goh SK, Yang KY, Koh JSB, Wong MK, Chua SY, Chua DTC, Howe TS. Subtrochanteric insufficiency fractures in patients on alendronate therapy. J Bone Joint Surg (Br). 2007;89-B:349–53.

    Article  Google Scholar 

  3. Odvina CV, Zerwekh JE, Rao DS, Gottschalk FA, Pak CYC. Severely suppressed bone turnover: a potential complication of alendronate therapy. J Clin Endocrinol Metab. 2005;90:1294–301.

    Article  CAS  PubMed  Google Scholar 

  4. Schilcher J, Michaëlsson K, Aspenberg P. Bisphosphonate use and atypical fractures of the femoral shaft. N Engl J Med. 2011;364:1728–37.

    Article  CAS  PubMed  Google Scholar 

  5. 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;25:2109–16.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Oh Y, Wakabayashi Y, Kurosa Y, Ishizuki M, Okawa A. Stress fracture of the bowed femoral shaft is another cause of atypical femoral fracture in elderly Japanese: a case series. J Orthop Sci. 2014;19:579–86.

    Article  PubMed  Google Scholar 

  7. Park YC, Yoon SP, Yang KH. Localization of atypical femoral fracture on straight and bowed femurs. J Bone Metab. 2019a;26(2):123–31.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Hagen JE, Miller AN, Ott SM, Gardner M, Morshed S, Jeray K, Alton TB, Ren D, Abblitt WP, Krieg JC. Association of atypical femoral fractures with bisphosphonate use by patients with varus hip geometry. J Bone Joint Surg Am. 2014;96(22):1905–9.

    Article  PubMed  Google Scholar 

  9. Ng AC, Png MA, Mohan PC, Koh JS, Howe TS. Atypical femoral fractures: transverse morphology at lateral cortex is a critical feature. J Bone Miner Res. 2014;29(3):639–43.

    Article  PubMed  Google Scholar 

  10. Shane E, Burr D, Ebeling PR, Abrahamsen B, Adler RA, Brown TD, Cheung AM, Cosman F, Curtis JR, Dell R, Dempster D, Einhorn TA, Genant HK, Geusens P, Klaushofer K, Koval K, Lane JM, Mc Kiernan F, Mc Kinney R, Ng A, Nieves J, O’Keefe R, Papapoulos S, Sen HT, van der Meulen MC, Weinstein RS, Whyte M, 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. 2010;25(11):2267–94.

    Article  PubMed  Google Scholar 

  11. Shane E, Burr D, Abrahamsen B, Adler RA, Brown TD, Cheung AM, Cosman F, Curtis JR, Dell R, Dempster DW, Ebeling PR, Einhorn TA, Genant HK, Geusens P, Klaushofer K, Lane JM, McKiernan F, McKinney R, Ng A, Nieves J, O’Keefe R, Papapoulos S, Howe TS, van der Meulen MC, Weinstein RS, Whyte MP. 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):1–23.

    Article  PubMed  Google Scholar 

  12. Schilcher J, Howe TS, Png MA, Aspenberg P, Koh JSB. Atypical fractures are mainly subtrochanteric in Singapore and Diaphyseal in Sweden: a cross-sectional study. J Bone Miner Res. 2015;30:2127–32.

    Article  PubMed  Google Scholar 

  13. Martelli S, Pivonka P, Ebeling PR. Femoral shaft strains during daily activities: implications for atypical femoral fractures. Clin Biomech. 2014;29:869–76.

    Article  Google Scholar 

  14. Cheon SH, Oh CW, Lee JY, Yi JH, Cho HS, Oh JK, Yang KH, Jung GH. Early diagnosis of impending femoral insufficiency fractures by use of MRI: case report and review of the literature. J Orthop Sci. 2013;18:843–8.

    Article  PubMed  Google Scholar 

  15. Kim SJ, Yang KH, Lim HS, Lee YK, Yoon HK, Oh CW, Park KK, Min BW, Ryu JA, Kwack KS, Lee YH. Detection of Prefracture hip lesions in atypical subtrochanteric fracture with dual-energy X-ray absorptiometry images. Radiology. 2014;270(2):487–95.

    Article  PubMed  Google Scholar 

  16. Van de Laarschot DM, Smits AAA, Buitendijk SKC, Stegenga MT, Zillikens MC. Screening for atypical femur fractures using extended femur scans by DXA. J Bone Miner Res. 2017;32:1632–9.

    Article  PubMed  Google Scholar 

  17. Lee KJ, Min BW, Bae KC, Cho CH, Lee SW, Kim BS. Progression of asymptomatic contralateral femur in patients with complete atypical femoral fracture, according to initial radiographic findings. J Bone Joint Surg Am. 2021;103:123–30.

    Article  PubMed  Google Scholar 

  18. Lee YK, Ha YC, Kang BJ, Chang JS, Koo K-H. Predicting need for fixation of atypical femoral fracture. J Clin Endocrinol Metab. 2013;98:2742–5.

    Article  CAS  PubMed  Google Scholar 

  19. Min BW, Koo KH, Park YS, Oh CW, Lim SJ, Kim JW, Lee KJ, Lee YK. Scoring system for identifying impending complete fractures in incomplete atypical femoral fractures. J Clin Endocrinol Metab. 2017;102:545–50.

    Article  PubMed  Google Scholar 

  20. Shon OJ, Yoon JY, Kim JW. Clinical outcomes of using contralateral-side laterally bent intramedullary nails in atypical femur fractures with femoral bowing. Arch Orthop Trauma Surg. 2021;141:1291–6.

    Article  PubMed  Google Scholar 

  21. Byun SE, Cho YH, Lee YK, Park JW, Kim SK, Koo KH, Byun YS. Straight nail insertion through a laterally shifted entry for diaphyseal atypical femoral fractures with bowing: good indications and limitations of this technique. Int Orthop. 2021;45:3223–32.

    Article  PubMed  Google Scholar 

  22. Yang KH, Park YC, Kang DH, Moon HS, Zheng X. Intramedullary nailing for femoral shaft fracture with excessive antero-lateral bowing. Video presented at the Annual Meeting of the American Academy of Orthopaedic Surgeons; 2016 Mar 1–5; Orlando, FL. http:// www.aaos.org/store/product/?productid=8638525. Accessed 2016 Dec 7.

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

    Article  PubMed  Google Scholar 

  24. Zimmer natural nail (ZNN) system, Antegrade femoral nail surgical technique. Zimmer-Biomet. 2015:1–31.

    Google Scholar 

  25. Cho JW, Oh CW, Leung F, Park KC, Wong MK, Kwek E, Kim HJ, Oh JK. Healing of atypical subtrochanteric femur fractures after Cephalomedullary nailing: which factors predict union? J Orthop Trauma. 2017;31:138–45.

    Article  PubMed  Google Scholar 

  26. Biber R, Bail HJ, Stedtfeld HW. Lateral cortical notching in specific cases of delayed unions or nonunions after intertrochanteric and reversed fractures. Arch Orthop Trauma Surg. 2013;133:495–501.

    Article  PubMed  Google Scholar 

  27. Zheng XL, Kang DH, Seok SO, Yoon YK, Yang KH. A blocking-wire technique for removal of a broken hollow intramedullary nail. Injury. 2016;46:2498–01.

    Google Scholar 

  28. Sasaki S, Miyakoshi N, Hongo M, Kasukawa Y, Shimada Y. Low-energy diaphyseal femoral fractures associated with bisphosphonate use and severe curved femur: a case series. J Bone Miner Metab. 2012 Sep;30(5):561–7.

    Article  PubMed  Google Scholar 

  29. Chang ST, Tenforde AS, Grimsrud CD, O'Ryan FS, Gonzalez JR, Baer DM, Chandra M, Lo JC. Atypical femur fractures among breast cancer and multiple myeloma patients receiving intravenous bisphosphonate therapy. Bone. 2012;51:524–7.

    Article  CAS  PubMed  Google Scholar 

  30. Kang H, Park YC, Yang KH. Paget’s disease: skeletal manifestations and effect of bisphosphonates. J Bone Metab. 2017;24:97–103.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Sobotta HP, Gösling T. Atypische subtrochantäre Femurfraktur unter Alendronsäuretherapie trotz intramedullärem Implantat. Unfallchirurg. 2017;120:171–5.

    Article  PubMed  Google Scholar 

  32. Kim YS, Chung PH, Kim JP KS, Lee HM, Moon HS. A rare case of bilateral proximal femoral insufficiency fractures after interlocking IM nailing for bilateral atypical femoral shaft fractures. Arch Orthop Trauma Surg. 2015;135:1227–32.

    Article  PubMed  Google Scholar 

  33. Kim JW, Oh CW, Park KH, Oh JK, Yoon YC, Kim JK. Peri-implant atypical femoral fracture after nail or plate osteosynthesis. J Orthop Sci. https://doi.org/10.1016/j.jos.2021.04.008

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Armed Forces Capital Hospital, Seongnam, Republic of Korea

    Kyu Hyun Yang

Authors
  1. Kyu Hyun Yang
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Kyu Hyun Yang .

Rights and permissions

Reprints and permissions

Copyright information

© 2022 The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd.

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Yang, K.H. (2022). Atypical Femoral Fracture (AFF). In: The Art of Intramedullary Nailing for Femoral Fracture. Springer, Singapore. https://doi.org/10.1007/978-981-19-3730-9_8

Download citation

  • DOI: https://doi.org/10.1007/978-981-19-3730-9_8

  • Published:

  • Publisher Name: Springer, Singapore

  • Print ISBN: 978-981-19-3729-3

  • Online ISBN: 978-981-19-3730-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation