In developing countries, osteoporosis, also known as osteonecrosis, and the resulting osteoporotic fractures cause significant morbidity, mortality and health care costs. In several randomized trials, pharmacological therapy for osteoporosis has been proven to lower the risks of hip fractures, vertebral, non-vertebral, and bisphosphonate medicines and have been linked to better survival in several studies. Anti-resorptive drugs can cause atypical femoral fractures (AFFs), a rare and often misdiagnosed treatment-related complication that has a significant impact on patients' quality of life.

Anti-resorptive medications like as bisphosphonates (BPs) and denosumab have been used to reduce the risk of osteoporotic fractures for many years. Their long-term usage, on the other hand, has been linked to a higher risk of AFF [1-6]. The safety of these anti-resorptive medications has been questioned in the wake of reports of these rare but significant side effects, particularly in long-term users [6, 9]. The overall risk of AFF is low; on the other hand, increased awareness of AFF, as well as other questions raised about how to properly treat osteoporosis patients, has coincided with a significant decline in osteoporosis drug use and a plateau in a promising decline in osteoporosis fractures [1-12].

Denosumab and bisphosphonates (BP) are antiresorptive medications that have been utilized for quite a long time against the danger of osteoporotic femoral breaks. Nonetheless, their drawn-out use has been related to increased risk of AFF. The reports of these uncommon yet genuine results bring up issues about the wellbeing of these antiresorptive medications, particularly in individuals who consume these medications for quite a while. The high risk of AFF is low; However, public concern about AFF, along with other unresolved questions about how to properly treat osteoporosis patients in the long term, has coincided with a significant decline in osteoporosis medication use and, in any case, with an encouraging decrease in osteoporosis damage [12-18].

This has highlighted the concern of healthcare professionals and academics that many people who require pharmaceuticals are either inadequate or not taking them. The long-term effects of denosumab and bisphosphonates on AFF have still to be fully identified, and the developmental processes of AFF remain unknown. Although there is some evidence that risk syndromes and feasible precursors may have hereditary components, it is not possible to predict the onset of AFF. Since millions of osteoporosis patients use these sources around the world, this unpredictability poses a serious danger [18, 7].

Long term utilization of antiresorptive medications, specifically intravenous circulatory strain in malignancy treatment, likewise raises concerns in view of their relationship with an expanded danger of osteonecrosis. ONJ, which shows itself in a few phases of seriousness, is a crippling condition that influences the patient's wellbeing and personal satisfaction. Information on the system of activity of bisphosphonates as an antiresorptive specialist has extended fundamentally. Yet, less is thought about the specific pathogenesis and etiology of ONJ, particularly after reports that biologics, for example, inhibitors of angiogenesis and denosumab, are additionally connected through ONJ. Further advancement in appreciative this uncommon foundational confusion in people, which is particularly present in the oral cavity, will rely upon revealing the complex inclusion of various frameworks [19, 3, 7].

Recently, much consideration has been paid to the possibility of a association among low energy fractures and long-term use of bisphosphonates of the femoral shaft and subtrochanteric suture. These fractures were termed "atypical fractures" to differentiate them from "typical fractures" of the neck trochanteric and femoral zone induced by low-energy trauma. The most severe femoral shaft fractures occur as a consequence of severe high-energy traumas such as vehicle accidents or falls from significant heights. Unlike another PD complication, osteonecrosis of the jaw, atypical femoral fractures (AFF) are not linked to elevated blood pressure (ONJ) [11-19].

The American Society for Bone and Mineral Research (ASBMR) created an interdisciplinary special committee in 2009 and issued a position paper in 2010 as part of a systematic approach to further understanding AFF. The working committee defined AFF after evaluating published studies on imaging, epidemiology, clinical management practice and risk factors. It was established that the incidence of AFF was extremely low, especially when compared to the number of hip and spine fractures that may have been avoided if BP had been used. They also stated that, despite the lack of statistical power, a causal association between AFF and BP had not been proven. AFF is described as less traumatic or atraumatic fractures in the subtrochanteric area or diaphysis of the femur, according to a 2010 Working Group study [2, 8].

Intertrochanteric fractures with spiral subtrochanteric extension, as well as periprosthetic fractures, associated with primary or the metastatic bone cancer were eliminated from the AFF classification. Transverse or short oblique shapes, as well as non-comminuted incomplete fractures affecting just the lateral cortex, were all major hallmarks of AFF. Complete fractures, on the other hand, penetrate both cortical layers and may have a medial extrusion. Localized periosteal reaction or lateral cortex curvature, widespread thickening of the cortical layer of the femoral shaft, bilateral fractures and symptoms, and delayed healing owing to certain drugs history of prodromal pain, and medical conditions are all minor indicators. All major criteria must be present for a fracture to be classified as "atypical," although minor traits may be lacking in certain circumstances [11]. In September 2011, the Food and Drug Administration (FDA) conducted a study of the situation. Atypical fractures are relatively slight or unusual, according to the report [12].

Incidence of AFF

In a case report published in 1978, Richardson with his colleagues discovered atypical stress fractures in women who are on premenopausal stage connected to osteoporosis. This was before the widespread usage of highly potent bisphosphonates. In 1985, McClung and Orwoll discovered a similar type of stress fracture in people with osteoporosis and low bone turnover. Bisphosphonates were approved for the treatment of acute and chronic osteoporosis in the United States in the mid-1990s, and they were widely utilised. In 2005, Odvina and colleagues reported nine people who had spontaneous non-spinal fractures while using alendronate, four of which were femur fractures. The researchers concluded that significant suppression of bone turnover during long-term alendronate treatment might result in fractures. Femoral stress fractures are abbreviated as AFFs [16-19].

Wang and Bhattacharya reported an analysis of average femur fractures and AFFs associated with bisphosphonate usage in the United States more than ten years after bisphosphonate-based medicines were first introduced in the United States in 2011. They determined that with bisphosphonate treatment, for each 100 commonplace osteoporotic femoral cracks forestalled, there was an expansion of one subtrochanteric break due to fragility. In another evaluation, Meyer and associates found a 47 percentage decrease in exemplary cracks, yet an expanded danger of AFF. 10.7

BPs reduces the risk of non-spinal and spinal bone fractures, such as typical and extensive hip fractures and intertrochanteric fractures, significantly. There is, however, evidence of a relationship between long-term blood pressure medication usage and a certain form of femoral and subcutaneous shaft fracture. on the other hand, typical femoral fractures are a matter of concern, and additional information is considered necessary, both to help identify individuals at high risk and to determine the length of BP medication. By modifying the BP labeling, doctors and patients should be aware of the likelihood of bilateral nature and atypical femur fractures. Given the rarity of atypical femoral fractures, new procedural and diagnostic codes for atypical femoral fractures should be created to aid future research, a worldwide registry should be created, and case registration quality should be enhanced.

Animal models should be developed, monitoring should be expanded, and more epidemiological data should be collected to determine the exact prevalence and risk factors of this ailment, as well as research into surgical and medicinal therapy options.