Atypical femoral fractures and management of implant failures: a ten-year university hospital case series from Scotland UK

Abstract

Introduction: The management of osteoporosis continues to evolve, and patients are increasingly prescribed long-term bisphosphonates.  Atypical femoral fracture (AFF) has been recently identified and its management remains a challenge with high risk of non-union and subsequent implant failure.

Objectives: To review ten years retrospective data of patients with AFF and surgical management of failure of the implants at University Hospital, Scotland, UK.

Materials & Methods: This is a retrospective review of patients with AFFs from 2009 to 2018 carried out at University Hospital Crosshouse, Kilmarnock, Scotland, UK. Patients were included based on American Society for Bone and Mineral Research (ASBMR) guidelines. Demographic data and use of bisphosphonates were collected from case notes. Postoperative radiographs were reviewed for fracture healing. EQ-5D-5L scoring system was collected over the phone to measure functional outcome of patients. The cases of implant failures which required revision surgery were reviewed.

Results: The study includes 22 patients (26 fractures) with mean age of 75 ± 7.7 years. There were 16 atypical subtrochanteric and 10 atypical femoral shaft fractures. Patients were on Bisphosphonates for a mean of 9.8 ± 3.3 years in 88% cases without any medication holiday. All the fractures were managed with intramedullary nails except one using locking plate fixation. The mean time to complete union in 19 fractures was 9.1 ± 4.7 months (range 4–19 months). Two showed early radiological signs of healing before death. There were two asymptomatic non-unions and three implant failures. The EQ-5D-5L score showed that 65% patients had none or mild pain and mobility was maintained in 88% cases. The implant failures were managed with proximal femoral replacement in two cases and third patient had an osteotomy and dynamic hip screw fixation.

Conclusion: Most of our patients with atypical femoral fractures were on long term bisphosphonates. The surgical management with intramedullary nailing is our recommended first-line of treatment with proximal femoral replacement a viable salvage option.