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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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