Abstract
We herein report two cases of atypical femoral fracture (AFF). X-ray examinations at the first visit of these two female patients showed a complete fracture of the femoral diaphysis diagnosed as an atypical femoral fracture (AFF). X-rays of these two cases also showed localized cortical thickening of the femoral diaphysis. Both patients had been taking alendronate for more than 3 years because of postmenopausal osteoporosis. We assumed that both of the fractures were associated with the long-term use of alendronate. However, we retrospectively identified localized cortical thickening of the femoral diaphysis on an X-ray taken before the alendronate therapy in both of these cases. Therefore, we suspected a pathogenesis of AFFs in which preexisting stress or an insufficient fracture unrelated to bisphosphonate (BP) therapy and subsequent suppression of bone turnover due to BP administration led to the occurrence of an AFF. The patient underwent surgery using intramedullary nails in both of these cases, followed by the administration of teriparatide, and they were able to walk without any support at the final follow-up examination.
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References
WHO Scientific Group on the Prevention and Management of Osteoporosis. Prevention and management of osteoporosis: report of a WHO scientific group. WHO Tech Rep Ser. 2003;921:96–107.
Shane E, Burr D, Ebeling PR, Abrahamsen B, Adler RA, Brown TD, et al. Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2010;25:2267–94.
Shane E, Burr D, Abrahamsen B, Adler RA, Brown TD, Cheung AM, et al. Atypical Subtrochanteric and diaphyseal femoral fractures: Second report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2014;29:1–23.
Marx RE. Pamidoronate (Aredia) and Zoredoronate (Zometa) induced avasucular necrosis of the jaw: A growing epidemic. J Oral Maxillofac Surg. 2003;61:1115–7.
Chen F, Wang Z, Bhattacharyya T. Absence of femoral cortical thickening in long-term bisphosphonate users: implications for atypical femur fractures. Bone. 2014;62:64–6.
Abrahamsen B. Atypical femur fractures: refining the clinical picture. J Bone Miner Res. 2012;27:975–6.
Unnanuntana A, Ashfaq K, Ton QV, Kleimeyer JP, Lane JM. The effect of long-term alendronate treatment on cortical thickness of the proximal femur. Clin Orthop Relat Res. 2012;470:291–8.
Lenart BA, Neviaser AS, Lyman S, Chang CC, Edobor-Osula F, Steele B, et al. Association of low-energy femoral fractures with prolonged bisphosphonate use: a case control study. Osteoporosis Int. 2009;20:1353–62.
Ettinger B, Burr DB, Ritchie RO. Proposed pathogenesis for atypical femoral fractures: Lessons from materials research. Bone. 2013;55:495–500.
Compston J. Pathophysiology of atypical femoral fractures and osteonecrosis of the jaw. Osteoporosis Int. 2011;22:2951–61.
Van der Meulen MC, Boskey AL. Atypical subtrochanteric femoral shaft fractures: role for mechanics and bone quality. Arthritis Res Ther. 2012;14:220.
Schilcher J, Aspenberg P. Incidence of stress fractures of the femoral shaft in women treated with bisphosphonate. Acta Orthop. 2009;80:413–5.
Ahlman MA, Rissing MS, Gordon L. Evolution of bisphosphonate-related atypical fracture retrospectively observed with DXA scanning. J Bone Miner Res. 2012;27:496–8.
McKiernan FE. Atypical femoral diaphyseal fractures documented by serial DXA. J Clin Densitom. 2010;13:102–3.
Saita Y, Ishijima M, Mogami A, Kubota M, Baba T, Kaketa T, et al. The fracture sites of atypical femoral fractures are associated with the weight-bearing lower limb alignment. Bone. 2014;14:105–10.
Sasaki S, Miyakoshi N, Hongo M, Kasukawa Y, Shimada Y. Low-energy diaphyseal femoral fractures associated with bisphosphonate use and severe curved femur: a case series. J Bone Miner Metab. 2012;30:561–7.
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Iizuka, Y., Takechi, R., Iizuka, H. et al. Localized cortical thickening of the femoral diaphysis captured on an X-ray before alendronate therapy in two cases of atypical femoral fracture. Skeletal Radiol 45, 1403–1407 (2016). https://doi.org/10.1007/s00256-016-2432-5
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DOI: https://doi.org/10.1007/s00256-016-2432-5