Efficacy of bone-end intervention on fracture healing in bisphosphonate-related atypical femoral fractures

Abstract

BackgroundDelayed unions are quite common in the treatment of atypical femur fractures, which are thought to result from the long-term use of bisphosphonates. The effects of interventions for sclerotic tissue on the fracture line in atypical femoral fractures are not fully known. For this reason, we compared the results of patients with atypical femoral fractures treated by closed intramedullary nailing to patients treated by open surgery accompanied with interventions for their sclerotic bone ends, aiming to answer: (1) In the treatment of atypical femoral fractures, do bone-end interventions have a positive effect on the radiological union rate and radiological union time? (2) Do bone-end interventions influence complication rates in the treatment of atypical femoral fractures? HypothesisBone-end interventions provide a faster and higher rate of union compared to closed intramedullary nailing and result in fewer complications in atypical femoral fractures. Patients and methodsA total of 32 patients who met the inclusion criteria and had atypical femoral fractures treated by intramedullary nailing between 01/01/2012 and 12/31/2016 were reviewed. Of these, 15 fractures were treated with intramedullary nailing (Group 1), and 17 were treated with open surgery and drilling of the bone ends followed by intramedullary nailing (Group 2). Demographic data, laboratory values, radiological union times, and complications were compared between the groups. Nonunion was defined as fractures with a persistent fracture line 12 months after surgery without any sign of union. ResultsA similar rate of primary union was obtained in both groups (Group 1, 13/15 [87%]; Group 2, 16/17 [94%]; p=0.471). The mean radiological consolidation period was shorter in Group 2 (Group 1, 6.8±1.8 months; Group 2, 5.1±1.3 months; p=0.004). Nonunion rates were similar between the groups (Group 1, 1/15 [7%]; Group 2, 1/17 [6%]; p=0.927). For 1 patient in Group 1, a femoral neck fracture occurred 10 months after surgery, and a revision was performed with a long femoral stem. DiscussionIn the treatment of atypical femoral fractures with intramedullary nailing, we found that the patients who were treated with open intervention of the bone ends had similar union and complication rates to those treated with closed methods, but radiological union time was found to be shorter in the open-intervention group. Level of evidenceIII, retrospective case-control study.