Construct Failure in an Atypical Femoral Fracture treated
with Intramedullary Nailing: A Case Report

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Abstract

The aim of this paper is to document a rare case of construct failure in a 68-year old Filipina who sustained an atypical femoral fracture (AFF) in her left subtrochanteric area. The patient previously had a 40-month history of alendronate 70mg + vitamin D 5600u therapy for osteoporosis and underwent closed intramedullary nailing for the AFF. Six months postoperatively, she began to experience progressive pain in her operated thigh. Radiographs revealed a broken nail at the proximal screw hole and non-union of the AFF. The patient was treated with exposure of the fracture site, removal of the broken device, exchange intramedullary nailing, and iliac bone grafting. She had radiographic and clinical union and was full weight bearing after three months.

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Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research.

Elizabeth Shane, David Burr, Bo Abrahamsen … (2014)

Bisphosphonates (BPs) and denosumab reduce the risk of spine and nonspine fractures. Atypical femur fractures (AFFs) located in the subtrochanteric region and diaphysis of the femur have been reported in patients taking BPs and in patients on denosumab, but they also occur in patients with no exposure to these drugs. In this report, we review studies on the epidemiology, pathogenesis, and medical management of AFFs, published since 2010. This newer evidence suggests that AFFs are stress or insufficiency fractures. The original case definition was revised to highlight radiographic features that distinguish AFFs from ordinary osteoporotic femoral diaphyseal fractures and to provide guidance on the importance of their transverse orientation. The requirement that fractures be noncomminuted was relaxed to include minimal comminution. The periosteal stress reaction at the fracture site was changed from a minor to a major feature. The association with specific diseases and drug exposures was removed from the minor features, because it was considered that these associations should be sought rather than be included in the case definition. Studies with radiographic review consistently report significant associations between AFFs and BP use, although the strength of associations and magnitude of effect vary. Although the relative risk of patients with AFFs taking BPs is high, the absolute risk of AFFs in patients on BPs is low, ranging from 3.2 to 50 cases per 100,000 person-years. However, long-term use may be associated with higher risk (∼100 per 100,000 person-years). BPs localize in areas that are developing stress fractures; suppression of targeted intracortical remodeling at the site of an AFF could impair the processes by which stress fractures normally heal. When BPs are stopped, risk of an AFF may decline. Lower limb geometry and Asian ethnicity may contribute to the risk of AFFs. There is inconsistent evidence that teriparatide may advance healing of AFFs.

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The outcome of surgically treated femur fractures associated with long-term bisphosphonate use.

A Foldes, Meir Liebergall, Ori Safran … (2011)

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 subtrochanteric and femoral shaft fractures associated with long-term BP use. The aim of this study was to describe the outcome of surgically treated femur fractures associated with prolonged BP use. Fifteen patients suffering from 17 atypical femoral fragility fractures associated with long-term (>3 years) BP use were located. Data included fracture type, time of BP use, last bone mineral density DEXA scores for the femoral neck and spine, type of surgery, and the need for revision. Fourteen female patients and one male patient were identified. The median age was 73 years (range, 51-80 years). The mean BP use was 7.8 years (range, 4-13 years). Fourteen patients had low-energy traumatic femoral shaft (proximal and distal) or low subtrochanteric fractures. The mean lumbar spine (for 13 patients) bone mineral density T-score was -3.0, whereas mean femoral neck T-score was -1.8 with only three patients in the osteoporotic range.Fracture healing after the first procedure for patients treated with nails was 54%, with 46% of patients requiring revision surgery. These included nail dynamization, exchange nailing, and one revision to a blade plate. All of these eventually healed. BP-related fractures are a recently described phenomenon. Despite initial osteoporosis, the DEXA scan may appear outside the osteoporotic range for the femoral neck in these patients. In addition, a much higher failure rate with intramedullary nailing requiring revision surgery may occur with these patients.

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Atypical forearm fractures associated with long-term use of bisphosphonate.

Nitin Bither, Belinda Lee, Ninad Moon (2013)

Recent reports on atypical femoral fracture have raised concerns about the long-term use of bisphosphonate. More recent case series focus specifically on the subtrochanteric fractures. But, there is relatively rarity and unawareness of atypical fracture in upper extremity. We report forearm fracture in two women receiving long-term bisphosphonate therapy. First woman presented with pain in the forearm and both thighs and radiographs showed incomplete fractures in a proximal ulnar shaft and bilateral femoral shaft. The other woman had a fracture in the radial shaft. This report suggests atypical fractures associated long-term use of bisphosphonate could occur in bones other than femur. More study is required to identify the magnitude of clinical features of this emerging concern.

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Author and article information

Journal

Journal ID (nlm-ta): Malays Orthop J

Journal ID (iso-abbrev): Malays Orthop J

Journal ID (publisher-id): MOJ

Title: Malaysian Orthopaedic Journal

Publisher: Malaysian Orthopaedic Association

ISSN (Print): 1985-2533

ISSN (Electronic): 2232-111X

Publication date (Print): March 2014

Volume: 8

Issue: 1

Pages: 82-84

Affiliations

Philippine Orthopedic Center, Maria Clara St. corner Banawe Ave., Quezon City, Philippines

Author notes

Peter Syson, Philippine Orthopedic Center, Maria Clara St. corner Banawe Ave., Quezon City, Philippines peteralbertsyson@ 123456gmail.com

Article

DOI: 10.5704/MOJ.1403.008

PMC ID: 4093543

PubMed ID: 25279084

SO-VID: 4095fd1b-8316-4c19-80ad-a81fc16f83f9

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This article is distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/3.0/ ), which permits unrestricted use and redistribution provided that the original author and source are credited.

Construct Failure in an Atypical Femoral Fracture treated with Intramedullary Nailing: A Case Report

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Fracture and Structural Integrity

Most cited references 6

Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research.

The outcome of surgically treated femur fractures associated with long-term bisphosphonate use.

Atypical forearm fractures associated with long-term use of bisphosphonate.

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