Canadian Association of Radiologists Journal 67 (2016) 304e306
www.carjonline.org
Letters to the Editor / Lettres a la redaction
Atypical Femoral Fracture Alert Program
We thank Dr Lian and colleagues for their recent audit and
description of the features of atypical femoral fractures
(AFFs) in a large acute-care Canadian institution. In their
review of 204 subtrochanteric fractures, radiologists had
diagnosed AFF in only 1 of the 24 patients with characteristic
radiographic signs of AFF [1]. We have been advocating for an
‘‘AFF alert program,’’ and these findings highlight that need.
Inadequate capture of the presence of an AFF in the radiology
report is a major concern across Canada and has resulted in the
continuation of bisphosphonate therapy or denosumab therapy
in the presence of an AFF. We propose that radiologists cap-
ture the presence of an AFF in the concluding comments of the
report and highlight their presence for the referring physician.
As outlined by the authors, complete AFFs have distinc-
tive radiographic features [1,2]: 1) situated from just distal to
the lesser trochanter to just proximal to the supracondylar
flare; 2) fracture line substantially transverse, though may
become more oblique medially; 3) fracture traverses both
cortices often with a medial spike; 4) localized periosteal or
endosteal thickening at the origin of the fracture in the lateral
cortex; and 5) noncomminuted or minimally comminuted. In
this retrospective audit, there was high concordance amongst
the investigators (an experienced radiologist and 2 radiology
residents) regarding the presence of an AFF radiographically.
As part of this AFF alert program, we recommend that
Canadian radiologists clearly document the presence of an AFF
in the final conclusion of the radiology report, and to indicate
that these fractures are frequently associated with bisphospho-
nate use. Radiographs of the contralateral femur should also be
recommended as AFFs have been reported to occur bilaterally
in up to 62.9% of cases [3]. These initiatives will alert the
referring physician to the presence of an AFF, allow them to
discontinue bisphosphonate or denosumab therapy if present,
and consider appropriate medical and/or surgical intervention.
Complete AFFs are often preceded radiographically by an
incomplete AFF. The incomplete AFF is characterised by
periosteal thickening and a lucent line, known as ‘‘beaking,’’
or endosteal thickening of the lateral cortex [2,4]. Here too
radiologists can improve patient management by reporting
these findings as a potential incomplete AFF, describing the
association with bisphosphonates, and recommending ra-
diographs of the contralateral femur. If the referring physi-
cian is searching for an AFF and only a hip radiograph has
DOI of original article: 10.1016/j.carj.2015.09.014.
0846-5371/$ - see front matter Ó 2016 Canadian Association of Radiologists. All rights reserved.
http://dx.doi.org/10.1016/j.carj.2016.04.002
been obtained, it is recommended that bilateral radiographs
of the entire femur be obtained. If these images are normal in
the presence of thigh or groin pain, further evaluation with
repeat imaging in 6 months is advised, as well as exclusion
of other causes of thigh or groin pain.
In the presence of an incomplete AFF, bisphosphonates or
denosumab therapy should be discontinued. Limited weight
bearing is advised and teriparatide, an anabolic agent that has
been associated with enhanced fracture healing in case re-
ports, may be considered [5]. Intramedullary nailing is
necessary for complete AFFs. Prophylactic nailing of
incomplete femoral fractures may be advisable depending on
the extent of the incomplete fracture.
The AFF alert program will enable radiologists to play a
key role in improving identification of AFFs and enhancing
quality of patient care. It is also expected that this will enable
appropriate coding of these fractures that in turn will allow a
more accurate assessment of the incidence of AFFs, the
associated health careerelated costs and the impact of these
fractures on our health care system.
Aliya A. Khan, MD, FRCPC
Division of Endocrinology and Metabolism
Department of Medicine, McMaster University
Oakville, ON, Canada
E-mail address: aliya@mcmaster.ca
Sian Iles, MD, FRCPC
Department of Diagnostic Radiology, Dalhousie University
Halifax, NS, Canada
Stephanie M. Kaiser, MD, FRCPC
Division of Endocrinology and Metabolism
Department of Medicine, Dalhousie University
Halifax, NS, Canada
Linda Probyn, MD, FRCPC
Department of Medical Imaging
Sunnybrook Health Sciences Centre
Toronto, ON, Canada
Angela Cheung, MD, FRCPC, PhD
Department of Medicine and Joint Department of Medical
Imaging
Centre of Excellence in Skeletal Health Assessment
University Health Network
Toronto, ON, Canada
 Letters to the editor / Canadian Association of Radiologists Journal 67 (2016) 304e306
Steven Burrell, MD, FRCPC
Department of Diagnostic Radiology
Dalhousie University
Halifax, NS, Canada
References
[1] Lian K, Trollip J, Sandhu S, et al. Audit of atypical femoral fracture and a
description of some of their features. Can Assoc Radiol J 2015;67:69e75.
[2] Shane E, Burr D, Abrahamsen B, et al. Atypical subtrochanteric and
diaphyseal femoral fractures: second report of a task force of the
American Society for Bone and Mineral Research. J Bone Miner Res
2014;29:1e23.
[3] Probyn L, Cheung AM, Lang C, et al. Bilateral atypical femoral frac-
tures: how much symmetry is there on imaging? Skeletal Radiol 2015;
44:1579e84.
[4] Khan AA, Leslie WD, Lentle B, et al. Atypical femoral fractures: a
teaching perspective. Can Assoc Radiol J 2015;66:102e7.
[5] Khan AA, Fortier M, Menopause and Osteoporosis Working Group,
et al. Osteoporosis in menopause. J Obstet Gynaecol Can 2014;36:
839e40.
Physician Involvement in Procurement Is
Essential for Optimal Patient Care
Innovation is essential for medicine’s evolution,
ensuring physicians treat patients with the best techniques
and equipment available. While recognizing the fiscal
constraints of our health care system, physicians must
participate in the procurement process; cognizant and
conscientious clinicians on the frontlines of patient care are
ideally positioned to know what tools we need in our
treatment arsenal [1].
Interventional radiology is 1 of many specialties that
may be adversely impacted by policies and procedures that
curb innovation. Conditions that previously required
lengthy incisions can now be treated via tiny skin nicks.
Less invasive therapies ultimately reduce the financial
burden to our health care system [1] with shorter hospital
stays and quicker returns to work for patients, the latter an
underestimated benefit. When discussing product pur-
chases, policies are frequently constructed prioritizing the
financial bottom line over effects on patient care, which can
hinder new advances [2].
For products such as syringes and standard wires, bulk
purchasing makes sense to achieve lower upfront costs; even
substantive changes to such commodity devices would not
significantly change patient outcomes or reduce costs.
However, new medical technologies may considerably alter
patient management and costs; transparent processes for
selecting innovative medical technologies are essential.
Optimal patient care requires access to a range of medical
devices; sole sourcing is risky especially in device-intensive
specialties. Using penicillin to treat all infections is
nonsensical and so is using the same stent in all vessels.
Collaborative consultation between physicians and
305
administrators can achieve both cost savings and excellent
patient outcomes [3]. Purchase groups may be helpful once
minimum standards and continuous assessment processes are
established.
Once contracts are awarded for a particular medical tech-
nology, developments to similar devices cannot be adopted,
stalling innovation. There is no incentive to price products
competitively for contract durations. Responding to extensive
requests for proposals also diverts funds from product research
and development to bureaucracy. We recommend shortened
contract durations and flexible request for proposal processes
to facilitate rapid turnover of technologies, lower costs, and
encourage competition.
It is incumbent on us as doctors to advocate for the best
care of our patients. We must collaborate on decision-making
procurement teams to ensure appropriate medical equipment
and treatments are available and create policies and pro-
cedures that foster innovation. Physicians do not treat
‘‘commodity’’ disease states and should not be held hostage
to commodity-type procurement processes.
Gillian Shiau, MD
Department of Diagnostic Radiology
Dalhousie University
Halifax, NS, Canada
E-mail address: geshiau@gmail.com
Amol Mujoomdar, MD
University of Western Ontario
London Health Sciences Centre
London, ON, Canada
Darren Ferguson, MD
Department of Diagnostic Imaging
Saint John Regional Hospital
Saint John, NB, Canada
Jason Wong, MD
Department of Diagnostic Imaging
Foothills Medical Centre
Calgary, AB, Canada
References
[1] Arshoff L, Henshall C, Juzwishin D, Racette R. Procurement change in
Canada: an opportunity for improving system performance. Healthc
Manage Forum 2012;25:66e9.
[2] O’Brien J, Baerlocher MO, Asch MR, Hayeems E, Kachura JR,
Collingwood P. Limitations infiuencing interventional radiology in
Canada: results of a National Survey by the Canadian Interventional
Radiology Association (CIRA). Cardiovasc Intervent Radiol 2007;30:
847e53.
[3] Healy WL, Iorio R, Lemos MJ, et al. Single price, case price purchasing
in orthopaedic surgery: experience at the Lahey Clinic. J Bone Joint
Surg Am 2000;82:607e12.