Search Results (26)

Background/Objectives: Surgical management of atypical femoral fractures (AFFs) stabilized with intramedullary (IM) nailing is frequently challenged by delayed union or nonunion due to the severely suppressed bone turnover characteristic of bisphosphonate-related bone pathology, often leading to a hypertrophic nonunion-like state at the fracture site. This consecutive case series aimed to evaluate the effectiveness of intraoperative percutaneous decortication at the hypertrophic cortex in promoting rapid bone healing in complete AFFs. Methods: This was a single-center consecutive case series of patients with complete atypical femoral fractures (AFFs) treated with intramedullary nailing and adjunctive percutaneous decortication since February 2021. The standardized surgical protocol—including percutaneous decortication performed through a small anterolateral incision using an osteotome to create bone chips and stimulate the sclerotic cortex—was applied prospectively to all consecutive patients from February 2021. Of the 20 patients who underwent surgery during this period, 14 with sufficient radiographic follow-up were included in the final retrospective analysis. Data collected included patient demographics, duration of bisphosphonate use, fracture location (diaphyseal vs. subtrochanteric), operative details (including iatrogenic fracture), and radiographic bone union time. Bone union was assessed on serial radiographs by two independent observers. Results: All 14 patients were female, with a median age of 75 years (IQR 67–79 years). Thirteen patients (92.9%) had prior bisphosphonate exposure for a median of 4.5 years (IQR 3–10 years). Six fractures were subtrochanteric fractures, and six were complicated by iatrogenic fracture during nail insertion. Postoperative teriparatide was administered to six patients. Radiographic bone union was achieved in all 14 patients at a median of 19 weeks (IQR 16–22 weeks; range 16–24 weeks). No major complications (infection, implant failure, nonunion, or neurovascular injury) occurred during follow-up. Conclusions: Percutaneous decortication is a simple, safe, and biologically plausible adjunct to intramedullary nailing. In this series of 14 elderly women with long-term bisphosphonate exposure (median 4.5 years), the technique was associated with 100% radiographic union at a median of 19 weeks without major complications, suggesting a promising strategy that warrants validation in larger, controlled trials. Full article

Background/Objectives: Atypical femoral fractures (AFFs) are rare and classically linked to long-term bisphosphonate therapy, but many occur without such exposure. We aimed to characterize atypical femoral fractures without bisphosphonate exposure (AFFwB) in older adults and to explore biochemical patterns using principal component analysis (PCA). Methods: We conducted a retrospective study of patients ≥65 years admitted with femoral fractures (January 2019–September 2024). AFFs were identified from ICD-9 codes and confirmed according to 2014 ASBMR criteria by two blinded reviewers. Demographic, clinical, densitometric, and metabolic data were collected. Correlations between biochemical variables were assessed, and PCA was applied to PTH, vitamin D, BMD, ALP, calcium, and creatinine. Results: Among 932 femoral fractures, 36 met AFF criteria, including 21 AFFwB cases. AFFwB patients were mostly women, and fractures were predominantly diaphyseal. Vitamin D insufficiency/deficiency and osteoporosis were observed in 77% and 66.7% of cases, respectively. Strong correlations were found between PTH and vitamin D and between PTH and ALP. PCA identified four components explaining 88.2% of variance, corresponding to endocrine–mineral regulation, bone turnover, renal function, and BMD as an independent domain. Exploratory comparison with bisphosphonate-exposed AFF suggested higher vitamin D levels and lower ALP in treated patients. Conclusions: In this cohort, AFFs occurred both in patients without bisphosphonate exposure and in those receiving antiresorptive therapy, indicating that AFFs may arise through different pathways. These findings suggest that both insufficient bone quality and excessive remodeling suppression can ultimately lead to atypical fractures. Further studies are needed to clarify these findings. Full article

Background/Objectives: Long-term bisphosphonate (BP) therapy is an effective treatment for osteoporosis but has been associated with rare complications such as atypical femoral fractures (AFFs). Emerging reports suggest that similar insufficiency fractures may also occur in other skeletal sites, including the lumbar pedicles. This study reports two rare cases of isolated bilateral lumbar pedicle stress fractures in patients on prolonged BP therapy. Along with a structured literature review, the objective was to evaluate whether diagnostic criteria derived from those used for AFFs may apply to these atypical vertebral fractures. Methods: Two patients with osteoporosis and on long-term BP therapy diagnosed with isolated lumbar pedicle stress fractures were retrospectively analyzed. A structured literature review identified similar reported cases. All cases were evaluated using the 2010 American Society for Bone and Mineral Research AFF criteria to assess applicability to isolated pedicle stress fractures. Results: Both patients demonstrated bilateral lumbar pedicle fractures without vertebral body involvement. One was treated conservatively; the other underwent robotic-assisted percutaneous pedicle screw fixation with documented fracture healing at six months. The literature review identified eight similar cases of isolated pedicle fractures in patients on prolonged BP therapy. Clinical course and imaging findings demonstrated stress-type features analogous to AFFs. The proposed AFF-based diagnostic criteria for pedicular insufficiency fractures were found to be applicable to all ten patients. Conclusions: Isolated bilateral pedicle stress fractures may represent a spinal analog of AFFs. Based on shared clinical and imaging features, we propose preliminary diagnostic criteria for atypical pedicular insufficiency fractures. Increased awareness and standardized criteria may aid in early diagnosis and reporting, encouraging further studies on this rare spinal entity. Full article

Background: Osteoporosis is a prevalent metabolic disorder frequently managed with bisphosphonates, which reduce fracture risk but, with prolonged use, may predispose to atypical femoral fractures (AFFs). These rare but serious complications highlight the need for individualized treatment strategies within the framework of precision medicine. Methods: We retrospectively analyzed six female patients (mean age around 70 years) with AFFs surgically treated at the University of Catania between September 2022 and March 2023. All patients had received bisphosphonate therapy for more than seven years. Demographic, clinical, and radiographic data were collected according to ASBMR criteria. Outcomes included fracture healing, hip and knee range of motion, quality of life (SF-36), and residual pain (VAS) at 12 months. Results: Fractures were subtrochanteric in two cases and mid-diaphyseal in four. All patients underwent intramedullary nailing. Mean radiographic union occurred at 5 ± 1.5 months, and functional recovery occurred at 4.5 ± 1.2 months. Quality of life declined from a pre-fracture SF-36 score of 77 to 57 at one year. Residual pain was minimal (VAS 2). Conclusions: Prolonged bisphosphonate therapy was strongly associated with AFFs, longer healing times, and reduced quality of life. These findings emphasize the importance of personalized management of osteoporosis, including risk-based treatment duration, tailored monitoring protocols, and early therapeutic adjustments to balance efficacy and safety in long-term care. Full article

An Incomplete Atypical femoral fracture is subtle and requires early diagnosis. However, artificial intelligence models for these fractures often fail in real-world clinical settings due to the “domain shift” problem, where performance degrades when applied to new data sources. This study proposes a data-centric approach to overcome this problem. We introduce an anatomy-based four-step preprocessing pipeline to normalize femoral X-ray images. This pipeline consists of (1) semantic segmentation of the femur, (2) skeletonization and centroid extraction using RANSAC, (3) rotational alignment to the vertical direction, and (4) cropping a normalized region of interest (ROI). We evaluate the effectiveness of this pipeline across various one-stage (YOLO) and two-stage (Faster R-CNN) object detection models. On the source domain data, the proposed alignment pipeline significantly improves the performance of the YOLO model, with YOLOv10n achieving the best performance of 0.6472 at mAP@50–95. More importantly, in zero-shot evaluation on a completely new domain, standing AP X-ray, the model trained on aligned data exhibited strong generalization performance, while the existing models completely failed (mAP = 0), YOLOv10s, which applied the proposed method, achieved 0.4616 at mAP@50–95. The first-stage detector showed more consistent performance gains from the alignment technique than the second-stage detector. Normalizing medical images based on inherent anatomical consistency is a highly effective and efficient strategy for achieving domain generalization. This data-driven paradigm, which simplifies the input to AI, can create clinically applicable, robust models without increasing the complexity of the model architecture. Full article

Background/Objectives: Periprosthetic joint infection (PJI) is a challenging problem in orthopedic surgery and is often associated with high morbidity. The treatment becomes even more challenging whenever the microorganism is virulent and/or not widely known as a causative organism on these occasions. This study aims to report on the clinical outcomes of hip hemiarthroplasty prosthetic hip joint infection by an atypical, rare microorganism, Morganella morganii (M. morganii), focusing on morbidity, revisions, and mortality. Methods: This is a retrospective series of four cases of prosthetic joint infections with Morganella morganii, a rare Gram-negative opportunistic facultative anaerobic pathogen, in four patients who received hip hemiarthroplasty for displaced femoral neck fractures at a level 1 trauma center. Clinical notes, laboratory findings, and radiographs were reviewed to extract relevant information regarding the history and outcomes. Results: The patients were four females, with a mean age of 84.27 years at the time of surgery. Two cases (50%) underwent surgical debridement and implant retention, followed by lifelong antibiotic suppression for symptomatic control of persistent wound drainage, and the other two underwent implant removal and resection arthroplasty (one patient) or received an antibiotic spacer (one patient), followed by chronic antibiotic therapy until wound closure. Conclusions: Periprosthetic hemiarthroplasty infection secondary to M. morganii was associated with overall poor outcomes. Antibiotic suppression could be a reasonable option after the surgical debridement or implant removal in M. morganii PJI to control the symptoms. Full article

Background: Atypical subtrochanteric femoral fractures (ASFs), frequently linked to long-term bisphosphonate use, present significant fixation challenges due to impaired bone healing. While intramedullary (IM) nailing is the standard treatment, delayed union or nonunion remains common. This study aimed to evaluate whether supplementing IM nailing with lateral plate augmentation improves radiographic healing in patients with ASFs. Methods: This retrospective comparative study included 12 elderly female patients with ASFs treated between October 2013 and October 2023. Five patients underwent IM nailing alone (IM group), while seven received IM nailing with additional lateral plate fixation (Plate + IM group). Fracture healing was assessed using the modified Radiographic Union Score for Tibial fractures (mRUST) at 3, 6, and 12 months postoperatively. Intergroup comparisons were performed using the Mann–Whitney U test. Results: The median mRUST scores in the IM group were 4 (IQR 3.5–4), 6 (IQR 4.5–6.5), and 8 (IQR 7–9) at 3, 6, and 12 months, respectively. In the Plate + IM group, the scores were 5 (IQR 4–6), 8 (IQR 8–8), and 10 (IQR 10–11), respectively. The Plate + IM group demonstrated significantly higher mRUST scores at all assessed time points (3 months: p = 0.018; 6 months: p = 0.003; 12 months: p = 0.006). No implant failures or postoperative infections occurred in either group during the 12-month follow-up period. One patient (20%) in the IM group developed fracture nonunion, while no nonunion cases were observed in the Plate + IM group. Conclusions: Lateral plate augmentation as an adjunct to IM nailing may promote faster and more consistent radiographic healing in atypical subtrochanteric femoral fractures. This dual-fixation strategy may offer a biomechanically more robust option for patients at risk of delayed union, potentially contributing to a lower risk of nonunion, though further prospective studies are required to confirm this finding. Full article

Background/Objectives: Osteoporosis is an important health issue worldwide, and bisphosphonates are commonly prescribed for its treatment. However, certain complications can occur with long-term bisphosphonate therapy. The complication highlighted in this study was atypical femoral fractures, which are rare but significant. The orthopedic consensus identifies surgical intervention as the gold-standard treatment for atypical femoral fractures, typically involving intramedullary or cephalomedullary nailing (CMN). The aim was to monitor patients for a follow-up period exceeding six months after surgical fixation with a CMN, with the majority of patients being followed up for more than 18 months after their initial surgery. Methods: This single-center analysis was conducted on a mixed cohort comprising a total of 10 patients. The study was conducted between September and November 2024. The inclusion criterion was surgical treatment for bisphosphonate-related atypical femoral fractures (AFFs) between June 2022 and November 2024 at a Level 1 Trauma Center, Cork University Hospital in the Republic of Ireland. The patients were monitored through a structured follow-up protocol that extended beyond six months, with the majority of patients being followed up for over 18 months. Follow-up assessments were conducted at defined intervals, including key evaluations at 3 and 6 months and at their final review. Clinical parameters such as pain, functional recovery, and radiological healing were considered. Results: No significant functional difference was observed at follow-up between the patients who sustained displaced fractures and those who presented with undisplaced fractures. Sixty percent of the patients remained pain-free from the 3-month postoperative follow-up, and the same percentage continued to be pain-free at the final follow-up. Conclusions: Cephalomedullary nailing is a safe option for the treatment of atypical femoral fractures. Patients with a bisphosphonate atypical femoral fracture should undergo bilateral screening and should be followed up for a longer period than the standard post-traumatic care intervals that are in place for typical femoral fractures. Full article

Background/Objectives: Osteoporotic fractures, particularly subcapital hip fractures (SCF), pose a significant healthcare and economic burden. The routine pathological examination of resected femoral heads in such cases is common practice, aimed at identifying malignancies that may have contributed to bone fragility. This study evaluated the cost-effectiveness and clinical utility of routine femoral head pathology in patients undergoing surgical treatment for SCF. Methods: A retrospective cohort study was conducted at a university-affiliated, tertiary care hospital. Patients undergoing surgical treatment for SCF between 2015 and 2018, with available femoral head pathology reports, were included. Data on demographics, prior or active malignancies, surgical procedures, and pathology results were analyzed. Results: The study included 230 patients with a mean age of 82.4 ± 14.1 years, of whom 57% were female. A total of 72 (31%) patients had a history of malignancy at the time of surgery. Pathological examination identified malignancies in eight patients (3.4%), all of whom had active malignancies at the time of admission. The most common malignancies detected were breast cancer and multiple myeloma (three cases each). None of the findings led to changes in patient management. Conclusions: The routine pathological examination of femoral heads following SCF provided a limited diagnostic yield and did not alter clinical management in this cohort. These findings suggest that routine pathology may not be cost-effective and support the adoption of selective screening approaches based on clinical risk factors such as a history of malignancy or atypical fracture presentations. Full article

Incomplete Atypical Femoral Fracture (IAFF) is a precursor to Atypical Femoral Fracture (AFF). If untreated, it progresses to a complete fracture, increasing mortality risk. However, due to their small and ambiguous features, IAFFs are often misdiagnosed even by specialists. In this paper, we propose a novel approach for accurately classifying IAFFs in X-ray images across various radiographic views. We design a Dual Context-aware Complementary Extractor (DCCE) to capture both the overall femur characteristics and IAFF details with the surrounding context, minimizing information loss. We also develop a Level-wise Perspective-preserving Fusion Network (LPFN) that preserves the perspective of features while integrating them at different levels to enhance model representation and sensitivity by learning complex correlations and features that are difficult to obtain independently. Additionally, we incorporate the Spatial Anomaly Focus Enhancer (SAFE) to emphasize anomalous regions, preventing the model bias toward normal regions, and reducing False Negatives and missed IAFFs. Experimental results show significant improvements across all evaluation metrics, demonstrating high reliability in terms of accuracy (0.931), F1-score (0.9456), and AUROC (0.9692), proving the model’s potential for application in real medical settings. Full article

Background: Owing to the risk of atypical femoral fractures, total hip arthroplasty presents unique challenges for patients with ipsilateral osteoarthritis and localized periosteal thickening in the femoral subtrochanteric region. Stem length selection is critical for minimizing stress concentration in the thickened cortex to avoid such fractures. Herein, we report the case of a 78-year-old woman with ipsilateral hip osteoarthritis and localized subtrochanteric periosteal thickening. Methods: Preoperative planning included a finite element analysis to assess the stress distribution across various stem lengths. A simulation was conducted to determine the optimal stem length to span the cortical thickening and reduce the risk of postoperative complications. Results: The finite element analysis indicated that a stem length of >150 mm was required to effectively reduce the stress at the site of cortical thickening. A 175 mm stem was selected for total hip arthroplasty, which provided a favorable stress distribution and avoided the risk of stress concentration. Conclusions: In cases of ipsilateral osteoarthritis with localized subtrochanteric periosteal thickening, finite element analysis can be valuable for preoperative planning to determine the optimal stem length, thereby reducing the risk of atypical femoral fractures. Further studies with multiple cases are recommended to validate these findings and improve surgical outcomes. Full article

The benefits of denosumab as an antiresorptive therapy and in reducing fragility fractures are well documented. However, its association with atypical femur fractures (AFFs), especially in the absence of prior bisphosphonate use, remains poorly understood and warrants further investigation. This case report presents a rare instance of bilateral AFFs in a 78-year-old bisphosphonate-naïve patient with a history of long-term denosumab therapy for previous metastatic breast cancer. Management involved intramedullary nail fixation after initial presentation with a unilateral AFF and a recommendation to cease denosumab therapy. However, the patient subsequently experienced a contralateral periprosthetic AFF below a total hip implant 5 months thereafter and was treated with open reduction internal fixation. This case report highlights the critical need for orthopedic surgeons to maintain a high level of suspicion and vigilance in screening for impending AFFs, especially in patients with a prolonged history of denosumab therapy without prior bisphosphonate use. Furthermore, the growing report of such cases emphasizes the urgent need for comprehensive research aimed at refining treatment protocols that balance the therapeutic benefits of denosumab and its associated risks of AFFs. Full article

This study explores the genetic factors associated with atypical femoral fractures (AFF), rare fractures associated with prolonged anti-resorptive therapy. AFF are fragility fractures that typically appear in the subtrochanteric or diaphyseal regions of the femur. While some cases resemble fractures in rare genetic bone disorders, the exact cause remains unclear. This study investigates 457 genes related to skeletal homeostasis in 13 AFF patients by exome sequencing, comparing the results with osteoporotic patients (n = 27) and Iberian samples from the 1000 Genomes Project (n = 107). Only one AFF case carried a pathogenic variant in the gene set, specifically in the ALPL gene. The study then examined variant accumulation in the gene set, revealing significantly more variants in AFF patients than in osteoporotic patients without AFF (p = 3.7 × 10⁻⁵), particularly in ACAN, AKAP13, ARHGEF3, P4HB, PITX2, and SUCO genes, all of them related to osteogenesis. This suggests that variant accumulation in bone-related genes may contribute to AFF risk. The polygenic nature of AFF implies that a complex interplay of genetic factors determines the susceptibility to AFF, with ACAN, SUCO, AKAP13, ARHGEF3, PITX2, and P4HB as potential genetic risk factors. Larger studies are needed to confirm the utility of gene set analysis in identifying patients at high risk of AFF during anti-resorptive therapy. Full article

Background: Glucocorticoids induce osteoporosis, while bisphosphonates treat it, yet both can lead to atypical femoral fractures. Patients on both agents may face challenges in healing from such fractures due to their pathophysiology and pharmacological effects. Methods: Intramedullary nail surgery was performed on 20 limbs in 19 patients with atypical femoral fractures and autoimmune diseases, who had received bisphosphonates for GC-induced osteoporosis. The average durations of glucocorticoid and bisphosphonate use were 17 and 9 years (standard deviation: 7.59 and 4.35), respectively, and the mean follow-up period was 66 months. Fifteen and five limbs were fractured at the subtrochanter and diaphysis, respectively. The surgical techniques (type of nail) and additional procedures performed in these cases were examined. The post-operative alignment and reduction status on radiographs were examined to determine their relationship with post-operative outcomes. Results: Cephalomedullary long nails were inserted in nine limbs and antegrade intramedullary nails in 11 limbs. As an additional surgical procedure, open reduction, bone grafting and drilling were carried out on six, two, and five limbs, respectively. Regarding malalignment on radiographs, AP images showed varus in four limbs, and lateral images showed extension in two limbs. Regarding the cortical discontinuity, the distal fragment of the 11th limb shifted posteriorly in the lateral view. Gaps at the fracture sites were observed in 11 limbs. As a result, bone union was confirmed in 13 limbs. Five of the seven nonunion limbs required additional surgery. When comparing union and nonunion, open reduction and drilling were involved in nonunion limbs. Conclusion: The surgical outcomes of atypical femoral fractures in patients with autoimmune disease and on long-term glucocorticoids and bisphosphonates were poor. Although it is not possible to affirm for sure based on these results alone, management with prophylactic surgery before complete fracture is considered to be required to improve outcomes. Full article

Atypical femoral fracture (AFF) is a rare complication related to the use of bisphosphonates (BPs). Herein, we analyzed the risk factors and onset patterns of AFF using the Japanese Adverse Drug Event Report database and reported the findings. First, the independent risk factors for AFF were gender (female), high body mass index, and medical history of osteoporosis, arthritis, and systemic lupus erythematosus (SLE). Drug-related risk factors for AFF included BPs (i.e., alendronic acid, ibandronic acid, etidronic acid, zoledronic acid, minodronic acid, risedronic acid), denosumab, prednisolone, lansoprazole, rabeprazole, exemestane, letrozole, eldecalcitol, and menatetrenone. Therefore, it appears that AFF is influenced by a combination of patient backgrounds and drugs, and that the risk of developing AFF is particularly high in patients with fragile bones (e.g., osteoporosis, arthritis, and SLE). Second, in the analysis of AFF onset patterns, the onset of AFF from BPs and denosumab took a long time (>1 year) to develop. Analysis using a Weibull distribution showed wear-out failure-type AFF onset for BPs and denosumab, and both osteoporosis and cancer patients with long-term administration of these drugs showed a tendency to have an increased risk of onset. AFF developed earlier in osteoporosis patients with long-term administration of BPs and denosumab than in cancer patients. Full article