Abstract
Summary
Using the American Society for Bone and Mineral Research Task Force case definition for atypical femoral fractures, sensitivity and specificity of radiographic fracture characteristics were calculated. Fracture pattern was the most sensitive and specific characteristic. This suggests that some characteristics should be weighted more heavily when identifying these fractures.
Introduction
To estimate the sensitivity and specificity of each radiographic criterion in the 2013 ASBMR atypical femoral fracture (AFF) case definition for distinguishing AFF from other subtrochanteric/diaphyseal fractures (non-AFF) among women enrolled in a large integrated health care organization.
Methods
Radiographs from 55 physician-confirmed AFFs and a sample of 39 non-AFFs were reviewed by four independent expert reviewers representing four medical specialties. One image per fracture was selected for review. Using a standardized data collection tool, based on the 2013 AFF case definition, reviewers indicated the presence or absence of the following characteristics viewable on radiograph: fracture pattern, comminution, periosteal and/or endosteal thickening, and cortical thickening. Sensitivity and specificity for each characteristic was calculated for each reviewer and summarized across reviewers with the mean and range. Agreement across reviewers was quantified using Fleiss’s kappa (FK) statistic.
Results
The most sensitive factors distinguishing AFF from non-AFF were lateral cortex transverse fracture pattern (mean 93.6 %, range 85.5–98.2 %), medial cortex transverse or oblique fracture pattern (mean 84.1 %, range 72.7–98.2 %), and minimal/non-comminution (mean 93.2 %, range 89.1–98.2 %). Specificity was the greatest for lateral cortex transverse fracture pattern (mean 95.5 %, range 92.3–97.4 %). Agreement across reviewers was the highest for lateral cortex transverse fracture pattern (FK 0.83) and incomplete fracture through the lateral cortex only (FK 0.80).
Conclusion
Lateral cortex transverse fracture pattern was the most sensitive and specific characteristic and the most highly agreed upon across reviewers. Other characteristics were less readily agreed upon across reviewers. Measurement of discrete combinations of individual characteristics may enhance sensitivity and/or specificity.
References
Food and Drug Administration (2011) Background document for meeting of advisory committee for reproductive health drugs and drug safety and risk management advisory committee. In: Food and drug administration, p 182
Dell RM, Adams AL, Greene DF, Funahashi TT, Silverman SL, Eisemon EO, Zhou H, Burchette RJ, Ott SM (2012) Incidence of atypical nontraumatic diaphyseal fractures of the femur. J Bone Miner Res 27:2544–2550. doi:10.1002/jbmr.1719
Feldstein AC, Black D, Perrin N et al (2012) Incidence and demography of femur fractures with and without atypical features. J Bone Miner Res 27:977–986. doi:10.1002/jbmr.1550
Girgis CM, Sher D, Seibel MJ (2010) Atypical femoral fractures and bisphosphonate use. N Engl J Med 362:1848–1849. doi:10.1056/NEJMc0910389
Giusti A, Hamdy NA, Papapoulos SE (2010) Atypical fractures of the femur and bisphosphonate therapy: a systematic review of case/case series studies. Bone 47:169–180. doi:10.1016/j.bone.2010.05.019
Kim SY, Schneeweiss S, Katz JN, Levin R, Solomon DH (2011) Oral bisphosphonates and risk of subtrochanteric or diaphyseal femur fractures in a population-based cohort. J Bone Miner Res 26:993–1001. doi:10.1002/jbmr.288
Lenart BA, Neviaser AS, Lyman S, Chang CC, Edobor-Osula F, Steele B, van der Meulen MC, Lorich DG, Lane JM (2009) Association of low-energy femoral fractures with prolonged bisphosphonate use: a case control study. Osteoporos Int 20:1353–1362. doi:10.1007/s00198-008-0805-x
Lo JC, Huang SY, Lee GA, Khandelwal S, Provus J, Ettinger B, Gonzalez JR, Hui RL, Grimsrud CD (2012) Clinical correlates of atypical femoral fracture. Bone 51:181–184. doi:10.1016/j.bone.2012.02.632
Meier RP, Perneger TV, Stern R, Rizzoli R, Peter RE (2012) Increasing occurrence of atypical femoral fractures associated with bisphosphonate use. Arch Intern Med 172:930–936. doi:10.1001/archinternmed.2012.1796
Park-Wyllie LY, Mamdani MM, Juurlink DN, Hawker GA, Gunraj N, Austin PC, Whelan DB, Weiler PJ, Laupacis A (2011) Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women. JAMA 305:783–789. doi:10.1001/jama.2011.190
Schilcher J, Michaelsson K, Aspenberg P (2011) Bisphosphonate use and atypical fractures of the femoral shaft. N Engl J Med 364:1728–1737. doi:10.1056/NEJMoa1010650
Vestergaard P, Schwartz F, Rejnmark L, Mosekilde L (2011) Risk of femoral shaft and subtrochanteric fractures among users of bisphosphonates and raloxifene. Osteoporos Int 22:993–1001. doi:10.1007/s00198-010-1512-y
Chan SS, Rosenberg ZS, Chan K, Capeci C (2010) Subtrochanteric femoral fractures in patients receiving long-term alendronate therapy: imaging features. AJR Am J Roentgenol 194:1581–1586. doi:10.2214/AJR.09.3588
Koeppen VA, Schilcher J, Aspenberg P (2012) Atypical fractures do not have a thicker cortex. Osteoporos Int 23:2893–2896. doi:10.1007/s00198-012-2173-9
Porrino JA Jr, Kohl CA, Taljanovic M, Rogers LF (2010) Diagnosis of proximal femoral insufficiency fractures in patients receiving bisphosphonate therapy. AJR Am J Roentgenol 194:1061–1064. doi:10.2214/AJR.09.3383
Schilcher J, Koeppen V, Ranstam J, Skripitz R, Michaelsson K, Aspenberg P (2013) Atypical femoral fractures are a separate entity, characterized by highly specific radiographic features. A comparison of 59 cases and 218 controls. Bone 52:389–392. doi:10.1016/j.bone.2012.10.016
Shane E, Burr D, Ebeling PR et al (2010) Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res 25:2267–2294. doi:10.1002/jbmr.253
Shane E, Burr D, Abrahamsen B et al (2014) Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res 29:1–23. doi:10.1002/jbmr.1998
Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174
Rosenberg ZS, La Rocca Vieira R, Chan SS et al (2011) Bisphosphonate-related complete atypical subtrochanteric femoral fractures: diagnostic utility of radiography. AJR Am J Roentgenol 197:954–960. doi:10.2214/AJR.10.6262
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This study was funded by Amgen Inc. (Grant PO 7100077618).
Conflicts of interest
Annette Adams has received research grants or funding from Amgen, Inc., Merck Inc. and Otsuka Pharmaceuticals. Fei Xue is an employee of Amgen Inc. and holds Amgen stock. Cathy Critchlow is an employee of Amgen Inc. and holds stock in Amgen Inc. Susan Ott gave one lecture and travel and expenses paid by Amgen. The following authors declare that they have no conflicst of interest: Jean Q. Chantra, Rick M. Dell, Stuart Silverman, and Joseph Giaconi.
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Adams, A.L., Xue, F., Chantra, J.Q. et al. Sensitivity and specificity of radiographic characteristics in atypical femoral fractures. Osteoporos Int 28, 413–417 (2017). https://doi.org/10.1007/s00198-016-3809-y
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DOI: https://doi.org/10.1007/s00198-016-3809-y