Atypical femur fractures in patients receiving bisphosphonate therapy: etiology and management
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Osteoporosis is a growing problem that is projected to affect more than 50% of American adults by 2020. Bisphosphonate therapy is currently the primary mode of treating osteoporosis in this population. While bisphosphonate therapy has been successful in increasing bone mineral density, data has shown an increased risk of atypical femur fractures with prolonged therapy. Atypical femur fractures are characterized by low-energy or atraumatic injuries that occur in the subtrochanteric region. They originate on the medial cortex, travel transversely, and typically have little or no comminution. Conservative therapy is indicated for patients with incomplete fractures without prodromal symptoms. Patients with incomplete fractures and significant prodromal symptoms or visible fracture line on radiographs, those who have failed conservative management, and those with complete fractures should be treated with intramedullary nail fixation. Evaluation should involve imaging of the contralateral femur. Teriparatide therapy may be considered for patients without contraindications. While the incidence of these fractures is low, it is likely that these rates will increase with the aging population and increased prevalence of patients being treated with bisphosphonate therapy.
KeywordsAtypical femur fracture Bisphosphonate therapy Stress fractures Osteoporosis
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Conflict of interest
The authors declare that they have no conflict of interest.
This article does not contain any studies with human participants or animals performed by any of the authors.
- 1.Office of the Surgeon General (US). Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville (MD): Office of the Surgeon General (US); 2004. Google Scholar
- 3.Gamsjaeger S, Buchinger B, Zwettler E, Recker R, Black D, Gasser JA et al (2011) Bone material properties in actively bone-forming trabeculae in postmenopausal women with osteoporosis after three years of treatment with once-yearly zoledronic acid. J Bone Miner Res 26(1):12–18CrossRefPubMedGoogle Scholar
- 6.Shane E, Burr D, Abrahamsen B, Adler RA, Brown TD, Cheung AM, Cosman F, Curtis JR, Dell R, Dempster DW, Ebeling PR, Einhorn TA, Genant HK, Geusens P, Klaushofer K, Lane JM, McKiernan F, McKinney R, Ng A, Nieves J, O'Keefe R, Papapoulos S, Howe TS, van der Meulen MC, Weinstein RS, Whyte MP (2014) 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 29(1):1–23Google Scholar
- 7.Shane E, Burr D, Ebeling PR, Abrahamsen B, Adler RA, Brown TD, Cheung AM, Cosman F, Curtis JR, Dell R, Dempster D, Einhorn TA, Genant HK, Geusens P, Klaushofer K, Koval K, Lane JM, McKiernan F, McKinney R, Ng A, Nieves J, O’Keefe R, Papapoulos S, Sen HT, van der Meulen MC, Weinstein RS, Whyte M (2010) American society for bone and mineral research. Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American society for bone and mineral research. J Bone Miner Res 25(11):2267–2294CrossRefPubMedGoogle Scholar
- 11.Bogdan Y, Tornetta P, Einhorn TA, Guy P, Leveille L, Robinson J, Bosse MJ, Haines N, Horwitz D, Jones C, Schemitsch E, Sagi C, Thomas B, Stahl D, Ricci W, Brady M, Sanders D, Kain M, Higgins TF, Collinge C, Kottmeier S, Friess D (2015) Healing time and complications in operatively treated atypical femur fractures associated with bisphosphonate use: a multicenter retrospective cohort. J Orthop Trauma. 2015 Dec 19. [Epub ahead of print]Google Scholar
- 14.Nachtrab O, Cassar-Pullicino VN, Lalam R, Tins B, Tyrrell PNM, Singh J (2012) Role of MRI in hip fractures, including stress fractures, occult fractures, avulsion fractures. Eur J Radiol 81(12):3813–3823Google Scholar
- 20.Dell R, Greene D, Tran D (2012) Stopping bisphosphonate treatment decreases the risk of having a second atypical femur fracture. Read at the annual meeting of the American academy of orthopaedic surgeons, Feb 7–11, San Francisco. Paper 190Google Scholar
- 21.Giusti A, Hamdy NAT, Papapoulos SE (2010) Atypical fractures of the femur and bisphosphonate therapy. A systematic review of case/case series studies. Bone 47(2):169–80Google Scholar
- 22.Fracture T, Trial I, Flex LE, Black DM, Schwartz AV, Ensrud KE et al (2013) Effects of continuing or stopping alendronate after 5 years of treatment. JAMA J Am Med Assoc 296(24):2927–2938Google Scholar