[Atypical fracture of the femur related to prolonged bisphosphonate use. The importance of saying 'enough's enough']

Osteoporosis is a highly prevalent disease with important consequences. The most widely used drugs to control this disease are bisphosphonates but their prolonged use is associated with the risk of atypical fractures. We report the cases of two patients under bisphosphonate treatment with bilateral atypical femoral fractures. In one patient the fractures occurred simultaneously, unprovoked by trauma, and in the other, they occurred as delayed fractures after mild trauma. In both cases, the fractures were preceded by pain. The fractures were treated with intramedullary nailing and bisphosphonate withdrawal with good outcomes. Although bisphosphonates have demonstrated effectiveness in preventing frailty-related fractures, their prolonged use has paradoxically been associated with atypical fractures. These fractures are usually preceded by pain. Consequently, when faced with this clinical picture, physicians should request imaging studies that could show incomplete fractures that could benefit from prophylactic nailing before becoming complete fractures.