Frequency of Incomplete Atypical Femoral Fractures in Asymptomatic Patients on Long-Term Bisphosphonate Therapy

Vieira, Renata; Rosenberg, Zehava Sadka; Allison, Mary B.; Im, Shelly A.; Babb, James S.; Peck, Valerie

doi:10.2214/ajr.11.7442

Cited by 42 publications

(20 citation statements)

References 33 publications

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“…One study found that two bisphosphonate users out of 100 studied prospectively had radiographic evidence of impending fracture such as beaking of the femoral cortex [3]. …”

Section: Introductionmentioning

confidence: 99%

Absence of femoral cortical thickening in long-term bisphosphonate users: Implications for atypical femur fractures

Chen

Zhong

Bhattacharyya

2014

Bone

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The radiographs of patients on long term bisphosphonates with atypical femur fractures demonstrate markedly thick cortices at the site of the fracture. We conducted a prospective clinical study to determine if cortical thickening is increased in long term bisphosphonate users. We recruited 43 patients who had taken bisphosphonates for more than 5 years. A group of 45 healthy volunteers and 12 patients recently diagnosed with osteoporosis served as controls. We measured the cortical thickening as the ratio of femoral cortical thickness to diameter of the femur, and looked for cortical beaking. No difference in the cortical thickness ratio was observed between long term bisphosphonate users and osteoporotic controls (0.53 vs. 0.54, p= 0.659). No cases of cortical beaking were seen and no increase in thigh pain was observed. The power of the study was 95% to detect a 10% difference in cortical thickness ratio. We conclude that long term bisphosphonate use does not produce a generalized increase in subtrochanteric femoral cortical thickening in the majority of patients.

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“…One study found that two bisphosphonate users out of 100 studied prospectively had radiographic evidence of impending fracture such as beaking of the femoral cortex [3]. …”

Section: Introductionmentioning

confidence: 99%

Absence of femoral cortical thickening in long-term bisphosphonate users: Implications for atypical femur fractures

Chen

Zhong

Bhattacharyya

2014

Bone

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“…Our results showed that 7/9 (78%) incomplete AFFs were not associated with a discernable fracture line in the bump on lateral femoral cortex. Such incomplete AFFs can be easily confirmed by a positive isotope bone scan or an MRI [12, 14, 32]. In a study of Koh et al [20], all 4 patients with complete AFF had a fracture line across the thickened cortex seen in pre-AFF radiographs.…”

Section: Discussionmentioning

confidence: 99%

“…Incomplete AFF is characterized by cortical thickening associated with a beaking or bump at the lateral cortex of the femur, in which a transverse fracture line is often visible [8]. However, several recent reports indicate that fracture line is not always seen in the bumps at lateral cortex of the femur [9–14]. Complete AFF, progressing from an incomplete fracture, extends through both cortices and usually has a medial spike, the fracture is in transverse or short-oblique orientation, and mostly not comminuted [8].…”

Section: Introductionmentioning

confidence: 99%

Bone Structure and Turnover Status in Postmenopausal Women with Atypical Femur Fracture After Prolonged Bisphosphonate Therapy

et al. 2016

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Atypical femur fracture (AFF), a serious complication of long-term bisphosphonate therapy, is usually preceded by an incomplete fracture appearing on the lateral femur. AFF is most likely the result of severely suppressed bone turnover (SSBT). However, the differences in bone structure and turnover between patients with incomplete and complete AFF remain unknown. We examined trans-iliac bone biopsies from 12 white postmenopausal women with AFF (incomplete = 5; complete = 7) on BP therapy of >5 years, and 43 healthy white premenopausal women. Histomorphometric measurements were performed separately in cancellous, intra-cortical and endosteal envelopes. Of the 43 histomorphometric measurements on 3 difference bone surfaces (cancellous, intracortical and endosteal), only 2 bone resorption variables (Oc.S/BS & Oc.S/NOS) on the endosteal surface, were significantly lower in patients with complete AFF than those with incomplete AFF. Compared to healthy premenopausal women, the trabecular bone volume, thickness and number were all significantly lower in patients with AFF. The dynamic bone formation variables in patients with AFF were significantly reduced on all bone surfaces. The likelihood of a biopsy with no tetracycline labeling was significantly higher in AFF patients than in healthy premenopausal women. Based on these results, we conclude that there are no significant differences in bone turnover between patients with incomplete and complete AFF, suggesting that the suppression of bone turnover had already existed in the femur with incomplete AFF. Compared to healthy premenopausal women, bone turnover is similarly suppressed in patients with either type of AFF.

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“…Long-term use can lead to quantitatively harder osseous matrix, but one that is inherently more brittle and less resilient to microtrauma, resulting in osteonecrosis of the jaw or atypical femoral subtrochanteric insufficiency fractures [36][37][38]. The incidence of atypical femoral subtrochanteric fractures in patients on bisphosphonate therapy for more than 3 years may be as high as 2 % [39,40]. These may be bilateral in up to 55 % of cases [41].…”

Section: Bisphosphonate-related Atypical Subtrochanteric Femoral Fracmentioning

confidence: 99%

“…Once a bisphosphonate-related atypical insufficiency fracture is recognized, conservative measures such as limited weightbearing and serial radiographs are performed [39]. In addition, radiographs of the opposite femur should be obtained, as these can be bilateral in up to 55 % of cases [41].…”

Section: Bisphosphonate-related Atypical Subtrochanteric Femoral Fracmentioning

confidence: 99%

Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options

et al. 2016

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Stress fracture, in its most inclusive description, includes both fatigue and insufficiency fracture. Fatigue fractures, sometimes equated with the term "stress fractures," are most common in runners and other athletes and typically occur in the lower extremities. These fractures are the result of abnormal, cyclical loading on normal bone leading to local cortical resorption and fracture. Insufficiency fractures are common in elderly populations, secondary to osteoporosis, and are typically located in and around the pelvis. They are a result of normal or traumatic loading on abnormal bone. Subchondral insufficiency fractures of the hip or knee may cause acute pain that may present in the emergency setting. Medial tibial stress syndrome is a type of stress injury of the tibia related to activity and is a clinical syndrome encompassing a range of injuries from stress edema to frank-displaced fracture. Atypical subtrochanteric femoral fracture associated with long-term bisphosphonate therapy is also a recently discovered entity that needs early recognition to prevent progression to a complete fracture. Imaging recommendations for evaluation of stress fractures include initial plain radiographs followed, if necessary, by magnetic resonance imaging (MRI), which is preferred over computed tomography (CT) and bone scintigraphy. Radiographs are the first-line modality and may reveal linear sclerosis and periosteal reaction prior to the development of a frank fracture. MRI is highly sensitive with findings ranging from periosteal edema to bone marrow and intracortical signal abnormality. Additionally, a brief description of relevant clinical management of stress fractures is included.

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Frequency of Incomplete Atypical Femoral Fractures in Asymptomatic Patients on Long-Term Bisphosphonate Therapy

Abstract: The 2% frequency of incomplete atypical femoral fractures in asymptomatic patients on long-term bisphosphonate therapy is higher than suggested in the literature. Aside from age and mean iPTH, there were no significant differences in clinical or laboratory data between the two groups.

Cited by 42 publications

References 33 publications

Absence of femoral cortical thickening in long-term bisphosphonate users: Implications for atypical femur fractures

Absence of femoral cortical thickening in long-term bisphosphonate users: Implications for atypical femur fractures

Bone Structure and Turnover Status in Postmenopausal Women with Atypical Femur Fracture After Prolonged Bisphosphonate Therapy

Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options

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