Undisturbed local bone formation capacity in patients with atypical femoral fractures: a case series

Osteoporos Int. 2017 Aug;28(8):2439-2444. doi: 10.1007/s00198-017-4058-4. Epub 2017 May 4.


We excised the fracture site in 8 patients with incomplete atypical femoral fractures by drilling an 11-mm-diameter hole. New bone formation could be seen in the hole within a normal time frame. Delayed healing of these fractures might be unrelated to an impaired capacity to form bone.

Introduction: Incomplete atypical femoral fractures (undisplaced cracks) heal slowly or not at all, and often progress to a complete fracture with minimal trauma. The impaired healing has been attributed to an impaired biologic healing capacity related to bisphosphonate use, or, alternatively, to the mechanical environment within the fracture crack. This study aimed to investigate the capacity for bone formation after resection of the fracture site.

Methods: Between 2008 and 2014, we recruited eight patients with incomplete atypical femoral fractures. All used oral bisphosphonates before the fracture for on average 8 years (range 4 to 15) and complained of thigh pain. The fractures were stabilized with reamed cephalomedullary nails. During surgery, the fracture site in the lateral cortex was resected with a cylindrical drill (diameter 11.5 mm). The cylindrical cortical defect allowed radiographic evaluation of new bone formation, and the patients were followed clinically and radiologically for 24 months (range 15 to 92).

Results: After 3 months, newly formed bone could be seen in the cortical defects in all patients. After 13-26 months, the previous defects showed continuous cortical bone. At final follow-up, all patients reported full recovery of pre-surgical complaints. No complications occurred and no reoperations were performed.

Conclusions: New bone formation occurred within a time frame that appears normal for healing of cortical bone defects. This suggests that the capacity to form new bone is intact.

Keywords: Atypical femoral fracture; Bisphosphonates; Fracture healing; Osteoporosis.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Bone Density Conservation Agents / adverse effects
  • Bone Density Conservation Agents / pharmacology
  • Diphosphonates / adverse effects
  • Diphosphonates / pharmacology
  • Female
  • Femoral Fractures / chemically induced
  • Femoral Fractures / diagnostic imaging
  • Femoral Fractures / physiopathology*
  • Femoral Fractures / surgery
  • Follow-Up Studies
  • Fracture Fixation, Intramedullary / methods
  • Fracture Healing / drug effects
  • Fracture Healing / physiology
  • Fractures, Stress / chemically induced
  • Fractures, Stress / diagnostic imaging
  • Fractures, Stress / physiopathology*
  • Fractures, Stress / surgery
  • Humans
  • Male
  • Middle Aged
  • Osteogenesis / drug effects
  • Osteogenesis / physiology*
  • Osteoporosis / drug therapy
  • Radiography


  • Bone Density Conservation Agents
  • Diphosphonates