title: Successful teriparatide treatment of atypical fracture after long-term use of alendronate without surgical procedure in a postmenopausal woman:  a case report.
abstract: OBJECTIVE
  Bisphosphonates are used as first-line therapy for postmenopausal osteoporosis owing to their potent inhibition of bone resorption. Long-term use of bisphosphonates may lead to low-energy femoral subtrochanteric or shaft fractures in a very few patients. The aim of this study was to describe the clinical course of a patient treated with alendronate for 3 years who developed an atypical femoral fracture and to hypothesize the beneficial effects of teriparatide on the healing of the patient's atypical femoral fracture.
  
  
  METHODS
  A 63-year-old Asian woman had a lumbar osteoporotic fracture and received 70 mg of alendronate for 3 years. Pain and soreness in the thigh presented initially and exacerbated thereafter. X-ray revealed a right femoral diaphysis stress fracture. She then received teriparatide for the treatment of osteoporosis and the femoral atypical fracture.
  
  
  RESULTS
  Pain and tenderness improved remarkably after teriparatide treatment for 1 month, and these symptoms disappeared after teriparatide treatment for 9 months. The patient also received raloxifen as further therapy, and the fracture line had completely disappeared by 15 months after treatment.
  
  
  CONCLUSIONS
  Even though a previous study has reported that teriparatide healed stress fractures in a rat model and even with the time course of fracture healing in our patient, we are still not certain that teriparatide played a primary role in the positive response to therapy. Vitamin D therapy, calcium, and alendronate discontinuation may have played secondary roles. This case report may serve to introduce a direction for future research into the pharmacological treatment of atypical femoral fractures. Surgical treatment of incomplete atypical femoral fractures may be a safer method.
authors.affiliation: Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzu-You First Road, Kaohsiung City, Taiwan.
authors.forename: Hsuan-Ti
authors.initials: HT
authors.lastname: Huang
authors.forename: Lin
authors.initials: L
authors.lastname: Kang
authors.forename: Peng-Ju
authors.initials: PJ
authors.lastname: Huang
authors.forename: Yin-Chih
authors.initials: YC
authors.lastname: Fu
authors.forename: Sung-Yen
authors.initials: SY
authors.lastname: Lin
authors.forename: Chih-Hsin
authors.initials: CH
authors.lastname: Hsieh
authors.forename: Jian-Chih
authors.initials: JC
authors.lastname: Chen
authors.forename: Yuh-Min
authors.initials: YM
authors.lastname: Cheng
authors.forename: Chung-Hwan
authors.initials: CH
authors.lastname: Chen
mesh_terms: D019386:Alendronate / Q000008:administration & dosage / Q000009:adverse effects*; D050071:Bone Density Conservation Agents / Q000627:therapeutic use*; D005260:Female; D005264:Femoral Fractures / Q000175:diagnosis / Q000188:drug therapy*; D015775:Fractures, Stress / Q000175:diagnosis / Q000188:drug therapy*; D006801:Humans; D008875:Middle Aged; D015663:Osteoporosis, Postmenopausal / Q000188:drug therapy*; D020849:Raloxifene Hydrochloride / Q000627:therapeutic use; D019379:Teriparatide / Q000627:therapeutic use*
chemical_list: D050071:Bone Density Conservation Agents; D019379:Teriparatide; D020849:Raloxifene Hydrochloride; D019386:Alendronate