{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T05:26:42Z","timestamp":1792042002582,"version":"4.4.0"},"reference-count":25,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2026,1,6]],"date-time":"2026-01-06T00:00:00Z","timestamp":1767657600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100019731","name":"Daegu Medical Association","doi-asserted-by":"crossref","award":["Dongwon Research Fund(no grant number)"],"award-info":[{"award-number":["Dongwon Research Fund(no grant number)"]}],"id":[{"id":"10.13039\/100019731","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: Surgical management of atypical femoral fractures (AFFs) stabilized with intramedullary (IM) nailing is frequently challenged by delayed union or nonunion due to the severely suppressed bone turnover characteristic of bisphosphonate-related bone pathology, often leading to a hypertrophic nonunion-like state at the fracture site. This consecutive case series aimed to evaluate the effectiveness of intraoperative percutaneous decortication at the hypertrophic cortex in promoting rapid bone healing in complete AFFs. Methods: This was a single-center consecutive case series of patients with complete atypical femoral fractures (AFFs) treated with intramedullary nailing and adjunctive percutaneous decortication since February 2021. The standardized surgical protocol\u2014including percutaneous decortication performed through a small anterolateral incision using an osteotome to create bone chips and stimulate the sclerotic cortex\u2014was applied prospectively to all consecutive patients from February 2021. Of the 20 patients who underwent surgery during this period, 14 with sufficient radiographic follow-up were included in the final retrospective analysis. Data collected included patient demographics, duration of bisphosphonate use, fracture location (diaphyseal vs. subtrochanteric), operative details (including iatrogenic fracture), and radiographic bone union time. Bone union was assessed on serial radiographs by two independent observers. Results: All 14 patients were female, with a median age of 75 years (IQR 67\u201379 years). Thirteen patients (92.9%) had prior bisphosphonate exposure for a median of 4.5 years (IQR 3\u201310 years). Six fractures were subtrochanteric fractures, and six were complicated by iatrogenic fracture during nail insertion. Postoperative teriparatide was administered to six patients. Radiographic bone union was achieved in all 14 patients at a median of 19 weeks (IQR 16\u201322 weeks; range 16\u201324 weeks). No major complications (infection, implant failure, nonunion, or neurovascular injury) occurred during follow-up. Conclusions: Percutaneous decortication is a simple, safe, and biologically plausible adjunct to intramedullary nailing. In this series of 14 elderly women with long-term bisphosphonate exposure (median 4.5 years), the technique was associated with 100% radiographic union at a median of 19 weeks without major complications, suggesting a promising strategy that warrants validation in larger, controlled trials.<\/jats:p>","DOI":"10.3390\/jcm15020436","type":"journal-article","created":{"date-parts":[[2026,1,6]],"date-time":"2026-01-06T13:49:46Z","timestamp":1767707386000},"page":"436","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Decortication in the Surgical Management of Complete Atypical Femoral Fractures: A Strategy to Accelerate Fracture Healing"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1527-7761","authenticated-orcid":false,"given":"Young-Ho","family":"Cho","sequence":"first","affiliation":[{"name":"Department of Orthopedic Surgery, Daegu Fatima Hospital, 99 Ayang-ro, Dong-gu, Daegu 41199, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-8652-3248","authenticated-orcid":false,"given":"Changhun","family":"Lim","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Daegu Fatima Hospital, 99 Ayang-ro, Dong-gu, Daegu 41199, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-9751-5126","authenticated-orcid":false,"given":"Dongha","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Daegu Fatima Hospital, 99 Ayang-ro, Dong-gu, Daegu 41199, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,1,6]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1535","DOI":"10.1016\/S0140-6736(96)07088-2","article-title":"Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group","volume":"348","author":"Black","year":"1996","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1007\/s001980050010","article-title":"Randomized trial of the effects of risedronate on vertebral fractures in women with established postmenopausal osteoporosis","volume":"11","author":"Reginster","year":"2000","journal-title":"Osteoporos. Int."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1241","DOI":"10.1359\/JBMR.040325","article-title":"Effects of oral ibandronate administered daily or intermittently on fracture risk in postmenopausal osteoporosis","volume":"19","author":"Chesnut","year":"2004","journal-title":"J. Bone Miner. Res."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1809","DOI":"10.1056\/NEJMoa067312","article-title":"HORIZON Pivotal Fracture Trial. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis","volume":"356","author":"Black","year":"2007","journal-title":"N. Engl. J. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1294","DOI":"10.1210\/jc.2004-0952","article-title":"Severely suppressed bone turnover: A potential complication of alendronate therapy","volume":"90","author":"Odvina","year":"2005","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"66","DOI":"10.5371\/hp.2013.25.1.66","article-title":"Bisphosphonate related atypical femoral fracture","volume":"25","author":"Sung","year":"2013","journal-title":"Hip Pelvis"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"346","DOI":"10.1097\/BOT.0b013e318172841c","article-title":"Low-energy femoral shaft fractures associated with alendronate use","volume":"22","author":"Neviaser","year":"2008","journal-title":"J. Orthop. Trauma"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1736","DOI":"10.1359\/jbmr.090408","article-title":"Bilateral fractures of the femur diaphysis in a patient with rheumatoid arthritis on long-term treatment with alendronate: Clues to the mechanism of increased bone fragility","volume":"24","author":"Somford","year":"2009","journal-title":"J. Bone Miner. Res."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"579","DOI":"10.1007\/s00776-014-0572-9","article-title":"Stress fracture of the bowed femoral shaft is another cause of atypical femoral fracture in elderly Japanese: A case series","volume":"19","author":"Oh","year":"2014","journal-title":"J. Orthop. Sci."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"333","DOI":"10.1210\/er.2018-00001","article-title":"Atypical femur fractures: Review of epidemiology, relationship to bisphosphonates, prevention, and clinical Management","volume":"40","author":"Black","year":"2019","journal-title":"Endocr. Rev."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"295","DOI":"10.1302\/0301-620X.99B3.BJJ-2016-0276.R2","article-title":"Atypical femoral fractures related to bisphosphonate treatment: Issues and controversies related to their surgical management","volume":"99-B","author":"Koh","year":"2017","journal-title":"Bone Jt. J."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"2295","DOI":"10.1007\/s11999-012-2412-6","article-title":"Bisphosphonate-associated femur fractures have high complication rates with operative fixation","volume":"470","author":"Prasarn","year":"2012","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1247","DOI":"10.1007\/s00264-013-2259-9","article-title":"Atypical femoral fractures after anti-osteoporotic medication: A Korean multicenter study","volume":"38","author":"Kang","year":"2014","journal-title":"Int. Orthop."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"2427","DOI":"10.1007\/s00198-018-4640-4","article-title":"Incidence, risk factors, and fracture healing of atypical femoral fractures: A multicenter case-control study","volume":"29","author":"Lim","year":"2018","journal-title":"Osteoporos. Int."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"138","DOI":"10.1097\/BOT.0000000000000743","article-title":"Healing of atypical subtrochanteric femur fractures after cephalomedullary nailing: Which factors predict union?","volume":"31","author":"Cho","year":"2017","journal-title":"J. Orthop. Trauma"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1819","DOI":"10.2106\/JBJS.23.01439","article-title":"Update on atypical femoral fractures","volume":"106","author":"Anderson","year":"2024","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1323","DOI":"10.1007\/s00198-023-06768-w","article-title":"The effect of teriparatide on fracture healing after atypical femoral fracture: A systematic review and meta-analysis","volume":"34","author":"Byun","year":"2023","journal-title":"Osteoporos. Int."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1097\/00003086-197209000-00011","article-title":"Muscle pedicle bone grafting of long bones by osteoperiosteal decortication","volume":"87","author":"Judet","year":"1972","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"301","DOI":"10.4055\/cios20227","article-title":"Osteoperiosteal decortication and autogenous cancellous bone graft combined with bridge plating for non-hypertrophic diaphyseal nonunion","volume":"13","author":"Cho","year":"2021","journal-title":"Clin. Orthop. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1430","DOI":"10.1016\/j.injury.2011.03.045","article-title":"Judet decortication and compression plate fixation of long bone non-union: Is bone graft necessary?","volume":"42","author":"Ramoutar","year":"2011","journal-title":"Injury"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1002\/jbmr.1998","article-title":"Atypical subtrochanteric and diaphyseal femoral fractures: Second report of a task force of the American Society for Bone and Mineral Research","volume":"29","author":"Shane","year":"2014","journal-title":"J. Bone Miner. Res."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1862","DOI":"10.2106\/JBJS.G.01580","article-title":"Variability in the assessment of fracture-healing in orthopaedic trauma studies","volume":"90","author":"Corrales","year":"2008","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1978","DOI":"10.2106\/JBJS.15.01422","article-title":"Factors associated with increased healing time in complete femoral fractures after long-term bisphosphonate therapy","volume":"98","author":"Lim","year":"2016","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1682","DOI":"10.1210\/clinem\/dgz295","article-title":"Medical Management of Patients After Atypical Femur Fractures: A Systematic Review and Recommendations From the European Calcified Tissue Society","volume":"105","author":"McKenna","year":"2020","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1016\/j.otsr.2019.07.028","article-title":"Efficacy of bone-end intervention on fracture healing in bisphosphonate-related atypical femoral fractures","volume":"106","author":"Canbek","year":"2020","journal-title":"Orthop. Traumatol. Surg. Res."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/2\/436\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,8]],"date-time":"2026-01-08T05:20:12Z","timestamp":1767849612000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/2\/436"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,6]]},"references-count":25,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,1]]}},"alternative-id":["jcm15020436"],"URL":"https:\/\/doi.org\/10.3390\/jcm15020436","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,6]]}}}