Atypical Femoral Fractures

We posted our first “Case Connections” article about bisphosphonate-related atypical femoral fractures (AFFs) one year ago. Since then, JBJS Case Connector has published three additional case reports on the same topic, suggesting that it’s time for a revisit. These three recent cases demonstrate that AFFs can occur despite prophylactic intramedullary (IM) nailing of an at-risk femur, that AFFs can present as periprosthetic fractures, and that men taking bisphosphonates—not just women—can experience AFFs. Patients who develop one AFF have a 28% to 65% chance of developing a similar fracture on the other side1-3, and prophylactic intramedullary nailing of the contralateral femur has proven to be an effective preventive measure. However, in the July 8, 2015, JBJS Case Connector, Schemitsch et al. described the case of a forty-three-year-old woman who sustained a complete fracture of a prophylactically nailed femur seven months after the preventive procedure. The patient had a history of premature idiopathic menopause and was taking bisphosphonates when she initially presented with a painful left thigh. Radiographs made at that time revealed lateral cortical hypertrophy of both femora and a cortical defect in the left femur. She declined prophylactic surgical intervention but was taken off bisphosphonates and switched to hormone replacement therapy. Ten months later, she presented after falling from a standing height and was found to have a left-side AFF. After closed reduction, surgeons inserted a locked reconstruction-type nail in the left femur, which healed uneventfully. Radiographs of the right femur revealed a cortical breach in the distal third of the bone. …