Skip to main content
SpringerLink
Log in

Stress fracture of the bowed femoral shaft is another cause of atypical femoral fracture in elderly Japanese: a case series

  • Original Article
  • Published:
Journal of Orthopaedic Science

Abstract

Background

We have studied stress fractures of the bowed femoral shaft (SBFs) among elderly Japanese for over a decade. On the other hand, severely suppressed bone turnover (SSBT) after long-term bisphosphonates (BPs) use has been considered to be one of the causes of low-energy diaphyseal femoral fractures, often called atypical femoral fractures (AFFs). Some studies have shown that BPs use for more than 5 years is associated with an increased risk of AFFs. Here, we present a report of our SBF case series experienced in the past 15 years in order to examine whether bowing deformity should be considered among the causes of AFFs.

Methods

Subjects were 13 Japanese female patients with low-energy femoral shaft fractures. Mean age at injury was 77.0 years (range 67–88 years). All patients met the criteria of the AFFs’ case definition. The first author treated 11 of the 13 patients over 8 years (2005–2012) based on the concept of SBFs. Regarding the regional characteristics of these patients, 10 were treated at 2 rural hospitals, and 3 were treated at 3 urban hospitals. Retrospectively, we assessed fracture type and location, existence of fracture on the contralateral side, bowing deformity, and duration of BPs use.

Results

All 13 cases were AO/OTA type 32-A. Incomplete or previous fracture on the contralateral side was noted in 10 cases. Obvious bowing deformity of the femoral shaft was noted in 12 cases. BPs were taken in 7 cases, only 3 of which involved BPs use for more than 5 years.

Conclusions

We experienced 12 cases of low-energy femoral shaft fractures associated with bowing deformity. Six cases were not treated with BPs at all. Stress fractures associated with a femoral shaft bowing deformity do actually exist and should be recognized as another cause of AFFs.

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

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Pentecost RL, Murray RA, Brindley HH. Fatigue, insufficiency, and pathologic fractures. JAMA. 1964;187:1001–4.

    Article  CAS  PubMed  Google Scholar 

  2. Devas M. Stress fractures of the femur. Stress fractures. Edinburgh: Churchill Livingstone; 1975. p. 107–29.

    Google Scholar 

  3. Niimi R, Hasegawa M, Sudo A, Uchida A. Unilateral stress fracture of the femoral shaft combined with contralateral insufficiency fracture of the femoral shaft after bilateral total knee arthroplasty. J Orthop Sci. 2008;13:572–5.

    Article  PubMed  Google Scholar 

  4. Lim HC, Bae JH, Yi JW, Park JH. Bilateral stress fracture of the femoral shaft after total knee arthroplasty. Knee. 2011;18:354–7.

    Article  PubMed  Google Scholar 

  5. Oh Y, Wakabayashi Y, Okawa A, Ishizuki M, Kurosa Y. Diagnosis and treatment for stress fractures of bilateral femoral shafts in the elderly. Bessatsu Seikeigeka (Orthopaedic Surgery). 2012;61:174–9 (in Japanese).

    Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  7. Goh SK, Yang KY, Koh JS, Wong MK, Chua SY, Chua DT, Howe TS. Subtrochanteric insufficiency fractures in patients on alendronate therapy: a caution. J Bone Joint Surg Br. 2007;89:349–53.

    Article  PubMed  Google Scholar 

  8. Kwek EB, Goh SK, Koh JS, Png MA, Howe TS. An emerging pattern of subtrochanteric stress fractures: a long-term complication of alendronate therapy? Injury. 2008;39:224–31.

    Article  PubMed  Google Scholar 

  9. Lenart BA, Lorich DG, Lane JM. Atypical fractures of the femoral diaphysis in postmenopausal women taking alendronate. N Engl J Med. 2008;358:1304–6.

    Article  CAS  PubMed  Google Scholar 

  10. Neviaser AS, Lane JM, Lenart BA, Edobor-Osula F, Lorich DG. Low-energy femoral shaft fractures associated with alendronate use. J Orthop Trauma. 2008;22:346–50.

    Article  PubMed  Google Scholar 

  11. Capeci CM, Tejwani NC. Bilateral low-energy simultaneous or sequential femoral fractures inpatients on long-term alendronate therapy. J Bone Joint Surg Am. 2009;91:2556–61.

    Article  PubMed  Google Scholar 

  12. Somford MP, Draijer FW, Thomassen BJ, Chavassieux PM, Boivin G, Papapoulos SE. Bilateral fractures of the femur diaphysis in a patient with rheumatoid arthritis on long-term treatment with alendronate: clues to the mechanism of increased bone fragility. J Bone Miner Res. 2009;24:1736–40.

    Article  PubMed  Google Scholar 

  13. Abrahamsen B, Eiken P, Eastell R. Subtrochanteric and diaphyseal femur fractures in patients treated with alendronate: a register-based national cohort study. J Bone Miner Res. 2009;24:1095–102.

    Article  CAS  PubMed  Google Scholar 

  14. Armamento-Villareal R, Napoli N, Diemer K, Watkins M, Civitelli R, Teitelbaum S, Novack D. Bone turnover in bone biopsies of patients with low-energy cortical fractures receiving bisphosphonates: a case series. Calcif Tissue Int. 2009;85:37–44.

    Article  CAS  PubMed  Google Scholar 

  15. De Das S, Setiobudi T, Shen L, De Das S. A rational approach to management of alendronate-related subtrochanteric fractures. J Bone Joint Surg Br. 2010;92:679–86.

    Article  Google Scholar 

  16. 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, Mckiernan F, McKinney 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;25:2267–94.

    Article  PubMed  Google Scholar 

  17. Ng YH, Gino PD, Lingaraj K, De Das S. Femoral shaft fractures in the elderly—role of prior bisphosphonate therapy. Injury. 2011;42:702–6.

    Article  CAS  PubMed  Google Scholar 

  18. Black DM, Kelly MP, Genant HK, Palermo L, Eastell R, Bucci-Rechtweg C, Cauley J, Leung PC, Boonen S, Santora A, de Papp A, Bauer DC, Fracture Intervention Trial Steering Committees, HORIZON Pivotal Fracture Trial Steering Committee. Bisphosphonates and fractures of the subtrochanteric or diaphyseal femur. N Engl J Med. 2010;362:1761–71.

    Article  CAS  PubMed  Google Scholar 

  19. 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 

  20. Park-Wyllie LY, Mamdani MM, Juurlink DN, Hawker GA, Gunraj N, Austin PC, Whelan DB, Weiler PJ, Laupacis A. Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women. JAMA. 2011;305:783–9.

    Article  CAS  PubMed  Google Scholar 

  21. Feldstein AC, Black D, Perrin N, Rosales AG, Friess D, Boardman D, Dell R, Santora A, Chandler JM, Rix MM, Orwoll E. Incidence and demograohy of femur fractures with and without atypical fractures. J Bone Miner Res. 2012;27:977–86.

    Article  PubMed  Google Scholar 

  22. Dell RM, Adams AL, Greene DF, Funahashi TT, Silverman SL, Eisemon EO, Zhou H, Burchette RJ, Ott SM. Incidence of atypical no traumatic diaphyseal fractures of the femur. J Bone Miner Res. 2012;27:2544–50.

    Article  PubMed  Google Scholar 

  23. Beaudouin-Bazire C, Dalmas N, Bourgeois J, Babinet A, Anract P, Chantelot C, Farizon F, Chopkin F, Briot K, Roux C, Cortet B, Thomas T. Real frequency of ordinary and atypical sub-trochanteric and diaphyseal fractures in France based on X-rays and medical file analysis. Joint Bone Spine. 2013;80:201–5.

    Article  PubMed  Google Scholar 

  24. Schneider JP, Hinshaw WB, Su C, Solow P. Atypical femur fractures: 81 individual personal histories. J Clin Endocrinol Metab. 2012;97:4324–8.

    Article  CAS  PubMed  Google Scholar 

  25. Shane E, Burr D, Abrahamsen B, Adler RA, Brown TD, Cheung AM, Cosman F, Curtis JR, Dell R, Dempster D, 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;29:1–24.

    Article  PubMed  Google Scholar 

  26. Egol KA, Chang EY, Cvitkovic J, Kummer FJ, Koval KJ. Mismatch of current intramedullary nails with the anterior bow of the femur. J Orthop Trauma. 2004;18:410–5.

    Article  PubMed  Google Scholar 

  27. Ehmke LW, Polzin BM, Madey SM, Bottlang M. Femoral nailing through the trochanter: the reamer pathway indicates a helical nail shape. J Orthop Trauma. 2006;20:668–74.

    PubMed  Google Scholar 

  28. Maehara T, Shinohara K, Yamashita K, Bun H, Kaneda D, Ikuma H. The morphology of the femur in elderly Japanese female: analysis using 3D-CT. Kossetsu (Fracture). 2012;34:451–5 (in Japanese).

    Google Scholar 

  29. Nanka O, Havranek P. Physiological bowing of the human femur and its clinical significance. Acta Chir Orthop Traumatol Cech. 2000;67:225–9 (in Czech).

    CAS  PubMed  Google Scholar 

  30. Kiura Y. A roentgenographical study on osteoarthritis of the knee by the evaluation of the alignment of the lower extremities. J Wakayama Med Soc. 1984;35:343–65 (in Japanese).

    Google Scholar 

Download references

Acknowledgments

This study is a retrospective clinical case series of 13 patients. We obtained consent from 5 patients, complying with the principles laid down in the Declaration of Helsinki. Since this study is retrospective research reaching back more than 10 years, we could not obtain consent from the other 8 patients due to interrupted follow-up. However, our reporting of patients is completely anonymous, protecting the privacy and dignity of these patients.

Conflict of interest

The authors declare no conflicts of interest and received no funding for this research.

Author information

Authors and Affiliations

  1. Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan

    Yoto Oh, Yoshiaki Wakabayashi & Atsushi Okawa

  2. Department of Orthopaedic Surgery, Saku Central Hospital, Saku , Japan

    Yoto Oh & Yoshiro Kurosa

  3. Department of Orthopaedic Surgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan

    Masafumi Ishizuki

Authors
  1. Yoto Oh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Yoshiaki Wakabayashi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yoshiro Kurosa
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Masafumi Ishizuki
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Atsushi Okawa
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Yoto Oh.

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Oh, Y., Wakabayashi, Y., Kurosa, Y. et al. Stress fracture of the bowed femoral shaft is another cause of atypical femoral fracture in elderly Japanese: a case series. J Orthop Sci 19, 579–586 (2014). https://doi.org/10.1007/s00776-014-0572-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00776-014-0572-9

Keywords

Search

Navigation