Surgical strategy of the treatment of atypical femoral fractures

Abstract

The atypical femoral fracture (AFF) has been attracting significant attention because of its increasing incidence; additionally, its treatment is challenging from biological and mechanical aspects. Although surgery is often required to manage complete AFFs, clear guidelines for the surgical treatment of AFFs are currently sparse. We reviewed and described the surgical treatment of AFFs and the surveillance of the contralateral femur. For complete AFFs, cephalomedullary intramedullary nailing spanning the entire length of the femur can be used. Various surgical techniques to overcome the femoral bowing common in AFFs include a lateral entry point, external rotation of the nail, and the use of a nail with a small radius of curvature, or a contralateral nail. In the case of a narrow medullary canal, severe femoral bowing, or pre-existing implants, plate fixation may be considered as an alternative. For incomplete AFFs, prophylactic fixation depends on several risk factors, such as a subtrochanteric location, presence of a radiolucent line, functional pain, and condition of the contralateral femur; the same surgical principles as those in complete AFFs can be applied. Finally, once AFF is diagnosed, clinicians should recognize the increased risk of contralateral AFFs, and close surveillance of the contralateral femur is recommended.

Keywords: Atypical femoral fracture; Surgical treatment; Surveillance; Contralateral femur; Femoral bowing

Core Tip: For complete atypical femoral fractures (AFFs), cephalomedullary intramedullary nailing spanning the entire femur and various surgical techniques to overcome femoral bowing should be considered. For incomplete AFFs, the recognition of impending complete fractures is important. For the contralateral femur, close surveillance is recommended because of the increased risk of contralateral AFF.