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Antiresorptive-associated spontaneous fractures of both tibiae, followed by an atypical femur fracture during the sequential treatment with alendronate, denosumab then teriparatide
  1. Juan Tan1,
  2. Hiroshige Sano2 and
  3. Kenneth Poole3
  1. 1 Department of Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
  2. 2 Department of Medicine, Cambridge University, Cambridge, UK
  3. 3 Metabolic Bone Disease Unit, Addenbrooke’s Hospital, Cambridge, UK
  1. Correspondence to Dr Juan Tan, tanjuan01{at}


A 35-year-old man with juvenile idiopathic arthritis since childhood presented with bilateral atypical tibial fractures, followed by a later, single atypical fracture of the femur. The fractures were associated with 6 years of oral alendronate treatment immediately followed by subcutaneous denosumab therapy and later teriparatide therapy for osteoporosis. Atypical fractures are known to occur in the femur following bisphosphonate therapy; however, there are only a few documented cases of atypical fractures in the tibia. Our case highlights a rare but serious complication of a commonly prescribed antiresorptive agent. It also shows that teriparatide, while helpful in increasing bone mass, does not fully prevent the development of atypical fractures. Careful investigation should be considered in patients on long-term antiresorptive therapy presenting with bony tenderness to exclude an atypical fracture.

  • musculoskeletal and joint disorders
  • drugs: musculoskeletal and joint diseases
  • osteoporosis
  • orthopaedic and trauma surgery
  • calcium and bone

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  • Contributors The case was supervised by KP. The patient was under the care of KP. The report was written by JT and HS.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Obtained.

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