Prophylactic Intramedullary Fixation for Bisphosphonate-related Subtrochanteric Stress Fracture

Abstract

Bisphosphonates are the most widely used medication to treat osteoporosis. Recent reports have documented an association between chronic bisphosphonate use and femoral insufficiency fractures. This article describes an 84-year-old woman with a diagnosis of osteoporosis treated with bisphosphonate medications for 9 years. She presented with left groin pain, and magnetic resonance imaging revealed a subtrochanteric femoral stress fracture. Operative and nonoperative management was discussed with the patient, and she chose to undergo prophylactic intramedullary nailing of the left femur. Six months postoperatively, she was asymptomatic and ambulating without assistive devices.This article describes successful management of a bisphosphonate-related femoral insufficiency fracture. The presence of groin or thigh pain in a patient taking bisphosphonates should alert the physician to the possibility of insufficiency fracture of the proximal femur, and plain radiographs should be obtained. If these radiographs show lateral cortical thickening, consideration should be given to prophylactic intramedullary femoral nailing. The risks and benefits of prophylactic fixation vs conservative management should be discussed with the patient. A recent series showed a high failure rate with conservative treatment of these fractures. A dialogue with the primary care physician should be initiated to determine the necessity of bisphosphonate therapy, and, if deemed necessary, an alternative class of medications should be considered.

¿Tardan más en consolidar las fracturas asociadas a bifosfonatos? [Is the time for consolidation of fractures associated with bisphosphonates higher?]

“…En los últimos años, se han publicado casos de fracturas subtrocantéricas por estrés relacionadas con el uso prolongado de estos fármacos, fracturas típicamente transversales o ligeramente oblicuas, en ocasiones, bilaterales y simultáneas, que habitualmente se desplazan como consecuencia de traumatismos de baja energía o incluso espontáneamente. 14,25,[30][31][32][33][34][35] Si bien se desconoce su fisiopatogenia, el patrón fracturario transversal en la cara de tensión del fémur, el dolor antes de que la fractura sea radiográficamente evidente y la hipertrofia cortical lateral sugieren que se trata de fracturas por estrés y que la alteración en la remodelación ósea difícilmente permita su curación sin un tratamiento adecuado. El hecho de que la región proximal del fémur se encuentre sometida a grandes requerimientos biomecánicos podría explicar la localización de estas fracturas.…”

Atypical femoral fractures

“…Due to the possible etiopathogenesis of AFFs, all antiresorptive drugs should be suspended. Finally, in the literature, there are case reports in which the use of anabolic drugs, such as teriparatide, have improved fracture healing (29)(30)(31)(32).…”

Prophylactic Nailing of Incomplete Atypical Femoral Fractures

“…Prophylactic fixation may prevent the fracture from progressing and the related morbidity. On the other hand, few studies have reported the results and risks of prophylactic fixation [11]. This study describes the ultimate outcomes of patients with incomplete atypical femoral fractures treated with intramedullary nailing.…”