The Journal of Bone and Joint Surgery (American). 2009;91:2556-2561.
doi:10.2106/JBJS.H.01774
© 2009 The Journal of Bone and Joint Surgery, Inc.
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Bilateral Low-Energy Simultaneous or Sequential Femoral Fractures in Patients on Long-Term Alendronate Therapy

Craig M. Capeci, MD1 and Nirmal C. Tejwani, MD2

1 Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, 301 East 17th Street, Suite 1401, New York, NY 10003. E-mail address: craig.capeci{at}nyumc.org
2 Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, 550 First Avenue, NBV 21W37, New York, NY 10016. E-mail address: nirmal.tejwani{at}nyumc.org

Investigation performed at the Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, NY

A commentary by Joseph M. Lane, MD, and Benjamin F. Ricciardi, MD, is available at www.jbjs.org/commentary and as supplemental material to the online version of this article.

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Background: While alendronate therapy has been shown to decrease the risk of vertebral and femoral neck fractures in postmenopausal osteoporotic patients, recent reports have associated long-term alendronate therapy with unilateral low-energy subtrochanteric and diaphyseal femoral fractures in a small number of patients. To our knowledge, there has been only one report of sequential bilateral femoral fractures in patients on long-term bisphosphonate therapy.

Methods: We retrospectively reviewed the case log of the senior author over the last four years to identify patients who presented with a subtrochanteric or diaphyseal femoral fracture after a low-energy mechanism of injury (a fall from standing height or less) and who had been taking alendronate for more than five years. Radiographs were reviewed, and the fracture patterns were recorded. Serum calcium levels were recorded when available.

Results: Seven patients who sustained low-energy bilateral subtrochanteric or diaphyseal femoral fractures while on long-term alendronate therapy were identified. One patient presented with simultaneous bilateral diaphyseal fractures, two patients had sequential subtrochanteric fractures, and four patients had impending contralateral subtrochanteric stress fractures noted at the time of the initial fracture. Of the latter four, one patient had a fracture through the stress site and the other three patients had prophylactic stabilization of the site with internal fixation. No patient had discontinued alendronate therapy prior to the second fracture. All patients were women with an average age of sixty-one years, and they had been on alendronate therapy for an average of 8.6 years. All fractures were treated with reamed intramedullary nailing and went on to union at an average of four months.

Conclusions: In patients on long-term alendronate therapy who present with a subtrochanteric or diaphyseal femoral fracture, we recommend radiographs of the contralateral femur and consideration of discontinuing alendronate in consultation with an endocrinologist. If a contralateral stress fracture is found, prophylactic fixation should be considered.

Level of Evidence: Prognostic Level IV. See Instructions to Authors for a complete description of levels of evidence.


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