Koh A, Guerado E, Giannoudis P V
Kobe Rosai Hospital, 4-1-23 Kagoike-dori, Chuo-ku, Kobe, 651-0053, Japan.
University of Malaga, Autovia A-7 K, 187 29603, Marbella, Malaga, Spain.
Bone Joint J. 2017 Mar;99-B(3):295-302. doi: 10.1302/0301-620X.99B3.BJJ-2016-0276.R2.
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.
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.
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.
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: 2017;99-B:295-302.
与双膦酸盐相关的非典型股骨骨折的治疗指南尚未确立。我们首先对非典型股骨骨折的治疗进行了系统评价，以评估完全性非典型骨折手术固定的效果，其次评估不完全性非典型骨折是否需要预防性手术。
从PubMed数据库中检索病例报告和系列研究，纳入描述非典型股骨骨折治疗的研究。共有77篇出版物符合纳入标准，确定了733例患者的834例非典型完全性或不完全性股骨骨折。
对于完全性骨折，主要通过髓内钉进行内固定。术后平均愈合时间为7.3个月（2至31个月）。77例骨折（12.6%）需要因骨不连或植入物失败进行翻修手术。钢板固定治疗的骨折需要翻修手术的比例（31.3%）高于髓内钉固定治疗的骨折（12.9%）（p<0.01）。不完全性骨折的非手术治疗失败，近一半患者（47%）最终需要手术，而预防性手术成功，愈合率达97%。
髓内钉是完全性骨折的一线治疗方法，尽管延迟愈合和翻修手术的风险似乎高于典型股骨骨折。非手术治疗似乎不是治疗不完全性骨折的可靠方法：如果患者疼痛难忍，应考虑预防性髓内钉固定。应常规拍摄对侧X线片以寻找无症状骨折。必须停用双膦酸盐，但建议以补充钙和/或维生素D的形式进行持续的代谢管理。特立帕肽治疗可作为替代治疗方法。引用本文：2017；99-B：295-302。
