I'm Angela Cheung
from Toronto, Canada,
and I am going to discuss
Atypical Femoral Fractures today.
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
on the Diagnosis, Management,
and Prevention of
Atypical Femoral Fractures.
I'm going to discuss
the definition, epidemiology,
clinical risk factors,
diagnosis and management,
of atypical femoral fractures.
Right now in osteoporosis,
these are the pharmacological therapies,
they are in Canada.
The first line therapies are
and estrogen in menopausal women
as well as bone formation therapy,
and we only have one,
it's called teriparatide.
These therapies have been shown
to reduce vertebral fracture,
and non-vertebral fractures
as you can see on the slide
based on randomized control trials.
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.
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,
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.
So the first thing we need to do is
look at the definition
of atypical femur fractures.
AFF are low-trauma stress fractures
in the subtrochanteric
or shaft region of the femur
with very specific radiographic findings
and they're associated
as well as denosumab therapy.
Hip fractures, the typical hip fractures
in the intertrochanteric area
or the femoral neck,
usually it's split 50-50
it can be in the subcapital area,
but it is actually less common
to be in the subtrochanteric area.
The ASBMR, the American Society
of Bone and Mineral Research
in 2010 and in 2014,
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.
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
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,
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.