Cited by 1,116Bone health and osteoporosis researchBone health and treatmentsOrthopaedic implants and arthroplasty

Atypical subtrochanteric and diaphyseal femoral fractures: Report of a task force of the american society for bone and mineral Research

Shane, Elizabeth, Burr, David, Ebeling, Peter R, Abrahamsen, Bo, Adler, Robert A, Brown, Thomas D, Cheung, Angela M, Cosman, Felicia +19 more·2010·Journal of Bone and Mineral Research

Abstract

Reports linking long-term use of bisphosphonates (BPs) with atypical fractures of the femur led the leadership of the American Society for Bone and Mineral Research (ASBMR) to appoint a task force to address key questions related to this problem. A multidisciplinary expert group reviewed pertinent published reports concerning atypical femur fractures, as well as preclinical studies that could provide insight into their pathogenesis. A case definition was developed so that subsequent studies report on the same condition. The task force defined major and minor features of complete and incomplete atypical femoral fractures and recommends that all major features, including their location in the subtrochanteric region and femoral shaft, transverse or short oblique orientation, minimal or no associated trauma, a medial spike when the fracture is complete, and absence of comminution, be present to designate a femoral fracture as atypical. Minor features include their association with cortical thickening, a periosteal reaction of the lateral cortex, prodromal pain, bilaterality, delayed healing, comorbid conditions, and concomitant drug exposures, including BPs, other antiresorptive agents, glucocorticoids, and proton pump inhibitors. Preclinical data evaluating the effects of BPs on collagen cross-linking and maturation, accumulation of microdamage and advanced glycation end products, mineralization, remodeling, vascularity, and angiogenesis lend biologic plausibility to a potential association with long-term BP use. Based on published and unpublished data and the widespread use of BPs, the incidence of atypical femoral fractures associated with BP therapy for osteoporosis appears to be very low, particularly compared with the number of vertebral, hip, and other fractures that are prevented by BPs. Moreover, a causal association between BPs and atypical fractures has not been established. However, recent observations suggest that the risk rises with increasing duration of exposure, and there is concern that lack of awareness and underreporting may mask the true incidence of the problem. Given the relative rarity of atypical femoral fractures, the task force recommends that specific diagnostic and procedural codes be created and that an international registry be established to facilitate studies of the clinical and genetic risk factors and optimal surgical and medical management of these fractures. Physicians and patients should be made aware of the possibility of atypical femoral fractures and of the potential for bilaterality through a change in labeling of BPs. Research directions should include development of animal models, increased surveillance, and additional epidemiologic and clinical data to establish the true incidence of and risk factors for this condition and to inform orthopedic and medical management.

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Crossref · 10.1002/jbmr.253

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Authors
Shane, E., Burr, D., Ebeling, P. R., Abrahamsen, B., Adler, R. A., Brown, T. D., Cheung, A. M., Cosman, F., Curtis, J. R., Dell, R., Dempster, D., Einhorn, T. A., Genant, H. K., Geusens, P., Klaushofer, K., Koval, K., Lane, J. M., McKiernan, F., McKinney, R., Ng, A., Nieves, J., O'Keefe, R., Papapoulos, S., Sen, H. T., van der Meulen, M. C., Weinstein, R. S., & Whyte, M.
Affiliations
  • Indiana University School of Medicine (US)
  • Author affiliations appear on pp. 2288–2289
Corresponding author
  • Shane, Elizabeth
  • Burr, David
Venue
Journal of Bone and Mineral Research
Published
2010-09-14
Volume
25
Issue
11
Pages
2267-2294
ISSN
  • 0884-0431 (ISSN-L)
  • 1523-4681
OpenAlex
W2624963411
Cited by
1,116
References
170
Citations by year
2026: 18 · 2025: 49 · 2024: 36 · 2023: 36 · 2022: 44 · 2021: 51 · 2020: 72 · 2019: 49 · 2018: 34 · 2017: 76 · 2016: 68 · 2015: 100 · 2014: 92 · 2013: 138 · 2012: 124
FWCI
123.52
Type
journal article
Language
en
Open access
closed
Locations
  • Journal of Bone and Mineral Research (publishedVersion)
  • PubMed (publishedVersion)
  • Research Publications (Maastricht University) (publishedVersion)
  • Research at the University of Copenhagen (University of Copenhagen) (publishedVersion)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
  • Leiden Repository (Leiden University) (submittedVersion)
  • Document Server@UHasselt (UHasselt) (submittedVersion)
  • University of Southern Denmark Research Portal (University of Southern Denmark) (submittedVersion)
  • Research Publications (Maastricht University) (submittedVersion)
Topics
  • Health Sciences › Medicine › Orthopedics and Sports Medicine › Bone health and osteoporosis research
  • Health Sciences › Medicine › Oncology › Bone health and treatments
  • Health Sciences › Medicine › Surgery › Orthopaedic implants and arthroplasty
Keywords
atypical femoral fractures, bisphosphonates, subtrochanteric fractures, femoral shaft fracture, fracture pathogenesis, collagen cross-linking, microdamage, advanced glycation end products, osteoporosis, antiresorptive agents, glucocorticoids, proton pump inhibitors, fracture incidence, underreporting, fracture registry, fracture risk factors
MeSH terms
Diagnostic Imaging, Diphosphonates, Femoral Fractures, Femur, Health Planning Guidelines, Hip Fractures, Humans, Minerals, Radiography, Research, Societies, Medical, Diaphyses, Advisory Committees

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