Bisphosphonate-related Fractures Research Articles

Long-term radiographic follow-up of bisphosphonate-associated atypical femur fractures.

To evaluate the appearance of bisphosphonate-related femur insufficiency fractures on long-term follow-up radiographic studies and to describe the rate of fracture line obscuration and cortical beak healing over time. In this retrospective study, bisphosphonate-related femur fracture radiographs were reviewed by two radiologists for the presence of a fracture line, callus, and the characteristic cortical beak. Kaplan-Meier curves were used to analyze the time to first indication of healing. Femurs were also subdivided into those who underwent early versus late surgical fixation and those who underwent early versus late discontinuation of bisphosphonate. Clinical data including pain level and medication history were collected. Forty-seven femurs with a bisphosphonate-related femur fracture were identified in 28 women. Eighty-five percent took a bisphosphonate for greater than 5 years and 59 % for greater than 10 years. The median time to beak healing was 265 weeks and the median time to fracture line healing was 56 weeks in the 31 femurs with a baseline fracture. No statistically significant difference was identified between surgical fixation and conservative management. Bisphosphonate-related fractures demonstrate notably prolonged healing time on long-term follow-up.

Audit of atypical hip fractures at the Royal Berkshire Hospital

Audit of atypical hip fractures at the Royal Berkshire Hospital Shilpa Selvan,1 Tom Mills,2 Jeremy McNally1 1Rheumatology Department, 2Radiology Department, The Royal Berkshire Hospital, Reading, UK Background: There is increasing evidence suggesting an association between bisphosphonate use and the occurrence of atypical femoral fractures, which account for less than 1% of hip and femoral fractures overall. The aim of this audit was to assess the prevalence of atypical, bisphosphonate-related femoral fractures and adherence to regional (Fracture Reduction in South Central England [FRiSC]) guidelines in our departmental cohort. Methods: We retrospectively reviewed 1,803 patients from the National Hip Fracture Database (NHFD) with femoral fractures admitted to a district general hospital during a 49-month period. We studied all subtrochanteric fractures in patients admitted on bisphosphonates. Corresponding hip radiographs were examined for features of atypical fractures according to the American Society for Bone and Mineral Research diagnostic criteria. Results: The mean age of the patients included was 63 ± 8.08 years. One hundred and sixty-one femoral fractures were identified in patients on bisphosphonates; 73 intertrochanteric, 68 intracapsular, and 20 subtrochanteric. Ninety-three percent of these fractures were in women. Radiographs of the 20 subtrochanteric fractures were reviewed and five were classified as atypical, bisphosphonate-related fractures according to American Society for Bone and Mineral Research diagnostic criteria. Adherence with FRiSC guidelines was inconsistent. A repeat dual-energy X-ray absorptiometry scan was performed in only two cases. The bisphosphonate was stopped in only two of the five patients following fracture. No clinical assessment of the contralateral femur or radiological assessment was done in any of the five cases. Conclusion: Overall, five atypical femoral fractures were found in a cohort of 1,803 patients at our district general hospital. This is 0.3% of the population studied, consistent with the incidence reported in the literature. Improvements in adherence with local guidelines for the management of atypical femoral fractures, along with increasing awareness of the nature of these fractures is necessary amongst rheumatologists, orthopedic surgeons, and geriatricians. Keywords: fracture, bisphosphonate, atypical

A Lesson from the Failure of Intramedullary Fixation of Atypical Subtrochanteric Fractures: A Report of Two Cases.

Surgical fixation of subtrochanteric fractures remains technically challenging, even to experienced fracture surgeons. These fractures are often treated with intramedullary devices; fixed-angle plating is an alternative. Recently, there have been an increasing number of reports about bisphosphonate-related atypical femoral fractures occurring at the subtrochanteric or proximal diaphyseal region1-4. These fractures are characterized by cortical beaking, thickening of the femoral cortex prior to fractures, and transverse or short oblique orientation in people who have been on long-term bisphosphonate therapy2,3,5,6. As with the vast majority of trauma-related subtrochanteric fractures, these bisphosphonate-related fractures are usually stabilized with cephalomedullary devices. Surgeons often do not pay adequate attention to the length of the intramedullary nail, which in effect is the working length of the fixation. Short nails are sometimes used for ease of insertion and their availability in most operating rooms. Spanning the distal femoral region with a longer nail is erroneously viewed as unnecessary. In fact, the less biomechanically sound fixation achieved by a short nail will predispose to the occurrence of delayed union, nonunion, and implant breakage. We report two cases of atypical subtrochanteric fractures in patients who had been on long-term bisphosphonate therapy; treatment with short cephalomedullary nails failed in both. We also discuss the underlying failure mechanism. Both patients were informed that data concerning their cases would be submitted for publication, and they provided consent. Case 1. An eighty-two-year-old woman who had taken alendronate for osteoporosis for six years was admitted to the hospital after a …

P86 Bisphosphonate-related fractures: a reality or myth?

P86 Bisphosphonate-related fractures: a reality or myth?

Bisphosphonate-Related Complete Atypical Subtrochanteric Femoral Fractures: Diagnostic Utility of Radiography

The objective of our study was to evaluate the diagnostic utility of conventional radiography for diagnosing bisphosphonate-related atypical subtrochanteric femoral fractures. Retrospective interpretation of 38 radiographs of complete subtrochanteric and diaphyseal femoral fractures in two patient groups-one group being treated with bisphosphonates (19 fractures in 17 patients) and a second group not being treated with bisphosphonates (19 fractures in 19 patients)-was performed by three radiologists. The readers assessed four imaging criteria: focal lateral cortical thickening, transverse fracture, medial femoral spike, and fracture comminution. The odds ratios and the sensitivity, specificity, and accuracy of each imaging criterion as a predictor of bisphosphonate-related fractures were calculated. Similarly, the interobserver agreement and the sensitivity, specificity, and accuracy of diagnosing bisphosphonate-related fractures (i.e., atypical femoral fractures) were determined for the three readers. Among the candidate predictors of bisphosphonate-related fractures, focal lateral cortical thickening and transverse fracture had the highest odds ratios (76.4 and 10.1, respectively). Medial spike and comminution had odd ratios of 3.8 and 0.63, respectively. Focal lateral cortical thickening and transverse fracture were also the most accurate factors for detecting bisphosphonate-related fractures for all readers. The sensitivity, specificity, and overall accuracy for diagnosing bisphosphonate-related fractures were 94.7%, 100%, and 97.4% for reader 1; 94.7%, 68.4%, and 81.6% for reader 2; and 89.5%, 89.5%, and 89.5% for reader 3, respectively. The interobserver agreement was substantial (κ > 0.61). Radiographs are reliable for distinguishing between complete femoral fractures related to bisphosphonate use and those not related to bisphosphonate use. Focal lateral cortical thickening and transverse fracture are the most dependable signs, showing high odds ratios and the highest accuracy for diagnosing these fractures.