In a patient with bisphosphonate induced bilateral atypical femur fractures, how would you approach timing of alternative osteoporosis treatments and surgical management?

Unfortunately, this is still a very common problem. Although the information that oral bisphosphonates should likely be limited to 5 years duration has been available for many years, my large orthopaedic practice continues to see 2-4 atypical femur fractures per month and often the patient has been on oral bisphosphonates for 10 or more years. We also see patients with AFF's on high-dose IV bisphosphonates or denosumab as part of their treatment for breast or prostate cancer.

If the patient is b...

I generally agree with what’s been stated. If a patient post, AFF does not have risk factors for osteoporosis and has a normal bone density, they do not need further treatment. However, if a patient does remain a steel product despite the AFF then additional treatment is needed. Longitudinal studies of subjects who have had a fifth show they continue to fracture so we need to better understand the subgroup. However, if a patient is post, AFF and still remains at high risk of osteoporosis, they s...