Clinical presentation and pathological features of atypical subtrochanteric fracture after bisphosphonate treatment

  • Hsi-Hsien Lin
  • Tung-Fu Huang
  • Shih-Chieh Hung
  • Hsiao-Li Ma
  • Chien-Lin Liu
Up-to date Review and Case Report

Abstract

In recent years, there have been increasing reports of fractures associated with long-term bisphosphonate treatment. Clinical presentation should be examined carefully because fractures after long-term bisphosphonate treatment present typical symptoms and radiological and pathological findings. The unique clinical features of such fractures include prodromal thigh pain and complete absence of trauma. The radiological features include stress reaction of the thickened cortex and transverse or short oblique fractures on plain-film radiography and bone marrow edema on magnetic resonance imaging. Careful surveillance and early preventive internal surgical fixation must be considered by both orthopedic and non-orthopedic physicians. In this study, we reviewed recent articles on atypical subtrochanteric fractures after long-term bisphosphonate treatment. We also present the case of a 72-year-old woman with this type of a fracture who had been using a bisphosphonate for 2 years. The findings at presentation and pathological features of the fracture are discussed, including those of imaging studies, and the treatment administered is described.

Keywords

Stress fracture Low-energy fracture Osteoporosis Bisphosphonate 

References

  1. 1.
    Yang TS, Chen YR, Chen YJ, Chang CY, Ng HT (2004) Osteoporosis: prevalence in Taiwanese women. Osteoporos Int 15(4):345–347PubMedCrossRefGoogle Scholar
  2. 2.
    Nieves JW, Cosman F (2010) Atypical subtrochanteric and femoral shaft fractures and possible association with bisphosphonates. Curr Osteoporos Rep 8(1):34–39PubMedCrossRefGoogle Scholar
  3. 3.
    Capeci CM, Tejwani NC (2009) Bilateral low-energy simultaneous or sequential femoral fractures in patients on long-term alendronate therapy. J Bone Joint Surg Am 91(11):2556–2561PubMedCrossRefGoogle Scholar
  4. 4.
    Patel VC, Lazzarini AM (2010) Bilateral simultaneous femoral diaphyseal fractures in a patient with long-term ibandronate use. Orthop 33(10):775. doi:10.3928/01477447-20100826-31 Google Scholar
  5. 5.
    Ott SM (2010) Atraumatic bilateral femur fracture in long-term bisphosphonate use. Orthop 33(7):468. doi:10.3928/01477447-20100526-10 Google Scholar
  6. 6.
    Neviaser AS, Lane JM, Lenart BA, Edobor-Osula F, Lorich DG (2008) Low-energy femoral shaft fractures associated with alendronate use. J Orthop Trauma 22(5):346–350PubMedCrossRefGoogle Scholar
  7. 7.
    Kwek EB, Goh SK, Koh JS, Png MA, Howe TS (2008) An emerging pattern of subtrochanteric stress fractures: a long-term complication of alendronate therapy? Inj 39(2):224–231CrossRefGoogle Scholar
  8. 8.
    Giusti A, Hamdy NA, Papapoulos SE (2010) Atypical fractures of the femur and bisphosphonate therapy: a systematic review of case/case series studies. Bone 47(2):169–180PubMedCrossRefGoogle Scholar
  9. 9.
    Amerling R, Harbord NB, Pullman J, Feinfeld DA (2010) Bisphosphonate use in chronic kidney disease: association with adynamic bone disease in a bone histology series. Blood Purif 29(3):293–299PubMedCrossRefGoogle Scholar
  10. 10.
    Bunning RD, Rentfro RJ, Jelinek JS (2010) Low-energy femoral fractures associated with long-term bisphosphonate use in a rehabilitation setting: a case series. Phys Med Rehabil 2(1):76–80Google Scholar
  11. 11.
    Aspenberg P, Schilcher J, Fahlgren A (2010) Histology of an undisplaced femoral fatigue fracture in association with bisphosphonate treatment. Frozen bone with remodelling at the crack. Acta Orthop 81(4):460–462PubMedCrossRefGoogle Scholar
  12. 12.
    O’Neal JM, Diab T, Allen MR, Vidakovic B, Burr DB, Guldberg RE (2010) One year of alendronate treatment lowers microstructural stresses associated with trabecular microdamage initiation. Bone 47(2):241–247PubMedCrossRefGoogle Scholar
  13. 13.
    Abrahamsen B (2010) Adverse effects of bisphosphonates. Calcif Tissue Int 86(6):421–435PubMedCrossRefGoogle Scholar
  14. 14.
    Allen MR, Burr DB (2010) Bisphosphonate effects on bone turnover, microdamage, and mechanical properties: What we think we know and what we know that we don’t know. Bone Oct 16. [Epub ahead of print]Google Scholar
  15. 15.
    Sellmeyer DE (2010) Atypical fractures as a potential complication of long-term bisphosphonate therapy. J Am Med Assoc 304(13):1480–1484CrossRefGoogle Scholar
  16. 16.
    Schmidt GA, Horner KE, McDanel DL, Ross MB, Moores KG (2010) Risks and benefits of long-term bisphosphonate therapy. Am J Health Syst Pharm 67(12):994–1001PubMedCrossRefGoogle Scholar
  17. 17.
    Marx RE, Cillo JE Jr, Ulloa JJ (2007) Oral bisphosphonate-induced osteonecrosis: risk factors, prediction of risk using serum CTX testing, prevention, and treatment. J Oral Maxillofac Surg 65(12):2397–2410PubMedCrossRefGoogle Scholar
  18. 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 Committee; HORIZON Pivotal Fracture Trial Steering Committee (2010) Bisphosphonates and fractures of the subtrochanteric or diaphyseal femur. N Engl J Med 362(19):1761–1771PubMedCrossRefGoogle Scholar
  19. 19.
    Odvina CV, Zerwekh JE, Rao DS, Maalouf N, Gottschalk FA, Pak CY (2005) Severely suppressed bone turnover: a potential complication of alendronate therapy. J Clin Endocrinol Metab 90(3):1294–1301PubMedCrossRefGoogle Scholar
  20. 20.
    Ing-Lorenzini K, Desmeules J, Plachta O, Suva D, Dayer P, Peter R (2009) Low-energy femoral fractures associated with the long-term use of bisphosphonates: a case series from a Swiss university hospital. Drug Saf 32(9):775–785PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Hsi-Hsien Lin
    • 1
  • Tung-Fu Huang
    • 1
  • Shih-Chieh Hung
    • 1
  • Hsiao-Li Ma
    • 1
  • Chien-Lin Liu
    • 1
  1. 1.Department of Orthopaedics & Traumatology, Taipei Veterans’ General Hospital, School of MedicineNational Yang-Ming UniversityTaipei CityTaiwan ROC

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