Minimally Invasive Prophylactic Plating for Bisphosphonate-induced Atypical Femoral Fracture Post Total Hip...

Periprosthetic fractures are excluded from Atypical Femur Fractures as per the report of American Society for Bone and Mineral Research. However, there are increasing reports demonstrating the existence of atypical periprosthetic femur fractures (APFF) which are related to chronic bisphosphonate use. Literature states that these fractures can be treated as per the atypical femur fracture treatment algorithm, and prophylactic fixation can be suitable to treat symptomatic incomplete fractures. An impending or incomplete APFF can be an important reason for post-operative lateral thigh pain, which needs to be kept in mind, appropriately investigated and treated. We present a case of Bisphosphonate-induced APFF treated with minimally invasive plating, leading to good clinical results and pain relief.

In this case report, we present a 86-year-old female who came with a history of bilateral hip and knee arthritis and osteoporosis for which her General Practitioner had started her on bisphosphonates in the form of Ibandronic Acid 150 mg each month. The patient had undergone a right total hip replacement a year after, following which she was progressing well in the subsequent post-operative period. However, she developed new complaints of right thigh pain beginning 6-8 months post-operative. Investigations such as magnetic resonance imaging lumbar spine were done to rule out other causes, and also some therapeutic interventions, like US-guided injection to trochanter and gluteus tendon and physiotherapy were also tried, but unfortunately, provided no relief. Further imaging revealed features of impending APFF, and the patient underwent a prophylactic plating for the same after discussions in the regional arthroplasty multidisciplinary team meeting.

This case report highlights the possibility of APFF in elderly patients with post-operative thigh pain who have had a history of bisphosphonate use. When prophylactic nailing is not possible, spanning the length of the bone with minimally invasive plating gives good results and pain relief.