Abstract
Bisphosphonates (BPs) are the mainstay of osteoporosis treatment due to their safety and efficacy. There is evidence that BPs medication may be complicated by atypical femoral fractures (AFFs). Prolonged administration of BPs is even more strongly associated with AFFs. AFF is a relatively rare complication of BPs when taking into account the huge population worldwide that benefits from this pharmacotherapy. AFF is, however, a serious complication of BPs treatment, which includes prolonged healing time and high revision rate when operative treatment is required. Less frequently, AFFs occur even without BPs administration, while these fractures have all the characteristics of “stress” or “insufficiency” fractures. The critical point of view in AFFs pathogenesis seems to be not only the biology of cortical bone, but also the mechanical issue. It has been proven that BPs, glucocorticoids and proton pump inhibitors (PPIs) can cause bone turnover suppression and affect the biological parameter of AFFs pathogenesis. Specific mechanical femoral bone properties predispose to AFFs pathogenesis. Several studies have already reported that increased femoral bowing > 5.250 degrees or decreased femoral neck-shaft angle <125 degrees, are associated with increased risk for diaphyseal and subtrochanteric AFFs respectively, regardless of BPs uptake. If these two parameters are simultaneously present, the probability for AFFs occurrence increases dramatically. Our scientific report, which is based on the current evidence about AFFs, is that if both femoral bowing angle and femoral neck-shaft angle are evaluated before BPs administration, this intervention may reduce the incidence of AFFs. Thus, in cases with excessive lateral femoral shaft bowing or very small femoral neck-shaft angle, the prescription of another anti-osteoporotic treatment than BPs should be recommended. If, however, BPs can’t be avoided, clinicians should be aware of the fact that long-term administration may be implicated with AFFs occurrence. In these cases, short term BPs administration with timely drug holiday between three and five years may be reasonable. Finally, roentgenographic evaluation of both femurs every six months and medical reference in case of any emerging thigh pain are also logical interventions to prevent and reduce AFFs.
Highlights
Atypical femoral fractures (AFFs) are often associated with bisphosphonates (BPs) administration for osteoporosis treatment [1]
Few studies have already reported several cases of AFFs without BPs usage [5], while in 2013 the American Society for Bone and Mineral Research revised the definition of AFFs by deleting the clause pertaining to BPs usage or other drugs that influence bone turnover suppression such as proton pump inhibitors (PPIs) and glucocorticoids [6]
As the prevalence of osteoporosis increases dramatically, AFF is a devastating complication of BPs usage, our scientific report, that is based on current evidence about AFFs, is that if both femoral bowing angle and femoral neck-shaft angle are evaluated before BPs administration it may reduce the incidence of AFFs
Summary
Atypical femoral fractures (AFFs) are often associated with bisphosphonates (BPs) administration for osteoporosis treatment [1]. As the prevalence of osteoporosis increases dramatically, AFF is a devastating complication of BPs usage, our scientific report, that is based on current evidence about AFFs, is that if both femoral bowing angle and femoral neck-shaft angle are evaluated before BPs administration it may reduce the incidence of AFFs. in cases with excessive lateral femoral shaft bowing or very small femoral neck-shaft angle, prescription of another anti-osteoporotic treatment other than BPs should be recommended. In these cases, short term BPs administration with timely drug holiday between three and five years may be reasonable. Patients with osteoporosis and increased BMI (body mass index) [5] should be monitored for these angles, because due to mechanical reasons they are more vulnerable to AFFs. we recommend clinicians to evaluate these angles in patients with osteoporosis and BPs usage, and in patients who consume drugs affecting bone turnover such as glucocorticoids or proton pump inhibitors. Glucocorticoid therapy, older age, increased BMI and decreased height are proposed as additional risk factors for AFFs by few studies [5,8], but further evaluation with large studies is mandatory
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