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Association of Atypical Femoral Fractures with Bisphosphonate Use by Patients with Varus Hip Geometry

Hagen, Jennifer E. MD; Miller, Anna N. MD; Ott, Susan M. MD; Gardner, Michael MD; Morshed, Saam MD; Jeray, Kyle MD; Alton, Timothy B. MD; Ren, Dennis BS; Abblitt, W. Parker MD; Krieg, James C. MD

Journal of Bone & Joint Surgery - American Volume: 19 November 2014 - Volume 96 - Issue 22 - p 1905–1909
doi: 10.2106/JBJS.N.00075
Scientific Articles

Background: There is increasing evidence associating “atypical” femoral fractures with prolonged exposure to bisphosphonate therapy. The cause of these fractures is unknown and likely multifactorial. This study evaluated the hypothesis that patients with primary osteoporosis who sustain atypical femoral fracture(s) while on chronic bisphosphonate therapy have a more varus proximal femoral geometry than patients who use bisphosphonates for primary osteoporosis but do not sustain a femoral fracture.

Methods: The femoral neck-shaft angle was measured on the radiographs of 111 patients with atypical femoral shaft fracture(s) and thirty-three asymptomatic patients; both groups were on chronic bisphosphonate therapy. Patients with characteristic lateral cortical thickening, stress lines, and thigh pain were included in the fracture group.

Results: The mean neck-shaft angle of the patients who sustained atypical femoral fracture(s) while taking bisphosphonates (case group) differed significantly from that of the patients on bisphosphonate therapy without a fracture (129.5° versus 133.8°; p < 0.001). Fifty-three (48%) of the patients in the case group had a neck-shaft angle that was lower than the lowest angle in the control group (128°). Side-to-side comparison in patients with a unilateral pathologic involvement and an asymptomatic contralateral lower limb did not demonstrate any significant difference between the neck-shaft angles in the two limbs.

Conclusions: Patients on chronic bisphosphonate therapy who presented with atypical femoral fracture(s) had more varus proximal femoral geometry than those who took bisphosphonates without sustaining a fracture. Although no causative effect can be determined, a finding of varus geometry may help to better identify patients at risk for fracture after long-term bisphosphonate use.

Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

1University of Maryland, 22 South Greene Street, Baltimore, MD 21202. E-mail address:

2Wake Forest Baptist Health, 131 Miller Street, Winston-Salem, NC 27103

3University of Washington, 4245 Roosevelt Way N.E., Box 35470, Seattle, WA 98105

4Washington University, 4921 Parkview Place, St. Louis, MO 63110

5University of California San Francisco, 2550 23rd Street, San Francisco, CA 94110

6Steadman Hawkins Clinic, 200 Patewood Drive, Suite C100, Greenville, SC 29615

7University of Washington, 1959 N.E. Pacific Street, #356500, Seattle, WA 98195

8Tulane School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112

9Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC 27157

10The Rothman Institute, Jefferson University, 925 Chestnut Street, Philadelphia, PA 19107

Copyright 2014 by The Journal of Bone and Joint Surgery, Incorporated
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