Abstract
Objective
To evaluate the appearance of bisphosphonate-related femur insufficiency fractures on long-term follow-up radiographic studies and to describe the rate of fracture line obscuration and cortical beak healing over time.
Materials and methods
In this retrospective study, bisphosphonate-related femur fracture radiographs were reviewed by two radiologists for the presence of a fracture line, callus, and the characteristic cortical beak. Kaplan–Meier curves were used to analyze the time to first indication of healing. Femurs were also subdivided into those who underwent early versus late surgical fixation and those who underwent early versus late discontinuation of bisphosphonate. Clinical data including pain level and medication history were collected.
Results
Forty-seven femurs with a bisphosphonate-related femur fracture were identified in 28 women. Eighty-five percent took a bisphosphonate for greater than 5 years and 59 % for greater than 10 years. The median time to beak healing was 265 weeks and the median time to fracture line healing was 56 weeks in the 31 femurs with a baseline fracture. No statistically significant difference was identified between surgical fixation and conservative management.
Conclusions
Bisphosphonate-related fractures demonstrate notably prolonged healing time on long-term follow-up.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Einhorn TA, Bogdan Y, Tornetta P. Bisphosphonate-associated fractures of the femur: pathophysiology and treatment. J Orthop Trauma. 2014;28(7):433–8.
Park-Wyllie LY, Mamdani MM, Juurlink DN, et al. Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women. JAMA. 2011;305(8):783–9.
Porrino Jr JA, Kohl CA, Taljanovic M, Rogers LF. Diagnosis of proximal femoral insufficiency fractures in patients receiving bisphosphonate therapy. Am J Roentgenol. 2010;194:1061–4.
Gedmintas L, Solomon DH, Kim SC. Bisphosphonates and risk of subtrochanteric, femoral shaft, and atypical femur fracture: a systemic review and meta-analysis. J Bone Miner Res. 2013;28(8):1729–37.
Khan SA, Kanis JA, Vasikaran S, et al. Elimination and biochemical response to intravenous alendronate in postmenopausal osteoporosis. J Bone Miner Res. 1997;12(10):1700–7.
Schilcher J, Koeppen V, Aspenberg P, Michaëlsson K. Risk of atypical femoral fracture during and after bisphosphonate use: full report of a nationwide study. Acta Orthop. 2015;86(1):100–7.
Schilcher J, Koeppen V, Aspenberg P, Michaëlsson K. Risk of atypical femoral fracture during and after bisphosphonate use. N Engl J Med. 2014;371(10):974–6.
Turnbull BW. Nonparametric estimation of a survivorship function with doubly censored data. J Am Stat. 1974;69(345):169–73.
Kalbfleisch JD, Prentice RL. The statistical analysis of failure time data. 2nd ed. Hoboken: John Wiley & Sons; 2011.
Diggle P, Heagerty P, Liang K-Y, Zeger S. Analysis of longitudinal data. Oxford: University Press; 2002. 396 pp.
Dijkman BG, Sprague S, Schemitsch EH, Bhandari M. When is a fracture healed? Radiographic and clinical criteria revisited. J Orthop Trauma. 2010;24 Suppl 1:S76–80.
Corrales LA, Morshed S, Bhandari M, Miclau T. Variability in assessment of fracture-healing in orthopedic trauma studies. J Bone Joint Surg Am. 2008;90(9):1862–8.
Browner BD, Jupiter JB, Levin AM, Trafton PG, Krettek C. Skeletal trauma: basic science, management and reconstruction. Philadelphia: Saunders Elsevier; 2009.
Nikolaou VS, Efstathopoulos N, Kontakis G, Kanakaris NK, Giannoudis PV. The influence of osteoporosis in femoral fracture healing time. Injury. 2009;40(6):663–8.
Marsell R, Einhorn TA. The biology of fracture healing. Injury. 2011;42(6):551–5.
Vigorita VJ, Silver JS, Eisemon EO. Osteoclast abnormalities in fractured bone during bisphosphonate treatment for osteoporosis: a case report. Skelet Radiol. 2012;41(7):861–5.
Molvik H, Khan W. Bisphosphonates and their influence on fracture healing: a systematic review. Osteoporos Int. 2015;26:1251–60.
Banffy MB, Vrahas MS, Ready JE, Abraham JA. Nonoperative versus prophylactic treatment of bisphosphonate-associated femoral stress fractures. Clin Orthop Relat Res. 2011;469(7):2028–34.
Egol KA, Park JH, Prensky C, Rosenberg ZS, Peck V, Tejwani NC. Surgical treatment improves clinical and functional outcomes for patients who sustain incomplete bisphosphonate-related femur fractures. J Orthop Trauma. 2013;27(6):331–5.
Egol KA, Park JH, Rosenberg ZS, Peck V, Tejwani NC. Healing delayed but generally reliable after bisphosphonate-associated complete femur fractures treated with IM nails. Clin Orthop Relat Res. 2014;472(9):2728–34.
Miyakoshi N, Aizawa T, Saski S, et al. Healing of bisphosphonate-associated atypical femoral fractures in patients with osteoporosis: a comparison between treatment with and without teriparatide. J Bone Miner Metab. 2015;33(5):553–9.
Zhang D, Potty A, Vyas P, Lane J. The role of recombinant PTH in human fracture healing: a systematic review. J Orthop Trauma. 2014;28(1):57–62.
Chiang CY, Zebaze RMD, Ghasem-Zadeh A, et al. Teriparatide improves bone quality and healing of atypical femoral fractures associated with bisphosphonate therapy. Bone. 2013;52(1):360–5.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Source of founding
None.
Conflict of interest
No conflict of interest.
Informed consent
HIPAA-compliant Institution Review Board approved retrospective study (#47482) with waiver of informed consent.
Rights and permissions
About this article
Cite this article
Favinger, J.L., Hippe, D. & Ha, A.S. Long-term radiographic follow-up of bisphosphonate-associated atypical femur fractures. Skeletal Radiol 45, 627–633 (2016). https://doi.org/10.1007/s00256-016-2346-2
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00256-016-2346-2