Objectives. Bisphosphonates are widely used as first-line treatment for primary and secondary prevention of fragility fractures. Whilst they have proved effective in this role, there is growing concern over their long-term use, with much evidence linking bisphosphonate-related suppression of bone remodelling to an increased risk of atypical subtrochanteric fractures of the femur (AFFs). The objective of this article is to review this evidence, while presenting the current available strategies for the management of AFFs. Methods. We present an evaluation of current literature relating to the pathogenesis and treatment of AFFs in the context of bisphosphonate use. Results. Six broad themes relating to the pathogenesis and management of bisphosphonate-related AFFs are presented. The key themes in fracture pathogenesis are: bone microdamage accumulation; altered bone mineralisation and altered collagen formation. The key themes in fracture management are: medical therapy and surgical therapy. In addition, primary prevention strategies for AFFs are discussed. Conclusions. This article presents current knowledge about the relationship between bisphosphonates and the development of AFFs, and highlights key areas for future research. In particular, studies aimed at identifying at-risk subpopulations and organising surveillance for those on long-term therapy will be crucial in both increasing our understanding of the condition, and improving population outcomes. Cite this article: N. Kharwadkar, B. Mayne, J. E. Lawrence, V. Khanduja. Bisphosphonates and atypical subtrochanteric fractures of the femur. Bone Joint Res 2017;6:144–153. DOI: 10.1302/2046-3758.63.BJR-2016-0125.R1

The October 2024 Trauma Roundup³⁶⁰ looks at: Early versus delayed weightbearing following operatively treated ankle fracture (WAX): a non-inferiority, multicentre, randomized controlled trial; The effect of early weightbearing and later weightbearing rehabilitation interventions on outcomes after ankle fracture surgery; Is intramedullary nailing of femoral diaphyseal fractures in the lateral decubitus position as safe and effective as on a traction table?; Periprosthetic fractures of the hip: Back to the Future, Groundhog Day, and horses for courses; Two big bones, one big decision: when to fix bilateral femur fractures; Comparison of ankle fracture fixation using intramedullary fibular nailing versus plate fixation; Unclassified acetabular fractures: do they really exist?

Periprosthetic fracture of the femur is an uncommon complication after total hip replacement, but appears to be increasing. We undertook a nationwide observational study to determine the risk factors for failure after treatment of these fractures, examining patient- and implant-related factors, the classification of the fractures and the outcome. Between 1979 and 2000, 1049 periprosthetic fractures of the femur were reported to the Swedish National Hip Arthroplasty Register. Of these, 245 had a further operation after failure of their initial management. Data were collected from the Register and hospital records. The material was analysed by the use of Poisson regression models. It was found that the risk of failure of treatment was reduced for Vancouver type B2 injuries (p = 0.0053) if revision of the implant was undertaken (p = 0.0033) or revision and open reduction and internal fixation (p = 0.0039) were performed. Fractures classified as Vancouver type B1 had a significantly higher risk of failure (p = 0.0001). The strongest negative factor was the use of a single plate for fixation (p = 0.001). The most common reasons for failure in this group were loosening of the femoral prosthesis, nonunion and re-fracture. It is probable that many fractures classified as Vancouver type B1 (n = 304), were in reality type B2 fractures with a loose stem which were not recognised. Plate fixation was inadequate in these cases. The difficulty in separating type B1 from type B2 fractures suggests that the prosthesis should be considered as loose until proven otherwise

Internal fixation for supracondylar fracture of the femur after total knee arthroplasty (TKA) is technically difficult and troublesome because the distal bony fragment is often osteoporotic and too small to fix by screws or K-wires. In addition, the femoral component interferes with the screws or K-wires to be inserted from distal direction for fixation of the fracture. Patients and Methods. Four knees in 4 patients (all female; average age, 81.5 +/− 2.6 years) with the fracture after TKA were treated with revision TKA. Follow-up period was between six months and 3 years postoperatively. Operative technique. All operations were performed with the patient in the supine position and using a curved anterior (Payer) approach with or without osteotomy of the tuberositas tibiae. The femoral component was removed with detachment from fractured bony fragments. New femoral component with long stem for fixation of the fracture were inserted with bone cement in each case. Post-operative regimen. On the third postoperative day the patient began flexion and exension exercise of the operated knee joint with a rehabilitation programmed by clinical path under the supervision of a physiotherapist. The use of crutches for ambulation was begun on the 10. th. to 14. th. postoperative day, and the extent of weight bearing was allowed individually according to the stability of the fixation of the fracture. The time to full weight bearing in each patient was 3 to 8 weeks postoperatively. Results. Postoperative courses were uneventful in all of the cases. The supracondylar fracture of the femur was rigidly fixed and healed radiographically within 8 weeks postoperatively in each case. The JOA scores were improved in all od the cases. The mean Japanese Orthopaedic Association (JOA) scores for the knees improved to 90 points postoperative. No femoral components had definite radiographic evidence of loosening and were re-revised. Discussion. In the current study of short-term results of revision total knee arthroplasty for treatment of supracondylar fracture of the femur after total knee with osteoporosis, the component have shown to remain stable in weight bearing conditions and functioned well. Fracture healing and good clinical outcome, evaluated according to the JOA score, were achieved in all cases. Longer-term outcome should be the subject of further investigation. Conclusion. The revision TKA was a successful method for treatment of the supracondylar fracture after TKA

Purpose: Treating fractures of the femur in patients with a total hip arthroplasty is a difficult task. The frequency of these fractures is estimated at 1% to 3%. The purpose of this work was to evaluate the long-term clinical and radiological outcome and to search, by type of fracture, for factors predictive of late complications in order to improve indications. Material and methods: Since 1985, we collected data on 29 patients (17 women and 12 men) mean age 73.3 years who had a fracture of the femur after total hip arthroplasty. By definition, intraoperative fractures were excluded. Two independent operators noted epidemiological, therapeutic and imaging data and classed the fractures using the Vancouver classification. Treatments used were noted and clinical and radiological outcomes at mean follow-up of 24 months (6–140) were analysed. Results: Falls were the cause of the fractures in 31 patients (84%). Six of these patients had a revision prosthesis. Five fractures were in a zone of unprotected weakness. The fractures were trochanteric (n=9), periprosthetic (n=18), or below the stem (n=2). Nine patients were treated by isolated osteosynthesis and eleven by replacing the prosthesis. The Beals score was used to assess outcome taking into account the stability and the quality of the implant fixation as well as fracture realignment. In patients whose fracture was around the stem, outcome was excellent in two, good in one, and poor in four. For fractures of the lesser trochanter (n=4), outcome was excellent in two and good in two. For fractures below the stem (n=2), outcome was good in both. There was one case of deep infection. Discussion: Considering the same types of fractures, orthopaedic treatments produced poor results (6/11), unlike prosthesis replacement (2/11) and osteosynthesis (1/9). The number of loosenings was underestimated, leading to failure of orthopaedic treatment. Conclusion: In the event of fracture of the proximal femur in patients with a total hip arthroplasty, any suspected loosening, particularly of a cemented stem, should lead to prosthesis revision rather than orthopaedic treatment or simple osteosynthesis

Between 1996 and 2003 six institutions in the United States and France contributed a consecutive series of 234 fractures of the femur in 229 children which were treated by titanium elastic nailing. Minor or major complications occurred in 80 fractures. Full information was available concerning 230 fractures, of which the outcome was excellent in 150 (65%), satisfactory in 57 (25%), and poor in 23 (10%). Poor outcomes were due to leg-length discrepancy in five fractures, unacceptable angulation in 17, and failure of fixation in one. There was a statistically significant relationship (p = 0.003) between age and outcome, and the odds ratio for poor outcome was 3.86 for children aged 11 years and older compared with those below this age. The difference between the weight of children with a poor outcome and those with an excellent or satisfactory outcome was statistically significant (54 kg vs 39 kg; p = 0.003). A poor outcome was five times more likely in children who weighed more than 49 kg

Aim: the aim of the study is to show that the supracon-dylar nail, for fracture of distal femur has only advantage. Materials and methods: Between 1996–2002 in our hospital we treated 25 fracture of distal femur with the supra-condylar nail. A.O. Classification A1=9, A2=6, A3=3 C1=4, C2=3, C3=0. Seven patients had and more than one fractures. We had two periprothetic fractures. We used open reduction in 8 patients, and closed reduction in 14 patient. We follow up 23 patient, 2 of them had died 2 and 3 years after the operative treatment. Result: The allayment of the leg was good in all patients. We saw callus formation in all fractures in 10–20 weeks (14 w.) no pseudarthrosis, no allograft had been used, no infection. The movement of the knee was full range of motion in type A fracture, and in type C was 100–110. We saw that all fracture united, we have no valgus or varus deformity. Conclusion: Our result shows that the stability of the fractures of distal femur with supracondylar nail is very good method throw a small incision in type A, and C fracture

The hospital records of 222 cases of ipsilateral fractures of the femur and tibia were reviewed, and patients were grouped according to the type of fracture and the method of treatment. Thirty-five per cent of patients required late operation for delayed union or non-union, osteomyelitis, refracture and malunion, regardless of the treatment group. A disturbing factor was the 30% incidence of osteomyelitis in patients treated by fixation of both fractures, almost three times the incidence when only one fracture was fixed. A 30% incidence of delayed union or non-union occurred in patients managed conservatively. Of sixty-three patients personally examined, the worst results found were those following conservative management of both fractures. More use of rigid external fixation and of cast bracing is recommended in the management of the fractured tibia, combined with internal fixation of the femoral fracture. Examination of the knee suggested that, with ipsilateral fractures, disruption of ligaments is a common occurrence and should always be suspected

Post-operative periprosthetic fracture of the femur (POPFF) is a growing problem associated with increased mortality. Most registry derived estimates of mortality only record patients who undergo revision and cohort studies are generally limited to a single center, which makes comparison for the purposes of service improvement difficult. The aim of this study is to perform a systematic review and meta-analysis of cohort studies reporting mortality following POPFF in the last decade. Study methodology was peer-reviewed (PROSPERO: CRD42020170819). Literature search was conducted using Medline and EMBASE. Primary exposure was the diagnosis of POPFF, and the primary outcome measure was all-cause mortality: whilst an inpatient, within 30-days, within 90-days and within one year of POPFF. Proportion of patients dying (95% CI [confidence interval]) was estimated using metaregression. Results were compared to mortality following neck of femur fracture (NOF) from international NOF registry data. 4841 patients from 35 cohort studies were included. Study quality was generally low with a majority limited to a single centre. Weighted mean follow-up was 2.3 years and the most common POPFF was UCS B. Pooled proportion dying as an inpatient was 2.4% (95% CI 1.6% to 3.4%). Pooled proportion dying within 30 days was 3.3% (95% CI 2.0% to 5.0%). Pooled proportion dying within 90 days was 4.8% (95% CI 3.6% to 6.1%). Pooled proportion dying within one year was 13.4% (95% CI 11.9% to 14.8%). Mortality following POPFF was similar to that of NOF up to 30 days, but better at one year. 3.3% of patients die following POPFF within 30 days of injury. Mortality is similar to that experienced by patients following NOF up to 30 days, but better at one year, which may represent the lower underlying risk of death in the POPFF cohort. These results may form the basis for evaluation of services treating POPFF in the future

This abridged account of a report to the British Medical Research Council describes a long-term investigation of 1,503 subcapital fractures of the femur, almost all of which were treated by reduction and internal fixation. With three exceptions, union occurred in all Garden Stage I and Stage II fractures and in 67% of Stage III and Stage IV fractures, of which only 14-5% were united at six months. In women, late segmental collapse was seen after union had occurred in 16% of Stage I and in 27-6% of Stage III and Stage IV fractures. Delay of up to one week before operation had no significant effect on the incidence of non-union or of late segmental collapse. The incidence of union followed by late segmental collapse was higher in women with normal bone density than in those with osteoporosis. Smith-Petersen nailing was found to be the least effective form of fixation in displaced fractures. The age and physical state of the patient, the accuracy of reduction, and the security of fixation had the greatest influence on union

Introduction: The amount of tension which surgeons apply to a two-side Dall-Miles cable during the fixation of periprosthetic fracture has not been reported. Current study is the first report that reveals the real cable tension data which was intraoperatively measured. Methods: In vivo data of tightening torque was measured intraoperatively during Dall-Miles cable fixation surgeries for periprosthetic fracture of the femur. And the numerical relationship between torque and cable tension was assessed through mechanical tests. Using the torque vs. cable tension relationship, intraoperatively measured tightening torque was converted into a cable tension. Intraoperative measurement of tightening torque In vivo data of the maximal torque which was applied by an experienced surgeon was measured using a torquemeter. Total 11 cases of periprosthetic femoral fractures from 11 patients were participated with their agreement. A two-side Dall-Miles cable tightener (Stryker Co., USA) was used. To measure the torque of Dall-Miles tightener applied by a surgeon, a torquemeter (Torque driver 80FTD2-N-S, TOHNICHI, JAPAN) was connected to the Dall-Miles tightener through a square groove. The groove was machined with 1cm × 1cm × 1cm in dimension on the proximal end of the rotational shaft of the Dall-Miles tightener. Laboratory measurement of torque and tension To reveal the relationship between the torque of Dall-Miles cable tensioner and the tension of the cable, mechanical tests were done. A two-side Dall-Miles cable tightener were mounted to INSTRON (INSTRON, Norwood, MA, USA) using a customized fixation jig. One cable of 2 mm in diameter was connected to the upper head of INSTRON, and another to the lower headA preload was slowly applied to the cables up to 10 N so that the initially loose interaction among a tightener, two cables, and two loading heads of INSTRON became tight. Once the preloading finished, tightening torque and cable tension were simultaneously measured. The tightening torque was increased in increment of 1 N-m; accordingly, at each torque the tension hung to Dall-Miles cable was measured by reading loadcell data of INSTRON. Results: Intraoperative tightening torque Intraoperatively measured maximal torque applied to the Dall-Miles cable tensioner was 5.7±0.5 N-m. Numerical expression of torque-tension relationship Based on the data of tightening torque and cable tension measured from mechanical tests, the relationship between the torque (T) and tension (P) of Dall-Midles cable fixation system was numerically expressed. Total range of measured tightening torques and cable tensions was linearized. The linear expression was “T=106.8 × P”. Based on this numerical relationship, the amount of cable tension applied to the cable was calculated as 606.6±58 N. Discussion: This study revealed that 606.6±58 N of cable tension has been applied when an experienced surgeon does cable fixation of periprosthetic fracture. Authors believe that the torque-tension relationship will provide a key biomechanical clue for biomechanics scientists, and the amount of intraoperative cable tension measured at the time of Dall-Miles cable fixation for periprosthetic fracture will provide an important surgical key reference for the surgeons who use the cable fixation system

Introduction. Total hip arthroplasty (THA) using short design stem is surging with increasing movement of minimally invasive techniques. Short stems are easier to insert through small incisions preserving muscles. We have used these types of short stems since 2010. Almost all of the patients have shown good clinical results. However, two patients developed fatigue fractures on femurs post operatively. We have reviewed the clinical and radiographic results of these patients. Patients and methods. From April 2010, we have performed 621 THAs with short design stems, Microplasty. R. , Biomet, using a muscle preservation approach, the Direct Anterior Approach (DAA). The age ranged from 31 to 88 years old. Case1: 56y.o. male, BMI 23.1kg/m. 2. Preoperative diagnosis was bilateral osteoarthritis. Simultaneous THAs were performed on bilateral hips. He was allowed to bear as much weight as he could tolerate using an assistive device immediately after surgery, and followed standard hip precautions for the first 3 weeks. He was discharged from hospital seven days after surgery and returned to his job two weeks after surgery. He noticed sudden left thigh pain three weeks after surgery without any obvious cause. Crutches were recommended to partially bear his weight. Six weeks after surgery, a fracture line became visible on the radiographs and new callus formation also became visible. Three months after surgery, he felt no pain and was able to walk without any crutches. Case2: 66y.o. female, BMI 27.5 kg/m. 2. Preoperative diagnosis was bilateral osteoarthritis. THAs were performed on the hips at a six month interval. The right hip was operated on first, followed by the left hip. She was discharged from hospital four days after surgery and returned to her job six weeks after surgery. Two months later after left hip surgery, she suddenly felt pain on her left femur without any obvious cause, and was unable to walk. Three weeks later, X-rays showed fatigue fracture lines and new callus formations. After two or three months using crutches, her pain improved and X-rays showed good callus formation and no stem subsidence. Discussions. Several reports showed insufficiency fractures of the pelvis following THA. But most of them occurred due to repetitive stress on fragile bones. But our cases showed no evidence of osteoporosis. They had no history of trauma. But they had some points in common, which were they were bilateral cases and their BMI were not low. The incident rate of fatigue fractures of femur with this short stem THAs was 0.3% in our cases. We suggested that one of the causes of these fatigue fractures was the shortness of the stems. The shortness of the stems concentrate the body weight to limited contact area of the femur, and the stress causes the fatigue fractures. We should consider the risk of fatigue fractures on the patients who are operated on bilaterally. However these two patients showed good callus formations and no stem subsidence after a few weeks of partial weight bearing

1. A case of femoral artery occlusion after fracture of the femur occurring several days after internal fixation with a medullary nail is described. 2. Arterial reconstruction was undertaken seventeen days after the internal fixation, twenty-seven days after the injury, with restoration of flow and recovery of the limb

Introduction. Long-term use of bisphosphonates has been known to induce femoral insufficiency fracture in osteoporotic patients. We followed patients who had femoral insufficiency fractures after a long-term use of bisphosphonates. Methods. Eleven patients (14 hips) were diagnosed as having an insufficiency fracture of the femur after long-term (> 4 years) use of bisphosphonate to treat osteoporosis between January 2002 and December 2008. All patients were women who had a mean age of 68 years (range, 57 to 82 years). The fracture site was located in the subtrochanteric area in 6 hips and the femoral shaft in 8 hips. Three patients had bilateral involvement. These patients were followed-up for a mean of 27 months (range, 12 to 60 months). Results. Five hips in five patients displaced during the follow-up period. The mean period from the diagnosis of insufficiency fracture to the displacement was 10 months (range, 1 to 19 months). Five hips (five patients) underwent internal fixation due to persistent pain. Thus, during the follow-up of 27 months, operation was necessary in 71% (10 hips) of 14 insufficiency fractures. Four hips (four patients) that did not undergo any operation had persistent pain at the latest follow-up. Conclusion. The insufficiency fractures after prolonged bisphosphonate therapy seldom healed spontaneously and most of them required operation due to fracture displacement or persistent pain. We recommend preventive surgery to prevent further fracture displacement and persistent pain

Introduction. Basicervical fracture of the femur is one type of hip fracture, which is regarded as an extra and intra-capsular fracture. We experienced an atypical type of this fractures, the fracture line exist between subcapital portion at anterior aspect and base of the neck at posterior aspect, running through the neck with a shearing fracture line shown in the coronal plane. We investigate the characteristic and result of this fractures in our cases. Material & Methods. We treated seven cases, the mean age was 85(57–101) years old, the mean follow-up period was sixteen (3–27)months, and the cause of injury was fall in all cases. We evaluate treatment method, radiographical and clinical outcomes. Results. Four cases were treated with hemiarthroplasty and three were treated with osteosynthesis. Bone union was obtained within six months. There was no incidence of complications. Discussion & Conclusion. In the diagnosis of this fracture, we should pay careful attention to radiological assessment. In the treatment of this fracture, the anterior portion of proximal fragment is shorter than posterior portion, we should consider this characteristic of the fracture. We should be aware of cortical defect of the calcar in hemiarthroplasty, and have difficulty of reduction in osteosynthesis

Purpose of this study is to compare the two techniques, [sliding nail plate, or locking intramedullary nail type ã], and to estimate their results of the surgical treatment of the subtrochanteric fractures of the femur. Material and methods. From the January 1999 till December 2002, 38 subtrochanteric fractures patients have been operated in our clinic. According to the classification of AO/ASIF 12 of them were type A, 18 were type B and 8 type C. 28 patients were female & 10 male, aged from 41 to 90 years (mean 85 years old). 22 of cases were followed up for at least 6 months up to 20 months. 5 of the patients died for reasons other than the fracture itself and its treatment. The remaining 11 cases failed to appear for a follow-up. They were all surgically treated. In 8 cases we performed the 135 DHS nailing and in the 21 cases the 95 DCP nailing. In the remaining 9 fracture cases we performed intramedullary nail type ã nail. In some cases, (plaiting – surgery) we used allograft. There were no intrasurgical complications. Two material breakages, [failure], occurred as post-surgical complication [95 DCP), the one was treated with locking intramedullary nail type ã, and the other with prosthetic replacement [ Thomson]. The patients started moving immediately, although they used partial wait bearing in a period of 3 days to 6 weeks, depending on the type of fracture and internal fixation. The operation lasted from 3/4h up to 2h and we transfused from 1 to 3 blood units (mean 2,5). Results were better with locking intramedullary nail, than with any type of plating, [biological advantages – less failure]. Conclusion. All subtrocanteric fractures should be treated by stable internal fixation. Our recent experience with the new undreamed AO nail, and its versatile proximal locking has been very favorable

1. Volkmann’s ischaemia is a real and threatening complication of fracture of the femur, and it is more common than reports in the literature would suggest. 2. The early signs and symptoms in the calf are ominous whereas the early vascular signs of a good tibial pulse, colour and temperature are often misleading. 3. Muscle decompression with or without arterial exploration has proved to be of no value. 4. Early recognition and radical treatment are imperative. Temporary paralysis of the lumbar sympathetic outflow has been shown to be an effective measure. 5. Transfixion of the calcaneum with a Kirschner wire for traction has the advantage of eliminating all bandages, suspending the tender calf and preventing an equinovarus deformity. 6. The only essential difference between the histological appearance of muscle which recovers and that which does not appears to be degeneration of muscle nuclei. The significance of engorged blood vessels remains in doubt. 7. Histological studies suggest that despite the typical gross appearance of an infarct some regeneration of muscle may occur

We report a prospective study of 198 cases of subcapital fracture of the femur treated by closed reduction and fixation with a sliding compression screw-plate. This was done without regard to the patient's age or the Garden stage of the fracture. Early weight-bearing was encouraged. Of the displaced fractures 23% failed in the first year because of non-union or infection. Of the fractures which united 27% had developed avascular necrosis after three years. Despite this we believe that the sliding compression screw-plate, of proven value in the treatment of intertrochanteric fractures, is also useful for the fixation of subcapital fractures

We conducted a randomised controlled trial to compare external fixation of trochanteric fractures of the femur with the more costly option of the sliding hip screw. Patients in both groups were matched for age (mean 67 years, 50 to 100) and gender. We excluded all pathological fractures, patients presenting at more than one week, fractures with subtrochanteric extension or reverse obliquity, multiple fractures or any bone and joint disease interfering with rehabilitation. The interval between injury and operation, the duration of surgery, the amount of blood loss, the length of hospital stay and the cost of treatment were all significantly higher in the sliding hip screw group (p < 0.05). The time to union, range of movement, mean Harris hip scores and Western Ontario and McMaster University knee scores were comparable at six months. The number of patients showing shortening or malrotation was too small to show a significant difference between the groups. Pin-track infection occurred in 18 patients (60%) treated with external fixation, whereas there was a single case of wound infection (3.3%) in the sliding hip screw group

1. A report is presented of the results of a trial to compare the effects of early and late weight-bearing in patients with a transcervical fracture of the femur treated by reduction of the fracture and internal fixation with a sliding nail-plate. 2. One hundred and twelve patients have been assessed clinically and radiologically three years after operation. 3. Retrospective analysis of factors that affect the outcome of treatment suggests that the two groups were fairly evenly balanced. 4. The results show that full weight-bearing two weeks after operation did not increase the incidence of failure of fixation or of non-union. 5. The higher incidence of superior segmental collapse in patients in whom weight-bearing was deferred for twelve weeks can be explained by the greater number of high fractures in this group and the greater number with a poor reduction