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04 September 2023 : Case report  Brazil

[In Press] A Case Report of Oral Bisphosphonate Treatment for Osteoporosis Leading to Atypical Femoral Fracture and Pathologic Mandibular Fracture

Challenging differential diagnosis, Unusual or unexpected effect of treatment, Patient complains / malpractice, Adverse events of drug therapy , Educational Purpose (only if useful for a systematic review or synthesis), Rare coexistence of disease or pathology

Tito LĂșcio Fernandes ORCID logo12ABDEF, Bruno Viezzer Fernandes ORCID logo12BEF, Chigueyuki Jitumori32BE, Gilson Cesar Nobre Franco ORCID logo1AEF

DOI: 10.12659/AJCR.941144

Am J Case Rep In Press; DOI: 10.12659/AJCR.941144  

Available online: 2023-09-04, In Press, Corrected Proof

Publication in the "In-Press" formula aims at speeding up the public availability of the pending manuscript while waiting for the final publication. The assigned DOI number is active and citable. The availability of the article in the Medline, PubMed and PMC databases as well as Web of Science will be obtained after the final publication according to the journal schedule


Bisphosphonates inhibit bone resorption in patients with postmenopausal osteoporosis and reduce osteoporotic fracture incidence. Medication-related osteonecrosis of the jaws (MRONJ) and atypical femoral fractures (AFF) are both rare but serious adverse effects of anti-resorptive drugs (ARD) such as bisphosphonates. The most advanced form of MRONJ is termed stage 3 and can lead to severe local sequelae like pathologic mandibular fractures (PMF). This study reports a case of MRONJ-related PMF and AFF with osteomyelitis secondary to bisphosphonate treatment for osteoporosis.
A 63-year-old white woman was diagnosed with PMF related to MRONJ stage 3 during treatment of an AFF with osteomyelitis. She had been treated for postmenopausal osteoporosis with 70 mg of alendronate weekly for 2 years. The PMF was treated by stable internal fixation combined with debridement and sequestrectomy, but further debridement was required and 2 mandibular implants were then removed. Postoperative recovery was uneventful and the mandibular infection was controlled after the second surgery. Three weeks later, she was discharged from the hospital, instructed to discontinue the use of alendronate, and referred for 30 sessions of hyperbaric oxygen therapy. At the 3-year follow-up, the PMF was completely healed without signs of mandibular infection or bone exposure.
This report raises awareness of both MRONJ and AFF as possible adverse effects of short-term bisphosphonate therapy for postmenopausal osteoporosis, and highlights the importance of dental and orthopedic follow-ups. It is crucial to emphasize the need for early diagnosis and treatment to prevent MRONJ progression to PMF.

Keywords: Bisphosphonate-Associated Osteonecrosis of the Jaw; Osteonecrosis; Mandibular Fractures; Osteomyelitis; Femoral Fractures

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Am J Case Rep In Press; DOI: 10.12659/AJCR.941877  

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American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923