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Gender related difference in the risk of bisphosphonate associated atypical femoral fracture and osteonecrosis of the jaw
  1. Mohammad Kharazmi1,
  2. Pär Hallberg2,
  3. Karl Michaëlsson3
  1. 1 Department of Oral and Maxillofacial Surgery, Central Hospital, Västerås, Sweden
  2. 2 Department of Medical Sciences, Uppsala University, Uppsala, Sweden
  3. 3 Section of Orthopaedics, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
  1. Correspondence to Dr Mohammad Kharazmi, Department of Oral and Maxillofacial Surgery, Central Hospital, Västerås SE-205 06, Sweden; kharazmi.mohammad{at}

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The pathophysiology of bisphosphonate associated atypical fractures (AFs) and osteonecrosis of the jaw (ONJ) are poorly defined1 ,2 but the underlying mechanisms are likely to differ. Nonetheless, the majority of both these adverse drug reactions (ADRs) occur in women, and one explanation might be a higher prescription rate of bisphosphonates in women as compared with men. However, women also tend to have a higher prevalence of bone microdamage, altered bone tissue mineral density, loss of connectivity, cortical porosity, and trabecular and cortical thinning.3 An additional biomechanical explanation, especially relevant for AF, could be the more pronounced stress on the femoral shaft in women due to a narrower bone; the bending strength of the femoral shaft is proportional to the fourth power of the radius.3 We therefore investigated whether gender per se is a risk factor for AF or ONJ, …

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  • Contributors MK and KM conceived and designed the study. MK and PH collected the data. PH supervised the collection of data and also obtained the ethical approval. KM provided statistical expertise. MK drafted the manuscript. All authors critically revised the manuscript for important intellectual content and approved the final revised version.

  • Funding The Swedish Medical Products Agency, Selander's fund, the Swedish Heart-Lung Foundation, the Swedish Research Council, Uppsala County Council Research Fund, and Thuréus foundation. The funding agencies had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

  • Competing interests None.

  • Ethics approval Granted from the regional ethical review board, Uppsala, Sweden (2011/231).

  • Provenance and peer review Not commissioned; externally peer reviewed.