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Atypical Femoral Fractures: What Do

Know About Them?

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Umanuntana,ML Anas Saleh,M2Kon A Mensah,Mn 7ohn

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Siri H" M J

isphosphonates are the most commonly prescribed qpe

of medication for the treatment of osteoporosis. Studies

have shown that bisphosphonates reduce the inci-

R Kleimeyer, h

and IOseph M. ,MD

L tt

/ar"S
"

Ny

..,..:
l\ zfuny case reports and case reviews have described several

lYlcommon

radiographic features of aqpical femoral frac-

dence of vertebral and nonvertebral fractures when used to

tures associated with bisphosphonate use, including a transverse,

treat postmenopausal osteoporosis'-". The indications for

noncomminuted fracture at the subtrochanteric or femoral shaft

region with a medial cortical spike at the fiacture area (Fig. 1).
Other features include prodromal pain and generalized thickening of the femoral cortices on radiographs.l{'16'i/-. Because of
the lack of clear criteria to define atlpical femoral fractures, the
ASBMR task force established major and minor features for both

of bisphosphonates aiso extend to other metabolic bone

diseases such as glucocorticoid-induced osteoporosis, Paget
disease, hlpercalcemia due to a variety of causes, and skeletal
metastases5-'. Treatment with bisphosphonates, however, is
not without adverse effects. Because bisphosphonates act by
inhibiting osteoclast function and inducing osteoclast apoptosisu'', there is a substantial concern regarding the potential
side effects related to severe suppression ofthe bone turnover
use

rate,
Several case reports and case series have indicated an association between a unique fracture type, so-called "atypical

femoral fiactures," and prolonged bisphosphonate use'o-".

These fractures differ from typical osteoporotic femoral fractures in many respects, including the mechanism of injury
location, and fracture configuration. Although the American
Society for Bone and Mineral Research (ASBMR) published a
task force report on atypical femoral fractures in 2010", little
information about this type of fiacture is known. The present
report will critically review current evidence on the characteristics, epidemiology, patlogenesis, and treatment outcomes
of atypical femoral fractures to identifr gaps in knowledge
calling for future research and to provide guidance for orthopaedic surgeons.

complete and incomplete aQpical fiactures of the femur'' (Table

I). All of the major features should be present to designate a

fracture as atypicai aod distinguish it from more common osteoporotic hip fiactures (FiS. 2). The minor features have also
been described in association with atypical femoral fractures, but
they are not required for diagnosis.
Although the ASBMR criteria are usefrrl for defining atypical femoral fractures and allowing consistent diagnosis across
studies, some features remain controversial. For instance, generalized cortical thickening (one of the minor radiographic features)
is believed to result from an impaired ability of bone to remodel
because of prolonged bisphosphonate use, leading to an accumulation of microdamage and compromised bone strength"-'',
However, a recent study by our group found that prolonged
alendronate treatrnent (>5 years) did not cause thickened femoral
cortjces'.. This result suggested that femoral cortices in patients
who have undergone long-term bisphosphonate treatrnent may
have already been thick prior to the initiation of bisphosphonate

Dbclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. One or moTe of the authors, or his or her institution, has had a financial relationship, in the thirly-six months pnor to submission of
this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No
author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what
is written in this work. The complete Dlsclosur6 of Poter*lal Conf,lc,ts of lntercst submitted by authors are always provided with the online version of the
article.

J8one Joint SurgAm.2013;95:o8(1-13)

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/102106/JBIS.L00568