Abstract
Purpose
Increasing numbers of atypical femoral fractures have been reported among long-term bisphosphonate users. We evaluated clinical characteristics of atypical femoral fractures throughout Korean multicenter studies.
Methods
We retrospectively analysed the bone mineral density, prodromal symptoms before femoral fracture, and medication history of osteoporosis in 76 cases of atypical femoral fracture.
Results
The mean age of cases was 71.4 ± 8.8 (range, 43–89) years old. The mean follow-up period after the fracture operation was 24.5 ± 12.9 (range, 12–79) months. BMI was 23.2 ± 3.0 on average. The mean BMD of femur was −1.9 ± 1.4 (range, −4.8 to 1.3). Prodromal symptoms including thigh pain before femoral fracture appeared in 22 (28.9 %) of 76 patients. All patients included in the study used bisphosphonate. The duration of taking bisphosphonate before fracture was 36.8 ± 50.8 (one–204 months) months. Fifty-seven (75 %) of 76 patients were taking the medication for more than three years. Delayed union occurred in 43 (56.5 %) of 76 patients. Delayed union was defined as a fractured bone that did not completely heal within six months of injury. The group of having taken anti-osteoporotic medication for more than three years showed relatively longer union period compared to that for a shorter period medication group (4.8 ± 2.5 months vs 9.3 ± 3.7 months, p = 0.017). The delayed union developed in 43 (56.5 %) of 76 patients and showed a significantly higher incidence in the group with long-term therapy (five/43 vs 38/43, p = 0.021). The bilateral femoral fractures developed in 23 (30.2 %) of 76 patients and showed a high incidence in the group medicated more than three years (two/23 vs 21/23, p = 0.039).
Conclusions
The longer bisphosphonates are used, the more the cases of delayed union and the more frequent the development of bilateral fractures following unilateral fractures. With regard to the delayed union, the methods of the acceleration of fracture healing may be beneficial in atypical femoral fracture patients who had been receiving long-term bisphosphonates therapy. Careful observation is required for contra-lateral femurs due to a high incidence of bilateral atypical femoral fractures.
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References
Ioannidis G, Papaioannou A, Hopman WM et al (2009) Relation between fractures and mortality: results from the Canadian multicentre osteoporosis study. CMAJ 181(5):265–271
Papaioannou A, Kennedy CC, Ioannidis G, CaMos Study Group et al (2009) The impact of incident fractures on health-related quality of life: 5 years of data from the Canadian multicentre osteoporosis study. Osteoporos Int 20(5):703–714
Haentjens P, Magaziner J, Colon-Emeric CS et al (2010) Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med 152(6):380–390
US Department of Health and Human Services (2004) Bone Health and Osteoporosis. A report of the surgeon general. US Dept of Health and Human Services, Office of the Surgeon General, Rockville
Haleem S, Lutchman L, Mayahi R, Grice JE, Parker MJ (2008) Mortality following hip fracture: trends and geographical variations over the last 40 years. Injury 39(10):1157–1163
Black DM, Schwartz AV, Ensrud KE et al (2006) Effects of continuing or stopping alendronate after 5 years of treatment: the Fracture Intervention Trial Long-term Extension (FLEX): a randomized trial. JAMA 296:2927–2938
Neer RM (1995) Skeletal safety of tiludronate. Bone 17(Suppl):501S–503S
Lenart BA, Neviaser AS, Lyman S et al (2009) Association of low-energy femoral fractures with prolonged bisphosphonate use: a case control study. Osteoporos Int 20:1353–1362
Schilcher J, Michaelsson K, Aspenberg P (2010) Bisphosphonate use and atypical fractures of the femoral shaft. N Engl J Med 364:1728–1737
Thompson RN, Phillips JR, McCauley SH, Elliott JR, Moran CG (2012) Atypical femoral fractures and bisphosphonate treatment: experience in two large United Kingdom teaching hospitals. J Bone Joint Surg Br 94:385–390
Shane E, Burr D, Ebeling PR 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):1–23. doi:10.1002/jbmr.1998
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
Watts NB, Diab DL (2010) Long-term use of bisphosphonates in osteoporosis. J Clin Endocrinol Metab 95:1555–1565
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(11):2267–2294
Rogers MJ, Crockett JC, Coxon FP, Mönkkönen J (2011) Biochemical and molecular mechanisms of action of bisphosphonates. Bone 49:34–41
Bukata SV, Kaback LA, Reynolds DG, Keefe RJ, Rosier RN (2009) 1–34 PTH at physiologic doses in humans shows promise as a helpful adjuvant in difficult to heal fractures: an observational cohort of 145 patients. Proceedings of the 55th Annual Meeting of the Orthopaedic Research Society, February 22–25, Las Vegas
Aspenberg P, Genant HK, Johansson T, Nino AJ, See K et al (2010) Teriparatide for acceleration of fracture repair in humans: a prospective, randomized, double-blind study of 102 postmenopausal women with distal radial fractures. J Bone Mineral Res 25:404–414
Rubin C, Bolander M, Ryaby JP, Hadjiargyrou M (2001) The use of low intensity ultrasound to accelerate the healing of fractures. J Bone Joint Surg Am 83-A:259–270
Jingushi S, Mizuno K, Matsushita T, Itoman M (2007) Low-intensity pulsed ultrasound treatment for postoperative delayed union or nonunion of long bone fractures. J Orthop Sci 12:35–41
De Das S, Setiobudi T, Shen L, De Das S (2010) A rational approach to management of alendronate-related subtrochanteric fractures. J Bone Joint Surg Br 92:679–686
Ha YC, Cho MR, Park KH, Kim SY, Koo KH (2010) Is surgery necessary for femoral insufficiency fractures after long-term bisphosphonate therapy? Clin Orthop Relat Res 468:3393–3398
Capeci CM, Tejwani NC (2009) Bilateral low-energy simultaneous or sequential femoral fractures in patients on long-term alendronate therapy. J Bone Joint Surg Am 91:2556–2561
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This multicenter study was approved by the institutional review board of the authors’ institute.
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Kang, J.S., Won, Y.Y., Kim, J.O. et al. Atypical femoral fractures after anti-osteoporotic medication: a Korean multicenter study. International Orthopaedics (SICOT) 38, 1247–1253 (2014). https://doi.org/10.1007/s00264-013-2259-9
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DOI: https://doi.org/10.1007/s00264-013-2259-9