Abstract
Objective
To review the literature on epidemiology and postoperative outcomes particularly surgical, functional and quality of life of atypical femoral fractures (AFFs) in the older population (aged ≥65 years) using the first and second American Society of Bone Mineral Research (ASBMR) Task Force consensus definition.
Methods
Electronic search for articles on AFFs and bisphosphonates published in English was performed. Eligible studies were reviewed systematically in relation to (a) the epidemiology of AFFs in older people and (b) postoperative outcomes of AFFs.
Results
Twenty-three studies on AFFs were included: 14 on epidemiology and 11 on treatment outcomes (two articles reported on both aspects). The epidemiological studies showed that the incidence of AFFs is low (3.0-9.8 per 100,000 person-years) but relative risk increased with longer duration of bisphosphonates use, especially after more than three years. Most cases of AFFs occurred in older people aged 65 years and above. However, in six studies, the mean age of patients with bisphosphonate-related AFFs is younger than those with typical proximal femoral fractures (mean age range of 66–75 years versus 75-89 years respectively). Varying postoperative and functional outcomes have been reported but differences in study population, management approaches and endpoints may account for these variations. For incomplete AFFs, prophylactic surgical intervention is potentially beneficial.
Conclusion
The benefits of bisphosphonates in reducing osteoporotic fractures still outweigh the risk of AFFs in view of its low absolute risk, when the ASBMR Task Force criteria for this type of fracture were applied. The risk of AFFs in different age groups is not well defined but tends to affect the younger patients more (aged <65 years) as compared to the older population (aged ≥65 years). Evidence supporting different types of treatment in AFFs such as intramedullary or extramedullary surgical devices and the use of teriparatide, a parathyroid hormone analogue, is not yet well established.
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References
Watts J, Abimanyi-Ochom J. Osteoporosis costing all Australians. A New Burden of Disease Analysis 2012-2022.
Marks R. Hip fracture epidemiological trends, outcomes, and risk factors, 1970-2009. Int J Gen Med 2010;3:1–17.
Leibson CL, Tosteson AN, Gabriel SE, Ransom JE, Melton LJ. Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study. J Am Geriatr Soc 2002;50(10):1644–1650.
McClung M, Harris ST, Miller PD, Bauer DC, Davison KS, Dian L, et al. Bisphosphonate therapy for osteoporosis: benefits, risks, and drug holiday. Am J Med 2013;126(1):13–20.
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(3):1294–1301.
Giusti A, Hamdy NA, Papapoulos SE. Atypical fractures of the femur and bisphosphonate therapy: A systematic review of case/case series studies. Bone 2010;47(2):169–180.
Shane E, Burr D, Ebeling PR, Abrahamsen B, Adler RA, Brown TD, et al. 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):2267–2294.
Shane E, Burr D, Abrahamsen B, Adler RA, Brown TD, Cheung AM, et al. 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.
Girgis CM, Seibel MJ. Atypical femur fractures: a review of the evidence and its implication to clinical practice. Ther Adv Musculoskelet Dis 2011;3(6):301–314.
Gedmintas L, Solomon DH, Kim SC. Bisphosphonates and risk of subtrochanteric, femoral shaft, and atypical femur fracture: a systematic review and meta-analysis. J Bone Miner Res 2013;28(8):1729–1737.
The Joanna Briggs Institute. Joanna Briggs Institute Reviewer’s Manual: 2014 edition. 2014 edition ed: The Joanna Briggs Institute.
Schilcher J, Michaelsson K, Aspenberg P. Bisphosphonate use and atypical fractures of the femoral shaft. N Engl J Med 2011;364(18):1728–1737.
Giusti A, Hamdy NA, Dekkers OM, Ramautar SR, Dijkstra S, Papapoulos SE. Atypical fractures and bisphosphonate therapy: a cohort study of patients with femoral fracture with radiographic adjudication of fracture site and features. Bone 2011;48(5):966–971.
Feldstein AC, Black D, Perrin N, Rosales AG, Friess D, Boardman D, et al. Incidence and demography of femur fractures with and without atypical features. J Bone Miner Res 2012;27(5):977–986.
Meier RP, Perneger TV, Stern R, Rizzoli R, Peter RE. Increasing occurrence of atypical femoral fractures associated with bisphosphonate use. Arch Intern Med 2012;172(12):930–936.
Dell RM, Adams AL, Greene DF, Funahashi TT, Silverman SL, Eisemon EO, et al. Incidence of atypical nontraumatic diaphyseal fractures of the femur. J Bone Miner Res 2012;27(12):2544–2550.
Shkolnikova J, Flynn J, Choong P. Burden of bisphosphonate-associated femoral fractures. ANZ J Surg 2013;83(3):175–181.
Thompson RN, Phillips JR, McCauley SH, Elliott JR, Moran CG. Atypical femoral fractures and bisphosphonate treatment: experience in two large United Kingdom teaching hospitals. J Bone Joint Surg Br 2012;94(3):385–390.
Warren C, Gilchrist N, Coates M, Frampton C, Helmore J, McKie J, et al. Atypical subtrochanteric fractures, bisphosphonates, blinded radiological review. ANZ J Surg 2012;82(12):908–912.
Beaudouin-Bazire C, Dalmas N, Bourgeois J, Babinet A, Anract P, Chantelot C, et al. 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(2):201–205.
Marcano A, Taormina D, Egol KA, Peck V, Tejwani NC. Are race and sex associated with the occurrence of atypical femoral fractures? Clin Orthop Relat Res 2014;472(3):1020–1027.
Saita Y, Ishijima M, Mogami A, Kubota M, Baba T, Kaketa T, et al. The incidence of and risk factors for developing atypical femoral fractures in Japan. J Bone Miner Metab 2015;33(3):311–318.
Meling T, Nawab A, Harboe K, Fosse L. Atypical femoral fractures in elderly women: a fracture registry-based cohort study. Bone Joint J 2014;96-B(8):1035–1040.
Luangkittikong S, Unnanuntana A. Prevalence of atypical femoral fractures in Thai patients at a single institution. J Med Assoc Thai 2014;97(6):635–643.
Juby AG, Crowther S, Cree M. Identifying atypical femoral fractures—a retrospective review. Calcif Tissue Int 2014;95(5):405–412.
Weil YA, Rivkin G, Safran O, Liebergall M, Foldes AJ. The outcome of surgically treated femur fractures associated with long-term bisphosphonate use. J Trauma 2011;71(1):186–190.
Prasarn ML, Ahn J, Helfet DL, Lane JM, Lorich DG. Bisphosphonate-associated femur fractures have high complication rates with operative fixation. Clin Orthop Relat Res 2012;470(8):2295–2301.
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 2013;472(9):2728–2734.
Chiang CY, Zebaze RM, Ghasem-Zadeh A, Iuliano-Burns S, Hardidge A, Seeman E. Teriparatide improves bone quality and healing of atypical femoral fractures associated with bisphosphonate therapy. Bone 2013;52(1):360–365.
Teo BJ, Koh JS, Goh SK, Png MA, Chua DT, Howe TS. Post-operative outcomes of atypical femoral subtrochanteric fracture in patients on bisphosphonate therapy. Bone Joint J 2014;96-B(5):658–664.
Miyakoshi N, Aizawa T, Sasaki S, Ando S, Maekawa S, Aonuma H, 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):553–559.
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):2028–2034.
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):331–335.
Oh CW, Oh JK, Park KC, Kim JW, Yoon YC. Prophylactic nailing of incomplete atypical femoral fractures. Scientific World Journal 2013;450148.
Adachi JD, Lyles K, Boonen S, Colon-Emeric C, Hyldstrup L, Nordsletten L, et al. Subtrochanteric fractures in bisphosphonate-naive patients: results from the HORIZON-recurrent fracture trial. Calcif Tissue Int 2011;89(6):427–433.
Rizzoli R, Akesson K, Bouxsein M, Kanis JA, Napoli N, Papapoulos S, et al. Subtrochanteric fractures after long-term treatment with bisphosphonates: a European Society on Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, and International Osteoporosis Foundation Working Group Report. Osteoporos Int 2011;22(2):373–390.
Bor A, Matuz M, Gyimesi N, Biczok Z, Soos G, Doro P. Gender inequalities in the treatment of osteoporosis. Maturitas 2015;80(2):162–169.
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Khow, K.S.F., Shibu, P., Yu, S.C.Y. et al. Epidemiology and postoperative outcomes of atypical femoral fractures in older adults: A systematic review. J Nutr Health Aging 21, 83–91 (2017). https://doi.org/10.1007/s12603-015-0652-3
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DOI: https://doi.org/10.1007/s12603-015-0652-3