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Review
. 2025 Dec;11(4):111-120.
doi: 10.1016/j.afos.2025.11.001. Epub 2025 Nov 24.

Asian Federation of Osteoporosis Societies 2025 consensus on atypical femoral fractures in patients with osteoporosis

Thanut Valleenukul  1 , Thawee Songpatanasilp  2 , Unnop Jaisamrarn  3 , Surapong Anuraklekha  4 , Varalak Srinonprasert  5 , Sumapa Chaiamnuay  6 , Aasis Unnanuntana  7 , Lalita Wattanachanya  8 , Hataikarn Nimitphong  9 , Noratep Kulachote  10 , Ong-Art Phruetthiphat  2 , Rahat Jarayabhand  1 , Tanawat Amphansap  11 , Ekasame Vanitcharoenkul  7 , Pojchong Chotiyarnwong  7 , Satoshi Mori  12 , Kwang-Kyoun Kim  13 , Swan Sim Yeap  14 , Sharmila Sunita Paramasivam  15 , Linsey Gani  16 , Ching-Lung Cheung  17 , Julie Li-Yu  18 , Mark Anthony Sandoval  19 , Chung-Hwan Chen  20 , Natthinee Charatcharoenwitthaya  21
Affiliations
Review

Asian Federation of Osteoporosis Societies 2025 consensus on atypical femoral fractures in patients with osteoporosis

Thanut Valleenukul et al. Osteoporos Sarcopenia. 2025 Dec.

Abstract

Atypical femoral fractures (AFFs) are a rare but serious complication of prolonged anti-resorptive therapy for osteoporosis. This study aimed to develop consensus-based recommendations for the clinical management of AFFs across the Asian Federation of Osteoporosis Societies (AFOS), for harmonizing practice and improving patient outcomes. A structured questionnaire covering ten key domains related to AFFs was distributed to expert representatives from the 10 AFOS member countries or regions. Responses were analyzed to identify areas of consensus and variation in regional practice. A concurrent narrative review of the literature was conducted to inform evidence-based recommendations. Survey responses were obtained from 8 of 10 participating AFOS member nations or regions. Among these, Thailand, Malaysia, South Korea, and Hong Kong reported established national guidelines or position statements on AFFs. Contributing risk factors include extended anti-resorptive therapy, femoral geometry, comorbidities, and specific pharmacologic exposures. Diagnosis depends on clinical suspicion and multimodal imaging, with high concordance in diagnostic criteria across regions. Screening emphasizes full-length femoral imaging in high-risk individuals. Incomplete AFFs are managed conservatively or with prophylactic fixation, while complete AFFs typically require intramedullary nailing, tailored to anatomic variations such as femoral bowing. Post-fracture care involves discontinuation of anti-resorptives, assessment for secondary osteoporosis, and potential initiation of anabolic therapy, including teriparatide, abaloparatide, and romosozumab. This AFOS-led initiative highlights the importance for early detection, individualized management, and region-specific strategies. A multidisciplinary, patient-centered approach-encompassing risk assessment, imaging surveillance, surgical intervention, and tailored pharmacologic treatment-is crucial to reduce AFFs impact and improve skeletal health outcomes across Asia.

Keywords: Anabolic therapy; Anti-resorptive therapy; Asian consensus; Atypical femoral fractures (AFFs); Osteoporosis; Regional guidelines.

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Conflict of interest statement

Chung-Hwan Chen reports lecture fees from 10.13039/100002429Amgen. Julie Li-Yu reports lecture fees and/or honoraria from Zuellig Pharma. Linsey Gani reports lecture fees from 10.13039/100002429Amgen, DKSH, Servier, Zuellig; Advisory board member of Viatris, Organon. Satoshi Mori reports lecture fees from 10.13039/100002429Amgen, Asahi-Kasei Pharma, Astellas Pharma. Ching-Lung Cheung reports research support from 10.13039/100002429Amgen, 10.13039/100030732MSD, and 10.13039/100004339Sanofi. The other authors declare no competing interests.

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