What question did this study set out to answer?

The aim is to analyze mortality differences in men treated with bisphosphonates who experienced atypical femoral fractures compared to other types of fractures.

February 25, 2026Journal of Bone and Mineral Research0 citationsOpen Access

Mortality Following Atypical Femoral Fractures in Men

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CHColton HofferAugusta University WOWiliam Obremskey BMBinni MakkerAugusta University

Key Points

The aim is to analyze mortality differences in men treated with bisphosphonates who experienced atypical femoral fractures compared to other types of fractures.
Analyzed data from the Veterans Affairs Corporate Data Warehouse over a nearly 20-year period.
Identified incidences of atypical femoral, hip, and subtrochanteric/femoral shaft fractures using ICD-9 and ICD-10 codes.
Performed radiographic reviews to classify fractures as atypical femoral fractures according to ASBMR guidelines.
Tracked mortality within 12 months and over 5 years post-fracture using Cox Proportional models.
4% mortality at 12 months for atypical femoral fractures compared to 25% for hip fractures and 15% for ST/FS fractures.
After 5 years, 30% of men with an atypical femoral fracture had died compared to 52% with hip fractures and 48% with ST/FS fractures.
Statistical analyses suggested no significant differences in mortality between atypical femoral and hip or ST/FS fractures (p > 0.10).

Abstract

Atypical Femoral Fractures (AFFs) are a very uncommon complication of long-term bisphosphonate (BP) treatment for osteoporosis. Prior studies of mortality following AFFs have shown lower mortality compared to typical hip or shaft fractures but have included few men. The purpose of this report was to determine differences in mortality among men treated with BPs who experienced AFFs, hip fractures, or typical subtrochanteric/femoral shaft (ST/FS) fractures. We included men from the Veterans Affairs Corporate Data Warehouse who filled at least one BP prescription over a nearly twenty-year span (October 1, 1999, through December 31, 2022). ST/FS and hip fractures after a first filled prescription for a BP were identified using ICD-9 and ICD-10 codes. Radiographic review was conducted for ST/FS fractures to determine which were AFFs using the American Society of Bone and Mineral Research (ASBMR) 2014 criterion. Demographic and clinical characteristics and cumulative duration of BP exposure prior to the incident fracture were determined. There were 23 men with an AFF, 4,591 with a hip fracture, and 225 with a (non-AFF) ST/FS fracture. At 12-months post fracture, 4% of men with an AFF had died, compared with 25% of men with a hip fracture and 15% of men with an ST/FS fracture. Over 5 years of follow-up, mortality following fracture differed among the three different fracture groups (χ2 = 6.21, d.f. = 2, p = 0.045) with death occurring in 7 of 23 (30%) men with an AFF, compared to 2,380 of 4,591 (52%) men with a hip fracture and 109 of 225 (48%) men with a ST/FS fracture. In Cox Proportional models, over five years, with and without adjustment for covariates, there were no significant differences in mortality following an AFF compared with a hip fracture or an AFF compared with a ST/FS fracture (p> 0.10 for all). It is possible that mortality is lower following AFF compared with a hip or ST/FS fracture, however limited sample size among those with AFF may have precluded ascertainment of such a difference.

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Mortality Following Atypical Femoral Fractures in Men

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Abstract

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