)283( COPYRIGHT 2021 © BY THE ARCHIVES OF BONE AND JOINT SURGERY Arch Bone Jt Surg. 2021; 9(3): 283-296. Doi: 10.22038/abjs.2020.52698.2608 http://abjs.mums.ac.ir the online version of this article abjs.mums.ac.ir Adel Ebrahimpour, MD 1, 2 ; Mehrdad Sadighi, MD 1 ; Amir Human Hoveidaei, MD 3, 4 ; Mohammadreza Chehrassan, MD 1 ; Reza Minaei, MD 5 ; Hamed Vahedi, MD 6 ; SM Javad Mortazavi, MD 3 Research performed at Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran Corresponding Author: SM Javad Mortazavi, Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran Email: smjmort@yahoo.com SYSTEMATIC REVIEW Received: 10 June 2020 Accepted: 20 December 2020 Surgical Treatment for Bisphosphonate-related Atypical Femoral Fracture: A Systematic Review Abstract Background: Atypical femoral fractures are the femoral fractures located anywhere between the lesser trochanter and the supracondylar fare of the femur. Long-term bisphosphonates, as the most common preventive and treatment medications for osteoporosis, are thought to have an important role in these fractures. Most of the fractures should be treated surgically, and the complications are considerable. Methods: We searched Medline, CENTRAL, Embase, and DART on February 26, 2020. One author reviewed and retrieved citations from these four databases for irrelevant and duplicate studies, and two other authors independently extracted data from the studies and rated their quality. Patients with surgical treatment of bisphosphonate-related atypical femoral fracture, according to the American Society for Bone and Mineral Research defnition, were included. Animal studies, case reports, studies with high-energy trauma, pathological fracture, or malignancy-related fractures were excluded. Results: In total, 316 patients (348 fractures) were included in this study. Mean age of patients was 70.47 years, and 97.5% of them were female. Duration of using bisphosphonates was 4.04 to 8.8 years, and Alendronate was the most common type. Moreover, 65.27% and 34.72% of the reported fractures were in diaphyseal and subtrochanteric, respectively. Moreover, the most common fxation type was intramedullary. Rate of complication was 17.52%, and the most frequent one was non-union, followed by implant failure. The main limitation of this research was that most of the studies did not have a high level of evidence. Conclusion: An increase in the rate of atypical femoral fracture with its challenging management makes it an important issue to be noted by orthopedic surgeons. Based on the results of this study, subtrochanteric fractures might have more complications post-operatively and are suggested to be operated on by more experienced surgeons. It was also found that extra-medullary fxation increases the risk of complications. Future studies on union time, outcomes of different surgical methods, and teriparatide therapy may help shed more light on the surgical management of these fractures. Level of evidence: III Keywords: Atypical femoral fractures, Bisphosphonates, Fracture fxation, Health policy, Osteoporosis, Teriparatide Introduction T he American Society for Bone and Mineral Research (ASBMR) developed criteria for the diagnosis of atypical femoral fractures (AFFs) in 2013, including five major and four minor features. Nevertheless, only four major features must be evident for the diagnosis of AFF [Appendix 1] (1). Long-term use of bisphosphonates is thought to play a crucial role in the development of these fractures by inhibition of bone resorption and