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Atypical femoral fractures: Possible association with long-term bisphosphonate usage
Prakash Selvam1, Sivamurugan Soundarapandian2, Ravisubramaniam Soundarapandian3, Cheralathan Senguttuvan4
1M.B.B.S., M.S.Orth, Consultant Orthopaedic Surgeon, Soundarapandian Bone and Joint Hospital and Research Institute, Chennai, Tamilnadu, India.
2M.B.B.S., D.Orth., Dip.N.B.(Orth), Consultant Orthopaedic Surgeon, Soundarapandian Bone and Joint Hospital and Research Institute, Chennai, Tamilnadu, India.
3M.B.B.S., M.Sc., (Orth) Oxford, Dip.N.B.(Orth), Consultant Orthopaedic Surgeon, Soundarapandian Bone and Joint Hospital and Research Institute, Chennai, Tamilnadu, India.
4M.B.B.S., D.Orth., M.S.Orth., Dip.N.B.Orth, Senior Resident, Soundarapandian Bone and Joint Hospital and Research Institute, Chennai, Tamilnadu, India.

Article ID: Z01201608CS10074PS
doi:10.5348/ijcri-201613-CS-10074

Address correspondence to:
Cheralathan Senguttuvan
Senior Resident, Soundarapandian Bone and Joint Hospital and Research Institute
AA-16, 3rd Main Road, Anna Nagar, Chennai
Tamilnadu
India, Postal code – 600 040

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How to cite this article
Selvam P, Soundarapandian S, Soundarapandian R, Senguttuvan C. Atypical femoral fractures: Possible association with long-term bisphosphonate usage. Int J Case Rep Images 2016;7(8):488–494.


Abstract
Introduction: Atypical femoral fractures are being identified as a specific type of femoral fracture with regards to the anatomical location, fracture pattern, low energy trauma and possible association with long-term usage of bisphosphonates. Though there is no conclusive evidence to suggest a causal association of bisphosphonates with this type of femur fracture, the recent increase in reporting of such fractures in patients under long-term usage of bisphosphonates justifies the need for research into the association between the two.
Case Series: We intend to report two such cases that presented to our institution. Both patients presented with the characteristics of atypical femoral fractures which included low energy trauma, anatomical location, transverse or short oblique configuration with a medial spike, no comminution and lateral cortical thickening. Both patients underwent surgical fixation and were followed-up till union of the fracture.
Conclusion: Identifying this specific fracture and treating it with caution is necessary as they tend to take more time to heal in comparison with high energy trauma femoral fracture. Educating physicians and surgeons regarding this type of fracture is of prime importance both in prevention as well as treatment of this type of fracture, which contributes to significant reduction of morbidity and mortality to the patient. Careful prescription of bisphosphonates for patients with definite indications and proper monitoring during follow-up would be another justifiable preventive measure.

Keywords: Atypical femoral fracture, Bisphosphonates, Stress fracture


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Author Contributions:
Prakash Selvam – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Sivamurugan Soundarapandian – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Ravisubramaniam Soundarapandian – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Cheralathan Senguttuvan – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
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The corresponding author is the guarantor of submission.
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Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2016 Prakash Selvam et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



About The Authors

Prakash Selvam is Consultant Orthopedic Surgeon at Soundarapandian Bone and Joint Hospital and Research Institute, Anna Nagar, Chennai. He earned undergraduate degree (MBBS) from Rajah Muthaiah Medical College, Chidambaram, Tamil Nadu, India and postgraduate degree (MS Orthopedics) from M S Ramaiah Medical College, Rajiv Gandhi University, Bangalore, India. He has presented several papers in national and state conferences, and attended various international conferences on hip replacement. His areas of interest are arthroplasty and trauma, and special interest in geriatric fractures prevention and its management especially hip.



Sivamurugan Soundarapandian is Director of Soundarapandian Bone and Joint Hospital and Research Institute, Anna Nagar, Chennai. He heads the Arthroplasty Unit in the same institution. He earned undergraduate degree (MBBS) from Madras Medical College, Madras University, India and postgraduate degrees (Diploma in Orthopedics) from Madras University and Diploma N.B. in Orthopedics from National Board of examinations, India. He underwent training at Nuffield Orthopedic centre, Oxford, U.K. He is an AO Trauma fellow, Switzerland. He has presented scientific papers in several conferences and had been faculty in many AO courses held in India. He has been organizing chairman for many academic events in India. He is an active member of Rotary Club Anna Nagar and also Vice-president of REACH (NGO). His research interests include primary, complex and revision knee arthroplasty.



Ravi Subramaniam Soundarapandian is Director of Soundarapandian Bone and Joint Hospital and Research Institute, Anna Nagar, Chennai. He heads the Arthroscopy Unit in the same institution. He earned undergraduate degree (MBBS) from Madras Medical College, Madras University, India and postgraduate degrees (Diploma N.B. in Orthopedics) from National Board of examinations, India and MSc in Orthopedics from University of Oxford. He also underwent training at Nuffield Orthopedic centre, Oxford, U.K. He has submitted a research thesis on 'Anatomy of the lumbosacral Junction', during Association of anatomists meet in Tamil Nadu, India during 1981. 'Gait Analysis of the ACL deficient Knee', University of Oxford. He has presented scientific papers in several conferences and had been faculty in many academic courses held in India and abroad. He has been organizing chairman for many academic events in India. His research interests include advanced arthroscopy and shoulder reconstruction.



Cheralathan Senguttuvan is Senior Resident at Soundarapandian Bone and Joint hospital and Research Institute, Anna Nagar, Chennai. He earned undergraduate degree (MBBS) from Kilpauk Medical College, The Tamil Nadu Dr. MGR Medical University, Chennai and postgraduate degrees (Diploma in Orthopedics) form Madras Medical College, The Tamil Nadu Dr. MGR Medical University, Chennai, India, (MS Orthopedics) from Kilpauk Medical College, The Tamil Nadu Dr. MGR Medical University, Chennai, India and Diploma N.B. Orthopedics from National board of examinations, India. He has published paper on internal jugular phlebectasia as an incidental finding in cervical spine surgery and pediatric snapping scapula syndrome and has submitted a research thesis on percutaneous osteosynthesis for transverse patellar fractures by modified carpenter's technique during his orthopedic residency. His research interests include arthroplasty and trauma. He intends to pursue fellowship in complex trauma and arthroplasty in future.