Clinical Orthopaedics and Related Research®

, Volume 467, Issue 7, pp 1921–1926 | Cite as

Case Reports: Two Femoral Insufficiency Fractures after Long-term Alendronate Therapy

Case Report


Bisphosphonates are widely used for treatment of postmenopausal osteoporosis. Although short-term safety and efficacy of these drugs have been investigated and documented, an increasing number of recent reports draw attention to the possible correlation between long-term alendronate therapy and the occurrence of insufficiency fractures in the proximal femur owing to what is known as severely suppressed bone turnover. We describe two femoral insufficiency fractures in two women receiving long-term alendronate therapy. The first woman sustained a periprosthetic fracture at the tip of the femoral stem whereas the other woman had a fracture in the subtrochanteric region. We analyze the characteristics and natural course of these two unique fractures, and emphasize the importance of being aware of the possible correlation between long-term alendronate therapy and insufficiency femoral fractures.


  1. 1.
    Black D, Schwartz A, Ensrud K, Rybak-Feiglin A, Gupta J, Lombardi A, Wallace R, Levis S, Quandt S, Satterfield S, Cauley J, Cummings S. A 5 year randomized trial of the long-term efficacy and safety of alendronate. J Bone Mineral Res. 2004;10(suppl 1):S45.Google Scholar
  2. 2.
    Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC, Bauer DC, Genant HK, Haskell WL, Marcus R, Ott SM, Torner JC, Quandt SA, Reiss TF, Ensrud KE. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet. 1996;348:1535–1541.PubMedCrossRefGoogle Scholar
  3. 3.
    Bone HG, Schurr W. Intravenous bisphosphonate therapy for osteoporosis: where do we stand? Curr Osteoporos Rep. 2004;2:24–30.PubMedCrossRefGoogle Scholar
  4. 4.
    Chalmers J. Subtrochanteric fractures in osteomalacia. J Bone Joint Surg Br. 1970;52:509–513.PubMedGoogle Scholar
  5. 5.
    Cheung RK, Leung KK, Lee KC, Chow TC. Sequential non-traumatic femoral shaft fractures in a patient on long-term alendronate. Hong Kong Med J. 2007;13:485–489.PubMedGoogle Scholar
  6. 6.
    Cummings SR, Black DM, Thompson DE, Applegate WB, Barrett-Connor E, Musliner TA, Palermo L, Prineas R, Rubin SM, Scott JC, Vogt T, Wallace R, Yates AJ, LaCroix AZ. Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial. JAMA. 1998;280:2077–2082.PubMedCrossRefGoogle Scholar
  7. 7.
    Currey JD. Effects of differences in mineralization on the mechanical properties of bone. Philos Trans R Soc Lond B Biol Sci. 1984;304:509–518.PubMedCrossRefGoogle Scholar
  8. 8.
    Esterberg J, Kassim RA, Redmon J, Coad J, Macari GS, Saleh KJ. Hip pain in a case of hypophosphatemic osteomalacia. Am J Orthop. 2003;32:455–458.PubMedGoogle Scholar
  9. 9.
    Fleisch H. Bisphosphonates: mechanisms of action. Endocr Rev. 1998;19:80–100.PubMedCrossRefGoogle Scholar
  10. 10.
    Gill TJ, Sledge JB, Orler R, Ganz R. Lateral insufficiency fractures of the femur caused by osteopenia and varus angulation: a complication of total hip arthroplasty. J Arthroplasty. 1999;14:982–987.PubMedCrossRefGoogle Scholar
  11. 11.
    Goh SK, Yang KY, Koh JS, Wong MK, Chua SY, Chua DT, Howe TS. Subtrochanteric insufficiency fractures in patients on alendronate therapy: a caution. J Bone Joint Surg Br. 2007;89:349–353.PubMedCrossRefGoogle Scholar
  12. 12.
    Kleerekoper M. Prevention of postmenopausal bone loss and treatment of osteoporosis. Semin Reprod Med. 2005;23:141–148.PubMedCrossRefGoogle Scholar
  13. 13.
    Kundu ZS, Marya KM, Devgan A, Yadav V, Rohilla S. Subtrochanteric fracture managed by intramedullary nail in a patient with pycnodysostosis. Joint Bone Spine. 2004;71:154–156.PubMedCrossRefGoogle Scholar
  14. 14.
    Kwek EB, Goh SK, Koh JS, Png MA, Howe TS. An emerging pattern of subtrochanteric stress fractures: a long-term complication of alendronate therapy? Injury. 2008;39:224–231.PubMedCrossRefGoogle Scholar
  15. 15.
    Lenart BA, Lorich DG, Lane JM. Atypical fractures of the femoral diaphysis in postmenopausal women taking alendronate. N Engl J Med. 2008;358:1304–1306.PubMedCrossRefGoogle Scholar
  16. 16.
    Lindahl H. Epidemiology of periprosthetic femur fracture around total hip arthroplasty. Injury. 2007;38:651–654.PubMedCrossRefGoogle Scholar
  17. 17.
    Morgan G, Ganapathi M, Afzal S, Grant AJ. Pathological fractures in primary hyperparathyroidism: a case report highlighting diagnostic difficulties. Injury. 2002;33:288–291.PubMedCrossRefGoogle Scholar
  18. 18.
    Neviaser AS, Lane JM, Lenart BA, Edobor-Osula F, Lorich DG. Low-energy femoral shaft fractures associated with alendronate use. J Orthop Trauma. 2008;22:346–350.PubMedCrossRefGoogle Scholar
  19. 19.
    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;90:1294–1301.PubMedCrossRefGoogle Scholar
  20. 20.
    Ott S. Long-term safety of bisphosphonates. Editorial. J Clin Endocrinol Metab. 2005;90:1897–1899.PubMedCrossRefGoogle Scholar
  21. 21.
    Pauwels F. [The significance of the structural principles of the locomotor apparatus to resist the forces applied on long bones] [in German]. Anat Embryol. 1948;114:1–2.CrossRefGoogle Scholar
  22. 22.
    Roth VG. Pycnodysostosis presenting with bilateral subtrochanteric fractures: case report. Clin Orthop Relat Res. 1976;117:247–253.PubMedGoogle Scholar
  23. 23.
    Sayed-Noor AS, Sjödén GO. Subtrochanteric displaced insufficiency fracture after long-term alendronate therapy: a case report. Acta Orthop. 2008;79:565–567.PubMedCrossRefGoogle Scholar
  24. 24.
    Schneider JP. Should bisphosphonates be continued indefinitely? An unusual fracture in a healthy woman on long-term alendronate. Geriatrics. 2006;61:31–33.PubMedGoogle Scholar
  25. 25.
    Schnitzler CM, Wing JR, Gear KA, Robson HJ. Bone fragility of the peripheral skeleton during fluoride therapy for osteoporosis. Clin Orthop Relat Res. 1990;261:268–275.PubMedGoogle Scholar
  26. 26.
    Tonino RP, Meunier PJ, Emkey R, Rodriguez-Portales JA, Menkes CJ, Wasnich RD, Bone HG, Santora AC, Wu M, Desai R, Ross PD. Skeletal benefits of alendronate: 7-year treatment of postmenopausal osteoporotic women. J Clin Endocrinol Metab. 2000;85:3109–3115.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons 2009

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgerySundsvall HospitalSundsvallSweden
  2. 2.Department of Surgical and Perioperative SciencesNorrland University HospitalUmeåSweden

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