Atypical femur fractures: 81 individual personal histories

Abstract

Context: An online voluntary association of individuals who had incurred one or more atypical femur fractures (AFFs) while taking bisphosphonates for prevention or treatment of osteoporosis provided an opportunity to collect long-term histories.

Setting: Individuals from a nationwide general community completed an anonymous survey documenting their history.

Participants: Within a larger cadre, cases were selected where the documentation, including fracture radiographs, verified the diagnosis based on published standards. Eighty-one of this group responded to the anonymous survey.

Interventions: We describe passively collected observational data only.

Outcome measures: The incidence of a large number of potential variations was determined.

Results: The mean duration of bisphosphonate treatment was 9.5 yr. Prevention was the initial indication in 68% of the subjects; 94% started on alendronate, 77% reported prodromal pain, only 16% of these were diagnosed with incident stress fractures, and 39.5% experienced a contralateral AFF from less than 1 month to 49 months after the first. Of 71 subjects with a completed first AFF, 38% reported delayed healing, 11% had a complete contralateral AFF, and 22% underwent prophylactic rodding for a contralateral stress AFF. Forty-four percent of subjects with complete AFFs were continued on a bisphosphonate after the fracture. Thirty-five percent incurred a metatarsal fracture.

Conclusions: AFF patients experienced delayed healing, prodromal pain, and persisting risk of a contralateral and/or other fracture. Femur pain evaluation in patients on long-term bisphosphonates may facilitate early diagnosis of stress AFFs, permitting intervention, thus reducing completed and/or contralateral or other fracture risk. The details of these histories will assist in counseling regarding prognosis after an initial AFF.