Research Article: Comparison of Atypical and Osteoporotic Femoral Shaft Fractures in the Elderly: A Multicenter Study

Date Published: May 16, 2018

Publisher: Hindawi

Author(s): Takanori Miura, Hiroaki Kijima, Noriyuki Ishikawa, Toshihito Ebina, Takayuki Tani, Shuichi Chida, Tetsuya Suzuki, Satoshi Yumto, Hiroshi Tazawa, Naohisa Miyakoshi, Yoichi Shimada.


In atypical femoral fractures, owing to the high rates of complications and delayed healing that accompany the plate fixation, the most favorable treatment is intramedullary nailing. Although there is insufficient evidence, plate fixation is chosen due to anterolateral bowing of the femur. This study compared the bone healing time and rates of complications in atypical femoral shaft fractures and osteoporotic femoral shaft fractures.

We searched the medical records of 3 institutions in Japan for patients with femoral shaft fractures who visited between 1 January 2010 and 31 December 2015. We identified 65 patients and excluded 37 among these due to high-energy injuries or being younger than 65 years. Among the remaining patients, we identified 17 and 11 women with atypical (AFF group) and osteoporotic femoral shaft fractures (OP group), respectively.

In surgical method, there were differences in intramedullary nailing (94.1% versus 27.2%) (p < 0.01). The mean bone healing time was 11.1 months versus 6.7 months in 2 groups (p < 0.01). Iatrogenic femoral fractures during intramedullary nail insertion were observed in both groups, and reoperation was only seen in atypical femoral fractures treated with a plate fixation, but there was no difference in the rate of complications (23.5% versus 9.1%). In the atypical femoral fracture group, intramedullary nailing was more chosen, but the bone healing time was delayed and plate fixation cases needed reoperation. There was no significant difference in the rate of complications between the 2 groups.

Partial Text

Atypical femoral fracture (AFF) is a fracture that occurs at the femoral subtrochanteric or shaft region. The occurrence of this type of fracture is associated with the long-term use of bisphosphonates (BPs) and bowed femoral shaft stress fractures [1–4]. It is a common conception that atypical femoral shaft fractures heal poorly [1, 5], but there have been few reports comparing patients with AFF and the control group with respect to bone healing times [5]. Among the treatment options, intramedullary nail fixation is most favorable. But in some cases with a high degree of lateral femoral bowing, it is difficult to insert the intramedullary nail, and there are consequently high rates of intraoperative fractures and implant failure during the procedure in patients with AFF [6, 7]. However, the sample size available for the examination of AFF in a single institution is limited. The present multicenter study aimed to compare the bone healing time and rates of complications in patients with atypical femoral shaft fractures and those with osteoporotic femoral shaft fractures.

The demographic data are shown in Table 1. All patients were women; 17 patients had complete atypical femoral shaft fractures [average age: 80.7 years (range: 77–88 years)], and the remaining 11 had osteoporotic femoral shaft fractures [average age: 81.0 years (range: 65–96 years)]. There were no significant differences in age between the two groups (p = 0.67). The patients with AFF used BPs more often (15 patients, 88%) compared to those with osteoporotic femoral fractures (2 patients, 18%) (p < 0.01). For treatment, all patients with atypical fractures and 81.8% (9 of 11) with osteoporotic fractures underwent surgery (p = 0.40). In the group with AFF, intramedullary nail fixation was performed in 94.1% (16 of 17) and plate fixation in 5.9% (1 of 17). In the group with osteoporotic femoral fractures, intramedullary nail fixation was performed in 27.2% (3 of 11), plate fixation in 36.3% (4 of 11), replacement arthroplasty in 18.2% (2 of 11), and conservative treatment in 18.2% (2 of 11). Intramedullary nail fixation was used more frequently in the group with atypical femoral fractures (94.1% versus 27.2%; p < 0.01). Teriparatide was used in 41.2% (7 patients) with AFF and in 18.2% (2 patients) with osteoporotic femoral fractures (p = 0.25). Low-intensity pulsed ultrasound (LIPUS) therapy was performed postoperatively in 23.5% (4 patients) in the group with AFF and in 9.1% (1 patient) in the group with osteoporotic femoral fractures (p = 0.30). The present study demonstrated a statistically significant difference in the bone healing time between patients with atypical femoral shaft fractures and those with osteoporotic femoral shaft fractures (11.1 months versus 6.7 months, p < 0.01). However, the rate of complications was 23.5% (AFF) versus 9.1% (osteoporotic femoral shaft fractures) for the two groups, which was not significant, although we experienced 1 plate failure and required revision surgery with intramedullary nail fixation in the AFF group. Atypical femoral shaft fractures are often seen in those treated with antiresorptive therapy; in this study, intramedullary nailing was chosen more often, but the time to bone healing was delayed compared with osteoporotic femoral fractures. There was no significant difference in complications rates, but iatrogenic femoral fractures occurred during intramedullary nail insertion, and plate fixation cases needed reoperation. Therefore, we should distinguish atypical femoral shaft fractures from osteoporotic femoral shaft fractures.   Source:


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