What are the remedies to reduce the healing time of these atypical fractures?
Dear Raju
As always you do very interesting questions.
There are some indications in the literature suggesting that osteoporosis per se is delaying fracture healing.
Backwalter J A, Einhorn T A, Bolander M E, Cruess R L. (1994). Healing of the musculoskeletal tissues. In: Heckman JD, ed. Fractures in adults. 4th ed. Philadelphia, NY: Lippincott-Raven; 261-304.
Osteoporosis delays healing
Meyer R A Jr, Tsahakis P J, Martin D F, Banks D M, Harrow M E, Kiebzak G M. (2001) Age and ovariectomy impair both the normalization of mechanical properties and the accretion of mineral by the fracture callus in rats. J Orthop Res. 19, 428-435.
Delay healing in osteoporotic rats.
I know that this may be disputed.
There is literature suggesting that the atypical femoral fractures due to bisphosphonates have to be treated with the help of other agents as teriparatide or strodium.
Nozaka K, Miyakoshi N, Kasukawa Y, Maekawa S, Noguchi H, Shimada Y. (2008). Intermittent administration of human parathyroid hormone enhances bone formation and union at the site of cancellous bone osteotomy in normal and ovariectomized rats. Bone. 42, 90-97.
But osteoporotic #s without h/o prolonged bisphosphonate use do not take unusually long time to heal
Carrying on with my previous entry as by mistake click the wrong button (apologies for this)
As I was writing there are people that they say that teriparadite or strondium can be used (carrying on the literature
Cipriano C A, Issack P S, Shindle L, Werner C M, Helfet D L, Lane J M. (2009). Recent advances toward the clinical application of PTH (1-34) in fracture healing. HSS J. 5, 149-153.
Huang H T, Kang L, Huang PJ, Fu Y C, Lin S Y, Hsieh C H, Chen J C, Cheng Y M, Chen C H. (2012). Successful teriparatide treatment of atypical fracture after long-term use of alendronate without surgical procedure in a postmenopausal woman: a case report. Menopause. 19(12), 1360-1363.
Rizzoli R. (2005). A new treatment for post-menopausal osteoporosis: strontium ranelate. J Endocrinol Invest. 28(suppl 8), 50-57
but there is a recent entry where is written that in two groups treated one with teriparatide and the second without, it was observed three month delay on the femoral healing in the group which was not treated with teriparatide.
Miyakoshi N, Aizawa T, Sasaki S, Ando S, Maekawa S, Aonuma H, Tsuchie H, Sasaki H, Kasukawa Y, Shimada Y. (2015). Healing of bisphosphonate-associated atypical femoral fractures in patients with osteoporosis: a comparison between treatment with and without teriparatide. J Bone Miner Metab. 33(5), 553-559.
Three months difference between the two groups.
Knowing that the majority of the fractures are in the sub-trochanderic region and knowing that this region has, due to the particular biomechanical conditions, a higher degree of "failure" it is expected in a normal person to heal between 3-6 months and it is noticed that on the patients with atypical femoral fractures this period goes up to 8-9 months.
The questions are:
Is the osteoporosis to be blamed?
Is the bisphosphonates?
Is the quality of the bone?
Is the location of the fracture?
Difficult to answer all this. Because we treat the majority of the times empirically and following the literature seems that we need to treat (for the moment, as we follow the latest indications) these people with the help of other agents and to tell them that the healing will be longer than to the "normal" population.
Thank you George. I do agree that the atypical femoral fractures take 2-3 times more than a normal post-traumatic and osteoporotic #s (without bisphosphonate use). BP have
BP have significant effect on bone turnover, inhibiting osseous resorption by suppressing osteoclast activity. This results in bone microarchitecture modifications. As they are metabolically inactive, they bind to bone, creating a reservoir that remains even after discontinuation of treatment. prolonged bisphosphonate therapy
may suppress bone remodeling to the extent that normal bone repair is impaired,
resulting in increased fracture risk. Fractures potentially resulting from
Fractures potentially resulting from suppressed bone turnover have been described as “atypical,” affecting sites such as the subtrochanteric femur that are infrequently affected by osteoporotic fractures. These atypical fractures are mostly located in subtrochanteric or diaphyseal regions of the femur and not classically in the proximal femur (as in the case of osteoporotic #s)
Dear Raju. You are right. This mechanism is also explaining the length of symptoms like pain and discomfort that patients have at the pre fracture period. It is known that these people suffering for a long time prior to the final fracture and despite that they go to their doctor they are turned away
BP induced insufficiency lesions and atypical fractures are unfortunately still poorly understood and not known to majority of treating physicians and surgeons
Salam, As I know, this fractures are rare, but are almost un-treatable, because of atypical form and fracture lines and so. So it is recommended that bisphosphonates prescription limit to whom that according to guidelines need it and it is useful for them.
My observations on the treatment have included stopping bisphosp;putting pt on Parathotmone and limited weight bearing OR stopping bisphosp for 6 months and IM nailing.
I agree completely with Raju that these fractures are not rare and possibly they may be more common if people could recognise them as atypical fractures of the femur.
Anti-resorptive drugs (all) bisphosphonates in particular (but also denosumab) are commonly used medications for treating osteoporosis. These reduce the risk of osteoporosis fractures, control hypercalcemia of malignancy and Paget’s disease, and bone metastasis, etc. However, frequent high doses or long-term use are associated with rare but serious adverse effects.
While, the fracture reduction benefits of bisphosphonate and denosumab beyond 5 years is minimal, incidence of dose and duration related serious adverse events, although relatively rare, increases. Thus, United States FDA recommends limiting treatment to less than 5 years. Nevertheless, the individual circumstances need to be accounted and right clinical judgment is critical. Discontinuation of bisphosphonates should be PERMANENT (6 months is undesirable and unhelpful).
Can stop the progress of impending and partial fractures into a full fracture by using conservative management as describe above together with a bone-specific anabolic agents to kck-start the bone remodelling.
Treating beyond 5 years is however, appropriate in patients in whom the reduction of fracture benefits outweighs adverse effects.
Yes Raju sir. I agree bisphosphonate induced atypical femoral fracture poeses problem in healing. We ve to stop bisphosphonate and supplement with bone specific anablic medications.
Sensible thing to do. We need to be cognizant that all potent anti-resorptive agents can cause atypical subtroch fractures.
An annual reassessment is recommended for patients with osteoporosis receiving these agents, to assess overall health, adherence to medication, and objective measures of improvements; exclude secondary causes of bone loss; and assess the need for continuation of anti-resorptive therapy or the restarting of a medication.
The overall incidence fo both ONJ/ osteomylitis of the jaw (OMJ) and Atypical subtroch femoral fractures steeply increase after the 5th year of treatment. Thus, in the presence of little or no fracture risk reduction benefits, prevention of serious complications is achieved by not prescribing these agents more than 5 years.
At that point, in most patients, the risks outweigh the benefits.
Sunil Wimalawansa
Professor of Medicine, Endocrinology & Nutrition
I do not think there is any evidence as yet as to atypical fractures are slow to heal. Since they are mostly subtrochanteric transverse fractures, these fractures are inherently unstable and require adequate stable fixation. I remember having treating at least 2 such cases in my whole practice of more than 20 years. Luckily both the fractures united without any problem. One was fixed in late 90s with DCS and the other was fixed around 10 years back with PFN.
There are several publications to confirm that these #s are notoriously slow to heal, despiste stable #fixation
1. Delayed healing of lower limb fractures with bisphosphonate therapy.
Yue B, Ng A, Tang H, Joseph S, Richardson M.
Ann R Coll Surg Engl. 2015 Jul;97(5):333-8. doi: 10.1308/003588415X14181254789321. Review.
PMID: 26264082 [PubMed - indexed for MEDLINE]
Similar articles
2. Healing of bisphosphonate-associated atypical femoral fractures in patients with osteoporosis: a comparison between treatment with and without teriparatide.
Miyakoshi N, Aizawa T, Sasaki S, Ando S, Maekawa S, Aonuma H, Tsuchie H, Sasaki H, Kasukawa Y, Shimada Y.
J Bone Miner Metab. 2015 Sep;33(5):553-9. doi: 10.1007/s00774-014-0617-3. Epub 2014 Sep 17.
PMID: 25227287 [PubMed - in process]
Similar articles
3. Histology of 8 atypical femoral fractures: remodeling but no healing.
Schilcher J, Sandberg O, Isaksson H, Aspenberg P.
Acta Orthop. 2014 Jun;85(3):280-6. doi: 10.3109/17453674.2014.916488. Epub 2014 Apr 30.
PMID: 24786905 [PubMed - indexed for MEDLINE] Free PMC Article
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4. Post-operative outcomes of atypical femoral subtrochanteric fracture in patients on bisphosphonate therapy.
Teo BJ, Koh JS, Goh SK, Png MA, Chua DT, Howe TS.
Bone Joint J. 2014 May;96-B(5):658-64. doi: 10.1302/0301-620X.96B5.32887.
PMID: 24788502 [PubMed - indexed for MEDLINE]
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5. Healing delayed but generally reliable after bisphosphonate-associated complete femur fractures treated with IM nails.
Egol KA, Park JH, Rosenberg ZS, Peck V, Tejwani NC.
Clin Orthop Relat Res. 2014 Sep;472(9):2728-34. doi: 10.1007/s11999-013-2963-1.
PMID: 23604648 [PubMed - indexed for MEDLINE] Free PMC Article
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6. Treatment of femoral fracture nonunion after long-term bisphosphonate use.
Grady MK, Watson JT, Cannada LK.
Orthopedics. 2012 Jun;35(6):e991-5. doi: 10.3928/01477447-20120525-51.
PMID: 22691683 [PubMed - indexed for MEDLINE]
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These article may expand the understanding on relation shies between bisphosphonates and ONJ as well as atypical femoral fractures:
Article Optimum duration and safety of long-term use of potent anti-...
.Article Bisphosphonate-Associated Osteomyelitis of the Jaw: Guidelin...
Article Insight into bisphosphonate-associated osteomyelitis of the ...
Article A Four-Year Randomized Controlled Trial of Hormone Replaceme...
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