What Do You Do About Atypical Femur Fractures?

Earlier this month, I had the privilege to lecture about osteoporosis at the annual Scientific Assembly of our American Academy of Family Physicians.  While osteoporosis is a bread & butter topic for geriatricians and family physicians who take care of large numbers of elders, our pharmaceutical armamentarium has been thrown into disarray by the recent findings of atypical femur fractures associated with bisphosphonate use.

The strength of the evidence, including its association with osteonecrosis of the jaw and possible esophageal+gastric cancer, is such that two of the Food & Drug Administration's advisory committees recently recommended that bisphosphonates be given for a finite period of time rather than the previous lifetime method.  Unfortunately, the committees were unable to arrive at a conclusion as to the duration of time for bisphosphonate use.

However, be that as it may, it's too late for the women who've already sustained an atypical femur fracture, as well as the ones who will, in all probability, develop one over the next several years given their length of use.  The big question is what do we have to offer these women?  In a study published in this month's Journal of Clinical Endocrinology & Metabolism, the authors demonstrated that strontium ranelate and teriparatide can heal these atypical femur fractures, even if they have been in a state of non-union for a year!  

Well, perhaps "study" isn't quite the right word since this was more a case report of 3 women who had sustained atypical femur fractures and did not heal until being adminstered either strontium ranelate or teriparatide.  In a related case report published earlier this summer in the same journal, the authors were able to help heal the atypical stress fracture sustained in a patient on alendronate for 13 years.  It should be noted that she was deficient in vitamin D which was subsequently rapidly repleted.

The point is to offer hope to women who've sustained rare atypical fractures while attempting to prevent the much more common osteoporotic hip fractures.  While the future will lead to more therapies, we need to practice now based upon the evidence before us, not what might be.

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