Bilateral Atypical Femoral Fractures Research Articles

Bilateral atypical femoral fracture in osteoporotic patient treated with bisphosphonates

Bilateral atypical femoral fracture in osteoporotic patient treated with bisphosphonates

Bilateral atypical femoral fracture in osteoporotic patient treated with bisphosphonates

Bilateral atypical femoral fracture in osteoporotic patient treated with bisphosphonates

FRI680 Atypical Femoral Fracture In Patients With Hypophosphatasia: A Systematic Review

Abstract Disclosure: N. Charoenngam: None. J. Thongpiya: None. P. Yingchoncharoen: None. B. Ponvilawan: None. M.S. Marangoz: None. J. Chenbhanich: None. P. Ungprasert: None. A growing number of case reports and case series have demonstrated that atypical femoral fracture (AFF) can occur in patients with hypophosphatasia (HPP). Due to the lack of summary of the clinical manifestation, risk factors, associated ALPL variants and treatment, we conducted this systematic review with the goal to summarize the characteristics of all reported patients with HPP who sustained AFF. Additionally, we aimed to identify all available evidence to quantify the rate of co-existence between HPP and AFF. Potentially eligible articles were identified from MEDLINE and EMBASE databases from inception to September 2022 using search strategy consisting of terms related to “Hypophosphatasia” and “Atypical femoral fracture”. Eligible articles must report one of the following information: 1.) individual data of patient(s) diagnosed with HPP and AFF, 2.) prevalence of HPP among patients with AFF or 3.) prevalence of AFF among patients of HPP. Characteristics of patients reported in each study were extracted. A total of 148 potentially eligible articles were identified from the databases. After systematic review, 23 articles met the eligibility criteria. A total of 27 patients with AFF and HPP were identified. The mean ± SD age of the reported patients was 53.8 ± 12.7 years and 21 patients (77.8%) were female. Nine patients (33.3%) received antiresorptive medication (bisphosphonate and/or denosumab) and two patients (7.4%) received teriparatide prior to development of AFF. Seven (25.9%) and 17 (63.0%) patients sustained unilateral and bilateral AFF, respectively. Twelve patients (44.4%) had a history of fractures at other sites. Four (14.8%) and six (21.4%) patients received asfotase alfa and teriparatide after sustaining AFF. Two studies that reported the prevalence of AFF among patients with HPP of approximately 10%. One study reported one HPP patient in a cohort of 72 patients with AFF. In summary, based on the limited evidence, AFF occurred in up to 10% of patients with HPP. Based on the 27 case reports, almost two-thirds did not receive antiresorptive treatment, suggesting the HPP itself could potentially be a risk factor for AFF. Presentation: Friday, June 16, 2023

OA07 A case of severe osteoporosis treated with teriparatide following the development of bilateral atypical femoral fractures due to IV zoledronic acid

Abstract Introduction Atypical femoral fractures (AFF) are a rare complication of long-term anti-resorptive therapy. A literature review of 310 cases of AFF did reveal a median duration of bisphosphonate therapy of 7 years. Additionally, simultaneous glucocorticoid use was seen in 34% of the cases and was reported to have a 5-fold increase in one case series. Around 70% of patients do describe a prodrome of thigh pain and around quarter of all cases will have bilateral involvement. Case description A 59-year-old lady with a background diagnosis of Behçet’s disease was referred for continuation of osteoporosis care. History of Fractures 2003- left-sided distal radial fracture; 2017 - refractured again after a fall; left 5th metatarsal fracture a few months later. 2019 - right navicular fracture, left pubic rami fracture and left iliac wing fracture, after a fall from the bus In 2023, she has tripped and fell from the standing height resulting in a left femoral shaft fracture, which had radiological features of an atypical femoral fracture. She denied any prodromal thigh pain. The orthopaedic team did an intramedullary nailing to the left femoral shaft. X-ray of the right femur shaft revealed cortical thickening of right mid femoral shaft. Treatment History In 2009, she was started on oral bisphosphonate therapy and from 2020 to 2022 received 3 doses of IV zoledronic acid at the national Behçet’s centre in Birmingham. She has been on long-term steroid therapy due to the underlying Behçet's disease and was on prednisolone 7mg daily when she was referred to us. Management of AFF The orthopaedic team initially recommended a watch and wait policy for the right side; however, following discussions with the patient and with us, prophylactic nailing of the right femoral shaft was done 2 months later. Investigations DXA scan in 2022: spine T-score of−3.3 (L2 −3.6, L3 −3.9, L4 −3.7); femoral neck T-score of −2.5. Despite treatment with oral and then parenteral bisphosphonates for the last 12 years, there is a significant reduction in BMD with 18.2% decrease in the spine and 7.1% decrease in the femoral neck compared to the last DEXA in 2019. Management plan The next step was to treat her with teriparatide, which she is currently having without any problems. We shall continue it for 24 months. Discussion Atypical femoral fractures are rare. Anti-resorptive medication including bisphosphonates and denosumab are known to cause atypical femoral fractures. Teriparatide, being anabolic agent, is not associated with the increased risk of atypical femoral fractures. While there are no randomised controlled studies about the use of teriparatide in healing atypical femoral fractures, there are some case reports where teriparatide had shown improved fracture healing in AFF. After the 24 months, to ‘lock in the effects’ of teriparatide, an anti-resorptive medication will be required. Because both femoral shafts have received intramedullary nailing, we would consider IV zoledronic acid after the 24 months of teriparatide. This is the approach supported by the European Calcified Tissue Society in their systemic review and recommendations on ‘Medical Management of Patients After Atypical Femur Fractures’ (https://doi.org/10.1210/clinem/dgz295). Key learning points Consider atypical femoral fracture in patients who are on anti-resorptive therapy and complain of thigh/groin pain. Atypical femoral fractures can be bilateral; therefore, evaluate both sides. Teriparatide can be used to treat osteoporosis in patients with atypical femoral fracture, but considerations will have to be made in relation to subsequent therapy.

Atypical Femoral Fracture in Hypophosphatasia: A Systematic Review.

To summarize the characteristics of all reported patients with hypophosphatasia (HPP) who sustained atypical femoral fracture (AFF) and identify all available evidence to quantify the rate of coexistence between HPP and AFF. Potentially eligible articles were identified from the MEDLINE and EMBASE databases from its inception to September 2022, using a search strategy consisting of terms related to "Hypophosphatasia" and "Atypical femoral fracture." Eligible articles must report one of the following information: (1) individual data of patients diagnosed with HPP and AFF, (2) prevalence of HPP among patients with AFF, or (3) prevalence of AFF among patients of HPP. Characteristics of patients reported in each study were extracted. A total of 148 articles were identified. After the systematic review, 24 articles met the eligibility criteria. A total of 28 patients with AFF and HPP were identified. The mean ± SD age of the reported patients was 53.8 ± 12.5 years, and 22 patients (78.6%) were female. Nine patients (32.1%) received antiresorptive medication (bisphosphonate and/or denosumab), and two patients (7.1%) received teriparatide prior to the development of AFF. Seven (25.0%) and eighteen (64.3%) patients sustained unilateral and bilateral AFF, respectively (laterality not reported in three cases). Thirteen patients (46.4%) had a history of fractures at other sites. Four (14.3%) and seven (25.0%) patients received asfotase alfa and teriparatide after sustaining AFF. Two studies reported the prevalence of AFF among patients with HPP of approximately 10%. One study reported one HPP patient in a cohort of 72 patients with AFF. Based on the limited evidence, AFF occurred in up to 10% of patients with HPP. Based on the 28 case reports, about two-thirds did not receive antiresorptive treatment, suggesting that the HPP itself could potentially be a risk factor for AFF.

Abstract #1403811: Rapidly Progressive Aortic Stenosis After Teriparatide Initiation: A Rare Case

Recombinant Parathyroid Hormone (rPTH) or Teriparatide is frequently used to manage severe osteoporosis due to its anabolic mode of action particularly in patients who are at a high risk of vertebral and non-vertebral fractures. Aortic valve stenosis is a common valve condition seen in the older population. There are multiple etiologies for aortic stenosis, but drug induced aortic stenosis is rare. Moreover, its natural history includes gradual progression towards severity. We present an interesting case of rapidly progressive aortic stenosis after teriparatide initiation. An 84-year-old female with history of hypertension, hyperlipidemia, atrial fibrillation presented to the endocrine clinic for management of osteoporosis. She was diagnosed with osteoporosis in 2000 at age 62. Initial etiology was assumed to be post-menopausal and was treated with oral bisphosphonates. As she had compression fractures of her spine while on treatment, secondary causes of osteoporosis were explored, and she was found to have primary hyperparathyroidism. Her labs were significant for PTH-84 pg/ml, Ca-10.8 mg/dl. She underwent parathyroidectomy in 2016 with normalization of PTH and calcium. After her surgery, she was treated with denosumab infusions every 6 months. She did well till June 2021. Her bone mineral density scores were stable throughout this period. At this point, she suffered bilateral atypical femoral fractures and was thought to be due to chronic anti-resorptive therapy. We stopped denosumab and transitioned her to teriparatide daily injections. She did well for 1 year but then presented to us for management in Aug 2022 prior to valve replacement for severe aortic stenosis. Her labs were significant for normal calcium, 25-hydroxy vitamin D and phosphorus levels. On reviewing her echocardiograms prior to and after initiation of teriparatide we found a rapid progression of her aortic stenosis from moderate to severe, based on mean gradients and peak velocities, over a span of 7 months. Natural progression of aortic stenosis from mild to severe happens over several years (mean duration-5 years), not just a few months. One possible explanation for this rapid progression seen in our patient is due to the presence of osteoblast like cells (arising from vascular endothelial cell precursor cells) in the aortic valve which appear to be stimulated by PTH and hence valve calcification/stenosis. On a thorough review of literature there were no clinical studies that have reported aortic stenosis progression from teriparatide use. To our knowledge, there was a single case report that reported the same phenomenon in Israel. As a result, we wanted to educate the community about the possible association between teriparatide use and worsening aortic stenosis in certain cases. Performing serial echocardiograms in high-risk patients and involving cardiology for early diagnosis and management is essential.

Multicenter study on atypical femoral fractures in patients with bone metastases taking bone- modifying agents

Bone-modifying agents (BMAs), with bone-resorptive inhibitory effects, such as zoledronic acid and denosumab, are widely used at higher doses for bone-related events caused by bone metastasis of malignant tumors. These drugs have been suggested to be associated with atypical femoral fractures (AFFs), and the relationship between BMAs and AFFs has attracted attention. To investigate the clinical features including bone union time of AFFs in patients administered BMA for bone metastasis, we conducted a retrospective multicenter study. Thirty AFFs from 19 patients were enrolled in this study. Thirteen patients had bilateral AFFs, and nineteen AFFs had prodromal symptoms. Eighteen AFFs underwent surgery after complete fracture, three failed to achieve bone union and required nonunion surgery, and 11 AFFs that achieved bone union had an average period until bone union of 16.2 months, which was much longer than that previously reported for ordinary AFFs. Seven patients discontinued the BMAs, but not due to AFFs. Stopping BMAs in patients with bone metastasis would make it difficult to secure their performance of activities of daily living, and AFF with BMA administration might require a longer time for union. Therefore, it would be important to prevent incomplete AFF from becoming complete AFF via prophylactic internal fixation.

Bilateral Atypical Femoral Fractures after Bisphosphonate Treatment for Osteoporosis: A Literature Review.

This literature review aimed to investigate the incidence, anatomical concerns, etiology, symptoms, diagnostic tools, management, and prognosis of bisphosphonate (BP)-associated bilateral atypical femoral fractures (AFFs). The PubMed, Cochrane Library, Web of Sciences, and CINAHL databases were searched up to 20 March 2022. All cases of bilateral AFFs were included, excluding those without any bisphosphonate treatment information and those in which the femoral fracture did not precisely fit into the diagnostic criteria for AFF. We identified 43 patients with bilateral AFFs associated with BP use and conducted a comprehensive analysis. Among 43 patients, 29 (67%) had prodromal symptoms. Regarding the simultaneity of fracture, 21 cases (49%) occurred simultaneously, and 22 cases (51%) occurred sequentially. Alendronate was the most commonly used BP treatment (59%). Regardless of the medication type, BP intake duration was more than 5 years in 77%. The initial diagnosis was performed using X-rays in all cases. A total of 53% of patients had complete fractures, and all patients underwent surgical treatment. Among the remaining patients with incomplete fractures, 18% and 29% received surgical and medical treatments, respectively. After BP discontinuation, teriparatide was most commonly used (63%). The careful evaluation of relevant imaging findings in patients with thigh/groin pain allows the identification of early incomplete fractures and timely management. Since the rate of contralateral side fractures is also high, imaging studies should be performed on the asymptomatic contralateral side.

Bilateral Bisphosphonate-related Atypical Femoral Neck Fracture in a Patient with Familial Mediterranean Fever: A Case Report

Bilateral Bisphosphonate-related Atypical Femoral Neck Fracture in a Patient with Familial Mediterranean Fever: A Case Report

Bisphosphonate therapy associated with bilateral atypical femoral fracture and delayed union.

Objectives The aim of this study was to identify the risk factors for developing atypical femoral fractures (AFF) and to examine the effect of bisphosphonate (BP) therapy on delayed bone union and bilateral fractures.Patients and methods Between January 1st, 2012 and December 31st, 2020, a total of 74 AFF patients (8 males, 66 females; mean age: 75.4±7.2 years; range, 51 to 94 years) were recorded in two centers and retrospectively analyzed. A control fragility fracture group (n=143) was compared to the AFF group according to fracture characteristics, surgical fixation methods, comorbidities, and medications. The AFF patients were selected and subdivided according to their BP therapy: Group 1 (without BP) and Group 2 (with BP). Group 2 was further classified into Group 2a (<5 years of BP) and Group 2b (<5 years of BP).Results The multivariate logistic regression model showed that, BP drug use was the most significant risk factor in development of AFF (p<0.001, odds ratio= 10.749, 95% confidence interval: 3.886-29.733). The patients on BP showed longer bone union (Group 2 - 8.3±3.5 vs. Group 1 - 6.4±3.1 months, p=0.02; Group 2b - 9±3.8 vs. Group 2a - 7.3 ±3.9 months, p=0.09). Of all 19 cases of bilateral fractures, 14 were in Group 2 with BP use (p=0.11). Of 74 cases, 26 (35%) contralateral femoral X-rays were taken on admission and 24 (92%) showed AFF minor criteria signs. Of these 24 patients, 10 (42%) developed contralateral AFF.Conclusion The most significant risk factor in development of AFF was BP drug use. Longer BP therapy (>5 years) showed longer delayed bone union, which was not significant. There was a relatively high risk of developing AFFs and bilateral fractures on BP therapy. In case of an AFF, a contralateral femoral X-ray must be always performed for signs of an impending fracture.

Prevalence of Low Serum Alkaline Phosphatase and Hypophosphatasia in Adult Patients with Atypical Femur Fractures

Hypophosphatasia (HPP) is a rare genetic disorder characterized by low serum alkaline phosphatase (ALP), its manifestations may include atypical femoral fractures (AFF). However, the prevalence of low serum ALP and HPP in patients with AFF remains unknown. We retrospectively analyzed ALP levels and clinical manifestations compatible with HPP in 72 adult patients with confirmed AFF by chart review. ALP values were compared with those of a control group of patients with prior proximal femoral fracture during antiresorptive treatment (n = 20). Among the AFF patients, 18 (25%) had at least one serum ALP value ≤ 40 IU/L, although in all but one case, at least one ALP value > 40 IU/L was also detected at another time point. Most low ALP values were associated with antiresorptive treatment (P = 0.049) and lowest levels of ALP did not differ between the AFF and the control groups (P = 0.129). However, low ALP values among AFF patients were associated with a higher rate of bilateral AFF (50% vs 22%, P = 0.025), metatarsal fracture (33% vs 7%, P = 0.006), and with trends for more frequent use of glucocorticoid (22% vs 8%, P = 0.089) and proton pump inhibitor (61% vs 44%, P = 0.220). In one AFF patient with low ALP and clinical suspicion of HPP, a rare pathogenic heterozygous variant of the ALPL gene was identified. In conclusion, low ALP values are common among subjects with AFF and mainly related to concomitant antiresorptive medication. Hence, low serum ALP has low specificity for HPP among AFF patients.

Bilateral atypical femoral fracture related to bisphosphonate therapy

Introduction. Although bisphosphonates represent the most commonly prescribed antiresorptive therapy for the treatment of osteoporosis and fracture prevention, paradoxically, their continuous use in some patients can lead to an atypical femoral fracture. This type of fracture is characterized by specific features regarding clinical presentation, mechanism of injury and radiological manifestations. The objective of this article was to present a case of a bilateral femoral fracture associated with bisphosphonate usage. Case outline. A 70-year-old female patient was admitted to the emergency department with a severe, throbbing pain in both thighs after a ground-level fall. Radiographs of both femurs verified bilateral complete fracture localized in the diaphyseal region. Prior to hospitalization, she had continuously been taking ibandronate for three years. The patient underwent percutaneous osteosynthesis with intramedullary nailing with interlocking screws of both femurs. Six weeks after the surgical treatment, radiographic findings indicated the presence of early signs of healing on both femurs. At the four-month follow-up, the complete union of the bone fragments was achieved and she managed to walk without any pain and walking aids. Conclusion. Physicians still face doubts regarding optimal duration of bisphosphonate therapy. Although atypical femoral fracture represents a rare adverse event related to bisphosphonate use, all patients receiving this antiresorptive treatment who are complaining of new-onset unexplained pain in the thighs for more than two weeks should be completely diagnostically evaluated in term of atypical femoral fracture. Patients with confirmed atypical femoral fracture should undergo surgical treatment.

Treatment of Bilateral Atypical Femoral Fractures (Ipsilateral Complete Fracture and Contralateral Incomplete Fracture) with Lateral Bowing &mdash;A Case of Using Intramedullary Nail Fitting the Bowing for Treatment and Prevention of Fractures&mdash;

Treatment of Bilateral Atypical Femoral Fractures (Ipsilateral Complete Fracture and Contralateral Incomplete Fracture) with Lateral Bowing &mdash;A Case of Using Intramedullary Nail Fitting the Bowing for Treatment and Prevention of Fractures&mdash;

Bilateral atypical femoral fractures during denosumab therapy in a patient with adult-onset hypophosphatasia.

SummaryHypophosphatasia (HPP) is a rare and under-recognised genetic defect in bone mineralisation. Patients presenting with fragility fractures may be mistakenly diagnosed as having osteoporosis and prescribed antiresorptive therapy, a treatment which may increase fracture risk. Adult-onset HPPhypophosphatasia was identified in a 40-year-old woman who presented with bilateral atypical femoral fractures after 4 years of denosumab therapy. A low serum alkaline phosphatase (ALP) and increased serum vitamin B6 level signalled the diagnosis, which was later confirmed by identification of two recessive mutations of the ALPL gene. The patient was treated with teriparatide given the unavailability of ALP enzyme-replacement therapy (asfotase alfa). Fracture healing occurred, but impaired mobility persisted. HPP predisposes to atypical femoral fracture (AFF) during antiresorptive therapy; hence, bisphosphonates and denosumab are contraindicated in this condition. Screening patients with fracture or ‘osteoporosis’ to identify a low ALP level is recommended.Learning pointsHypophosphatasia (HPP) is a rare and under-recognised cause of bone fragility produced by impaired matrix mineralisation that can be misdiagnosed as a fragility fracture due to age-related bone loss.Antiresorptive therapy is contraindicated in HPP.Low serum alkaline phosphatase (ALP) provides a clue to the diagnosis.Elevated serum vitamin B6 (an ALP substrate) is indicative of HPP, while identification of a mutation in the ALPL gene is confirmatory.Enzyme therapy with recombinant ALP (asfotase alfa) is currently prohibitively costly.Treatment with anabolic bone agents such as teriparatide has been reported, but whether normally mineralized bone is formed requires further study.

Bilateral Atypical Femoral Fracture(AFF) After Teriparatide and Subsequent Anti-Resorptive Therapy: A Management Dilemma

Introduction: Femoral fractures carry devastating morbidity for long term ambulation. Atypical femoral fractures (AFF) are uncommon, and bilateral AFFs are more rare with added post-fracture limitations. We report two patients with bilateral AFFs despite receiving teriparatide (TPTD). Case 1: A 72 y.o. Filipino lady with osteoporosis since late 1990 was treated with bisphosphonates (BP) intermittently over 25 years with drug holidays for dental work. She stopped alendronate in mid-2013 and continued raloxifene. She suffered a spontaneous left mid-femur AFF in June, 2015 that was treated with intramedullary (IM) rod and nailing. In July, 2015 she started TPTD 20 mcg daily for 23 months until May, 2017. Alendronate was restarted weekly. In December, 2018 she developed right thigh and hip prodromal pain without x-ray changes. In April, 2019 (46 months after the left AFF and 23 months after TPTD), she sustained a spontaneous right sub-trochanteric AFF. BP was stopped. After IM rod and nailing, she began a second course of TPTD. Case 2: 72 y.o Caucasian lady with osteoporosis since 2000 was treated with alendronate until April, 2006. She was switched to daily TPTD for 22 months from May, 2006 to March, 2008. Oral BP was resumed in April, 2008. She suffered a left AFF in November, 2009; BP was stopped in March, 2010. In July, 2010 she sustained a right AFF (9 months after the left AFF and 28 months post-TPTD). Each spontaneous AFF occurred after prodromal pain, and each was treated with IM rod placement with nailing. She received BP infusion in 2011 and TPTD from March, 2012 to March, 2014. DXA scan in 2020 showed lumbar spine osteopenia. She currently takes calcium and Vit D supplementation. Discussion: TPTD is reported as a potential treatment for enhancing AFF healing, bone mineral density and pain resolution. The expectation is that it might prevent contralateral AFF. No randomized studies of prevention of AFF with TPTD exist. Available reports show variable results. Prolonged presence of BP in bone may contribute to this variation. We identified 7 reported AFF patients treated with TPTD who then developed a contralateral AFF. We found 2 patients with new AFF after TPTD as in our Case 2. In all cases there was previous exposure to BP. Perhaps the 28–30% risk of a contralateral AFF within 4 years in the setting of BP is irremediable. Conclusion: TPTD increases healing of AFF in some reports, but prevention of an initial or further AFF has not been well documented. Our 2 patients and 9 others reported suggest a possible subset with increased sensitivity to the effect of BP and increased AFF risk. The best choice after TPTD is unclear, but it may include permanent removal of anti-resorptive agents. The anti-sclerostin antibody romosozumab also has been associated with AFF. Choices are limited for these patients other than excellent surgical care, adequate calcium/vitamin D intake, and periodic imaging as symptoms dictate.

Atypical ulnar fracture with bilateral atypical femoral fracture; A case report

Atypical ulnar fracture with bilateral atypical femoral fracture; A case report

Nontraumatic bilateral atypical femoral fractures associated with long-term alendronate therapy

Alendronate is a bisphosphonate commonly used in the treatment of post-menopausal and steroid-associated osteoporosis. Bisphosphonates have an evidence base for reducing the occurrence of typical osteoporotic fractures. However, there has been growing recognition of a correlation with the use of long-term therapy with bisphosphonates, and rare occurrence of atypical femoral fractures (AFFs). This report describes a 72-year-old caucasian woman presenting with evolving groin and thigh pains of two weeks duration. Plain X-rays noted features compatible with bilateral impending femoral subtrochanteric fractures. She had been taking oral alendronate 70mg weekly for ten consecutive years as treatment for osteoporosis. Based on the medication history, the absence of preceding trauma or a fall, and the presence of supportive radiological findings, the diagnosis was made of impending bilateral proximal femur fractures secondary to long-term bisphosphonate therapy. The alendronate was discontinued, and the patient managed with two planned successive surgeries involving the insertion of intertrochanteric antegrade nails (inter-TAN) to both femurs. Following a period of rehabilitation, she was successfully discharged home. Some pharmacokinetic and pharmacodynamic considerations of bisphosphonates are discussed. The write-up presents a brief literature review of AFFs. The index report is further reviewed in relation to the American society for bone and mineral research (ASBMR) task force’s recommended case definition of what constitutes AFFs. The discussion concludes with the application of two previously validated causality assessment systems (CAS). In this instance, both CAS indicated a ‘probable’ classification for the adverse drug reaction (ADR) to prolonged usage of oral alendronate.

Clinical Features and Outcomes of Bilateral Atypical Femoral Fractures

Bilateral atypical femoral fractures (AFFs) are relatively rare. In this report, we retrospectively researched clinical features and outcomes of bilateral AFFs treated at our institution. We previously treated 4 patients (8 limbs) with intramedullary nailing for complete AFFs (6 limbs) and incomplete AFFs (2 limbs). The mean age at the first operation was 53.3 years, and all patients were female. Of the 4 patients, two had breast cancer, and another two had systemic lupus erythematosus. Three of them received bisphosphonates, and 2 received denosumab, proton pump inhibitor, or glucocorticoid therapy. Only 2 of 6 cases of incomplete AFFs had prodromal pain before progressing to complete fracture. The mean interval from the first surgery to contralateral fracture or prophylactic surgery was 16 months. Radiographically, complete bone union was achieved in 6 limbs. However, a small gap at the lateral cortex of fracture site remained in 2 limbs. Finally, all of the patients were pain-free and able to walk without a cane. It is absolutely necessary to confirm contralateral femoral conditions; however, prediction of progression to complete fracture based solely on prodromal pain was difficult. Therefore, we should advise patients about the danger of progression to complete AFFs even if they are asymptomatic, and a prophylactic surgery should be performed after obtaining informed consent.

Bir stres kırığı olgusu: Altta yatan neden nedir?

Stress fractures are encountered commonly in clinical practice. Many features of stress fractures are in common, but the differences depend on the condition of the underlying bone. The clinician should approach according to the type of stress fracture. We report a 71-year-old female patient with osteoporosis, who had been taking prolonged bisphosphonate therapy and a single dose denosumab, sustained bilateral atypical femoral fractures (AFF) eight months apart.

Bilateral Atypical Femoral Fractures after Prolonged Bisphosphonate Therapy: A Case Report and New Approach to the Management of Iatrogenic Fractures

Bilateral Atypical Femoral Fractures after Prolonged Bisphosphonate Therapy: A Case Report and New Approach to the Management of Iatrogenic Fractures