Mehmet Hakan ÖZSOY, MEHMET ATIF EROL AKSEKİLİ, Onur KIZILAY, Veysel Ercan DİNÇEL, NEVRES HÜRRİYET AYDOĞAN, Arzu ÖZSOY

Femoral insufficiency fractures in the elderly - Excessive medial femoral bowing complicates intramedullary nailing

Objective: The aim of this study was to evaluate the characteristics of low-energy femoral insufficiency fractures in elderly patients.Methods: The study retrospectively evaluated the clinical course of 4 patients with low-energy femoral shaft and subtrochanteric fractures admitted to our department between 2009 and 2011. Three patients had prior long-term alendronate therapy and one had prior glucocorticoid therapy.Results: There were 5 femoral shaft fractures, 2 incomplete shaft fractures, 2 subtrochanteric and 1 intertrochanteric fractures. All femoral shaft fractures had characteristic fracture patterns with thickened lateral cortices at the proximal fragment. Six femurs had excessive medial femoral bowing, which complicated intramedullary nailing. Additional fractures were seen on both femurs of one patient who had been primarily treated with short implants. A bifocal femoral fracture was seen in one femur. Union was achieved in all patients. Two patients were able to walk independently, one with a cane and one with double crutches.Conclusion: We suggest the addition of another radiographic pattern of 'excessive medial femoral bowing' in low-energy femoral shaft fractures in elderly patients. This bowing complicates intramedullary nailing. Moreover, these insufficiency fractures should be fixed with long cephalomedullary nails.

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1. Einhorn TA, Bogdan Y, Tornetta P 3rd. Bisphosphonateassociated fractures of the femur: pathophysiology and treatment. J Orthop Trauma 2014;28:433-8.

2. Giusti A, Hamdy NA, Papapoulos SE. Atypical fractures of the femur and bisphosphonate therapy: A systematic review of case/case series studies. Bone 2010;47:169-80.

3. Çakmak S, Mahiroğulları M, Keklikçi K, Sarı E, Erdik B, Rodop O. Bilateral low-energy sequential femoral shaft fractures in patients on long-term bisphosphonate therapy. Acta Orthop Traumatol Turc 2013;47:162-72.

4. Graham J, Irgit K, Smith WR, Bowen TR. Diaphyseal femur fractures associated with bisphosphonate use. Acta Orthop Traumatol Turc 2013;47:255-60.

5. Murphy CG, O'Flanagan S, Keogh P, Kenny P. Subtrochanteric stress fractures in patients on oral bisphosphonate therapy: an emerging problem. Acta Orthop Belg 2011;77:632-7.

6. Yoon RS, Hwang JS, Beebe KS. Long-term bisphosphonate usage and subtrochanteric insufficiency fractures: a cause for concern? J Bone Joint Surg Br 2011;93:1289-95.

7. Feldstein AC, Black D, Perrin N, Rosales AG, Friess D, Boardman D, et al. Incidence and demography of femur fractures with and without atypical features. J Bone Miner Res 2012;27:977-86.

8. 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;71:186-90.

9. Ha YC, Cho MR, Park KH, Kim SY, Koo KH. Is surgery necessary for femoral insufficiency fractures after longterm bisphosphonate therapy? Clin Orthop Relat Res 2010;468:3393-8.

10. Demiralp B, Ilgan S, Ozgur Karacalioglu A, Cicek EI, Yildrim D, Erler K. Bilateral femoral insuffiency fractures treated with inflatable intramedullary nails: a case report. Arch Orthop Trauma Surg 2007;127:597-601.

11. Mashiba T, Hirano T, Turner CH, Forwood MR, Johnston CC, Burr DB. Suppressed bone turnover by bisphosphonates increases microdamage accumulation and reduces some biomechanical properties in dog rib. J Bone Miner Res 2000;15:613-20.

12. Mashiba T, Turner CH, Hirano T, Forwood MR, Johnston CC, Burr DB. Effects of suppressed bone turnover by bisphosphonates on microdamage accumulation and biomechanical properties in clinically relevant skeletal sites in beagles. Bone 2001;28:524-31.

13. Boivin GY, Chavassieux PM, Santora AC, Yates J, Meunier PJ. Alendronate increases bone strength by increasing the mean degree of mineralization of bone tissue in osteoporotic women. Bone 2000;27:687-94.

14. Goh SK, Yang KY, Koh JS, Wong MK, Chua SY, Chua DT, et al. Subtrochanteric insufficiency fractures in patients on alendronate therapy: a caution. J Bone Joint Surg Br 2007;89:349-53.

15. Kwek EB, Goh SK, Koh JS, Png MA, Howe TS. An emerging pattern of subtrochanteric stress fractures: a long-term complication of alendronate therapy? Injury 2008;39:224-31.

16. Lenart BA, Lorich DG, Lane JM. Atypical fractures of the femoral diaphysis in postmenopausal women taking alendronate. N Engl J Med 2008;358:1304-6.

17. Lenart BA, Neviaser AS, Lyman S, Chang CC, EdoborOsula F, Steele B, et al. Association of low-energy femoral fractures with prolonged bisphosphonate use: a case control study. Osteoporos Int 2009;20:1353-62.

18. Puhaindran ME, Farooki A, Steensma MR, Hameed M, Healey JH, Boland PJ. Atypical subtrochanteric femoral fractures in patients with skeletal malignant involvement treated with intravenous bisphosphonates. J Bone Joint Surg Am 2011;93:1235-42.

19. Wang K, Moaveni A, Dowrick A, Liew S. Alendronate-associated femoral insufficiency fractures and femoral stress reactions. J Orthop Surg (Hong Kong). 2011;19:89-92.

20. Cermak K, Shumelinsky F, Alexiou J, Gebhart MJ. Case reports: subtrochanteric femoral stress fractures after prolonged alendronate therapy. Clin Orthop Relat Res 2010;468:1991-6.

21. Isaacs JD, Shidiak L, Harris IA, Szomor ZL. Femoral insufficiency fractures associated with prolonged bisphosphonate therapy. Clin Orthop Relat Res 2010 Dec;468:3384-92.

22. 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;25:2267-94.

23. Puah KL, Tan MH. Bisphosphonate-associated atypical fracture of the femur: Spontaneous healing with drug holiday and re-appearance after resumed drug therapy with bilateral simultaneous displaced fractures-a case report. Acta Orthop 2011;82:380-2.

24. Bjørgul K, Reigstad A. Atypical fracture of the ulna associated with alendronate use. Acta Orthop 2011;82:761-3.

25. Patton JT, Cook RE, Adams CI, Robinson CM. Late fracture of the hip after reamed intramedullary nailing of the femur. J Bone Joint Surg Br 2000;82:967-71.