UNMASKING ATYPICAL FEMORAL FRACTURES IN OSTEOPOROSIS

A CASE SERIES OF HIGH-RISK PATIENTS

Abstract

INTRODUCTION/BACKGROUND
Atypical femoral fractures (AFFs) are rare but serious complications associated with long-term antiresorptive therapy for osteoporosis. These fractures often occur in the femoral diaphysis, particularly in the subtrochanteric or mid-shaft regions, and may arise without trauma or with minimal trauma. Corticosteroid use and other comorbidities, such as chronic inflammation, further increase the risk of AFFs in susceptible individuals.

CASE
We report three cases of AFFs in female patients aged 61 to 75 years. The mean duration of bisphosphonate use prior to AFF was 5 years and 8 months. Two out of three patients had a history of chronic glucocorticoid use and one had rheumatoid arthritis who was on methotrexate. Only one patient had prodromal thigh pain. All patients presented with complete AFF and one patient with contralateral incomplete AFF. Most complete AFFs were sustained from a simple fall while one case was atraumatic. All complete AFFs were treated with intramedullary nailing and recovered well postoperatively. The patient with contralateral incomplete AFF was counselled for prophylactic surgical intervention which she declined. Anti-osteoporotic treatment was switched from bisphosphonate to anabolic agents following surgery.

CONCLUSION
Early recognition of AFFs and proactive intervention can prevent further fractures. Clinicians should consider drug holidays or switching therapies for patients on long-term bisphosphonates, especially those with additional risk factors, to optimize bone health.