Clinical Orthopaedics and Related Research®

, Volume 468, Issue 12, pp 3393–3398 | Cite as

Is Surgery Necessary for Femoral Insufficiency Fractures after Long-term Bisphosphonate Therapy?

  • Yong-Chan Ha
  • Myung-Rae Cho
  • Ki Hong Park
  • Shin-Yoon Kim
  • Kyung-Hoi Koo
Clinical Research



Prolonged use of bisphosphonates in patients with osteoporosis reportedly induces femoral insufficiency fractures. However, the natural course of these fractures and how to treat them remain unknown.


We determined the rates of fracture displacement and subsequent operations of undisplaced insufficiency fractures of the femur in patients treated with prolonged bisphosphonate therapy.

Patients and Methods

We retrospectively collected and reviewed the clinical course of 11 patients (14 fractures) who had been diagnosed as having an insufficiency fracture of the femur after prolonged use (mean, 4.5 years; range, 3–10 years) of bisphosphonate. All patients were women with a mean age of 68 years (range, 57–82 years). The fracture site was subtrochanteric in six and femoral shaft in eight. The minimum followup was 12 months (mean, 27 months; range, 12–60 months).


During the followup period, secondary displacement of the fracture occurred in five of the 14 fractures after a mean of 10 months (range, 1–19 months). Three fractures were treated with internal fixation using a compression hip screw and two with intramedullary nailing. Because five additional fractures were treated surgically owing to intractable pain, surgery was performed in 10 of 14 insufficiency fractures during the followup period. All 10 fractures healed during followup. The remaining four patients (four fractures) not undergoing any surgery had persistent pain.


Femoral insufficiency fractures after prolonged bisphosphonate therapy seldom healed spontaneously and most patients had surgery either for fracture displacement or persistent pain.

Level of Evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.


Alendronate Internal Fixation Intramedullary Nailing Insufficiency Fracture Bony Union 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Allen MR, Iwata K, Phipps R, Burr DB. Alterations in canine vertebral bone turnover, microdamage accumulation, and biomechanical properties following 1-year treatment with clinical treatment doses of risedronate or alendronate. Bone. 2006;39:872–879.CrossRefPubMedGoogle Scholar
  2. 2.
    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. Bisphosphonates and fractures of the subtrochanteric or diaphyseal femur. N Engl J Med. 2010;362:1761–1771.CrossRefPubMedGoogle Scholar
  3. 3.
    Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Am J Sports Med. 2001;29:100–111.PubMedGoogle Scholar
  4. 4.
    Boivin GY, Chavassieux PM, Santora AC, Yates J, Meunier PJ. Alendronate increases bone strength by increasing the mean degree of mineralization of bone tissue in osteoporotic women. Bone. 2000;27:687–694.CrossRefPubMedGoogle Scholar
  5. 5.
    Bone HG, Hosking D, Devogelaer JP, Tucci JR, Emkey RD, Tonino RP, Rodriguez-Portales JA, Downs RW, Gupta J, Santora AC, Liberman UA; Alendronate Phase III Osteoporosis Treatment Study Group. Ten years’ experience with alendronate for osteoporosis in postmenopausal women. N Engl J Med. 2004;350:1189–1199.CrossRefPubMedGoogle Scholar
  6. 6.
    Capeci CM, Tejwani NC. Bilateral low-energy simultaneous or sequential femoral fractures in patients on long-term alendronate therapy. J Bone Joint Surg Am. 2009;91:2556–2561.CrossRefPubMedGoogle Scholar
  7. 7.
    Eastell R, Barton I, Hannon RA, Chines A, Garnero P, Delmas PD. Relationship of early changes in bone resorption to the reduction in fracture risk with risedronate. J Bone Miner Res. 2003;18:1051–1056.CrossRefPubMedGoogle Scholar
  8. 8.
    Frolke JP, Patka P. Definition and classification of fracture non-unions. Injury. 2007;38(suppl 2):S19–S22.CrossRefPubMedGoogle Scholar
  9. 9.
    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.CrossRefPubMedGoogle Scholar
  10. 10.
    Heckman JD, Ryaby JP, McCabe J, Frey JJ, Kilcoyne RF. Acceleration of tibial fracture-healing by non-invasive, low-intensity pulsed ultrasound. J Bone Joint Surg Am. 1994;76:26–34.PubMedGoogle Scholar
  11. 11.
    Iwamoto J, Takeda T. Insufficiency fracture of the femoral neck during osteoporosis treatment: a case report. J Orthop Sci. 2002;7:707–712.CrossRefPubMedGoogle Scholar
  12. 12.
    Kanis JA, Melton LJ 3rd, Christiansen C, Johnston CC, Khaltaev N. The diagnosis of osteoporosis. J Bone Miner Res. 1994;9:1137–1141.CrossRefPubMedGoogle Scholar
  13. 13.
    Komatsubara S, Mori S, Mashiba T, Ito M, Li J, Kaji Y, Akiyama T, Miyamoto K, Cao Y, Kawanishi J, Norimatsu H. Long-term treatment of incadronate disodium accumulates microdamage but improves the trabecular bone microarchitecture in dog vertebra. J Bone Miner Res. 2003;18:512–520.CrossRefPubMedGoogle Scholar
  14. 14.
    Komatsubara S, Mori S, Mashiba T, Li J, Nonaka K, Kaji Y, Akiyama T, Miyamoto K, Cao Y, Kawanishi J, Norimatsu H. Suppressed bone turnover by long-term bisphosphonate treatment accumulates microdamage but maintains intrinsic material properties in cortical bone of dog rib. J Bone Miner Res. 2004;19:999–1005.CrossRefPubMedGoogle Scholar
  15. 15.
    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.CrossRefPubMedGoogle Scholar
  16. 16.
    Mashiba T, Hirano T, Turner CH, Forwood MR, Johnston CC, Burr DB. Suppressed bone turnover by bisphosphonates increases microdamage accumulation and reduces some biomechanical properties in dog rib. J Bone Miner Res. 2000;15:613–620.CrossRefPubMedGoogle Scholar
  17. 17.
    Mashiba T, Turner CH, Hirano T, Forwood MR, Johnston CC, Burr DB. Effects of suppressed bone turnover by bisphosphonates on microdamage accumulation and biomechanical properties in clinically relevant skeletal sites in beagles. Bone. 2001;28:524–531.CrossRefPubMedGoogle 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.CrossRefPubMedGoogle Scholar
  19. 19.
    Niimi R, Hasegawa M, Sudo A, Uchida A. Unilateral stress fracture of the femoral shaft combined with contralateral insufficiency fracture of the femoral shaft after bilateral total knee arthroplasty. J Orthop Sci. 2008;13:572–575.CrossRefPubMedGoogle Scholar
  20. 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;90:1294–1301.CrossRefPubMedGoogle Scholar
  21. 21.
    Sayed-Noor AS, Sjoden GO. Case reports: two femoral insufficiency fractures after long-term alendronate therapy. Clin Orthop Relat Res. 2009;467:1921–1926.CrossRefPubMedGoogle Scholar
  22. 22.
    Stepan JJ, Burr DB, Pavo I, Sipos A, Michalska D, Li J, Fahrleitner-Pammer A, Petto H, Westmore M, Michalsky D, Sato M, Dobnig H. Low bone mineral density is associated with bone microdamage accumulation in postmenopausal women with osteoporosis. Bone. 2007;41:378–385.CrossRefPubMedGoogle Scholar
  23. 23.
    Visekruna M, Wilson D, McKiernan FE. Severely suppressed bone turnover and atypical skeletal fragility. J Clin Endocrinol Metab. 2008;93:2948–2952.CrossRefPubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2010

Authors and Affiliations

  • Yong-Chan Ha
    • 1
  • Myung-Rae Cho
    • 2
  • Ki Hong Park
    • 3
  • Shin-Yoon Kim
    • 4
  • Kyung-Hoi Koo
    • 5
  1. 1.Department of Orthopaedic SurgeryChung-Ang University College of MedicineSeoulSouth Korea
  2. 2.Department of Orthopaedic SurgeryDaegu Catholic University College of MedicineDaeguSouth Korea
  3. 3.Department of Orthopaedic SurgeryChung General HospitalSeongnamSouth Korea
  4. 4.Department of Orthopaedic SurgeryKyungpook National University College of MedicineDaeguSouth Korea
  5. 5.Department of Orthopaedic SurgerySeoul National University Bundang HospitalSeongnamSouth Korea

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