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Clinical characteristics, densitometric parameters and outcomes of patients with atypical femoral fractures related to bisphosphonate treatment for osteoporosis

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Abstract

Purpose

We described the clinical and densitometric characteristics and treatment outcomes of patients who developed atypical femoral fractures (AFF) while on bisphosphonate for osteoporosis.

Methods

We performed a retrospective cohort study including all adults aged ≥50 years who developed AFF while on bisphosphonates between 1 January 2008 and 31 December 2020, and subsequently managed in the Osteoporosis Centre at Queen Mary Hospital in Hong Kong. A control group of patients who developed fragility hip fractures while on bisphosphonates in the same period was included for comparison. We compared the clinical and densitometric characteristics between the two groups, and described the clinical outcomes for the AFF group.

Results

In total, 75 patients were included (AFF: n = 35; fragility hip fracture: n = 40). All were related to oral bisphosphonates. The AFF group was characterised by a longer duration of bisphosphonate use (median of 5 years), higher bone mineral density (BMD) and more acute neck-shaft angle (all p < 0.05). Following AFF, 8 patients (22.9%) did not receive any subsequent bone-active agents: due to refusal to use an injectable, or BMD out of osteoporotic range. Most of those who received bone-active agents were given teriparatide, followed by raloxifene, and achieved stable BMD. However, subsequent fragility risk remained high. Nonetheless, AFF did not confer excess morbidity and mortality.

Conclusion

AFF was characterised by usually long duration of bisphosphonate use, higher BMD and more acute neck-shaft angle. AFF did not confer significant impairment in mobility or mortality. Nonetheless, further research work is necessary to optimise bone health among patients who develop AFF.

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Data availability

Datasets generated during and/or analysed during the current study are not publicly available but are available from the corresponding author on reasonable request.

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Author notes

  1. These authors contributed equally: Chun Ho Wong, Andy Ka Chun Kan

Authors and Affiliations

  1. Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China

    Chun Ho Wong, Andy Ka Chun Kan, Kimberly Hang Tsoi, Stacey Sheung Yi Chan, Nancy Su Jiang, Connie Hong Nin Loong, Carol Ho Yi Fong, Chi Ho Lee, Kathryn Choon Beng Tan, Yu Cho Woo & David Tak Wai Lui

  2. Department of Orthopaedics and Traumatology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China

    Janus Siu Him Wong & Graham Ka Hon Shea

  3. Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China

    Ching Lung Cheung

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Contributions

C.H.W., A.K.C.K. and D.T.W.L. wrote the manuscript. C.H.W., A.K.C..K., K.H.T., S.S.Y.C., N.S.J., C.H.N.L., Y.C.W. and D.T.W.L. researched the data. C.H.W., C.H.Y.F., Y.C.W. and D.T.W.L. performed statistical analyses. J.S.H.W., G.K.H.S., C.L.C., C.H.L., K.C.B.T. and Y.C.W. critically reviewed and edited the manuscript. D.T.W.L. and Y.C.W. initiated and supervised the study, are the guarantors of this work and as such had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Corresponding authors

Correspondence to Yu Cho Woo or David Tak Wai Lui.

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The authors declare no competing interests.

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The study followed the principles in the Declaration of Helsinki and was approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (UW 22-043).

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Wong, C.H., Kan, A.K.C., Tsoi, K.H. et al. Clinical characteristics, densitometric parameters and outcomes of patients with atypical femoral fractures related to bisphosphonate treatment for osteoporosis. Endocrine 84, 223–235 (2024). https://doi.org/10.1007/s12020-023-03608-z

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