ECTS2016 Poster Presentations Osteoporosis: pathophysiology and epidemiology (55 abstracts)
Atypical femur fractures (AFF): a case-control study
Erik Imel 1, , George Eckert 3 , Katie Allen 2 , Julie Chandler 4 , Joel Martin 2 , Siu Hui 2, , C Conrad Johnston 1 , Anne DePapp 4 , Art Santora 4 , Robert Choplin 1 , Trenton Roth 1 & Ziyue Liu 3
1Indiana University School of Medicine, Indianapolis, Indiana, USA; 2Regenstrief Institute, Indianapolis, Indiana, USA; 3Indiana University School of Public Health, Indianapolis, Indiana, USA; 4Merck, Sharp and Dohme, Whitehouse Station, New Jersey, USA.
Atypical femur fractures (AFF) have been associated with antiresorptive therapy. In a retrospective case-control study, we identified AFF using ASBMR 2013 criteria. Femoral shaft fractures were identified using ICD9 codes. We screened 1479 radiographs. Radiographs were excluded for high-energy trauma, tumor, or periprosthetic fracture. Two radiologists blinded to treatment scored 482 radiographs for AFF features, and jointly adjudicated discrepancies. The required AFF feature, low-energy trauma fractures between the lesser trochanter and supracondylar flare, occurred in 98 patients. These 98 had additional major AFF feature prevalence of: 64% lateral or uncertain origin; 98% complete/incomplete lateral fracture; 71% minimally comminuted/noncomminuted; 49% periosteal/endosteal reaction. A total of 57 (58%) of the femoral shaft fractures met AFF criteria (16% of the 98 having four major features, and 42% having five major features). Initial radiologist score agreement for AFF was 93%. All 11 patients with bilateral femoral shaft fractures had AFF (ten with bilateral AFF).
Fifty-four AFF cases were race- and sex-matched to 108 controls having non-AFF femoral fractures. Clinical variables were similar between controls having non-AFF fractures in the femoral shaft (n=29) and those with non-shaft control fractures (n=79). Drug use was determined primarily from dispensing records and augmented by chart review. AFF were associated with bisphosphonates within 5 years, glucocorticoid use at fracture occurrence, prodromal pain and lower alkaline phosphatase. Age, cortical thickness, prior osteoporotic fracture, other medical conditions and proton pump inhibitors were not associated with AFF.
| Cases (N=54) | Controls (N=108) | OR (CI) | P-value | |
| Age (S.D.) years | 72.8 (11.0) | 74.0 (16.5) | 1.00 (0.97–1.02) | 0.67 |
| Prodromal pain | 39% | 5% | 13.04 (3.87–43.88) | <0.0001 |
| Bisphosphonates in 5 years | 57% | 8% | 13.69 (4.81–38.99) | <0.0001 |
| Oral glucocorticoids | 17% | 3% | 6.00 (1.62–22.16) | <0.01 |
Over half of the low-energy trauma femoral shaft fractures met the ASBMR 2013 AFF criteria. Though strongly associated with bisphosphonates, additional risk factors should be considered for AFF.
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