title: Atypical femoral fractures related to bisphosphonate treatment: issues and controversies related to their surgical management.
abstract: OBJECTIVE
  Treatment guidelines for atypical femoral fractures associated with bisphosphonates have not been established. We conducted a systematic review of the treatment of atypical femoral fractures first, to evaluate the outcomes of surgical fixation of complete atypical fractures and secondly, to assess whether prophylactic surgery is necessary for incomplete atypical fractures.
  
  
  METHODS
  Case reports and series were identified from the PubMed database and were included if they described the treatment of atypical femoral fractures. In total, 77 publications met our inclusion criteria and 733 patients with 834 atypical complete or incomplete femoral fractures were identified.
  
  
  RESULTS
  For complete fractures, internal fixation was predominantly achieved by intramedullary nailing. The mean time to healing post-operatively was 7.3 months (2 to 31). Revision surgery for nonunion or implant failure was needed in 77 fractures (12.6%). A greater percentage of fractures treated with plate fixation (31.3%) required revision surgery than those treated with intramedullary nailing (12.9%) (p < 0.01). Non-operative treatment of incomplete fractures failed and surgery was eventually needed in nearly half of the patients (47%), whereas prophylactic surgery was successful and achieved a 97% rate of healing.
  
  
  CONCLUSIONS
  Intramedullary nailing is the first-line treatment for a complete fracture, although the risk of delayed healing and revision surgery seems to be higher than with a typical femoral fracture. Non-operative treatment does not appear to be a reliable way of treating an incomplete fracture: prophylactic intramedullary nailing should be considered if the patient is in intractable pain. Radiographs of the opposite side should be obtained routinely looking for an asymptomatic fracture. Bisphosphonates must be discontinued but ongoing metabolic management in the form of calcium and/or vitamin D supplements is advisable. Teriparatide therapy can be considered as an alternative treatment. Cite this article:Bone Joint J2017;99-B:295-302.
authors.affiliation: Kobe Rosai Hospital, 4-1-23 Kagoike-dori, Chuo-ku, Kobe, 651-0053, Japan.
authors.forename: A
authors.initials: A
authors.lastname: Koh
authors.affiliation: University of Malaga, Autovia A-7 K, 187 29603, Marbella, Malaga, Spain.
authors.forename: E
authors.initials: E
authors.lastname: Guerado
authors.affiliation: NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, Leeds, UK.
authors.forename: P V
authors.initials: PV
authors.lastname: Giannoudis
mesh_terms: D050071:Bone Density Conservation Agents / Q000009:adverse effects*; D001860:Bone Plates; D004164:Diphosphonates / Q000009:adverse effects*; D005264:Femoral Fractures / Q000139:chemically induced* / Q000601:surgery*; D005593:Fracture Fixation, Internal / Q000379:methods*; D005594:Fracture Fixation, Intramedullary; D017102:Fracture Healing; D005598:Fractures, Spontaneous / Q000139:chemically induced / Q000601:surgery; D006801:Humans; D012086:Reoperation / Q000379:methods
chemical_list: D050071:Bone Density Conservation Agents; D004164:Diphosphonates
keywords: Atypical femoral fracture; Bisphosphonate; Non-operative treatment; Prophylactic surgery; Surgical management