Atypical femoral fractures

Published on October 31, 2016   31 min
0:00
I'm Angela Cheung from Toronto, Canada, and I am going to discuss Atypical Femoral Fractures today.
0:09
These are my disclosures. I have received honoraria from, for CME events and/or grants to my institution from these companies. And I've also been a member of the ASBMR International Task Force on Atypical Femoral Fractures, as well as the Osteoporosis Canada Guidelines on the Diagnosis, Management, and Prevention of Atypical Femoral Fractures.
0:37
I'm going to discuss the definition, epidemiology, clinical risk factors, diagnosis and management, and prevention of atypical femoral fractures.
0:49
Right now in osteoporosis, these are the pharmacological therapies, they are in Canada. The first line therapies are antiresorptive therapies with bisphosphonates, denosumab, raloxifene, and estrogen in menopausal women with symptoms as well as bone formation therapy, and we only have one, it's called teriparatide. These therapies have been shown to reduce vertebral fracture, hip fractures, and non-vertebral fractures as you can see on the slide based on randomized control trials.
1:30
They've also been shown, especially the antiresorptive therapies with bisphosphonates and denosumab in a meta-analysis done by Bolland, they have been shown to reduce mortality as well. The relative risk here of 0.89 is statistically significant.
1:51
However, the issues with the current osteoporosis therapies is the issue of side effects. And there have been various side effects that have been discussed but one of the hot areas is around atypical femur fractures or atypical femoral fractures. It's been estimated to occur in 1 in a 1000 patient years after between 5-10 years of use. And that calls into question the issue of, how long should we treat, in terms of osteoporosis medications, especially with antiresorptive therapies?
2:33
One of the issues with atypical femur fractures is that everyone has a little bit of a snip pit of the whole picture. It's, kind of, like the blind man feeling the elephant. Some people think it's one thing and another person think it's another. And so it's really important that we get together and put our thinking hats together as well as actually looking at all the data that is out there as well.
3:02
So the first thing we need to do is look at the definition of atypical femur fractures.
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AFF are low-trauma stress fractures in the subtrochanteric or shaft region of the femur with very specific radiographic findings and they're associated with bisphosphonates as well as denosumab therapy.
3:27
Hip fractures, the typical hip fractures are usually in the intertrochanteric area or the femoral neck, usually it's split 50-50 and occasionally, it can be in the subcapital area, but it is actually less common to be in the subtrochanteric area.
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The ASBMR, the American Society of Bone and Mineral Research in 2010 and in 2014, published recommendations from the ASBMR Task Force on these atypical femur fractures. And I'm going to go through the definition that has been proposed by the task force.
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In 2010, the task force defined atypical femoral fractures with major features and minor features. All of the major features have to be satisfied but none of the minor features need to be satisfied to qualify as an atypical femur fracture. The major features include the location which is below the lesser trochanter and above the supracondylar flare of the femur has to involve little or no trauma, has to be transverse or short oblique configuration, non-comminuted, and the complete fractures extend through both cortices and may have a medial spike. The incomplete ones involve only the lateral cortex. And then there are many, sort of, minor features that have been discussed including delayed healing, localized periosteal reaction of the lateral cortex, general increase in cortical thickness, and prodromal symptoms, and also being bilateral as well as associate with some conditions and some drugs as well.
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Atypical femoral fractures

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