Proposed pathogenesis for atypical femoral fractures: Lessons from materials research

Atypical femoral fractures (AFFs) have been well defined clinically and epidemiologically. Less clear are the underlying mechanisms responsible. This commentary points out the likely sources of decreased resistance to fracture using lessons from bone material studies and biomechanics. We hypothesize that the key element in the cascade of events leading to failure of the largest and strongest bone in the human body is long-term suppression of normal bone turnover caused by exposure to potent anti-remodeling agents, most notably the bisphosphonates (BPs). Suppressed bone turnover produces changes in bone that alter its material quality and these changes could lead to adverse effects on its mechanical function. At the submicroscopic [< 1 μm] level of collagen fibrils, suppression of bone turnover allows continued addition of non-enzymatic cross links that can reduce collagen's plasticity and this in turn contributes to reduced bone toughness. Further, adverse changes in hydroxyapatite crystalline structure and composition can occur, perhaps increasing collagen's brittleness. At the microscopic level [~ 1–500 μm] of the bone-matrix structure, suppressed bone turnover allows full mineralization of cortical bone osteons and results in a microstructure of bone that is more homogeneous. Both brittleness and loss of heterogeneity allow greater progression of microscopic cracks that can occur with usual physical activity; in crack mechanical terms, normal mechanisms that dissipate crack tip growth energy are greatly reduced and crack progression is less impeded. Further, the targeted repair of cracks by newly activated BMUs appears to be preferentially suppressed by BPs. We further hypothesize that it is not necessary to have accumulation of many cracks to produce an AFF, just one that progresses — one that is not stopped by bone's several protective mechanisms and is allowed to penetrate through a homogeneous environment. The remarkable straight transverse fracture line is an indicator of the slow progression of a “mother crack” and the failure of usual mechanisms to bridge or deflect the crack. Research in AFF mechanisms has been focused at the organ level, describing the clinical presentation and radiologic appearance. Although today we have not yet connected all the dots in the pathophysiology of BP-induced AFF, recent advances in measuring bone mechanical qualities at the submicroscopic and tissue levels allow us to explain how spontaneous catastrophic failure of the femur can occur.

► Atypical femoral fractures are associated with suppression of bone turnover. ► During states of low bone turnover, several pathophysiologic steps can lead to progression of a major crack. ► Advances in the study of bone mechanics at the submicroscopic and microscopic scales inform the mechanism of crack progression.