Osteoporosis International

, Volume 30, Issue 12, pp 2417–2428 | Cite as

Natural history of incomplete atypical femoral fractures in patients after a prolonged and variable course of bisphosphonate therapy—a long-term radiological follow-up

  • M.A. PngEmail author
  • P.C. Mohan
  • J.S.B. Koh
  • C.Y. Howe
  • T.S. Howe
Original Article



Understanding the natural history of lateral femoral stress fractures helps to guide their management. Improvement in their radiographic characteristics is rare. Progression was generally sequential, most developing an incomplete fracture line before fracture displacement. Stopping bisphosphonates decreased the fracture rate, a feasible management option for lesions without incomplete fracture lines.


Retrospective study evaluating the natural history of lateral femoral stress fractures (FSF) by serial radiography over a variable period of time in a cohort of patients treated for some time with bisphosphonates for osteoporosis, whilst also identifying the fracture response in cases where bisphosphonates were discontinued.


The radiographs of 76 consecutive patients (92 femurs) with 161 FSF were reviewed to document their change over time. Femurs were classified into the following: A—normal, B—focal cortical thickening, C—dreaded black line and D—displaced fracture. Bisphosphonate history was recorded.


66.5% FSF showed group stability between the first and last radiographs: group B (79.1%), group C (45.7%). 28.6% progressed, mostly following an ordered sequence starting from group A, progressing to B, then C, before culminating in D. Progression rate was as follows: A—100% (11/11), B—18.3% (21/115), C—40% (14/35). Regression in FSF was uncommon—5.6% (8/161). 34.8% (32/92) sustained displaced fractures. Kaplan-Meier analysis showed statistically significant difference between the groups; median survival (95% CI): A—4189 (-), B—3383.0 (-), C—1807 (0.0–3788.6) and progression to displaced fracture when bisphosphonate had been stopped for at least 6 months. The group without recent bisphosphonates had a lower group progression rate (17.1%, 12/70). Nevertheless, 10.9% (5/46) progressed to displaced fracture. This group also had the highest proportion of stable (77.1%, 54/70) and regressive lesions (5.7%, 4/70).


In FSF, there is natural progression from normal bone, to focal cortical thickening, to dreaded black line and eventually to displaced fracture. Most lesions persist, remaining static or progressing, especially if a dreaded black line is present and bisphosphonates are continued. Regression is uncommon and more frequent when bisphosphonates are discontinued. Despite stopping bisphosphonates, there remains a 10.9% risk of progression to displaced fracture.


Atypical femoral fracture management Bisphosphonate Conservative management Insufficiency fracture Osteoporosis treatment Prophylactic surgery 


Compliance with ethical standards

The retrospective cohort study was approved by our institutional review board with waiver of informed consent.

Conflicts of interest

Meng Ai Png, P. Chandra Mohan, Choong Yin Howe and Tet Sen Howe declare that they have no conflict of interest.

Joyce S.B. Koh has received Overseas conference sponsor from Amgen Dec 2017 and Chairperson fee from Amgen Nov 2018. Amgen produces and markets Denosumab.


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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2019

Authors and Affiliations

  1. 1.Department of Diagnostic RadiologySingapore General HospitalSingaporeSingapore
  2. 2.Duke-NUS Medical SchoolSingaporeSingapore
  3. 3.Department of Orthopedic SurgerySingapore General HospitalSingaporeSingapore
  4. 4.Faculty of MathematicsUniversity of CambridgeCambridgeUK

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