These Fractures Have Several Atypical Characteristics: Prodromal Symptoms, Occurrence With Minimal Trauma, Distinctive Radiographic Changes

(Posted by Tom Lamb at DrugInjuryWatch.com)

Three new medical journal articles about bisphosphonate-related femur fractures came to our attention in early September 2012.

The first, "Seek and ye shall find – subtrochanteric stress fractures in patients on oral bisphosphonate therapy; an emerging problem", points out in the Introduction section of its Abstract: "This fracture is often preceded by pain and distinctive radiographic changes, and associated with a characteristic fracture pattern."

In more detail, from the Results section of this article from the Journal of Bone & Joint Surgery, British Volume:

Results  11 fractures were found in 10 patients matching the inclusion criteria outlined. All were female, and taking bisphosphonates for a mean of 4.3 years. 5 of the 10 patients described prodromal symptoms, for an average of 7.8 months before fracture. Although all fractures were deemed low velocity, 5 of 11 were atraumatic. 3 patients have had bilateral subtrochanteric fractures. Presence of the distinctive radiological ‘bleb’ was common. Surveillance on 2 patients shows lateral cortical blebs on the contralateral femur which merit close follow up.

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The second article is "Atypical subtrochanteric femoral shaft fractures: role for mechanics and bone quality.", from the August 29, 2012 edition of Arthritis Research & Therapy.  In part, the authors set forth some of the unique characteritics commonly found in atypical femoral fractures (AFF) in the subtrochanteric region or the diaphysis with patients using bisphosphonates such as Fosamax (alendronate), Actonel (risedronate), Boniva (ibandronate):

These fractures have several atypical characteristics, including occurrence with minimal trauma; younger age than typical osteoporotic fractures; occurrence at cortical, rather than cancellous sites; early radiographic appearance similar to that of a stress fracture; transverse fracture pattern rather than the familiar spiral or transverse-oblique morphologies; initiation on the lateral cortex; and high risk of fracture on the contralateral side, at the same location as the initial fracture.

The last article, "Spontaneous incomplete transverse subtrochanteric femoral fracture with cortical thickening possibly secondary to risedronate use: a case report.", from the Journal of Medical Case Reports, discusses an atypical femur fracture secondary to relatively short-term Actonel use:

We consider this case report not only interesting but also important and unusual because it is about a patient who developed a potentially rare and serious side effect of long-term bisphosphonate use, estimated to affect 2.3 in every 10,000 patients, and who presented with a pelvic X-ray that showed the characteristic features of atypical fractures secondary to [Actonel (risedronate)] use. In addition, most of the documented cases have been associated with many years of bisphosphonate use whereas our patient had been on risedronate for only four years.

We will continue to monitor the journals for developments in the medical literature concerning femur fractures associated with bisphosphonates such as Actonel, Boniva, and Fosamax.

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