scholarly journals Histopathological Finding of Microdamage Accumulation in Atypical Subtrochanteric Femoral Fracture

2021 ◽  
Vol 2021 ◽  
pp. 1-6
Author(s):  
Yo Watanabe ◽  
Naoki Kondo ◽  
Tomomi Fukuhara ◽  
Norio Imai ◽  
Masahiko Yamada ◽  
...  
Keyword(s):  
Fracture Healing ◽  
Revision Surgery ◽  
Femoral Fracture ◽  
Femoral Fractures ◽  
Fracture Site ◽  
Atypical Femoral Fractures ◽  
Histopathological Findings ◽  
Primary Surgery ◽  
Microdamage Accumulation ◽  
Subtrochanteric Femoral Fracture

Atypical femoral fracture is a low-energy stress fracture in the subtrochanteric region or the femoral shaft and is a complication of the long-term use of bisphosphonates. Histopathological findings of atypical femoral fractures have not been clarified. Herein, we report the case of a 61-year-old woman who fell while walking, which prompted her to visit our facility. She had a 7-year history of alendronate use to treat osteoporosis. A radiograph showed an atypical subtrochanteric femoral fracture, following which she underwent a primary surgery, where an intramedullary femoral nail was used. Implant breakage was discovered 8 weeks after the primary surgery. The patient underwent a revision surgery in which the entry point for the revised intramedullary hole was created to prevent varus position. The lag screw was successfully inserted into the center of the femoral head. Cancellous bone, isolated from the right ilium, was autogenously implanted into the fracture site. Fracture healing was promoted using low-intensity pulse ultrasonography. Callus formation was detected on a radiograph, and full weight-bearing was advised 12 weeks after the revision surgery. The fracture had healed completely at 13 months after the revision surgery. The patient was able to walk without support and could independently perform activities of daily life. Laboratory findings suggested that the concentrations of her bone formation markers were normal, while those of bone resorption markers were elevated. Iliac bone histomorphometry did not reveal severely suppressed bone turnover. In the cortex of fracture site, the lacunar density was markedly lower than the osteocyte density, and microcracks were detected, suggesting impaired osteocyte function and a low potential for fracture healing. This case is notable because it helps to clarify the histopathological findings of atypical femoral fractures.

scholarly journals Exchange Nailing as Revision Surgery for Post-operative Non-union of Atypical Femoral Fractures: A Case Report and Treatment Strategy

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Tomohiro Yasuda ◽  
Masayuki Arai ◽  
Daichi Shinohara ◽  
Yuki Samejima ◽  
Koji Kanzaki ◽  
...  
Keyword(s):  
Case Report ◽  
Revision Surgery ◽  
Femoral Fracture ◽  
Callus Formation ◽  
Femoral Fractures ◽  
Femoral Shaft ◽  
Medullary Canal ◽  
Atypical Femoral Fractures ◽  
Non Union ◽  
Exchange Nailing

Introduction: Atypical femoral fractures account for only 0.5% of femoral shaft fractures, but delayed union or non-union occurs in 50% of atypical femoral fractures accompanied by femoral lateral bowing. Such fractures are difficult to treat. Case Report: The case was an 84-year-old woman. She was diagnosed post-operative non-union of atypical femoral fracture. We planned a revision surgery for post-operative non-union of the atypical proximal femoral fracture. A two-dimensional template was used to simulate the intramedullary nail (IMN). Due to the advanced femoral lateral bowing deformity, a mismatch with the nail was noted when the unaffected femur was used to construct the template. When the opposite side nail was used as a template, the nail was aligned with the medullary canal, and the tip of the nail coincided with the center of the medullary canal; hence, the opposite side nail was chosen. Radiographical assessments of healing of the fracture confirmed callus formation and complete bone union 3 months and 1 year after the operation, respectively. Conclusion: We found that exchange nailing as revision surgery for post-operative non-union of atypical femoral fractures combined with an IMN on the opposite side was useful. Keywords: Alendronate, femoral fracture, osteoporosis, revision surgery.

scholarly journals Endoprosthetic Reconstruction for a Displaced Atypical Femoral Fracture in a Cancer Patient with Poor Prognosis

2018 ◽  
Vol 2018 ◽  
pp. 1-5
Author(s):  
Hironari Tamiya ◽  
Hiroki Hagizawa ◽  
Takaaki Nakai ◽  
Yoshinori Imura ◽  
Takaaki Tanaka ◽  
...  
Keyword(s):  
Cancer Patient ◽  
Activities Of Daily Living ◽  
Cancer Patients ◽  
Femoral Fracture ◽  
Daily Living ◽  
Poor Prognosis ◽  
Femoral Fractures ◽  
Endoprosthetic Reconstruction ◽  
Atypical Femoral Fractures ◽  
Patients With Poor Prognosis

Zoledronate or denosumab treatment is beneficial for cancer patients with bone metastasis. However, each agent may trigger atypical femoral fractures. Incomplete atypical femoral fractures can be successfully treated with prophylactic intramedullary nailing. On the other hand, intramedullary nailing for displaced atypical femoral fractures occasionally causes problems with regard to bone healing, resulting in long-term treatment. In cancer patients with poor prognosis who experience atypical femoral fractures, improvement in activities of daily living should be the priority. Thus, we performed endoprosthetic reconstruction for a displaced atypical femoral fracture in a breast cancer patient with poor prognosis to enable walking in the early stage after the operation. Two weeks after the operation, she could successfully walk. The postoperative Musculoskeletal Tumor Society score was 47%, and it had improved to almost the preoperative level before injury (50%). In conclusion, endoprosthetic reconstruction for displaced atypical femoral fractures may be a first-line treatment approach to acquire early postoperative walking ability for improving activities of daily living in cancer patients with poor prognosis.

scholarly journals Clinical Features and Outcomes of Bilateral Atypical Femoral Fractures

2020 ◽  
Vol 2020 ◽  
pp. 1-7
Author(s):  
Kosuke Hamahashi ◽  
Toshihiro Noguchi ◽  
Yoshiyasu Uchiyama ◽  
Masato Sato ◽  
Masahiko Watanabe
Keyword(s):  
Clinical Features ◽  
Lupus Erythematosus ◽  
Femoral Fractures ◽  
Fracture Site ◽  
Prophylactic Surgery ◽  
Atypical Femoral Fractures ◽  
Lateral Cortex ◽  
Previously Treated ◽  
The Mean ◽  
Complete Fracture

Bilateral atypical femoral fractures (AFFs) are relatively rare. In this report, we retrospectively researched clinical features and outcomes of bilateral AFFs treated at our institution. We previously treated 4 patients (8 limbs) with intramedullary nailing for complete AFFs (6 limbs) and incomplete AFFs (2 limbs). The mean age at the first operation was 53.3 years, and all patients were female. Of the 4 patients, two had breast cancer, and another two had systemic lupus erythematosus. Three of them received bisphosphonates, and 2 received denosumab, proton pump inhibitor, or glucocorticoid therapy. Only 2 of 6 cases of incomplete AFFs had prodromal pain before progressing to complete fracture. The mean interval from the first surgery to contralateral fracture or prophylactic surgery was 16 months. Radiographically, complete bone union was achieved in 6 limbs. However, a small gap at the lateral cortex of fracture site remained in 2 limbs. Finally, all of the patients were pain-free and able to walk without a cane. It is absolutely necessary to confirm contralateral femoral conditions; however, prediction of progression to complete fracture based solely on prodromal pain was difficult. Therefore, we should advise patients about the danger of progression to complete AFFs even if they are asymptomatic, and a prophylactic surgery should be performed after obtaining informed consent.

Mid-term outcomes after the surgical treatment of atypical femoral fractures

2021 ◽  
Vol 103-B (11) ◽  
pp. 1648-1655
Author(s):  
Soo-Young Jeong ◽  
Kyu-Tae Hwang ◽  
Chang-Wug Oh ◽  
Joon-Woo Kim ◽  
Oog Jin Sohn ◽  
...  
Keyword(s):  
Plate Fixation ◽  
Femoral Fractures ◽  
Delayed Union ◽  
Fracture Site ◽  
High Grade ◽  
Atypical Femoral Fractures ◽  
Factors Affecting ◽  
The Mean

Aims The incidence of atypical femoral fractures (AFFs) continues to increase. However, there are currently few long-term studies on the complications of AFFs and factors affecting them. Therefore, we attempted to investigate the outcomes, complications, and risk factors for complication through mid-term follow-up of more than three years. Methods From January 2003 to January 2016, 305 patients who underwent surgery for AFFs at six hospitals were enrolled. After exclusion, a total of 147 patients were included with a mean age of 71.6 years (48 to 89) and 146 of whom were female. We retrospectively evaluated medical records, and reviewed radiographs to investigate the fracture site, femur bowing angle, presence of delayed union or nonunion, contralateral AFFs, and peri-implant fracture. A statistical analysis was performed to identify the significance of associated factors. Results The mean follow-up period was 70.2 months (36 to 191). There were 146 AFFs (99.3%) in female patients and the mean age was 71.6 years (48 to 89). The AFFs were located in the subtrochanter and shaft in 52 cases (35.4%) and 95 (64.6%), respectively. The preoperative mean anterior/lateral femoral bowing angles were 10.5° (SD 5.7°)/6.1° (SD 6.2°). The postoperative mean anterior/lateral bowing values were changed by 8.7° (SD 5.4°)/4.6° (SD 5.9°). Bisphosphonates had been used contemporarily in 115 AFFs (78.2%) for a mean of 52.4 months (1 to 204; SD 45.5) preoperatively. Nailing was performed in 133 AFFs (90.5%), and union was obtained at a mean of 23.6 weeks (7 to 85). Delayed union occurred in 41 (27.9%), and nonunion occurred in 13 (8.8%). Contralateral AFF occurred in 79 patients (53.7%), and the use of a bisphosphonate significantly influenced the occurrence of contralateral AFFs (p = 0.019). Peri-implant fractures occurred in a total of 13 patients (8.8%), and a significant increase was observed in cases with plating (p = 0.021) and high grade of postoperative anterolateral bowing (p = 0.044). Conclusion The use of a bisphosphonate was found to be a risk factor for contralateral AFF, and high-grade postoperative anterolateral bowing and plate fixation significantly increased the occurrence of peri-implant fractures. Long-term follow-up studies on the bilaterality of AFFs and peri-implant fractures are warranted. Cite this article: Bone Joint J 2021;103-B(11):1648–1655.

Metallurgical Failure Analysis of Intramedullary Nail Used for Femoral Fracture Stabilization

2016 ◽  
Vol 695 ◽  
pp. 178-182
Author(s):  
Brandusa Ghiban ◽  
Iulian Antoniac ◽  
Gheorghe Dan ◽  
Alexandru Ghiban ◽  
Razvan Ene
Keyword(s):  
Intramedullary Nail ◽  
Femoral Fracture ◽  
Microstructural Analysis ◽  
Femoral Fractures ◽  
Austenitic Stainless Steels ◽  
Longitudinal Section ◽  
Fracture Site ◽  
Fractographic Analysis ◽  
Fracture Stabilization ◽  
Tear Propagation

Currently orthopedics challenge is the use of intramedullary nails to straighten diaphyseal femoral fractures. In this paper it was conducted a case study on an intramedullary nail used for femoral fracture stabilization, in the case of one young patient. The evolution was unfavorable to the fracture site and the implant failed after three month of first surgical intervention. Intramedullary nail dimensions were 300mm length and 10mm in diameter. The following investigations were made in order to establish the failure causes: determination of the chemical composition through spectral analysis, macrostructural analysis using stereomicroscopy, optical microstructural analysis using optical microscopy, fractographic analysis using scanning electron microscopy. The final conclusions showed that the metallic biomaterial used for manufacturing the intramedullary nail was approximately an austenitic stainless steel AISI 316L, but with major microstructural defects. Macro-structural analysis revealed the presence of two zones of cracking, which are very rare at austenitic stainless steels. Also breaking with a fragile character has radial front tear propagation. In longitudinal section, cracks were evidenced due to the extraction operation and also the presence of corrosion products was shown. From fractographic analysis it was determined that intramedullary nail failure was predominantly through the mechanism of brittle fracture that took place at the point of maximum bending of the implant fragile.

scholarly journals Fraturas Atípicas do Fémur Associadas a Terapêutica Prolongada com Bisfosfonatos

2013 ◽  
Vol 26 (6) ◽  
pp. 746
Author(s):  
Francisco Flores Santos ◽  
José Pinheiro da Silva ◽  
Paulo Felicíssimo
Keyword(s):  
Femoral Fracture ◽  
Scientific Evidence ◽  
Femoral Fractures ◽  
Osteoporotic Fractures ◽  
Femoral Shaft ◽  
Term Treatment ◽  
Atypical Femoral Fractures ◽  
Long Term Treatment

Introduction: Long-term treatment with bisphosphonates has been associated to atypical femoral fractures whose features are now clearly defined.Clinical Cases: We present two cases of female patients under bisphosphonate treatment for over 10 years who were admitted to our institution for subtrochanteric and femoral shaft fractures after low-energy trauma. They presented, respectively, a transverse and a short oblique femoral fracture, with thickening of the lateral cortex. They underwent surgical treatment obtaining good functional and imaging result.Discussion: These cases fulfill the established criteria for atypical femoral fracture, thereby illustrating a serious adverse event of long-term treatment with bisphosphonates. Such relationship has still not been clearly established by scientific evidence. However, its effectiveness in preventing osteoporotic fractures is well proven.Conclusion: The atypical femoral fractures are possibly a serious adverse effect of the long-term treatment with bisphosphonates. Scientific evidence still supports its use, however, the physician must be aware of these events and closely follow-up these patients.

scholarly journals 505 Failed Femoral Nail with Significant Operative Technical Difficulty: A Practical Solution to Achieve Metalwork Extraction Using Conical Screw Remover

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
A Paluch ◽  
A Clarke ◽  
S Smith ◽  
S Adams
Keyword(s):  
Revision Surgery ◽  
Femoral Fractures ◽  
Technical Difficulty ◽  
Distal Segment ◽  
Fracture Site ◽  
Practical Solution ◽  
Non Union ◽  
Femoral Nail ◽  
Operative Difficulty ◽  
Im Nailing

Abstract Introduction There is a greater risk of delayed healing and revision surgery in atypical femoral fractures (AFFs). Although non-union in reamed intra-medullary (IM) nailing is relatively uncommon, it can lead to fracture of the nail and present a considerable challenge to the treating surgeon. Case Report We present a case of AFF treated with IM nail fixation. Metalwork failure of the nail prompted removal of distal locking screws and plating of the fracture site at 8 months. Failure of the plate-bone interface 3 months later led to further revision surgery to remove the broken metalwork. We focus on the significant operative difficulty encountered during removal of the failed IM metalwork and provide a novel practical solution to overcome this particular challenge - insertion of a conical cannulated screw remover under fluoroscopy guidance to create an interference fit with the distal segment of the broken nail. Discussion This case is an example of significant and unexpected intra-operative technical difficulty, requiring improvisation and teamwork to manage. We introduce an accessible and uncomplicated alternative to the existing techniques for removal of a broken femoral nail and in doing so hope to benefit peers and colleagues should they encounter similar difficulties in the future.

scholarly journals Outcomes for Elderly Patients With Atypical Femoral Fractures Compared to Typical Femoral Fractures for Length of Stay, Discharge Destination, and 30-Day Mortality Rate

2018 ◽  
Vol 9 ◽  
pp. 215145931882022 ◽  
Author(s):  
Dominic Davenport ◽  
James Duncan ◽  
Robert Duncan ◽  
Alastair Dick ◽  
Mohit Bansal ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Femoral Fracture ◽  
Femoral Fractures ◽  
Proximal Femoral Fracture ◽  
Short Term ◽  
Fractured Neck Of Femur ◽  
Neck Of Femur ◽  
Geriatric Population ◽  
Atypical Femoral Fractures ◽  
Trauma Unit

Introduction: Despite increasing recognition of atypical femoral fractures (AFFs), there’s conflicting evidence about incidence, aetiology, and short-term outcomes of these injuries. This study reports the incidence of AFFs at our center and compares the early postoperative outcomes against typical femoral fractures (TFFs). Methods: A retrospective observational cohort study of patients presenting to our trauma unit between November 2015 and July 2016 was undertaken. Inclusion criteria required radiologically confirmed proximal femoral fracture, which was then categorized as AFF or TFF. Primary outcome measures included length of stay, discharge destination, and 30-day mortality. Results: Two hundred thirty-nine patients presented to our trauma unit over 9 months with either a fractured neck of femur or proximal femoral fracture. A total of 122 were identified as pertrochanteric, subtrochanteric, or proximal femoral shaft fractures of which 25 (20.5%) displayed atypical radiographic features consistent with AFF. The 2 groups were similar for average age (TFF 85.3 years vs AFF 85.0 years), gender (19% vs 16% male gender), American Society of Anaesthesiology grade (3.0 vs 3.0), cognitive score (abbreviated mental test score = 7.03 vs 7.08), and preinjury place of residence (88.9% vs 92.0% lived in own home). Typical fractures were fixed with either dynamic hip screw or intramedullary nailing, all atypical fractures were fixed with intramedullary nailing. There was no statistical difference between the 2 groups for length of stay (12.8 days vs 14.3 days; P > .05), discharge to preinjury residence (45.1% vs 36%; P > .05), or 30-day mortality (8.1% vs 12%; P > .05). Discussion: In our predominantly geriatric population atypical radiographic features were observed in around 10% of patients presenting with proximal femoral fractures or fractured neck of femur. Previous studies have reported poor outcomes for pain, mobility, and length of stay after AFF. However, we observed no difference in short-term outcome measures when compared to patients with typical proximal femoral fracture patterns at our trauma unit. Conclusion: With modern principles of trauma care outcomes achieved following AFFs may be equivalent to typical femoral fractures in the geriatric population.

scholarly journals A Retrospective Review on Atypical Femoral Fracture: Operative Outcomes and the Risk Factors for Failure

2019 ◽  
Vol 10 ◽  
pp. 215145931986473 ◽  
Author(s):  
Yuen Shan Lai ◽  
Jackie Yee Man Chau ◽  
Siu Bon Woo ◽  
Christian Fang ◽  
Tak Wing Lau ◽  
...  
Keyword(s):  
Risk Factors ◽  
Femoral Fracture ◽  
Retrospective Review ◽  
Significant Risk ◽  
Femoral Fractures ◽  
Primary Outcome Measure ◽  
Atypical Femoral Fracture ◽  
Fisher Exact Test ◽  
Atypical Femoral Fractures

Background: Atypical femoral fractures have been demonstrated to have high risks of reoperation and nonunion. The aim of this study is to evaluate whether the quality of reduction following operative fixation of atypical femoral fracture predicts failure. Methods: This is a 6.5-year retrospective review of atypical femoral fractures from 2 centers in a high-income region. A total of 56 patients with 66 fractures met our inclusion criteria. The quality of reduction was evaluated from postoperative films according to Hoskins’ modification of Baumgartner criteria for subtrochanteric fractures. Our primary outcome measure was failure of treatment, defined as either reoperation or nonunion at 12 months. Results: There were a total of 8 reoperations (12% of all fractures) and 8 nonunion (12% of all fractures), affecting a total of 12 fractures (18%) in 12 patients (21%). Closed reduction ( P = .04) and poor quality of reduction ( P = .0227 Fisher exact test) are statistically significant risk factors for failure. Conclusions: An aim for anatomical reduction with both <4 mm maximal cortical displacement and <10° angulation can improve the operative outcome of atypical femoral fractures. The addition of open reduction may be beneficial.

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