Advertisement

Journal of Bone and Mineral Metabolism

, Volume 30, Issue 5, pp 561–567 | Cite as

Low-energy diaphyseal femoral fractures associated with bisphosphonate use and severe curved femur: a case series

  • Satoshi Sasaki
  • Naohisa Miyakoshi
  • Michio Hongo
  • Yuji Kasukawa
  • Yoichi Shimada
Original article

Abstract

Recent reports have raised concerns about low-energy subtrochanteric and diaphyseal femoral fractures after long-term bisphosphonate treatment, which may be associated with severely suppressed bone turnover (SSBT). However, diaphyseal femoral fractures without bisphosphonate treatment have also been reported in patients with severely curved femur, which are commonplace in the elderly. The purpose of this study was therefore to investigate associations between occurrence of such fractures, bisphosphonate use, and curvature of the femur. Nine consecutive elderly patients treated for low-energy diaphyseal femoral fractures between 2005 and 2010 were retrospectively reviewed. Three patients sustained bilateral fractures. Eight patients were administered bisphosphonates and one patient was administered raloxifene. Duration of osteoporosis treatment, type of fractures, surgical procedure, cortical thickness and curvature of opposite femur were evaluated. The cortical thickness and femoral curvature were further compared with those of 24 control subjects without fractures. The mean duration of drug administration was 3.6 years. All fractures showed similar X-ray patterns of simple transverse fracture with medial spike. Only one femur showed thickening of the femoral cortex. One case was treated with locking plate fixation, while the other cases were operated with intramedullary nails (9 antegrade nails, 2 retrograde nails). One femur treated with retrograde nail showed delayed bone union. The femoral curvature was significantly higher in the low-energy fracture group than the control group (P < 0.01); however, cortical thickness did not show a significant difference between the groups. In addition to SSBT, increased femoral curvature might be a causative factor for low-energy diaphyseal femoral fracture in the elderly.

Keywords

Osteoporosis Bisphosphonate Diaphyseal femoral fracture Curved femur Severely suppressed bone turnover 

Notes

Acknowledgments

We wish to thank Drs. Hiroshi Matsuura, and Hidetomo Saito who treated the patients in this study.

Conflict of interest

No disclosures.

References

  1. 1.
    Cranney A, Wells G, Willan A (2002) Meta-analysis of therapies for postmenopausal osteoporosis. Meta-analysis of alendronate for the treatment of postmenopausal women. Endocr Rev 23:508–516PubMedCrossRefGoogle Scholar
  2. 2.
    Papapoulas SE, Quandt SA, Liberman UA, Hochberg MC, Thompson DE (2005) Meta-analysis of the efficacy of alendronate for the prevention of hip fractures in postmenopausal women. Osteoporor Int 16:468–474CrossRefGoogle Scholar
  3. 3.
    Cranney A, Tugwell P, Adachi J (2002) Meta-analysis of therapies for postmenopausal osteoporosis. Meta-analysis of risedronate for the treatment of postmenopausal women. Endocr Rev 23:517–523PubMedCrossRefGoogle Scholar
  4. 4.
    McClung MR, Geusens P, Miller PD, Zippel H, Bensen WG, Roux C, Adami S, Fogelman I, Diamond T, Eastell R, Meunier PJ, Reginster JY (2001) Effect of risedronate on the risk of hip fractures in elderly women. N Engl J Med 344:333–340PubMedCrossRefGoogle Scholar
  5. 5.
    Watts NB, Diab DL (2010) Long-term use of bisphosphonates in osteoporosis. J Clin Endocrinol Metab 95:1555–1565PubMedCrossRefGoogle Scholar
  6. 6.
    Abrahamsen B (2010) Bisphosphonates adverse effects, lessons from large databases. Curr Opin Rheumatol 22:404–409PubMedCrossRefGoogle Scholar
  7. 7.
    Bamias A, Terpos E, Dimopoulos MA (2010) Avascular osteonecrosis of the jaw as a side effect of bisphosphonate treatment. Onkologie 33:288–289PubMedCrossRefGoogle Scholar
  8. 8.
    Odvina CV, Zerwekh JE, Rao DS, Maalouf N, Gottschalk FA, Pak CYC (2005) Severely suppressed bone turnover: a potential complication of alendronate therapy. J Clin Endocrinol Metab 90:1294–1301PubMedCrossRefGoogle Scholar
  9. 9.
    Cheung RKH, Leung KK, Lee KC, Chow TC (2007) Sequential non-traumatic femoral shaft fractures in a patient on long-term alendronate. Hong Kong Med J 13:485–489PubMedGoogle Scholar
  10. 10.
    Neviaser AS, Lane JM, Lenart BA, Edobar-Osula F, Lorich DG (2008) Low-energy femoral shaft fractures associated with alendronate use. J Orthop Trauma 22:346–350PubMedCrossRefGoogle Scholar
  11. 11.
    Kwek EBK, Goh SK, Koh JSB, Png MA, Howe TS (2008) An emerging pattern of subtrochanteric stress fractures: A long-term complication of alendronate therapy? Injury 39:224–231PubMedCrossRefGoogle Scholar
  12. 12.
    Lenart BA, Neviaser AS, Lyman S, Chang CC, Edoba-Osula F, Steele B, van der Meulen MCH, Lorich DG, Lane JM (2009) Association of low-energy femoral fractures with prolonged bisphosphonate use: a case control study. Osteoporos Int 20:1353–1362PubMedCrossRefGoogle Scholar
  13. 13.
    Schilcher J, Aspenberg P (2009) Incidence of stress fractures of the femoral shaft in women treated with bisphosphonate. Acta Orthopaedica 80:413–415PubMedCrossRefGoogle Scholar
  14. 14.
    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 32:775–785PubMedCrossRefGoogle Scholar
  15. 15.
    Schneider JP (2009) Bisphosphonates and low-impact femoral fractures: current evidence on alendronate-fracture risk. Geriatrics 64:18–23PubMedGoogle Scholar
  16. 16.
    Burr DB, Diab T, Koivunemi A, Koivunemi M, Allen MR (2009) Effects of 1 to 3 years’ treatment with alendronate on mechanical properties of the femoral shaft in a canine model: implications for subtrochanteric femoral fracture risk. J Orthop Res 27:1288–1292PubMedCrossRefGoogle Scholar
  17. 17.
    Isaacs JD, Shidiak L, Harris IA, Szomor ZL (2010) Femoral insufficiency fractures associated with prolonged bisphosphonate therapy. Clin Orthop Relat Res 468:3384–3392PubMedCrossRefGoogle Scholar
  18. 18.
    Taniguchi M, Shiode H, Sakamoto H, Murakami H, Matsumoto Y, Matsushita M (2009) Three cases of atypical fracture of the diaphysis in bisphosphonate therapy (in Japanese). Chubuseisaisi 52:661–662Google Scholar
  19. 19.
    Armamento-Villareal R, Napoli N, Diemer K, Watkins M, Civitelli R, Teitelbaum S, Novack D (2009) Bone turnover in bone biopsies of patients with low-energy cortical fractures receiving bisphosphonates: a case series. Calcif Tissue Int 85:37–44PubMedCrossRefGoogle Scholar
  20. 20.
    Aspenberg P, Schilcher J, Fahlgren A (2010) Histology of an undisplaced femoral fatigue fracture in association with bisphosphonate treatment, frozen bone with remodeling at the crack. Acta Orthop 81:460–462PubMedCrossRefGoogle Scholar
  21. 21.
    Shane E, Burr D, Ebeling PR, Adler RA, Abrahamsen B et al (2010) Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American Society for Bone and Mineral Research. J Bone Min Res 25:2267–2294CrossRefGoogle Scholar
  22. 22.
    Ozawa H, Ishizuki M, Kitai A, Nagashima M (2004) Fatigue fracture of the femoral shaft in elderly; a case report (in Japanese). Seikeigeka 55:696–699Google Scholar
  23. 23.
    Hashimoto N, Naka K, Takino T, Muraoka H (2000) Femoral shaft fracture with minor trauma: a report of 2 cases (in Japanese). Higashinihonseisaikaisi 12:362–365Google Scholar
  24. 24.
    Lambrinoudaki I, Christodoulakos G, Botsis D (2006) Bisphosphonates. Ann N Y Acad Sci 1092:397–402PubMedCrossRefGoogle Scholar
  25. 25.
    Kuroda K, Yokokawa A, Nishimura T, Kobayashi T, Inaya H (2010) Femoral shaft fractures in 3 patients on long-term bisphosphonate therapy (in Japanese). Chubuseisaisi 53:463–464Google Scholar
  26. 26.
    Tan SC, Koh SBJ, Goh SK, Howe TS (2010) Atypical femoral stress fractures in bisphosphonate-free patients. Osteoporos Int 22:2211–2212PubMedCrossRefGoogle Scholar
  27. 27.
    Giusti A, Hamdy NAT, Dekkers OM, Ramautar SR, Dijkstra S, Papapoulos SE (2011) Atypical fractures and bisphosphonate therapy: a cohort study of patients with femoral fracture with radiographic adjudication of fracture site and femurs. Bone 48:966–971PubMedCrossRefGoogle Scholar
  28. 28.
    Unnanuntana A, Ashfaq K, Ton QV, Kleimeyer JP, Lane JM (2012) The effect of long-term alendronate treatment on cortical thickness of the proximal femur. Clin Orthop Relat Res 470:291–298PubMedCrossRefGoogle Scholar
  29. 29.
    Abrahamsen B, Eiken P, Eastell R (2009) Subtrochanteric and diaphyseal femur fractures in patients treated with alendronate: a register-based national cohort study. J Bone Miner Res 24:1095–1102PubMedCrossRefGoogle Scholar
  30. 30.
    Yoshida K (1976) A biomechanical study of the hip joint and femur (in Japanese). Kurumeigakukaizasshi 44:1046–1069Google Scholar

Copyright information

© The Japanese Society for Bone and Mineral Research and Springer 2012

Authors and Affiliations

  • Satoshi Sasaki
    • 1
  • Naohisa Miyakoshi
    • 2
  • Michio Hongo
    • 2
  • Yuji Kasukawa
    • 2
  • Yoichi Shimada
    • 2
  1. 1.Department of Orthopedic SurgeryYuri-Kumiai General HospitalYuri-HonjoJapan
  2. 2.Department of Orthopedic SurgeryAkita University Graduate School of MedicineAkitaJapan

Personalised recommendations