Screening for Atypical Femur Fractures Using Extended Femur Scans by DXA

Atypical femur fractures (AFFs) are a rare but serious complication associated with the use of antiresorptive drugs such as bisphosphonates. Assessment of incomplete AFFs on extended femur scans by dual-energy X-ray absorptiometry (DXA) may prevent the development of complete fractures. The aim of this study was to evaluate the potential of extended femur scans by DXA as a screening tool for incomplete AFFs. From June 2014 until September 2016, extended femur scans were routinely performed in all consecutive patients undergoing DXA scanning who had used bisphosphonates or denosumab at any given moment in the previous year. When "beaking" was found, defined as a localized periosteal or endosteal thickening of the lateral cortex, a radiograph of the femur was performed to confirm incomplete AFF. Beaking was detected in 12 of 282 patients (4.3%) with extended scans of both femora. In 9 patients (3.2%), beaking corresponded with the radiological presence of incomplete AFFs, of whom 4 already had an X-ray made because of a previous complete AFF of the other leg. Five patients (1.8%) were newly diagnosed with 6 yet unknown incomplete AFFs. No additional X-ray was performed in 2 patients because of loss of follow-up. Beaking was explained by known soft tissue calcifications in 1 patient. The positive predictive value of beaking on extended femur scan was 83.3% in our study. Three cases in whom the new diagnosis of incomplete AFF has affected medical and surgical treatment are further discussed to illustrate the relevance of early detection. We conclude that extended femur scans by DXA can detect incomplete AFFs in patients on antiresorptive treatment and should therefore be considered a clinically relevant screening tool because early identification of AFFs has therapeutic consequences. © 2017 American Society for Bone and Mineral Research.