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Nonoperative versus Prophylactic Treatment of Bisphosphonate-associated Femoral Stress Fractures

  • Clinical Research
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Several studies have identified a specific fracture in the proximal diaphysis of the femur in patients treated with bisphosphonates. The fractures typically are sustained after a low-energy mechanism with the presence of an existing characteristic stress fracture. However, it is unclear whether these patients are best treated nonoperatively or operatively.

Questions/purposes

What is the likelihood of nonoperatively treated bisphosphonate-associated femoral stress fractures progressing to completion and during what time period? If prophylactic fixation is performed, do patients have a shorter hospital length-of-stay compared with patients having surgical fixation after fracture completion?

Patients and Methods

We retrospectively searched for patients older than 50 years receiving bisphosphonate therapy, with either incomplete, nondisplaced stress fractures or completed, displaced fractures in the proximal diaphysis of the femur between July 2002 and April 2009. After applying exclusion criteria, we identified 34 patients with a total of 40 bisphosphonate-associated fractures. The average duration of bisphosphonate use was 77 months. Twenty-eight of 40 (70%) fractures were completed, displaced fractures. Six of the 12 nondisplaced stress fractures initially were treated nonoperatively. The remaining six stress fractures were treated with prophylactic cephalomedullary nail fixation. The minimum followup was 12 months (mean, 36.5 months; range, 12–72 months).

Results

Five of the six stress fractures treated nonoperatively progressed to fracture completion and displacement at an average of 10 months (range, 3–18 months). The average hospital stay was 3.7 days for patients treated prophylactically and 6.0 days for patients treated after fracture completion.

Conclusions

Our data suggest nonoperative treatment of bisphosphonate-related femoral stress fractures is not a reliable way to treat these fractures as the majority progress to fracture completion. Prophylactic fixation of femoral stress fractures also reduces total hospital admission time.

Level of Evidence

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

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA, USA

    Michael B. Banffy MD, Mark S. Vrahas MD, John E. Ready MD & John A. Abraham MD

  2. Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street WHT 535, Boston, MA, 02114, USA

    Michael B. Banffy MD & Mark S. Vrahas MD

Authors
  1. Michael B. Banffy MD
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  2. Mark S. Vrahas MD
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  3. John E. Ready MD
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  4. John A. Abraham MD
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Corresponding author

Correspondence to Michael B. Banffy MD.

Additional information

Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Each author certifies that his or her institution has approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at Massachusetts General Hospital and Brigham and Women’s Hospital.

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Banffy, M.B., Vrahas, M.S., Ready, J.E. et al. Nonoperative versus Prophylactic Treatment of Bisphosphonate-associated Femoral Stress Fractures. Clin Orthop Relat Res 469, 2028–2034 (2011). https://doi.org/10.1007/s11999-011-1828-8

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  • DOI: https://doi.org/10.1007/s11999-011-1828-8

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