The prevention as well as the treatment of atypical femur fractures (AFFs) remains controversial but there have been many clinical recommendations suggested. We have summarized these recommendations as well as expanded upon them in this paper.
BACKGROUND: The purpose of the paper was to develop a clinical practice guideline that both treats AFF and decreases the risk of AFF in patients requiring antiresorptive medications. Examples of these medications include bisphosphonates and denosumab for the treatment of osteoporosis.
METHODS: A literature review looking for recommendations on AFF identification, management, and prevention was done. We also performed an updated review of clinical guidelines on AFF prevention and treatment that were developed for the Kaiser Permanente osteoporosis/fracture prevention team.
RESULTS: Concise clinical practice guidelines are presented that can be applied in treatment of AFF as well as help reduce the risk of developing an AFF in patients requiring antiresorptive medications. These guidelines are based on using both typical fracture and AFF risk assessment to determine duration of antiresorptive of 3 to 5 years before consideration if a drug holiday is needed. Specific groups such as younger Asian women should be reassessed at 3 years with DXA and FRAX to see if a drug holiday is needed whereas patients at higher risk for typical fractures may be reassessed at 5 years of treatment. The DXA rescreening can now be accessed if focal or generalized lateral cortex changes are present that may indicate incomplete AFFs are present. If an incomplete AFF is discovered either by DXA or by other imaging studies, it is imperative to stop antiresorptive medications and to take additional measures to lower the risk of progression to a complete AFF. If complete AFF does occur, then antiresorptive medications should be stopped and additional measures should be taken to decrease the risk of developing an AFF on the contralateral femur.
CONCLUSIONS: Clinical practice guidelines for the treatment and prevention of AFF will benefit clinicians who are frequently faced with having to make clinical decisions in patients requiring antiresorptive medications.