Bilateral Incomplete Atypical Femoral Fracture due to Long-Term Bisphosphonate Use: A Case Report

Year 2017, Volume: 18 Issue: 2, 139 - 143, 31.08.2017

Sibel Başaran İlke Coşkun Benlidayı , Burçak Akın , Rengin Güzel

Abstract

Although the overall safety profile of bisphosphonates (BP) is favorable, adverse effects associated with long-term use have came up during recent years. In this report, a case of bilateral incomplete atypical femoral fracture (AFF) due to prolonged BP use was presented. A 69-year-old patient, who has been in surgical menopause for 20 years and was started on BP following vertebral fracture almost 10 years ago, was admitted with thigh pain, which was increased two weeks ago. On physical examination, she had antalgic gait, increased thoracic kyphosis and tenderness to percussion over the thoracolumbar region. Lateral cortical thickness in the subtrochanteric region of both femurs and cortical radiolucency on the left femur were observed on plain radiography. Loss of height in L3 and L4 vertebrae was detected on vertebral radiography. Serum 25-hydroxy vitamin D [25(OH) D], parathyroid hormone, alkaline phosphatase and calcium levels, along with osteoporosis markers were all within the normal ranges. As the patient was diagnosed with AFF, BP therapy was terminated and vitamin D-calcium supplementation was continued. Since she did not have severe pain, conservative management (limited weight bearing, using a walking stick) was recommended for 3 months. Teriparatide therapy was started and she was discharged with recommendations. AFF, which is a rare disorder, should be kept in mind in patients on long-term BP treatment who are admitted with thigh pain and, necessary interventions should be tailored before the occurrence of complete fracture.

Keywords

Atypical femoral fracture , bisphosphonate , osteoporosis , teriparatide

References

• 1. Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster JY; Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) and the Committee of Scientific Advisors of the International Osteoporosis Foundation (IOF). European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 2013; 24: 23-57.
• 2. Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, et al. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int 2014; 25: 2359-81.
• 3. Brown JP, Morin S, Leslie W, Papaioannou A, Cheung AM, Davison KS, et al. Bisphosphonates for treatment of osteoporosis. Expected benefits, potential harms, and drug holidays. Can Fam Physician 2014; 60: 324-33.
• 4. Suresh E, Pazianas M, Abrahamsen B. Safety issues with bisphosphonate therapy for osteoporosis. Rheumatology (Oxford) 2014; 53: 19-31.
• 5. Lewiecki EM. Safety of long-term bisphosphonate therapy for the management of osteoporosis. Drug 2011; 71: 791-814.
• 6. Gedmintas L, Solomon DH, Kim SC. Bisphosphonates and risk of subtrochanteric, femoral shaft, and atypical femur fracture: a systematic review and meta-analysis. J Bone Miner Res 2013; 28: 1729-37.
• 7. Wang Z, Bhattacharyya T. Trends in incidence of subtrochanteric fragility fractures and bisphosphonate use among the US elderly, 1996-2007. J Bone Miner Res 2011; 26: 553-60.
• 8. Shane E, Burr D, Abrahamsen B. Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the american society for bone and mineral research. J Bone Miner Res 2014; 29: 1-24.
• 9. Juby AG, Crowther S, Cree M. Identifying atypical femoral fractures-a retrospective review. Calcif Tissue Int 2014; 95: 405-12.
• 10. Unnanuntana A, Saleh A, Mensah KA, Kleimeyer JP, Lane JM. Atypical femoral fractures: what do we know about them? AAOS exhibit selection. J Bone Joint Surg Am 2013; 95: e8 1-13.
• 11. Rosenberg ZS, La Rocca Vieira R, Chan SS, Babb J, Akyol Y, Rybak LD, et al. Bisphosphonate-related complete atypical subtrochanteric femoral fractures: diagnostic utility of radiography. AJR Am J Roentgenol 2011; 197: 954-60.
• 12. Wang Z, Ward MM, Chan L, Bhattacharyya T. Adherence to oral bisphosphonates and the risk of subtrochanteric and femoral shaft fractures among female medicare beneficiaries. Osteoporos Int 2014; 25: 2109-16.
• 13. Sutton RA, Mumm S, Coburn SP, Ericson KL, Whyte MP. Atypical femoral fractures during bisphosphonate exposure in adult hypophosphatasia. J Bone Miner Res 2012; 27: 987-94.
• 14. Saleh A, Hegde VV, Potty AG, Schneider R, Cornell CN, Lane JM. Management strategy for symptomatic bisphosphonate-associated incomplete atypical femoral fractures. HSSJ 2012; 8: 103-10.
• 15. Gomberg SJ, Wustrack RL, Napoli N, Arnaud CD, Black DM. Teriparatide, vitamin D, and calcium healed bilateral subtrochanteric stress fractures in a postmenopausal woman with a 13-year history of continuous alendronate therapy. J Clin Endocrinol Metab 2011; 96: 1627-32.
• 16. Huang HT, Kang L, Huang PJ, Fu YJ, Lin SY, Hsieh CH, et al. Successful teriparatide treatment of atypical fracture after long-term use of alendronate without surgical procedure in a postmenopausal woman: a case report. Menopause 2012; 19: 1360-3.