Management of Atypical Femoral Fractures

  • Joseph M. Lane
  • Libi Z. Galmer
  • David S. Wellman
  • Abigail L. Campbell
  • Jonathan E. Jo


Atypical femoral fractures are characterized by a lateral stress-mitrated reaction, a transverse fracture line, and medial beaking. These fractures occur as a small percentage of hip and femur fracture. Prior prolonged bisphosphonate treatment is most common, usually greater than 5 years. There is a high likelihood of bilateral fractures in approaching 50 %. MRI edema and bone scan activity are usually present. The key elements of treatment initiate with diagnostic imaging to determine location and activity. All patients should cease bisphosphonates and switch to anabolic agents such as PTH 1-34 as well as correct calcium and Vitamin D. Complete fractures are best treated by intramedullary nailing or compression plating requiring ORIF if a fracture line is present. Simple stress reaction without a cortical defect may respond to medical management.


Atypical femoral fracture Transverse fracture Beaking History of bisphosphonate use Cortical thickening Bilateral Slow healing 


  1. 1.
    *Shane E, Burr D, Abrahamsen B, Adler RA, Brown TD et al. 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: 1-23. *A task force that defines atypical fractures, diagnosis, pathophysiology and treatment.Google Scholar
  2. 2.
    **Dell R, Abrams A, Greene D, Funahashi T, Silverman S, Eisemon E, et al. Incidence of atypical nontraumatic diaphyseal fractures of the femur. J Bone Miner Res. 2012;27(12):2544–50. **Note association of prolonged bisphosphonate treatment and atypical femoral fracture.PubMedCrossRefGoogle Scholar
  3. 3.
    *Markman L, Allison M, Rosenberg Z, Vieira R, Babb J, Tejwani N, et al. A retrospective review of patients with atypical femoral fractures while on long-term bisphosphonates: including pertinent biochemical and imaging studies. Endocr Pract. 2013;19(3):456–61. *Define characteristics of patients obtaining an AFF.PubMedCrossRefGoogle Scholar
  4. 4.
    La **Rocca VR, Rosenberg Z, Allison M, Im S, Babb J, Peck V. Frequency of incomplete atypical femoral fractures in asymptomatic patients on long-term bisphosphonate therapy. AJR Am J Roentgenol. 2012;198(5):1144–51. **Further confirmation on patients with complete and incomplete AFF.CrossRefGoogle Scholar
  5. 5.
    **Kang S, Hwang B, Son H, Cheong I, Lee S, Chung T. Changes in bone mineral density in post menopausal women treated with epidural steroid injections for lower back pain. Pain Phys. 2012;15(3):229–36. **Define spine alteration in patients receiving epidural injections.Google Scholar
  6. 6.
    **Khan S, Kanis J, Vasikaran S, Kline W, Matuszewski B, McCloskey E, et al. Elimination and biochemical responses to intravenous alendronate in postmenopausal osteoporosis. J Bone Miner Res. 1997;12(10):1700–7. **The prolonged presence of bisphosphonate in bone.PubMedCrossRefGoogle Scholar
  7. 7.
    **Lin J. Bisphosphonates: a review of their pharmacokinetic properties. Bone. 1996;18(2):75–85. **Detailed pharmacokinetic properties of bisphosphonates in bone.PubMedCrossRefGoogle Scholar
  8. 8.
    **Bolland M, Avenell A, Baron J, Grey A, MacLennan G, Gamble G, et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. Br Med J. 2010;341:C3691. **High calcium intake may result in cardiac disease.CrossRefGoogle Scholar
  9. 9.
    **Ross A, Manson J, Abrams S, Aloia J, Brannon P, Clinton S, et al. The 2011 report on dietary reference intakes for calcium and vitamin D from the institute of medicine: what clinicians need to know. J Clin Endocrinol Metab. 2011;96(1):53–8. **Institute recommendation of vitamin D for patients.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    **Dam T, Von Muhlen D, Barrett-Connor E. Sex-specific association of serum vitamin D levels with physical function in older adults. Osteoporos Int. 2009;20(5):751–60. **Challenged vitamin D levels set by Institute of Medicine.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    **Binkley N, Gemar D, Engelke J, Gangnon R, Ramamurthy R, Krueger D, et al. Evaluation of ergocalciferol or cholecalciferol dosing, 1,600 IU daily or 50,000 IU monthly in older adults. J Clin Endocrinol Metab. 2011;96(4):981–8. **Description of vitamin D supplementation dosing.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    **Snijder M, Van Schoor N, Pluijm S, Van Dam R, Visser M, Lips P. Vitamin D status in relation to one-year risk of recurrent falling in older men and women. J Clin Endocrinol Metab. 2006;91(8):2980–5. **How vitamin D influences fall rates.PubMedCrossRefGoogle Scholar
  13. 13.
    **LeBoff M, Hawkes W, Glowacki J, Yu-Yahiro J, Hurwitz S, Magaziner J. Vitamin D-deficiency and post-fracture changes in lower extremity function and falls in women with hip fractures. Osteoporos Int. 2008;19(9):1283–90. **Low vitamin D is associated with falls.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    **Aspenberg P, Johansson T. Teriparatide improves early callus formation in distal radial fractures. Acta Orthop. 2010;81(2):234–6. **PTH 1-34 improves fracture healing of distal radius in randomized study.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    **Peichl P, Holzer L, Maier R, Holzer G. Parathyroid hormone 1-84 accelerates fracture-healing in pubic bones of elderly osteoporotic women. J Bone Joint Surg. 2011;93(17):1583–7. **PTH 1-84 markedly enhances pelvic fracture healing.PubMedGoogle Scholar
  16. 16.
    **Ohtori S, Inoue G, Orita S, Yamaguchi K, Equchi Y, Ochiai N, et al. Comparison of teriparatide and bisphosphonate treatment to reduce pedicle screw loosening after lumbar spinal fusion surgery in postmenopausal women with osteoporosis from a bone quality perspective. Spine. 2013;38(8):E487–92. **PTH 1-34 lowers spine fusion failure and prevent pedicle screw pullout.PubMedCrossRefGoogle Scholar
  17. 17.
    **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(2):e8 1–13. **Original overview of AFF including treatment options.CrossRefGoogle Scholar
  18. 18.
    **Egol KA, Park JH, Rosenberg ZS, Peck V, Tejwani NC. Healing delayed but generally reliable after bisphosphonate-associated complete femur fractures treated with IM nails. Clin Orthop Relat Res. 2013 Apr 20. **Delayed healing of AFF with nailing.Google Scholar
  19. 19.
    **Weil YA, Rivkin G, Safran O, Liebergall M, Foldes AJ. The outcome of surgically treated femur fractures associated with long-term bisphosphonate use. J Trauma. 2011;71(1):186–90. **Complication and results of treating AFF surgically.PubMedCrossRefGoogle Scholar
  20. 20.
    **Prasarn ML, Ahn J, Helfet DL, Lane JM, Lorich DG. Bisphosphonate-associated femur fractures have high complication rates with operative fixation. Clin Orthop Relat Res. 2012;470(8):2295–301. **A series of AFF’s treated with nails and plates – results.PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    **Tang WM, Chiu KY, Kwan MF, Ng TP, Yau WP. Sagittal bowing of the distal femur in Chinese patients who require total knee arthroplasty. J Orthop Res. 2005;23(1):41–5. **Structural deformity associated with AFF – in Chinese patients.PubMedCrossRefGoogle Scholar
  22. 22.
    **Leung KS, Procter P, Robioneck B, Behrens K. Geometric mismatch of the gamma nail to the Chinese femur. Clin Orthop Relat Res. 1996;323:42–8. **Difficulty of nail geometry and Asian femurs.PubMedCrossRefGoogle Scholar
  23. 23.
    **Lin TL, Wang SJ, Fong YC, Hsu CJ, Hsu HC, Tsai CH. Discontinuation of alendronate and administration of bone-forming agents after surgical nailing may promote union of atypical femoral fractures in patients on long-term alendronate therapy. BMC Res Notes. 2013;6:11. doi: 10.1186/1756-0500-6-11. **Shifting from bisphosphonates to anabolic agents enhances healing of AFF’s.PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    **Homma Y, Zimmermann G, Hernigou P. Cellular therapies for the treatment of non-union: the past, present and future. Injury. 2013;44 suppl 1:S46–9. **The rational for cell based therapy in cases of delayed fracture healing.PubMedGoogle Scholar
  25. 25.
    **Allison MB, Markman L, Rosenberg Z, Vieira RL, Babb J, Tejwani N, et al. Atypical incomplete femoral fractures in asymptomatic patients on long term bisphosphonate therapy. Bone. 2013;55(1):113–8. **The problem of treating incomplete AFF’s.PubMedCrossRefGoogle Scholar
  26. 26.
    *Shane E, Burr D, Ebeling PR, Abrahamsen B, Adler RA, Brown TD, et al. Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American society for bone and mineral research. J Bone Miner Res. 2010;25(11):2267–94. *Original task force recommendation for AFF’s.PubMedCrossRefGoogle Scholar
  27. 27.
    *Egol KA, Park JH, Prensky C, Rosenberg ZS, Peck V, Tejwani NC. Surgical treatment improves clinical and functional outcomes for patients who sustain incomplete bisphosphonate-related femur fractures. J Orthop Trauma. 2013;27(6):331–5. *Thorough evaluation of options of care for incomplete AFF’s.PubMedCrossRefGoogle Scholar
  28. 28.
    **Banffy MB, Vrahas MS, Ready JE, Abraham JA. Nonoperative versus prophylactic treatment of bisphosphonate-associated femoral stress fractures. Clin Orthop Relat Res. 2011;469(7):2028–34. **A discussion of operative vs. conservative care of incomplete AFF’s.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    **Ha YC, Cho MR, Park KH, Kim SY, Koo KH. Is surgery necessary for femoral insufficiency fractures after long-term bisphosphonate therapy? Clin Orthop Relat Res. 2010;468(12):3393–8. **Clear benefit for surgical treatment of incomplete AFF’s.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    **Oh CW, Oh JK, Park KC, Kim JW, Yoon YC. Prophylactic nailing of incomplete atypical femoral fractures. ScientificWorldJournal. 2013;2013:450148. **Advantage of prophylactic nailing of incomplete AFF’s.PubMedPubMedCentralGoogle Scholar
  31. 31.
    **Saleh A, Hegde VV, Potty AG, Schneider R, Cornell CN, Lane JM. Management strategy for symptomatic bisphosphonate-associated incomplete atypical femoral fractures. HSS J. 2012;8(2):103–10. **Comprehensive medical and surgical approach to incomplete AFF’s.PubMedPubMedCentralCrossRefGoogle Scholar
  32. 32.
    **Lee YK, Ha YC, Kang BJ, Chang JS, Koo KH. Predicting need for fixation of atypical femoral fracture. J Clin Endocrinol Metab. 2013;98(7):2742–5. **Breakdown of incomplete AFF’s that need surgical fixation.PubMedCrossRefGoogle Scholar
  33. 33.
    *Chiang CY, Zebaze RM, Ghasem-Zadeh A, Iuliano-Burns S, Hardidge A, Seeman E. Teriparatide improves bone quality and healing of atypical femoral fractures associated with bisphosphonate therapy. Bone. 2013;52(1):360–5. *Role of teriparatide in restoring bone health after bisphosphonate therapy.PubMedCrossRefGoogle Scholar
  34. 34.
    **Ward WGS, Carter CJ, Wilson SC, Emory CL. Femoral stress fractures associated with long-term bisphosphonate treatment. Clin Orthop Relat Res. 2012;470(3):759–65. **Advantage of timely nailing of incomplete AFF’s.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  • Joseph M. Lane
    • 1
  • Libi Z. Galmer
    • 1
  • David S. Wellman
    • 2
    • 3
  • Abigail L. Campbell
    • 4
  • Jonathan E. Jo
    • 3
  1. 1.Metabolic Bone Disease Service, OrthopaedicsHospital for Special SurgeryNew YorkUSA
  2. 2.Orthopaedic SurgeryHospital for Special Surgery, New York Presbyterian HospitalNew YorkUSA
  3. 3.Orthopaedic SurgeryWeill Cornell Medical CollegeNew YorkUSA
  4. 4.Orthopaedic SurgeryNYU Hospital for Joint DiseasesNew YorkUSA

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