Management of atypical femoral fracture: a scoping review and comprehensive algorithm

Abstract

BackgroundAtypical femoral fractures (AFF) are a rare type of femoral stress fracture recently described, potentially associated with prolonged bisphosphonate therapy. Evidence-based recommendations regarding diagnosis and management of these fractures are scarce. The purpose of this study is to propose an algorithm for the diagnosis and management of AFF.MethodsWe performed a PubMed search of the last ten years using the keywords “atypical femoral fractures” and identified further articles through an evaluation of the publications cited in these articles. Relevant studies were included by agreement between researchers, depending on their specialization. Pertinent points of debate were discussed based on the available literature, allowing for consensus regarding the proposed management algorithm.ResultsUsing a systematic approach we performed a scoping review that included a total of 137 articles.ConclusionsA practical guide for diagnosis and management of AFF based on the current concepts is proposed. In spite of the impressive large volume of published literature available since AFF were initially identified, the level of evidence is mostly poor, in particular regarding treatment choice. Therefore, further studies are required.

Case of atypical femoral fractures that mimicked the typical imaging findings of prostate cancer‐induced bone metastasis

“…We could not dismiss the possibility of bone metastasis. The characteristics of the fracture often made it difficult to differentiate developing stress fractures like AFF from malignancies . In this case, the result of MRI and PET‐CT also mimics bone metastasis (Fig.…”

Simultaneous Bilateral Atypical Femoral Fracture: Case Presentation

“…In most studies it is recommended to use cephalomedicular nails [6,9,[16][17][18][19], it is also worth mentioning that most of the FFAs are in the subtrochanteric region, in our patient the fractures were diaphyseal and it was decided to use universal nails for having them available at the institution and perform the surgery immediately.…”

“…On the other hand, when the patient is asymptomatic, conservative treatment can be attempted for the first 2 or 3 months, with strict observation in order to quickly perform prophylactic surgery if signs of fracture progression or non-union appear. In incomplete asymptomatic fractures associated with a simultaneous contralateral complete fracture, prophylactic surgery could be the gold standard to allow early loading, but the final decision depends on the patient's preferences [9,25].…”

“…The incidence of these fractures is 110 per 100,000 people [8]. The risk of fracture is higher with long-term treatment, over 5 years and decreases 70% per year since the last use [7,9].…”

“…Although the pathogenesis is not well known these fractures are considered as stress fractures, BPN would suppress bone remodeling which would cause a deterioration of the bone micro architecture that would deteriorate the repair process and lead to an accumulation of micro fractures [6,9]. Although rare, these lesions account for almost 9% of all "low-energy" femoral fractures.…”