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Are the Atypical Femoral Fractures a problem in order to Osteoporosis Treatment?: Its Management and Consequences

Paredes-Carnero Xavier*, Fernández-Cebrián, Antonio María

Introduction: Bisphosphonates (BPs) evolved as the mainstay for the treatment of osteoporosis, reducing the incidence of fractures. Recently several publications described the occurrence of low-energy sub-trochanteric and femoral shaft fractures associated with long-term BPs use; those have been defined as atypical femoral fractures (AFF). The aim of this study was to value the influence of BPs on the shaft and sub-trochanteric fractures and to describe the outcome of surgically treated femur fractures associated with prolonged BPs use.

Material and Methods: Between 2010 and 2014, a total of 129 patients 50 years and older were hospitalized with a sub-trochanteric or femoral shaft fracture at a single university medical centre. Admission x-ray and medical and treatment records were examined, and patients were classified as having atypical or classic femoral fractures. X-ray and clinical controls were assessed to describe the healing-fracture process. Chi-square test was used to assess the association of bisphosphonate use and atypical femoral fracture.

Results: Fourteen patients with AFF (10.8%) and 115 patients with typical fractures (89.1%) were identified. All patients with AFF had been treated with BPs (100%), compared with 7 (6%) in the typical fractures group (Chi-square statistic was 80.76. This result is significant at p<0.05). The mean BPs use was 56.7 months in the AFF while in the typical fractures was 63.6 months (p>0.05). A contralateral fracture occurred in 2 of atypical cases. The mean time of bone consolidation was 13.2 months in AFF and 11.6 months in typical fractures (p>0.05). The follow-up was 38.4 months in AFF and 40.6 in typical fractures (0>0.05). No reoperations were identified in the patients with AFF, while 13 reoperations were observed in the patients with typical fractures (2 dynamizations, 9 exchanges nail and 2 plates) (p<0.05).

Conclusions: The BPs use increased AFF respect to typical fractures in our population. The patients with an AFF must be stopped and an anabolic agent should be employed. These patients should also have daily calcium and vitamin-D supplementation. No more reoperations were observed in patients with AFF who were treated with an intramedullary nail compared with patients who suffered typical fractures.