how do they decide what size femur rod to use

Abstract

This written report aimed to identify differences in femur geometry between patients with subtrochanteric/shaft atypical femur fractures (AFFs) and the general population, and to evaluate the biomechanical factors related to femoral bowing in AFFs. We retrospectively reviewed 46 patients. Data on age, and history and duration of bisphosphonate use were evaluated. Femur computed tomography images were reconstructed into a 3D model, which was analyzed with a geometry assay program to obtain the femur length, femur width and length, and femoral bowing. Patients were divided into 2 groups according to fracture location: the subtrochanteric and shaft AFF groups. We compared all parameters between groups, and also betwixt each group and a general population of 300 women ≥ 60 years. 30-five patients had a history of bisphosphonate employ (average duration, 6.1 years; range, 0.viii–20 years). There was no statistical deviation in bone turnover markers between the two groups. The shaft AFF group had a lower radius of curvature (ROC) (P = 0.001), lower bone mineral density (BMD, T score) (P = 0.020), and lower calcium (P = 0.016). However, other parameters and rate of bisphosphonate use were not significantly dissimilar. In that location were no significant differences in the parameters of the subtrochanter AFF group and the general population, but the shaft AFF group demonstrated a wider femur width (P < 0.001), longer anteroposterior length (P = 0.001), and lower ROC (P < 0.001) than the full general population. Femoral bowing and width increased in shaft AFFs, but similar to subtrochanter AFFs compared to the general population. Our results highlight the biomechanical factors of femur geometry in AFFs.

Introduction

The American Lodge for Os and Mineral Research (ASBMR) defines atypical femur fracture (AFF) as a consummate or incomplete fracture with major features, such as an atraumatic or minimal-trauma fracture, a transverse or short oblique orientation, a medial spike when the fracture is complete, non-comminuted or minimally comminuted, and localized periosteal or endosteal thickening of the lateral cortex (Table ane)¹. Since Odvina et al.² reported that AFF is associated with severe suppression of bone turnover later long-term use of bisphosphonate (BP) in 2005, BP has been suggested to be the main cause of AFFⁱⁱⁱ. However, the second report of ASBMR showed that Asian ethnicity is a potential contributor to AFF risk¹.

Table 1 ASBMR Chore Force 2013 revised instance definition of AFFs.

Total size table

Moreover, the role of low limb geometry has emerged every bit a risk factor for AFF⁴. Abnormal lower-limb geometry is thought to drag stress within the lateral cortex of the femoral shaft and cause AFF by increasing mechanical fatigue, and numerous studies in East Asia support this explanation^5,vi,7,8. Notwithstanding, in a comparison of different indigenous groups in America, Asian populations showed an increased risk of AFF relative to other races^{9,10,eleven,12}. Asian women have a more curved femur than Caucasians, while Africans tend to have the straightest femurs^xiii,xiv,15, which would explain the high prevalence of AFF in Asians. Information technology has too been reported that diaphyseal AFF is more common than subtrochanter AFF in Korean patients with AFF^6,16.

However, at that place is a lack of testify for a departure in femoral bowing between the general population and patients with AFF. We hypothesized that femoral bowing of the diaphyseal shaft in AFF is unlike from that in the full general population. Therefore, nosotros aimed to identify differences in the femur geometry, including femoral bowing, between patients with subtrochanteric/shaft AFF and the full general population. We also sought to compare differences in bone turnover markers between patients with subtrochanter and shaft AFF.

Materials and methods

Study subjects

This study was approved by the Institutional Review Board of ASAN MEDICAL Centre (protocol no. 2019-1568; November, 2019). The institutional committee waived the demand for informed consent. The inclusion criteria were as follows: (1) presence of AFF, equally divers by the ASBMR in 2014ⁱ, and (2) patients with full-browse computed tomography (CT) images of femurs, including an intact femur. Patients with peri-implant fractures (n = two), periprosthetic fractures (northward = 1), or bone metastasis (northward = 0) were excluded. Initially, amidst 92 AFF patients screened from a unmarried center betwixt 2015 and 2020, 46 patients with AFF were enrolled. All patients were women with > 60 years of age, with an average age of 75.1 years (range, 61–90 years). A subtrochanteric fracture was defined every bit a fracture extending up to five cm below the lesser trochanter. A shaft fracture was defined equally a fracture extending from the subtrochanteric region to the supracondylar metaphyseal flare. Information, including age, body mass index (BMI), bone mineral density (BMD), and history and duration of BP use, were evaluated. BMD was measured using the Prodigy dual-energy X-ray absorptiometry system (Advance™, GE-Lunar, Madison, WI, USA).

Analysis of femur geometry using a 3D model

The participants' femur CT images were imported into a 3D modeling software (AVIEW Modeler; Coreline Soft, Seoul, South korea) to produce 3D samplings of anatomical elements of the femur (Fig. 1). With the use of reconstruction and parametrization from these datasets, the structured data were segmented in obj format to form a 3D model representing both the bone surface and the corticocancellous interface (Fig. 2). The geometry analysis program using skeletonization was adult and conducted to obtain compact representation of the femur¹⁷. The following femur geometric parameters were calculated: (1) femur length from the upper pole of the femoral head to the bicondylar baseline (Fig. three); (2) femur shaft length from the tip of the greater trochanter to the bicondylar line; (iii) the narrowest diameter of the medullary canal; (iv) anteroposterior length and lateral width of the entire femur; and (five) radius of curvature (ROC) of the femur, including the degree of bowing. Parameters 3, four, and 5 were calculated from the level of the lesser trochanter to the level of the supracondylar area.

Figure i

Masking, segmentation, and solid modeling process.

Total size image

Figure 2

Femur length of the 3D model. (A) Contralateral femur of the patient with femur AFF. (B) Contralateral femur of the patient with subtrochanteric AFF.

Full size epitome

Figure 3

Delineation of the analysis. (A) Determination of solid model. (B) Identification of the center of the cross-exclusive area with a rendered and transparent model. (C) Termination of the identification of the center at all level of the femur. (D). Measurement the medullary culvert, femur AP.

Total size image

Measurement of bone turnover markers (BTMs)

The serum concentration of 25OH-Vit.D3 was measured by radioimmunoassay using DIAsource 25OH-Vit.D3-Ria-CT Kit (DIAsource ImmunoAssays South.A.; Lauvain-la-Neuve, Belgium). The intra- and inter-assay coefficients of variation (CVs) were 7.2–viii.7% and 7.2–7.3%, respectively. Os turnover markers (BTMs), including serum osteocalcin, parathyroid hormone (PTH), C-telopeptide (CTX), Ca, P, element of group i phosphatase (ALP), and albumin, were reviewed. The serum calcium level was measured using the o-Cresolphthalein-complex i with a Toshiba 200FR autoanalyzer (Toshiba Medical Systems, Tokyo, Japan), and serum ALP was besides measured. The serum intact PTH level was measured using an ELSA-PTH immunoradiometric assay (Cisbio Bioassays., Codolet. France), with a lower limit of detection of 0.vii pg/ml. The intra- and inter-assay CVs were 4.two–vii.five% and 3.four–half dozen.8%, respectively. The serum C-terminal telopeptide of type I collagen (CTX; normal range, 0.556 ± 0.226 ng/mL) concentration was measured using an electrochemiluminescence immunoassay on a Cobas 8000 e602 analyzer (Roche Diagnostics, Mannheim, Germany) with intra- and inter-assay CVs of 2.0–5.five% and 2.7–seven.6%, respectively. The serum osteocalcin (OC; normal range, xv–46 ng/mL) concentration was besides measured using an electrochemiluminescence immunoassay on a Cobas 8000 e602 analyzer (Roche Diagnostics) with intra- and inter-assay CVs of 0.7–0.8% and 1.v–1.6%, respectively.

Statistics analysis

Patients were divided into 2 groups according to fracture location: group ane, with subtrochanteric AFFs, and group ii, with shaft AFFs. All parameters were compared betwixt the two groups, and femur geometry parameters were compared between each group and a full general population of 300 women ≥ 60 years, which was published in our previous written report¹⁷. Descriptive statistics were used to determine the group means and standard deviations for numerical information. Each parameter was compared using a t-test. To identify adventure factors of AFF, multivariate regression analysis was performed. Statistical significance was defined as a P-value < 0.05. Statistical assay was performed using SPSS version 23.0 (IBM Corp., Armonk, NY, Us).

Ethical approval

All procedures involving human participants were performed in accordance with the ethical standards of the institutional committee.

Informed consent

The institutional commission waived the need for informed consent.

Results

At that place were 20 patients with subtrochanteric AFF and 26 with shaft AFFs. The average tiptop and weight of the patients were 150.9 cm (range, 135.0–168.4 cm) and 53.vii kg (range, 36.half-dozen–70.5 kg). The average BMI was 23.8 kg/m^two (range, 16.9–35.7 kg/1000²). Thirty-five patients (76.ane%) had a history of BP use, with an average duration of 6.1 years (range, 0.8–20 years). The rate of the history of BP utilize was not significantly different between the two groups. BMD was evaluated in 42 patients (91.3%); the mean T score of BMD was − 3.1 (range, − 1.5 to − 7.0), and 32 patients had osteoporosis (T score ≤ − 2.5) and 10 had osteopenia (− 2.five <T score < − 1.0). The mean serum 25(OH) Vit. D level was 33.8 ng/ml (range, seven.6–66.seven ng/ml), and the rate of below xx ng/ml was 23.iii%. The hateful serum CTX level was 0.26 ng/ml (range, 0.03–0.67), and the rate of lower level CTX (< 0.104 ng/ml) was 23.7%. BTM showed no statistical difference between the 2 groups (Tabular array 2).

Table two Comparison between subtrochanter fracture and shaft fracture.

Full size table

The average femur length was 401.2 ± 24.3 mm and the boilerplate femur shaft length was 361.8 ± 21.three mm. The average femur width was 28.vi ± 2.1 mm and the average femur AP diameter was 27.6 ± ii.1 mm. The average narrowest bore of the medullary canal was 9.0 ± 1.ix mm. The average ROC was 703.8 ± 162.6 mm.

In a comparison of the fracture location in AFF, the shaft AFF group had a lower ROC (642.iii mm vs 783.8 mm, P = 0.001), lower BMD (T score) (− iii.5 vs − ii.7, P = 0.020), and lower calcium (8.7 mg/dl vs 9.3 mg/dl, P = 0.016). Even so, the other parameters were not significantly different (Table 2).

Table iii shows the comparing betwixt the subtrochanter AFF group and the full general elderly population. None of the parameters of the subtrochanter AFF group were significantly different compared to the general population. Still, the shaft AFF group had wider femur width (29.0 mm vs 27.5 mm, P < 0.001), greater AP length (28.0 mm vs 26.7 mm, P = 0.001), and lower ROC (642.three mm vs 820.5 mm, P < 0.001) than the general population (Table four). Tabular array 5 summarized the risk factors of AFF. Among the variables including historic period, BMI, and femur geometry factors, femur width, AP length, and ROC was pregnant factors in the shaft AFF, but at that place were no significance in the subtrochanter AFF.

Tabular array 3 Comparing between subtrochanter fracture and female population (> 60 twelvemonth).

Total size table

Tabular array 4 Comparison between shaft fracture and female person population (> sixty yr).

Total size table

Table 5 Run a risk factors of AFF according to the fracture location.

Total size table

Discussion

Our results demonstrate that the femurs of patients with shaft AFFs were more bowed than those with subtrochanter AFFs, which agrees with the findings of previous studies^{5,8,18,xix,20,21,22}. Mechanically, the lateral cortex of the femur needs to endure tensile stress because of bending. The bending stress becomes severe when the femur is more than bowed. The CT-based finite element assay showed a correlation between femoral bowing and maximum principal stress, which indicates tensile stress⁵. Moreover, patients with mid-shaft AFF, who take more bowed femurs, showed marked diffuse tensile stress in the anterolateral surface of the shaft. In these patients, CT-based finite element analysis showed maximum tensile stress adjacent to the level of the fracture site in the mid-shaft. Oh et al. presented that a significantly higher lateral bowing angle and inductive radius of curvature of the femur in shaft AFF was related with a college maximum principal stress (weakest fracture resistance) in a prospective finite elementary analysis (FEA) written report of 18 patients²³. Haider et al. showed a comparable result using ii-level full factorial analysis of an FEA of 10 patients in 2018²⁴. Many previous studies, and the current results, have identified an association betwixt femoral curvature and fracture location; therefore, we can conclude that increased elevated femoral bowing is associated with a more distal fracture location.

To the all-time of our knowledge, this is the first study to compare femur geometry betwixt patients with AFF and a general elderly population. The results showed that there were differences in the femur geometry of patients with shaft AFF, merely non those with subtrochanter AFFs compared to the general population. Patients with shaft AFF had wider femurs considering of osteoporotic changes caused by the aging process²⁵. BMD also decreases with the aging process of bone, leading to a refuse in cortical area and bone strength. This chemical change in bone composition subjects the lateral cortex of the femur to greater bending stress. The compensation to overcome this angle stress increases the width of the femur considering the angle strength of the bone is proportional to its area moment of inertia^26,27. Therefore, a wider shaft bore would reflect a decrease in BMD, which increases the risk of insufficiency fractures, including AFF. Both femoral bowing and shaft diameter touch on the magnitude and volume of the strain in the femoral shaft²⁴. The more than bowed and wider the femoral shaft is, the more it will be exposed to stronger tensile stress at mid-shaft biomechanically, and tensile stress by loading stress can cause the evolution of AFF⁵. Compared to the full general population, the femur geometry of patients with shaft AFF is more vulnerable to repetitive significant tensile stress in the lateral cortex around the fracture site. Therefore, shaft AFF could occur equally a result of a mechanical factor of unlike femoral geometry regardless of a land of BP-induced oversuppressed bone turnover.

A recent study of AFF with bone metabolism markers and histological assay also indicated that shaft AFF is an insufficiency fracture (stress fracture). Biological activity tends non to be suppressed in mid-shaft stress fractures of the bowed femoral shaft, while subtrochanteric AFFs involve bone turnover suppression²⁸. This previous study also revealed that the level of the bone resorption marker, serum tartrate-resistant acid phosphatase-5b (TRACP-5b), was significantly lower in the subtrochanteric AFF group than in the mid-shaft AFF group, while the levels of the bone germination markers, Due north-terminal propeptide of blazon 1 procollagen and bone alkaline metal phosphatase (BAP) were non statistically different between shaft (n = 18) and subtrochanter AFF (n = 19) groups. 2-thirds of the patients with AFF had a history of BP or denosumab use, but histological analysis revealed that shaft AFFs showed agile bone remodeling. In our written report, there was no meaning difference in BP use, or os resorption and formation markers, although we have no histological data. Therefore, because that the use of BP and the resulting subtract in os turnover markers practise not necessarily bespeak "over-suppression" of bone remodeling, further understanding of the "femur geometry of bowing" volition shed new low-cal on the etiology of AFFs.

A recent report past our group¹⁷ revealed that the femur in Asian (Korean) elderly women was more than bowed than that in young women or elderly men. This study showed that the femur in shaft AFF was much more bowed than that of general population elderly women who have more bowed femurs than immature women or elderly men. The issue suggested that femurs with severe bowing are prone to insufficiency femur shaft fracture, a blazon shaft AFF. Additionally, there is some evidence to suggest that individuals with diaphyseal AFF tend to be older and weigh less than those with subtrochanteric AFF^4,6,21,29. Therefore, the femoral geometric characteristics of Asian populations may explain why more shaft AFFs occur in Asians, fifty-fifty in BP‐naïve patients, although over-suppression of bone remodeling past BP employ is still considered the main reason for AFFs.

This study has several limitations. First, we take no data to bespeak the os turnover state, such equally BMD or elapsing of BP utilise, in the full general population. Therefore, it is difficult to compare BP apply or the bone remodeling state population. In future, a study about etiology of AFF related with correlation between the employ of bisphosphonates and femoral geometry would exist clarified. 2nd, the electric current information just included bone turnover markers, and non histological findings, which limited our ability to evaluate the biological activity of os remodeling. In the most future, we intend to perform a comparison of the biological action of bone remodeling and bone turnover markers between patients with AFF and the full general populations. Finally, this written report is retrospective nature and compared with a modest cohort apropos the general population published in a previous report. Greater patient numbers could provide more information in validation, merely rarity of AFF limits enrollment. Despite these limitations, this written report is the starting time study to compare the femur geometry of patients with AFF to that of the general population. As a issue of our findings, we suggest the possibility that shaft AFF is an insufficiency (stress) fracture.

Determination

Many patients (76%) with AFF had history of the use of BP regardless of the fracture location. This geometry assay demonstrated that femoral bowing and increased width is observed in shaft AFFs, simply similar to subtrochanter AFFs compared to the general population. Our results highlight the biomechanical factors of femur geometry as an etiology of AFFs.

Information availability

Nosotros did not add together supplement information and materials in submission but are available in request to the corresponding author if it is necessary for review.

References

1. Shane, Eastward. et al. Singular subtrochanteric and diaphyseal femoral fractures: 2nd report of a task force of the American Society for Bone and Mineral Inquiry. J. Bone Miner. Res. 29, 1–23. https://doi.org/10.1002/jbmr.1998 (2014).

   Article  PubMed  Google Scholar

2. Odvina, C. Five. et al. Severely suppressed bone turnover: A potential complication of alendronate therapy. J. Clin. Endocrinol. Metab. 90, 1294–1301. https://doi.org/10.1210/jc.2004-0952 (2005).

   CAS  Commodity  PubMed  Google Scholar

3. Franceschetti, P. et al. Risk factors for development of atypical femoral fractures in patients on long-term oral bisphosphonate therapy. Bone 56, 426–431. https://doi.org/10.1016/j.bone.2013.07.010 (2013).

   CAS  Article  PubMed  Google Scholar

4. Haider, I. T., Schneider, P. S. & Edwards, West. B. The role of lower-limb geometry in the pathophysiology of singular femoral fracture. Curr. Osteoporos. Rep. 17, 281–290. https://doi.org/10.1007/s11914-019-00525-x (2019).

   Commodity  PubMed  Google Scholar

5. Oh, Y., Fujita, K., Wakabayashi, Y., Kurosa, Y. & Okawa, A. Location of atypical femoral fracture tin be determined by tensile stress distribution influenced by femoral bowing and neck-shaft angle: A CT-based nonlinear finite chemical element assay model for the assessment of femoral shaft loading stress. Injury 48, 2736–2743. https://doi.org/x.1016/j.injury.2017.09.023 (2017).

   Commodity  PubMed  Google Scholar

6. Kim, J. W. et al. Factors affecting fracture location in atypical femoral fractures: A cross-sectional study with 147 patients. Injury 48, 1570–1574. https://doi.org/10.1016/j.injury.2017.05.033 (2017).

   Article  PubMed  Google Scholar

7. Lim, S. J. et al. Incidence, risk factors, and fracture healing of atypical femoral fractures: A multicenter case–command study. Osteoporos. Int. 29, 2427–2435. https://doi.org/ten.1007/s00198-018-4640-4 (2018).

   CAS  Article  PubMed  Google Scholar

8. Jang, Due south. P. et al. Atypical femoral shaft fractures in female bisphosphonate users were associated with an increased anterolateral femoral bow and a thicker lateral cortex: A instance–command study. Biomed. Res. Int. 2017, 5932496. https://doi.org/10.1155/2017/5932496 (2017).

   CAS  Article  PubMed  PubMed Fundamental  Google Scholar

9. Lo, J. C. et al. Clinical correlates of singular femoral fracture. Os 51, 181–184. https://doi.org/x.1016/j.bone.2012.02.632 (2012).

   Article  PubMed  Google Scholar

10. Lo, J. C. et al. The clan of race/ethnicity and adventure of atypical femur fracture among older women receiving oral bisphosphonate therapy. Bone 85, 142–147. https://doi.org/10.1016/j.bone.2016.01.002 (2016).

    Article  PubMed  PubMed Central  Google Scholar

11. Dell, R. One thousand. et al. Incidence of atypical nontraumatic diaphyseal fractures of the femur. J. Bone Miner. Res. 27, 2544–2550. https://doi.org/x.1002/jbmr.1719 (2012).

    Article  PubMed  Google Scholar

12. Marcano, A., Taormina, D., Egol, K. A., Peck, 5. & Tejwani, Northward. C. Are race and sex associated with the occurrence of atypical femoral fractures?. Clin. Orthop. Relat. Res. 472, 1020–1027. https://doi.org/10.1007/s11999-013-3352-5 (2014).

    Article  PubMed  Google Scholar

13. Maratt, J. et al. Variation in the femoral bow: A novel high-throughput assay of 3922 femurs on cross-exclusive imaging. J. Orthop. Trauma 28, vi–9. https://doi.org/10.1097/BOT.0b013e31829ff3c9 (2014).

    Article  PubMed  Google Scholar

14. Ballard, M. East. Anterior femoral curvature revisited: Race assessment from the femur. J. Forensic Sci. 44, 700–707 (1999).

    CAS  PubMed  Google Scholar

15. Thiesen, D. Thou. et al. Femoral antecurvation-A 3D CT analysis of 1232 developed femurs. PLoS I 13, e0204961. https://doi.org/10.1371/journal.pone.0204961 (2018).

    CAS  Article  PubMed  PubMed Central  Google Scholar

16. Yoo, H., Cho, Y., Park, Y. & Ha, S. Lateral femoral bowing and the location of singular femoral fractures. Hip Pelvis 29, 127–132. https://doi.org/x.5371/hp.2017.29.2.127 (2017).

    Article  PubMed  PubMed Key  Google Scholar

17. Jung, I. J., Choi, Due east. J., Lee, B. Grand. & Kim, J. Westward. Population-based, three-dimensional analysis of age- and sex-related femur shaft geometry differences. Osteoporos. Int. https://doi.org/10.1007/s00198-021-05841-6 (2021).

    Article  PubMed  Google Scholar

18. Morin, Due south. N. et al. Assessment of femur geometrical parameters using EOS™ imaging applied science in patients with singular femur fractures; Preliminary results. Bone 83, 184–189. https://doi.org/10.1016/j.bone.2015.10.016 (2016).

    Article  PubMed  Google Scholar

19. Soh, H. H., Chua, I. T. & Kwek, Eastward. B. Atypical fractures of the femur: Effect of anterolateral bowing of the femur on fracture location. Arch. Orthop. Trauma Surg. 135, 1485–1490. https://doi.org/10.1007/s00402-015-2297-4 (2015).

    Article  PubMed  Google Scholar

20. Shin, Westward. C., Moon, N. H., Jang, J. H., Park, One thousand. Y. & Suh, K. T. Anterolateral femoral bowing and loss of thigh muscle are associated with occurrence of atypical femoral fracture: Issue of failed tension band machinery in mid-thigh. J. Orthop. Sci. 22, 99–104. https://doi.org/10.1016/j.jos.2016.09.009 (2017).

    CAS  Commodity  PubMed  Google Scholar

21. Hyodo, K. et al. Location of fractures and the characteristics of patients with atypical femoral fractures: Analyses of 38 Japanese cases. J. Os Miner. Metab. 35, 209–214. https://doi.org/10.1007/s00774-016-0747-x (2017).

    Article  PubMed  Google Scholar

22. Sasaki, S., Miyakoshi, N., Hongo, K., Kasukawa, Y. & Shimada, Y. Low-energy diaphyseal femoral fractures associated with bisphosphonate apply and severe curved femur: A case series. J. Os Miner. Metab. thirty, 561–567. https://doi.org/10.1007/s00774-012-0358-0 (2012).

    Article  PubMed  Google Scholar

23. Oh, Y., Wakabayashi, Y., Kurosa, Y., Fujita, K. & Okawa, A. Potential pathogenic machinery for stress fractures of the bowed femoral shaft in the elderly: Mechanical assay by the CT-based finite element method. Injury 45, 1764–1771. https://doi.org/10.1016/j.injury.2014.08.037 (2014).

    Article  PubMed  Google Scholar

24. Haider, I. T., Schneider, P., Michalski, A. & Edwards, W. B. Influence of geometry on proximal femoral shaft strains: Implications for singular femoral fracture. Os 110, 295–303. https://doi.org/10.1016/j.os.2018.02.015 (2018).

    Commodity  PubMed  Google Scholar

25. Clarke, B. Fifty. & Khosla, Southward. Physiology of bone loss. Radiol. Clin. North Am. 48, 483–495. https://doi.org/10.1016/j.rcl.2010.02.014 (2010).

    Article  PubMed  PubMed Primal  Google Scholar

26. Koh, J. Due south., Goh, S. K., Png, Yard. A., Ng, A. C. & Howe, T. South. Distribution of atypical fractures and cortical stress lesions in the femur: Implications on pathophysiology. Singapore Med. J. 52, 77–80 (2011).

    CAS  PubMed  Google Scholar

27. Donnelly, Eastward. et al. Reduced cortical bone compositional heterogeneity with bisphosphonate treatment in postmenopausal women with intertrochanteric and subtrochanteric fractures. J. Bone Miner. Res. 27, 672–678. https://doi.org/ten.1002/jbmr.560 (2012).

    CAS  Article  PubMed  Google Scholar

28. Oh, Y. et al. Biological activeness is not suppressed in mid-shaft stress fracture of the bowed femoral shaft dissimilar in "typical" atypical subtrochanteric femoral fracture: A proposed theory of atypical femoral fracture subtypes. Bone 137, 115453. https://doi.org/10.1016/j.os.2020.115453 (2020).

    CAS  Article  PubMed  Google Scholar

29. Chen, L. P., Chang, T. K., Huang, T. Y., Kwok, T. G. & Lu, Y. C. The correlation between lateral bowing bending of the femur and the location of singular femur fractures. Calcif. Tissue Int. 95, 240–247. https://doi.org/ten.1007/s00223-014-9887-y (2014).

    CAS  Article  PubMed  Google Scholar

Download references

Funding

This inquiry was supported past the Educatee Research Grant (2020) of University of Ulsan, Higher of Medicine, Seoul, Korea and past the National Research Foundation of Korea (NRF) grant funded past the Korea government (MSIT) (2021R1A2C1012972).

Writer data

Affiliations

1. University of Ulsan College of Medicine, Seoul, Republic of Korea

   Ik Jae Jung

2. Department of Orthopedic Surgery, Asan Medical Centre, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea

   Ji Wan Kim

Contributions

I.J.J.: methodology, investigation, data curation, validation, formal analysis, writing—original draft, and visualization. J.W.K.: conceptualization, methodology, writing—original draft, review and editing, supervision, and funding acquisition.

Corresponding writer

Correspondence to Ji Wan Kim.

Ethics declarations

Competing interests

The authors declare no competing interests.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Eatables Attribution 4.0 International License, which permits use, sharing, accommodation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(south) and the source, provide a link to the Creative Commons licence, and point if changes were made. The images or other third political party material in this article are included in the article'south Creative Eatables licence, unless indicated otherwise in a credit line to the fabric. If material is not included in the article'southward Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you lot volition need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/iv.0/.

Reprints and Permissions

About this article

Cite this article

Jung, I.J., Kim, J.W. Differences in femur geometry and bone markers in atypical femur fractures and the general population. Sci Rep 11, 24149 (2021). https://doi.org/10.1038/s41598-021-03603-2

Download citation

• Received: thirteen August 2021

• Accepted: 07 December 2021

• Published: 17 Dec 2021

• DOI : https://doi.org/10.1038/s41598-021-03603-ii

Comments

By submitting a comment you agree to abide by our Terms and Community Guidelines. If you lot find something calumniating or that does not comply with our terms or guidelines please flag it every bit inappropriate.

stevensthwifer64.blogspot.com

Source: https://www.nature.com/articles/s41598-021-03603-2

Share this post