Surgical Treatment for Bisphosphonate-related Atypical Femoral Fracture: A Systematic Review

Document Type : SYSTEMATIC REVIEW

Authors

1 Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran- Physiotherapy Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran

2 Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran

3 Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran - Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran

4 Akhtar Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran

5 Orthopaedic Sports Medicine, Houston Methodist Hospital, Houston, TX, USA

6 Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran

Abstract

Background: Atypical femoral fractures are the femoral fractures located anywhere between the lesser trochanter
and the supracondylar flare of the femur. Long-term bisphosphonates, as the most common preventive and treatment
medications for osteoporosis, are thought to have an important role in these fractures. Most of the fractures should be
treated surgically, and the complications are considerable.
Methods: We searched Medline, CENTRAL, Embase, and DART on February 26, 2020. One author reviewed and
retrieved citations from these four databases for irrelevant and duplicate studies, and two other authors independently
extracted data from the studies and rated their quality.
Patients with surgical treatment of bisphosphonate-related atypical femoral fracture, according to the American Society
for Bone and Mineral Research definition, were included. Animal studies, case reports, studies with high-energy trauma,
pathological fracture, or malignancy-related fractures were excluded.
Results: In total, 316 patients (348 fractures) were included in this study. Mean age of patients was 70.47 years,
and 97.5% of them were female. Duration of using bisphosphonates was 4.04 to 8.8 years, and Alendronate was the
most common type. Moreover, 65.27% and 34.72% of the reported fractures were in diaphyseal and subtrochanteric,
respectively. Moreover, the most common fixation type was intramedullary. Rate of complication was 17.52%, and the
most frequent one was non-union, followed by implant failure. The main limitation of this research was that most of the
studies did not have a high level of evidence.
Conclusion: An increase in the rate of atypical femoral fracture with its challenging management makes it an important
issue to be noted by orthopedic surgeons. Based on the results of this study, subtrochanteric fractures might have more
complications post-operatively and are suggested to be operated on by more experienced surgeons. It was also found
that extra-medullary fixation increases the risk of complications. Future studies on union time, outcomes of different
surgical methods, and teriparatide therapy may help shed more light on the surgical management of these fractures.
Level of evidence: III

Keywords

References

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The Archives of Bone and Joint Surgery
Volume 9, Issue 3
May 2021
Pages 283-296

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History

  • Receive Date: 10 October 2020
  • Revise Date: 19 December 2020
  • Accept Date: 20 December 2020

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