Impact of Prolonged Bisphosphonate Therapy on Atypical Femoral Fractures: Insights from a Single-Center Experience

Background: Osteoporosis is a prevalent metabolic disorder frequently managed with bisphosphonates, which reduce fracture risk but, with prolonged use, may predispose to atypical femoral fractures (AFFs). These rare but serious complications highlight the need for individualized treatment strategies within the framework of precision medicine. Methods: We retrospectively analyzed six female patients (mean age around 70 years) with AFFs surgically treated at the University of Catania between September 2022 and March 2023. All patients had received bisphosphonate therapy for more than seven years. Demographic, clinical, and radiographic data were collected according to ASBMR criteria. Outcomes included fracture healing, hip and knee range of motion, quality of life (SF-36), and residual pain (VAS) at 12 months. Results: Fractures were subtrochanteric in two cases and mid-diaphyseal in four. All patients underwent intramedullary nailing. Mean radiographic union occurred at 5 ± 1.5 months, and functional recovery occurred at 4.5 ± 1.2 months. Quality of life declined from a pre-fracture SF-36 score of 77 to 57 at one year. Residual pain was minimal (VAS 2). Conclusions: Prolonged bisphosphonate therapy was strongly associated with AFFs, longer healing times, and reduced quality of life. These findings emphasize the importance of personalized management of osteoporosis, including risk-based treatment duration, tailored monitoring protocols, and early therapeutic adjustments to balance efficacy and safety in long-term care.