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Osteoporosis International

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01-12-2019 | Femoral Fracture | Original Article

Natural history of incomplete atypical femoral fractures in patients after a prolonged and variable course of bisphosphonate therapy—a long-term radiological follow-up

Authors: M.A. Png, P.C. Mohan, J.S.B. Koh, C.Y. Howe, T.S. Howe

Published in: Osteoporosis International | Issue 12/2019

Abstract

Summary

Understanding the natural history of lateral femoral stress fractures helps to guide their management. Improvement in their radiographic characteristics is rare. Progression was generally sequential, most developing an incomplete fracture line before fracture displacement. Stopping bisphosphonates decreased the fracture rate, a feasible management option for lesions without incomplete fracture lines.

Introduction

Retrospective study evaluating the natural history of lateral femoral stress fractures (FSF) by serial radiography over a variable period of time in a cohort of patients treated for some time with bisphosphonates for osteoporosis, whilst also identifying the fracture response in cases where bisphosphonates were discontinued.

Methods

The radiographs of 76 consecutive patients (92 femurs) with 161 FSF were reviewed to document their change over time. Femurs were classified into the following: A—normal, B—focal cortical thickening, C—dreaded black line and D—displaced fracture. Bisphosphonate history was recorded.

Results

66.5% FSF showed group stability between the first and last radiographs: group B (79.1%), group C (45.7%). 28.6% progressed, mostly following an ordered sequence starting from group A, progressing to B, then C, before culminating in D. Progression rate was as follows: A—100% (11/11), B—18.3% (21/115), C—40% (14/35). Regression in FSF was uncommon—5.6% (8/161). 34.8% (32/92) sustained displaced fractures. Kaplan-Meier analysis showed statistically significant difference between the groups; median survival (95% CI): A—4189 (-), B—3383.0 (-), C—1807 (0.0–3788.6) and progression to displaced fracture when bisphosphonate had been stopped for at least 6 months. The group without recent bisphosphonates had a lower group progression rate (17.1%, 12/70). Nevertheless, 10.9% (5/46) progressed to displaced fracture. This group also had the highest proportion of stable (77.1%, 54/70) and regressive lesions (5.7%, 4/70).

Conclusions

In FSF, there is natural progression from normal bone, to focal cortical thickening, to dreaded black line and eventually to displaced fracture. Most lesions persist, remaining static or progressing, especially if a dreaded black line is present and bisphosphonates are continued. Regression is uncommon and more frequent when bisphosphonates are discontinued. Despite stopping bisphosphonates, there remains a 10.9% risk of progression to displaced fracture.

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Title: Natural history of incomplete atypical femoral fractures in patients after a prolonged and variable course of bisphosphonate therapy—a long-term radiological follow-up
Authors: M.A. Png
P.C. Mohan
J.S.B. Koh
C.Y. Howe
T.S. Howe
Publication date: 01-12-2019
Publisher: Springer London
Keywords: Femoral Fracture
Bisphosphonate
Osteoporosis
Osteoporosis
Published in: Osteoporosis International / Issue 12/2019
Print ISSN: 0937-941X
Electronic ISSN: 1433-2965
DOI: https://doi.org/10.1007/s00198-019-05067-7

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Natural history of incomplete atypical femoral fractures in patients after a prolonged and variable course of bisphosphonate therapy—a long-term radiological follow-up

Abstract

Summary

Introduction

Methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Summary

Introduction

Methods

Results

Conclusions

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