Virginia Via Research Day Book 2026

Medical Resident Research Case Reports

12 BACKFIRING BISPHOSPHONATES: A TALE OF TWO FRACTURES

Tanner Weaver, DO, PGY3; Patrick Szukics, DO Corresponding author:Tanner.Weaver@lpnt.net

Sovah Health - Danville, Danville, Virginia

in the left subtrochanteric region and the right mid diaphysis, without complete fracture, displacement, or vascular collapse. Treatment: Given the patient's presentation and high risk of complete transverse fracture with a low energy event, the patient was scheduled to the OR the following week. The patient underwent bilateral long femoral cephalomedullary nailing without intraoperative complications. In order to limit fat embolism risk, a unicortical hole was drilled into the lateral aspect of the femur, and suction was introduced. The patient was monitored in the hospital post-op and developed an AKI and was complicated by anemia requiring 2 units of RBCs. At discharge, the patient was sent to subacute rehab for continued PT. Diagnosis: Bilateral atypical femoral fractures due to prolonged bisphosphonate use. Comment: In this patient, an 82-year-old female on bisphosphonate therapy for the last 15 years, was found to have bilateral atypical femoral fractures. Literature review revealed the rarity of the fracture type, with

one study of 1,234 women with subtrochanteric or shaft fractures, and only 4.6% of them being atypical. Further review showed that the absolute risk of atypical fracture in patients taking bisphosphonates for less than 5 years was 3.2 and 50 cases per 100,000 patient years, with use of more than 5 years increasing the risk to about 100 per 100,000 patients. After cessation of bisphosphonates, risk of atypical fractures fell by 70%. Conclusion: After five years of bisphosphonate use, risk/benefit discussion should be had and alternative agents, such as anabolic biologics, like teriparatide or biologics like denosumab, should be considered in these patients.

Context: Atypical femoral fractures are a rare but serious side effect of prolonged bisphosphonate use in the treatment of osteoporosis. Case Report: An 82-year-old female presented to the outpatient clinic for evaluation of bilateral leg pain ongoing for 8 months. There was no known inciting traumatic event leading to the pain. The pain is described as deep bone pain and rated a 7/10. Imaging revealed increased signal intensity on the left femur in the subtrochanteric region, lateral cortex, as well as the lateral cortex of the right mid-shaft femur, consistent with stress fractures. The patient was found to have 15+ years of bisphosphonate use for the treatment of osteoporosis. This raised concern for atypical femoral fractures. Pertinent comorbidities include CKD3, severe scoliosis, and fibromyalgia. On initial presentation, the physical exam was significant for tenderness to palpation on bilateral thighs, 4+/5 muscle strength at the hip flexors, extensors, the knee flexors, and extensors, ankle in dorsiflexion, and plantar flexion. The exam was limited secondary to the patient’s pain. Repeat imaging was performed, which showed lateral cortical thickening and transverse stress line appearance

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