Table 1.

Patients characteristics, fracture type, fixation type, and outcome in selected studies

General information of studies and demographic characteristics of patients				Past medical and drug history			Operative management (fracture location and fixation type)		Post-op management and evaluation
First Author, Country, Publication Year	Level of Evidence Study design	Total number of AFF (surgically treated)	Mean age ---- Female (All patients)	Risk factors	Type of BP	Duration of BP therapy	Fracture location	Fracture fixation type	Teriparatide medical therapy	Outcome measure	Complications	Follow-up
Canbek, Turkey, 2019	Level III Retrospective case-control study	32	74±6 ---- 32 (32)	Diabetes Mellitus	NA	Open Surgery GP: 6.7±1.4 years Close Surgery GP: 7.2±1.5 years	Femoral Shaft - all	CMN GP1: (n=8) GP2: (n=8) Standard GP1: (n=7) GP2: (n=9)	-	Primary union Radiologic union time: (months) GP1: 6.8±1.8 GP2: 5.1±1.3	Non-union GP1: (n=1) - revision GP2: (n=1)	Months GP1: 41±10 GP2: 34±8 At least 24
Rajput, Pakistan, 2019	Level III Retrospective cohort	11	68.8 ---- 10 (10)	-	Alendronate (n=4) Ibandronate (n=3) Zoledronic acid (n=3)	58.3 months	Subtrochanteric (n=9) Femoral shaft (n=2)	IMN: (n=2) PFNA: (n=9)	-	Radiologic union time: (months) (9.9) (6-16)	Delayed union (n=5) - Dynamization:1 Bone grafting:4	12 months
Greenspan, USA, 2018	Level I Randomized clinical trial	13	74.2±2.5 ---- 13 (13)	-	Alendronate (n=6) Risedronate (n=4) Ibandronate (n=3)	NA	Femoral shaft - all	Plate/wire/screw Immediate GP: (n=3) Delayed GP: (n=1) IMN Immediate: (n=4) Delayed: (n=5)	N=13 Immediate GP (20 μg subcutaneous daily for 12 months) vs Delayed GP (initiated 6 months later)	Radiographic indices Composite score BMD Healing score Quality of life questionnaire Pain assessment Hospitalizations	Implant failure Delayed GP: (n=1)	Months Mean: 14.7 Delayed GP: 18 Immediate GP: 12
Rocos, UK, 2018	Level III Retrospective cohort	12	71 ---- 9 (10)	Diabetes Mellitus, Rheumatoid Arthritis, Polymyalgia Rheumatica, Ankylosing Spondylitis, Colitis, gout, Ischemic heart disease	Alendronate (n=10) Ibandronate (n=1) {One was using both}	6 months to 8 years	NA	Nail Gamma 3: (n=11) Recon: (n=1)	-	Prodromal pain Union time: (days) Medial: 144.7 Lateral: 199.8 Position of final reduction	Nonunion (n=6) – revision Iatrogenic fracture (n=1) - revision	2 years
Eisenstein, UK, 2017	Level III Retrospective cohort	7	71.1 ---- 6 (7)	NA	Alendronate (n=6) Pamidronate (n=1)	NA	NA	IMN - all	-	Incidence of AFF	-	NA
Kayali, Turkey, 2017	Level IV Retrospective case series	26	73 ----- 22 (22)	NA	NA	7.6 years	Femoral Shaft - all	IMN Open GP: 21 Close GP: 5	-	Femur stress reaction BMD Union time: (months) (7.4)	Nonunion (n=5) – revision: 3	NA
Lee, South Korea, 2017	Level III Retrospective cohort	46	70.1 ---- 44 (44)	High BMI	NA	5.1 years	Subtrochanteric (n=15) Femoral shaft (n=31)	IMN - all	N=14	Radiographic union time: (weeks) (24.9) Body mass index	Delayed union (n=15) Nonunion (n=2) – revision: 2	12 months
Philips, UK, 2017	Level III Retrospective cohort	12	71.6 ---- 12 (12)	polymyalgia rheumatica, hypothyroidism, nephritic syndrome	Alendronate (n=12)	8.33 years	Subtrochanteric (n=12)	Gamma nail -all	-	Radiologic union time: (weeks) (24)	Broken nail (n=1) – revision Nonunion (n=2) – bone stimulation: 2	25.9 weeks for 11 cases
Yeh, Taiwan, 2017	Level III Retrospective cohort	16	70.15±6.36 ---- 13 (13)	hypertension, diabetes mellitus, breast cancer	Alendronate (n=13)	4.04 years	Subtrochanteric (n=10) Femoral haft (n=6)	IMN: (n=8) Recon: (n=5) Gamma3 nail: (n=2) PFNA: (n=1)	N=8	Radiologic union time: (months) Teriparatide GP: 4.4 Non-Teriparatide GP: 6.2 months	Nonunion and implant failure in non-teriparatide GP (n=1) – Revision: twice	1 year
Teo, Singapore, 2014	Level III Retrospective cohort	33	67.5 ---- 33 (33)	-	Alendronic acid (n=33)	4.9 years	Subtrochanteric (n=33)	IMN; (n=6) PFNA: (n=4) DCS: (n=10) DHS: (n=8) Plate and screw: (n=5)	N=10	Rate of failure and revision Radiologic union time: (months) IM: (10) Extramedullary: (10.9)	Implant failure (n=7) – revisions: 6 Nonunion (n=1) Delayed union (n=4) – Bone graft: 4	21.7 months for 30 patients
Egol, USA, 2013	Level III Retrospective cohort	41	66.8 ---- 31 (33)	NA	Alendronate (n=33)	8.8 months	Subtrochanteric (n=25) Femoral shaft (n=16)	IMN: (n=18) CMN (n=23)	NA (“small number”)	Union time: (months) (8.3)	Nonunion & implant failure: (n=1) - revision	1 year
Prasarn, USA, 2012	Level III Retrospective cohort	25	71 ---- 25	Diabetes Mellitus, Alcohol, Tobacco	NA	7.6 years	Femoral Shaft - all	CMN: (n=15) Plate: (n=10)	N=16	Radiologic union time: (weeks) (26)	Iatrogenic fracture (n=5) Implant failure (Post-op) {Plate: (n=3) Nail: (n=1)} Nonunion (n=1)	29 months At least 5
Shkolnikova, Australia, 2012	Level III Retrospective cohort	18	72.64 ---- 11 (14)	Breast cancer, Hypothyroidism, Gastroesophageal reflux, Paget’s disease, heart failure, smoker, alcohol consumer	Alendronate (n=14)	6 years	NA	IMN - all	-	Pre- and post-fracture level of function	Nonunion (n=1) - revision Delayed union (n=1) Fat embolism (n=1)	NA
Banffy, USA, 2011	Level III Retrospective cohort	39	68.5 ---- 33 (33)	-	NA	77 months	Femoral Shaft - all	CMN (n=39)	-	Length of hospital stay Nonunion Non-operative treatment outcomes	Nonunion (n=1) - revision	36.5 months At least 12
Weil, Israel, 2011	Level IV Retrospective cohort	17	73 ---- 14 (15)	NA	NA	7.8 years	Subtrochanteric (n=4) Femoral shaft (n=13)	IMN: (n=12) CMN: (n=4) Plate: (n=1)	N=3	bone mineral density Complications	Dynamization (n=4) Nail exchange (n=2) Plating: (n=1)	1 year

AFF: atypical femoral fracture, BP: bisphosphonate, NA: not available, GP: group, CMN: cephalomedullary nail, IM: intramedullary, IMN: intramedullary nail, PFNA: proximal femoral nail antirotation, DHS: dynamic hip screw, DCS: dynamic condylar screw