Surgical treatment for Bisphosphonate-related atypical femoral fracture: A systematic review

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 of 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 through the 26th of February 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, regarding the American Society for Bone and Mineral Research definition, are included. Animal studies, cases reports, studies with high energy trauma, pathological fracture or malignancy related fractures were excluded. Results A total of 316 patients (348 fractures) were included. Mean age was 70.47 years, and 97.5% were female. Bisphosphonates using duration was 4.04 to 8.8 years, and Alendronate was the most common type. Among the reported fractures, 65.27% were diaphyseal, and 34.72% subtrochanteric. The most common fixation type was intramedullary. There was 17.52% complication rate, the most frequent was nonunion, followed by implant failure. The main limitation of the study was that most of the studies were not in a high-quality evidence level. Conclusions The increasing rate of atypical femoral fractures with its challenging management, makes it an important issue to be noted by the orthopedic surgeons. This study shows subtrochanteric fractures might have more complications post-operatively and are suggested to be operated by more experienced surgeons. Extramedullary fixation also increases the risk of complications. Future studies on union time, outcomes of different surgical methods, and Teriparatide therapy may help shed a better light on the surgical management of these fractures.