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Bone Abstracts (2016) 5 P352 | DOI: 10.1530/boneabs.5.P352

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1Indiana University School of Medicine, Indianapolis, Indiana, USA; 2Regenstrief Institute, Indianapolis, Indiana, USA; 3Indiana University School of Public Health, Indianapolis, Indiana, USA; 4Merck, Sharp and Dohme, Whitehouse Station, New Jersey, USA.


Atypical femur fractures (AFF) have been associated with antiresorptive therapy. In a retrospective case-control study, we identified AFF using ASBMR 2013 criteria. Femoral shaft fractures were identified using ICD9 codes. We screened 1479 radiographs. Radiographs were excluded for high-energy trauma, tumor, or periprosthetic fracture. Two radiologists blinded to treatment scored 482 radiographs for AFF features, and jointly adjudicated discrepancies. The required AFF feature, low-energy trauma fractures between the lesser trochanter and supracondylar flare, occurred in 98 patients. These 98 had additional major AFF feature prevalence of: 64% lateral or uncertain origin; 98% complete/incomplete lateral fracture; 71% minimally comminuted/noncomminuted; 49% periosteal/endosteal reaction. A total of 57 (58%) of the femoral shaft fractures met AFF criteria (16% of the 98 having four major features, and 42% having five major features). Initial radiologist score agreement for AFF was 93%. All 11 patients with bilateral femoral shaft fractures had AFF (ten with bilateral AFF).

Fifty-four AFF cases were race- and sex-matched to 108 controls having non-AFF femoral fractures. Clinical variables were similar between controls having non-AFF fractures in the femoral shaft (n=29) and those with non-shaft control fractures (n=79). Drug use was determined primarily from dispensing records and augmented by chart review. AFF were associated with bisphosphonates within 5 years, glucocorticoid use at fracture occurrence, prodromal pain and lower alkaline phosphatase. Age, cortical thickness, prior osteoporotic fracture, other medical conditions and proton pump inhibitors were not associated with AFF.

Cases (N=54)Controls (N=108)OR (CI)P-value
Age (S.D.) years72.8 (11.0)74.0 (16.5)1.00 (0.97–1.02)0.67
Prodromal pain39%5%13.04 (3.87–43.88)<0.0001
Bisphosphonates in 5 years 57%8%13.69 (4.81–38.99)<0.0001
Oral glucocorticoids 17%3%6.00 (1.62–22.16)<0.01

Over half of the low-energy trauma femoral shaft fractures met the ASBMR 2013 AFF criteria. Though strongly associated with bisphosphonates, additional risk factors should be considered for AFF.

Volume 5

43rd Annual European Calcified Tissue Society Congress

Rome, Italy
14 May 2016 - 17 May 2016

European Calcified Tissue Society 

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