Atypical femur fractures associated with chronic bisphosphonates use: A case series with 66 patients^[*]

Abstract

Objective The present study aims to describe outcomes from a series of surgically treated patients with atypical femoral fracture due to bisphosphonates use, in addition to correlate the time of previous medication use with fracture consolidation time, and to compare the consolidation time of complete and incomplete fractures.

Methods This is an observational, retrospective study with 66 patients diagnosed with atypical femur fractures associated with chronic bisphosphonates use. The patients underwent orthopedic surgical treatment at a referral hospital from January 2018 to March 2020.

Results All patients were females, with two bilateral cases. Fracture consolidation occurred in all cases, with an average time of 2.3 months and a follow-up time of 5.8 months. The average time of bisphosphonates use was 7.8 years. There was no correlation between the time of previous bisphosphonates use and the time for fracture consolidation. Consolidation time differed in complete and incomplete fractures.

Conclusion Surgical treatment with a long cephalomedullary nail resulted in consolidation in all patients. The consolidation time was longer in complete fractures when compared with incomplete lesions, and there was no correlation between the time of previous bisphosphonates use and the consolidation time .

Level of evidence Level IV, case series

Keywords

femoral fractures - bisphosphonate - osteoporosis

^* Study developed at the Department of Orthopedics and Traumatology, Instituto Prevent Senior, São Paulo, SP, Brazil.

Publication History

Received: 16 September 2020

Accepted: 01 December 2020

Article published online:
31 March 2021

• Referências

• 1 Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group. World Health Organ Tech Rep Ser 1994; 843: 1-129
• 2 Cummings SR, Melton LJ. Epidemiology and outcomes of osteoporotic fractures. Lancet 2002; 359 (9319): 1761-1767
• 3 Wells GA, Cranney A, Peterson J. et al. Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev 2008; (01) CD001155
• 4 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 (03) 1294-1301
• 5 Shane E, Burr D, Abrahamsen B. 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 (01) 1-23
• 6 Schilcher J, Michaëlsson K, Aspenberg P. Bisphosphonate use and atypical fractures of the femoral shaft. N Engl J Med 2011; 364 (18) 1728-1737
• 7 Russell RG. Bisphosphonates: the first 40 years. Bone 2011; 49 (01) 2-19
• 8 Dell RM, Adams AL, Greene DF. et al. Incidence of atypical nontraumatic diaphyseal fractures of the femur. J Bone Miner Res 2012; 27 (12) 2544-2550
• 9 Giannoudis PV, Ahmad MA, Mineo GV, Tosounidis TI, Calori GM, Kanakaris NK. Subtrochanteric fracture non-unions with implant failure managed with the “Diamond” concept. Injury 2013; 44 (Suppl. 01) S76-S81
• 10 Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br 2002; 84 (08) 1093-1110
• 11 Azevedo Filho FA, Cotias RB, Azi ML, Teixeira AA. Reliability of the radiographic union scale in tibial fractures (RUST). Rev Bras Ortop 2016; 52 (01) 35-39
• 12 R: A language and environment for statistical computing. [computer program]. Vienna, Austria: R Foundation for Statistical Computing; 2013
• 13 Savaridas T, Wallace RJ, Salter DM, Simpson AH. Do bisphosphonates inhibit direct fracture healing?: A laboratory investigation using an animal model. Bone Joint J 2013; 95-B [phone]
• 14 Weil YA, Rivkin G, Safran O, Liebergall M, Foldes AJ. The outcome of surgically treated femur fractures associated with long-term bisphosphonate use. J Trauma 2011; 71 (01) 186-190
• 15 Das De S, Setiobudi T, Shen L, Das De S. A rational approach to management of alendronate-related subtrochanteric fractures. J Bone Joint Surg Br 2010; 92 (05) 679-686
• 16 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 (11) 2556-2561
• 17 Thompson RN, Phillips JR, McCauley SH, Elliott JR, Moran CG. Atypical femoral fractures and bisphosphonate treatment: experience in two large United Kingdom teaching hospitals. J Bone Joint Surg Br 2012; 94 (03) 385-390
• 18 Wang K, Moaveni A, Dowrick A, Liew S. Alendronate-associated femoral insufficiency fractures and femoral stress reactions. J Orthop Surg (Hong Kong) 2011; 19 (01) 89-92
• 19 Lee YK, Lee YJ, Lee NK, Nho JH, Koo KH. Low Positive Predictive Value of Bone Scan to Predict Impending Complete Fracture among Incomplete Atypical Femoral Fracture. J Korean Med Sci 2018; 33 (22) e157
• 20 Gustafsson A, Schilcher J, Grassi L, Aspenberg P, Isaksson H. Strains caused by daily loading might be responsible for delayed healing of an incomplete atypical femoral fracture. Bone 2016; 88: 125-130
• 21 Papakostidis C, Psyllakis I, Vardakas D, Grestas A, Giannoudis PV. Femoral-shaft fractures and nonunions treated with intramedullary nails: the role of dynamisation. Injury 2011; 42 (11) 1353-1361
• 22 Goh SK, Yang KY, Koh JS. et al. Subtrochanteric insufficiency fractures in patients on alendronate therapy: a caution. J Bone Joint Surg Br 2007; 89 (03) 349-353
• 23 Peichl P, Holzer LA, Maier R, Holzer G. Parathyroid hormone 1-84 accelerates fracture-healing in pubic bones of elderly osteoporotic women. J Bone Joint Surg Am 2011; 93 (17) 1583-1587