Audit of atypical hip fractures at the Royal Berkshire Hospital

Abstract

Background:

There is increasing evidence suggesting an association between bisphosphonate use and the occurrence of atypical femoral fractures, which account for less than 1% of hip and femoral fractures overall. The aim of this audit was to assess the prevalence of atypical, bisphosphonate-related femoral fractures and adherence to regional (Fracture Reduction in South Central England [FRiSC]) guidelines in our departmental cohort.

Methods:

We retrospectively reviewed 1,803 patients from the National Hip Fracture Database (NHFD) with femoral fractures admitted to a district general hospital during a 49-month period. We studied all subtrochanteric fractures in patients admitted on bisphosphonates. Corresponding hip radiographs were examined for features of atypical fractures according to the American Society for Bone and Mineral Research diagnostic criteria.

Results:

The mean age of the patients included was 63 ± 8.08 years. One hundred and sixty-one femoral fractures were identified in patients on bisphosphonates; 73 intertrochanteric, 68 intracapsular, and 20 subtrochanteric. Ninety-three percent of these fractures were in women. Radiographs of the 20 subtrochanteric fractures were reviewed and five were classified as atypical, bisphosphonate-related fractures according to American Society for Bone and Mineral Research diagnostic criteria. Adherence with FRiSC guidelines was inconsistent. A repeat dual-energy X-ray absorptiometry scan was performed in only two cases. The bisphosphonate was stopped in only two of the five patients following fracture. No clinical assessment of the contralateral femur or radiological assessment was done in any of the five cases.

Conclusion:

Overall, five atypical femoral fractures were found in a cohort of 1,803 patients at our district general hospital. This is 0.3% of the population studied, consistent with the incidence reported in the literature. Improvements in adherence with local guidelines for the management of atypical femoral fractures, along with increasing awareness of the nature of these fractures is necessary amongst rheumatologists, orthopedic surgeons, and geriatricians.

Keywords::

• fracture
• bisphosphonate
• atypical