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Same-site recurrence of an incomplete atypical femoral fracture 8 years after prophylactic intramedullary nailing following bisphosphonate re-exposure in an 81-year-old woman in Korea: a case report
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Youngho Cho, Changhun Lim
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Received May 31, 2026 Accepted July 1, 2026 Published online September 1, 2026
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DOI: https://doi.org/10.12671/jmt.2026.00227
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 Abstract
- An 81-year-old woman with osteoporosis presented in April 2024 with recurrent right thigh pain, 8 years after prophylactic intramedullary nailing for an incomplete atypical femoral fracture (AFF) in February 2016. She had a history of bisphosphonate use for approximately 10 years followed by a 5-year drug holiday and three ibandronate infusions before the index fracture in 2016; after a subsequent 4-year antiresorptive-free interval, bisphosphonate therapy was resumed in 2020–2021 following a new vertebral compression fracture. Plain radiographs in 2024 showed recurrent lateral cortical thickening and a transverse radiolucent line at the same site as the previous lesion, with intact hardware. Bone scintigraphy confirmed intense uptake consistent with a recurrent stress reaction. Laboratory testing showed markedly suppressed bone turnover markers, with a serum β-isomerized C-terminal telopeptide of type I collagen (β-CTX) level of 0.048 ng/mL, below the lower limit of the reference range (0.112 ng/mL). The lesion healed during conservative management consisting of bisphosphonate discontinuation, calcium and vitamin D supplementation, retained mechanical stabilization, and a 4-month course of off-label teriparatide. The independent contribution of teriparatide cannot be determined from this single case. This case highlights the rare phenomenon of same-site incomplete AFF recurrence long after prophylactic fixation in association with bisphosphonate resumption and describes successful conservative healing with short-term teriparatide in the presence of preexisting hardware.
Level of evidence: V.
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