1. Atypical Femoral Fractures: What Do We Know About Them?
by Aasis Unnanuntana, Anas Saleh, Kofi A. Mensah, John P. Kleimeyer, and Joseph M. Lane
J Bone Joint Surg Am
Volume 95(2):e8
January 16, 2013
©2013 by The Journal of Bone and Joint Surgery, Inc.

2. Radiographs of patients diagnosed with atypical femoral fractures.
Radiographs of patients diagnosed with atypical femoral fractures. The radiographic features of an atypical femoral fracture include a common location in the subtrochanteric (Fig. 1-A) or femoral shaft region (Fig. 1-B), transverse or short oblique fracture configurations, absence of comminution, a medial spike (asterisks), localized periosteal thickening of the lateral cortex (black arrowheads), and generalized thickening of the femoral cortices (white arrows).
Aasis Unnanuntana et al. J Bone Joint Surg Am 2013;95:e8
©2013 by The Journal of Bone and Joint Surgery, Inc.

3. Radiographs and a table comparing common clinical and radiographic features of an atypical femoral fracture (Fig. 2-A), an osteoporotic femoral fracture (Fig. 2-B), and a high-energy fracture of the femur (Fig. 2-C).
Radiographs and a table comparing common clinical and radiographic features of an atypical femoral fracture (Fig. 2-A), an osteoporotic femoral fracture (Fig. 2-B), and a high-energy fracture of the femur (Fig. 2-C).
Aasis Unnanuntana et al. J Bone Joint Surg Am 2013;95:e8
©2013 by The Journal of Bone and Joint Surgery, Inc.

4. Flowchart illustrating the potential pathogenesis by which long-term bisphosphonate treatment may increase the risk of atypical femoral fractures.
Flowchart illustrating the potential pathogenesis by which long-term bisphosphonate treatment may increase the risk of atypical femoral fractures.
Aasis Unnanuntana et al. J Bone Joint Surg Am 2013;95:e8
©2013 by The Journal of Bone and Joint Surgery, Inc.

5. Figs. 4-A and 4-B Radiographs of a fifty-eight-year-old postmenopausal Thai woman with an atypical femoral fracture.
Figs. 4-A and 4-B Radiographs of a fifty-eight-year-old postmenopausal Thai woman with an atypical femoral fracture. Fig. 4-A An anteroposterior radiograph of the proximal aspect of the femur revealed an ellipsoidal thickening in the left subtrochanteric region (arrow), compatible with a chronic stress reaction of the lateral femoral cortex. Fig. 4-B A complete fracture developed from the stress reaction, creating a beak in the cortex on one side (arrowhead). (Reproduced from: Unnanuntana A, Kleimeyer JP. Osteoporosis: risk factors, evaluation and management. In: Peña AR, Perez VO, editors. Osteoporosis: risk factors, symptoms and management. Hauppauge, New York: Nova Science Publishers; This material is reproduced with permission of Nova Science Publishers, Inc.)‏
Aasis Unnanuntana et al. J Bone Joint Surg Am 2013;95:e8
©2013 by The Journal of Bone and Joint Surgery, Inc.

6. Fourier transform infrared (FTIR) images and associated pixel histograms with Gaussian fits of collagen maturity (Fig. 5-A) and crystallinity (Fig. 5-B) in cortical bone treated (+BIS) and untreated (−BIS) with bisphosphonate.
Fourier transform infrared (FTIR) images and associated pixel histograms with Gaussian fits of collagen maturity (Fig. 5-A) and crystallinity (Fig. 5-B) in cortical bone treated (+BIS) and untreated (−BIS) with bisphosphonate. The mean and the full width at half maximum (FWHM) values of the Gaussian curve are indicated on each histogram. (Reproduced from: Donnelly E, Meredith DS, Nguyen JT, Gladnick BP, Rebolledo BJ, Shaffer AD, Lorich DG, Lane JM, Boskey AL. Reduced cortical bone compositional heterogeneity with bisphosphonate treatment in postmenopausal women with intertrochanteric and subtrochanteric fractures. J Bone Miner Res. 2012;27(3): Copyright 2012 by the American Society for Bone and Mineral Research. This material is reproduced with permission of John Wiley & Sons, Inc.)‏
Aasis Unnanuntana et al. J Bone Joint Surg Am 2013;95:e8
©2013 by The Journal of Bone and Joint Surgery, Inc.

7. Figs. 6-A, 6-B, and 6-C Radiographs of a sixty-five-year-old woman with a history of alendronate treatment for five years.
Figs. 6-A, 6-B, and 6-C Radiographs of a sixty-five-year-old woman with a history of alendronate treatment for five years. Fig. 6-A An atypical femoral fracture on the right side was diagnosed. Fig. 6-B There were no signs of fracture-healing at seven months after the initial fixation with a cephalomedullary nail, and a diagnosis of nonunion was made (arrow). Fig. 6-C Revision of the internal fixation was performed with a fibular strut allograft and plate fixation. The patient also received teriparatide along with calcium and vitamin-D supplementation. A postoperative radiograph at one year after the revision surgery revealed a healed fracture (arrow).
Aasis Unnanuntana et al. J Bone Joint Surg Am 2013;95:e8
©2013 by The Journal of Bone and Joint Surgery, Inc.

8. Figs. 7-A and 7-B Imaging studies showing stress fractures of the femur.
Figs. 7-A and 7-B Imaging studies showing stress fractures of the femur. Fig. 7-A Technetium bone scintigraphy revealed increased tracer uptake in the femoral shaft on both sides. Fig. 7-B Magnetic resonance imaging showed an increased intensity around the subtrochanteric region of the left femur. An ellipsoidal cortical thickening was also noted at this region (arrow).
Aasis Unnanuntana et al. J Bone Joint Surg Am 2013;95:e8
©2013 by The Journal of Bone and Joint Surgery, Inc.

9. A proposed guideline for management of patients with atypical femoral fractures.
Aasis Unnanuntana et al. J Bone Joint Surg Am 2013;95:e8
©2013 by The Journal of Bone and Joint Surgery, Inc.

10. A proposed guideline for management of patients on prolonged bisphosphonate treatment.
Aasis Unnanuntana et al. J Bone Joint Surg Am 2013;95:e8
©2013 by The Journal of Bone and Joint Surgery, Inc.