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Aims. Treatment guidelines for atypical femoral fractures associated
with bisphosphonates have not been established. We conducted a systematic
review of the treatment of atypical femoral fractures first, to
evaluate the outcomes of surgical fixation of complete atypical fractures
and secondly, to assess whether prophylactic surgery is necessary
for incomplete atypical fractures. Materials and Methods. Case reports and series were identified from the PubMed database
and were included if they described the treatment of atypical femoral
fractures. In total, 77 publications met our inclusion criteria
and 733 patients with 834 atypical complete or incomplete femoral fractures
were identified. Results. For complete fractures, internal fixation was predominantly achieved
by intramedullary nailing. The mean time to healing post-operatively
was 7.3 months (2 to 31). Revision surgery for nonunion or implant
failure was needed in 77 fractures (12.6%). A greater percentage
of fractures treated with plate fixation (31.3%) required revision
surgery than those treated with intramedullary nailing (12.9%) (p
<
0.01). Non-operative treatment of incomplete fractures failed and surgery
was eventually needed in nearly half of the patients (47%), whereas
prophylactic surgery was successful and achieved a 97% rate of healing. Conclusion. Intramedullary nailing is the first-line treatment for a complete
fracture, although the risk of delayed healing and revision surgery
seems to be higher than with a typical femoral fracture. Non-operative
treatment does not appear to be a reliable way of treating an incomplete
fracture: prophylactic intramedullary nailing should be considered
if the patient is in intractable pain. Radiographs of the opposite
side should be obtained routinely looking for an asymptomatic fracture.
Bisphosphonates must be discontinued but ongoing metabolic management
in the form of calcium and/or vitamin D supplements is advisable.
Teriparatide therapy can be considered as an alternative treatment. Cite this article: Bone Joint J 2017;99-B:295–302