title: Incidence and medical management of bisphosphonate-associated atypical femoral fractures in a major trauma centre: a retrospective observational study.
abstract: Atypical femoral fractures (AFFs) are rare events associated with increased duration of bisphosphonate exposure. Recommended management of AFFs include cessation of bisphosphonates and imaging of the contralateral femur. The aims of this study were to identify the local incidence of AFFs in bisphosphonate users and to audit the medical management of AFFs against published recommendations.
  
  
  
  A retrospective analysis of the admissions database for a major trauma centre identified all femoral fractures (3150) in a five-year period (July 2009 to June 2014). Electronic health records and radiographs were reviewed using the 2013 American Society for Bone and Mineral Research (ASBMR) diagnostic criteria for AFF to establish the number of cases. To estimate incidence, the total number of bisphosphonate users was derived from primary care prescription and secondary care day-case records. Medical management of cases with AFF on bisphosphonates was audited against guidance from ASBMR and Medicines & Healthcare Products Regulatory Agency.
  
  
  
  10 out of 3150 femoral fractures met criteria for AFF; 7 of these patients had a history of exposure to bisphosphonates (6 oral, 1 intravenous). There were 19.1 AFFs per 100,000 years of bisphosphonate use in our region. Bisphosphonates were stopped and the contralateral femur imaged in only 2 of the 7 patients treated with bisphosphonates.
  
  
  
  Our local incidence is in line with published figures; however, this is the first published evidence suggesting that medical management and identification of AFF may be suboptimal. Managing these patients remains challenging due to their rarity and possible lack of awareness.
authors.affiliation: Royal Centre for Defence Medicine, Birmingham, UK.|Department of Trauma and Orthopaedics, Royal Stoke University Hospital, Stoke-On-Trent, UK.|School of Chemical Engineering, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
authors.forename: Neil
authors.initials: N
authors.lastname: Eisenstein
authors.affiliation: Department of Rheumatology, Haywood Hospital, Stoke-On-Trent, UK.
authors.forename: Ganesh
authors.initials: G
authors.lastname: Kasavkar
authors.affiliation: Department of Trauma and Orthopaedics, Royal Stoke University Hospital, Stoke-On-Trent, UK.
authors.forename: Dhruva
authors.initials: D
authors.lastname: Bhavsar
authors.affiliation: Department of Trauma and Orthopaedics, Royal Stoke University Hospital, Stoke-On-Trent, UK.
authors.forename: Faisal Shehzaad
authors.initials: FS
authors.lastname: Khan
authors.affiliation: Department of Rheumatology, Haywood Hospital, Stoke-On-Trent, UK. z.paskins@keele.ac.uk.|Research Institute for Primary Care & Health Sciences, Keele University, Keele, ST5 5BG, UK. z.paskins@keele.ac.uk.
authors.forename: Zoe
authors.identifier: 0000-0002-7783-2986
authors.initials: Z
authors.lastname: Paskins
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D050071:Bone Density Conservation Agents / Q000627:therapeutic use*; D004164:Diphosphonates / Q000009:adverse effects / Q000627:therapeutic use*; D019468:Disease Management; D057286:Electronic Health Records; D005260:Female; D005264:Femoral Fractures / Q000139:chemically induced* / Q000000981:diagnostic imaging / Q000453:epidemiology*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D014193:Trauma Centers
chemical_list: D050071:Bone Density Conservation Agents; D004164:Diphosphonates
keywords: Atypical; Bisphosphonate; Denosumab; Femur; Fracture; Osteoporosis; Subtrochanteric