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Nohmi S, Kogawa M, Ogawa T. A secondary atypical diaphyseal femoral fracture after intramedullary nailing for an atypical subtrochanteric femoral fracture: A case report. Trauma Case Rep 2024; 51:101024. [PMID: 38628457 PMCID: PMC11019263 DOI: 10.1016/j.tcr.2024.101024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2024] [Indexed: 04/19/2024] Open
Abstract
Intramedullary nailing is the gold standard of treatment for atypical femoral fractures, with a few reports of secondary atypical subtrochanteric femoral fractures following intramedullary nailing for atypical diaphyseal femoral fractures. However, there are no reports of secondary atypical diaphyseal femoral fractures following intramedullary nailing for atypical subtrochanteric femoral fractures. A 71-year-old woman with adult-onset Still's disease sustained a right atypical subtrochanteric femoral fracture and was treated with a mid-length intramedullary nail. One year after the surgery, the patient sustained a contralateral atypical diaphyseal femoral fracture and was treated with a long-length intramedullary nail. Moreover, 6 months after the second surgery, the patient complained of right-thigh pain, and a radiograph of the lateral view of the femur revealed a diaphyseal femoral fracture at the distal screw-insertion site. Revision surgery was performed using a long-length nail and screws directed toward the femoral head. Bony union of the bilateral diaphyseal femoral lesion was obtained, but the subtrochanteric lesion remained unhealed 1.5 years postoperatively. Mid-length intramedullary nailing for atypical subtrochanteric femoral fractures can cause secondary atypical diaphyseal fractures because of stress concentration at the distal screw-insertion site. For atypical subtrochanteric femoral fractures, the use of long-length nails and proximal screws directed toward the femoral head may be important to prevent secondary atypical diaphyseal femoral fractures.
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Affiliation(s)
- Shuya Nohmi
- Department of Orthopaedic Surgery, Misawa City Hospital, 164-65 Horiguchi, Misawa, Misawa-shi, Aomori 033-0022, Japan
| | - Masakazu Kogawa
- Department of Orthopaedic Surgery, Hachinohe City Hospital, 3-1-1 Tamukai, Hachinohe-shi, Aomori 031-8555, Japan
| | - Taro Ogawa
- Department of Orthopaedic Surgery, Misawa City Hospital, 164-65 Horiguchi, Misawa, Misawa-shi, Aomori 033-0022, Japan
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Hwang S, Seo M, Lim D, Choi MS, Park JW, Nam K. Bilateral Atypical Femoral Fractures after Bisphosphonate Treatment for Osteoporosis: A Literature Review. J Clin Med 2023; 12:jcm12031038. [PMID: 36769684 PMCID: PMC9917519 DOI: 10.3390/jcm12031038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION This literature review aimed to investigate the incidence, anatomical concerns, etiology, symptoms, diagnostic tools, management, and prognosis of bisphosphonate (BP)-associated bilateral atypical femoral fractures (AFFs). METHODS The PubMed, Cochrane Library, Web of Sciences, and CINAHL databases were searched up to 20 March 2022. All cases of bilateral AFFs were included, excluding those without any bisphosphonate treatment information and those in which the femoral fracture did not precisely fit into the diagnostic criteria for AFF. RESULTS We identified 43 patients with bilateral AFFs associated with BP use and conducted a comprehensive analysis. Among 43 patients, 29 (67%) had prodromal symptoms. Regarding the simultaneity of fracture, 21 cases (49%) occurred simultaneously, and 22 cases (51%) occurred sequentially. Alendronate was the most commonly used BP treatment (59%). Regardless of the medication type, BP intake duration was more than 5 years in 77%. The initial diagnosis was performed using X-rays in all cases. A total of 53% of patients had complete fractures, and all patients underwent surgical treatment. Among the remaining patients with incomplete fractures, 18% and 29% received surgical and medical treatments, respectively. After BP discontinuation, teriparatide was most commonly used (63%). CONCLUSIONS The careful evaluation of relevant imaging findings in patients with thigh/groin pain allows the identification of early incomplete fractures and timely management. Since the rate of contralateral side fractures is also high, imaging studies should be performed on the asymptomatic contralateral side.
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Affiliation(s)
- SeokJoon Hwang
- Department of Physical Medicine and Rehabilitation, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang-si 10326, Gyeonggi-do, Republic of Korea
| | - Minsu Seo
- Department of Physical Medicine and Rehabilitation, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang-si 10326, Gyeonggi-do, Republic of Korea
| | - Dongin Lim
- Department of Physical Medicine and Rehabilitation, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang-si 10326, Gyeonggi-do, Republic of Korea
| | - Min Suk Choi
- Department of Thoracic and Cardiovascular Surgery, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang-si 10326, Gyeonggi-do, Republic of Korea
| | - Jin-Woo Park
- Department of Physical Medicine and Rehabilitation, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang-si 10326, Gyeonggi-do, Republic of Korea
| | - Kiyeun Nam
- Department of Physical Medicine and Rehabilitation, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang-si 10326, Gyeonggi-do, Republic of Korea
- Correspondence: ; Tel.: +82-31-961-8460; Fax: +82-31-961-7488
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The importance of reconstruction nailing for diaphyseal atypical femoral fractures: a comparative study with standard nailing. Arch Orthop Trauma Surg 2022; 142:2677-2683. [PMID: 34244873 DOI: 10.1007/s00402-021-04057-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Subtrochanteric atypical femoral fractures (AFFs) usually require long cephalomedullary or reconstruction nailing to achieve satisfactory healing. Recently, this type of nailing has also been recommended to fix diaphyseal AFFs and prevent fragility fractures around the proximal femur, although standard antegrade nailing seems sufficient from a biomechanical perspective. This study aimed to compare treatment outcomes and complications between reconstruction and standard nailing for diaphyseal AFFs. MATERIALS AND METHODS A retrospective comparative study of 48 female patients with diaphyseal AFFs who underwent surgical treatment with either reconstruction or standard nailing was conducted. The reconstruction nailing group comprised 23 patients with a mean age of 74.4 years and included 16 complete and 7 incomplete AFFs. The mean follow-up period was 30 months. The standard nailing group comprised 25 patients with a mean age of 71.1 years and included 16 complete and 9 incomplete AFFs. The mean follow-up period was 57.8 months. The healing rate, time to union, and complications were analyzed and compared between the two groups. RESULTS Bony union was achieved in all 23 cases (100%) of the reconstruction nailing group by a mean of 19.3 weeks postoperative. In the standard nailing group, 23 of 25 cases healed (92%) by a mean of 16 weeks postoperative. The standard nailing group included two delayed fragility fractures of the femoral neck (5 and 10 years after the initial surgery), four cases of newly developed subtrochanteric AFFs at the distal screw of the proximal interlocking screws of the nail (one complete and three incomplete fractures), and two cases of nonunion. Complications only occurred in the standard nailing group (p = 0.01, Fisher's exact test). CONCLUSIONS In diaphyseal AFFs, reconstruction nailing may achieve a satisfactory outcome and can also decrease delayed peri-implant fragility fractures of the hip, newly developed subtrochanteric AFFs, and nonunion.
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Kim JW, Oh CW, Park KH, Oh JK, Yoon YC, Kim JK. Peri-implant atypical femoral fracture after nail or plate osteosynthesis. J Orthop Sci 2022; 27:866-875. [PMID: 34052080 DOI: 10.1016/j.jos.2021.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 03/23/2021] [Accepted: 04/12/2021] [Indexed: 02/09/2023]
Abstract
BACKGROUND A lack of scientific information regarding the risk factors and diagnosis of peri-implant atypical femoral fracture (PI-AFF) exists. We report a case series of developed PI-AFF with a nail or plate construct wherein prior femoral fractures were already healed after osteosynthesis. This study aimed to identify the cause and risk factors of PI-AFF and to devise a preventive method based on this. METHODS We identified 11 PI-AFFs displaying features of AFFs. All patients were ambulant females (mean age, 74.9 years). The mean T-score of the femur measured by DEXA (Dual Energy X-ray Absorptiometry) scan was 3.5. Osteosynthesis was performed with a plate and an intramedullary nail in six and five patients, respectively. Possible risk factors were investigated, including the used implant, the medication of bisphosphonate, the characteristics of previous fracture (AFF or non-AFF), and the co-existence of AFF on the contralateral side. RESULTS The PI-AFFs developed at an average of 6.6 years from the time of prior fracture. All fractures were located at the screw through the plate or nail. Regarding anatomic locations, seven and four fractures were at the subtrochanteric area and diaphysis, respectively. Diaphyseal PI-AFFs occurred in plating cases, all of which were associated with excessive femoral bowing. Subtrochanteric PI-AFFs included all five patients with nail fixation, which occurred near a proximal interlocking screw. Six of the 11 patients were on bisphosphonate treatment before or at the time of fracture. The duration of bisphosphonate treatment was 6 years on average. Concerning the previous femoral fractures, seven and four patients were AFF and non-AFF, respectively. Considering the pathology on the contralateral leg, eight had suffered diaphyseal AFF. Four patients were treated nonoperatively. Seven patients needed an operation; 6 of them healed after reconstruction nailing, and one needed hip arthroplasty because of the associated displaced femoral neck fracture. CONCLUSIONS PI-AFFs may develop through the screw hole at the subtrochanteric or diaphyseal area due to femoral fragility and stress riser effect of the implant. An improved osteosynthesis strategy may be necessary to avoid PI-AFFs when fixing osteoporotic femoral fractures.
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Affiliation(s)
- Joon-Woo Kim
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, 41944, Republic of Korea
| | - Chang-Wug Oh
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, 41944, Republic of Korea.
| | - Kyeong-Hyeon Park
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, 41944, Republic of Korea
| | - Jong-Keon Oh
- Department of Orthopaedic Surgery, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Yong-Cheol Yoon
- Orthopedic Trauma Division, Trauma Center, Gachon University College of Medicine, 21, Namdong-daero 774 Beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea
| | - June-Kyu Kim
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, 41944, Republic of Korea
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Kim KK, Ryu SK, Lee SW, Cha HJ. Is Full-Length Intramedullary Nail Necessary for Atypical Subtrochanteric Femoral Fracture Associated with Bisphosphonate? J Bone Metab 2020; 27:133-142. [PMID: 32572374 PMCID: PMC7297621 DOI: 10.11005/jbm.2020.27.2.133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/07/2020] [Accepted: 04/19/2020] [Indexed: 02/01/2023] Open
Abstract
Background American Society for Bone and Mineral Research recommend the use of intramedullary reconstruction of full length-nail for atypical subtrochanteric femoral fracture (ASFF). However, there is no study on the incidence of the ipsilateral femoral fracture after index operation of ASFF, and full-length nail has disadvantage as iatrogenic fracture and leg length discrepancy (LLD). The aim of this study was to investigate the incidence of ipsilateral secondary fracture after using partial-length nail, and to compare the outcomes on surgery of ASFF between partial length-nails and full length-nails. Methods Forty-five consecutive fractures with ASFFs which had undergone intramedullary fixation using cephalomedullary nail between 2011 and 2018 were enrolled. The 45 cases were grouped based on nail length into the partial-length nail group (n=26) and the full-length nail group (n=19). Ipsilateral secondary fracture, time to union, intra-operative iatrogenic fracture, metal failure, LLD, operative duration, and post-operative 24-hr blood loss were investigated. Results There was no ipsilateral secondary fracture after index operation. There were no statistically significant differences between the partial-length nail and full-length nail groups in the time to union, LLD, and post-operative 24-hr blood loss (P=0.427, 0.478, and 0.228, respectively). Operative duration showed statistically significant difference between 2 groups (P=0.034). Metal failure were occurred in 1 (3%) case of the partial-length nail group and 2 (10%) cases of the full-length nail group. Iatrogenic fractures during nail insertion occurred in 2 (7%) cases of the partial-length-nail group and 3 cases (15%) of the full-length nail group. Conclusions Although large scale studies are required, our study indicate that full-length nails are not usually required for the treatment of ASFF.
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Affiliation(s)
- Kwang-Kyoun Kim
- Department of Orthopaedic Surgery, Konyang University Hospital, Daejeon, Korea
| | - Seung Kwon Ryu
- Department of Orthopaedic Surgery, Yuseong Sun Hospital, Daejeon, Korea
| | - Seok-Won Lee
- Department of Orthopaedic Surgery, Konyang University Hospital, Daejeon, Korea
| | - Hyun-Jae Cha
- Department of Orthopaedic Surgery, Konyang University Hospital, Daejeon, Korea
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Kim YS, Lee HM, Kim JP, Bae EW, Oh CW, Kim JW. Proximal femoral insufficiency fracture after interlocking intramedullary nailing for atypical femoral fracture. ACTA ACUST UNITED AC 2020. [DOI: 10.23736/s0394-3410.20.03965-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Toro G, Ojeda-Thies C, Calabrò G, Toro G, Moretti A, Guerra GMD, Caba-Doussoux P, Iolascon G. Management of atypical femoral fracture: a scoping review and comprehensive algorithm. BMC Musculoskelet Disord 2016; 17:227. [PMID: 27215972 PMCID: PMC4878072 DOI: 10.1186/s12891-016-1086-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 05/17/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Atypical femoral fractures (AFF) are a rare type of femoral stress fracture recently described, potentially associated with prolonged bisphosphonate therapy. Evidence-based recommendations regarding diagnosis and management of these fractures are scarce. The purpose of this study is to propose an algorithm for the diagnosis and management of AFF. METHODS We performed a PubMed search of the last ten years using the keywords "atypical femoral fractures" and identified further articles through an evaluation of the publications cited in these articles. Relevant studies were included by agreement between researchers, depending on their specialization. Pertinent points of debate were discussed based on the available literature, allowing for consensus regarding the proposed management algorithm. RESULTS Using a systematic approach we performed a scoping review that included a total of 137 articles. CONCLUSIONS A practical guide for diagnosis and management of AFF based on the current concepts is proposed. In spite of the impressive large volume of published literature available since AFF were initially identified, the level of evidence is mostly poor, in particular regarding treatment choice. Therefore, further studies are required.
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Affiliation(s)
- Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, Second University of Naples, Via De Crecchio, 4, 80138 Naples, Italy
| | - Cristina Ojeda-Thies
- Trauma Unit, Department of Orthopaedic Surgery and Traumatology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Giampiero Calabrò
- Unit of Orthopaedics and Traumatology, Villa Malta Hospital, Sarno, Italy
| | - Gabriella Toro
- Unit of Radiology, Santa Maria della Speranza Hospital, Battipaglia, Italy
| | - Antimo Moretti
- Department of Medical and Surgical Specialties and Dentistry, Second University of Naples, Via De Crecchio, 4, 80138 Naples, Italy
| | | | - Pedro Caba-Doussoux
- Trauma Unit, Department of Orthopaedic Surgery and Traumatology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, Second University of Naples, Via De Crecchio, 4, 80138 Naples, Italy
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