Rare non-traumatic periprosthetic femoral fracture with features of an atypical femoral fracture: a case report

INTRODUCTION: Atypical femoral fractures have emerged as one of the potential complications of bisphosphonates during the past decade. The American Society for Bone and Mineral Research published a Task Force report on atypical femoral fractures in 2010 and a second report in 2014. Although the current definition of atypical femoral fractures in these reports excludes periprosthetic fractures, each of three published case reports describe a bisphosphonate-associated atypical femoral fracture that occurred around the stem of a total hip arthroplasty. We report a rare case of an atypical femoral fracture that occurred at the stem tip of a total hip arthroplasty that fulfills the major criteria defined by the second American Society for Bone and Mineral Research Task Force report for an atypical femoral fracture and that was associated with prolonged use of bisphosphonate. CASE PRESENTATION: A 69-year-old Japanese woman with a right cementless total hip arthroplasty undertaken 44 months previously had a right femoral shaft fracture that occurred without trauma. She related that the bone fractured while she was standing, after which she fell down. Radiographs showed a noncomminuted transverse fracture located at the tip of the stem with localized periosteal thickening of the lateral cortex. The fracture was complete, extending through both cortices, and was associated with a medial spike. Her history revealed that she had been taking prednisolone to treat dermatomyositis and interstitial pneumonia for approximately 15 years. Alendronate was administered for more than 7 years. We performed open reduction and internal fixation using a locking plate with cable grip. The latest follow-up was performed 2 years after the fracture surgery. Bony union was successful. She regained the ability to walk, although her activity was limited by her comorbidities. CONCLUSIONS: Although the current definition of an atypical femoral fracture excludes periprosthetic fractures, there may be a periprosthetic fracture with the same or similar pathology as that of an atypical femoral fracture. We must be vigilant and aware of this type of fracture, especially in patients with prolonged bisphosphonate use.