1. Chapter 81 Chapter 81 Osteonecrosis of the Jaw and Atypical Femoral Fractures Copyright © 2013 Elsevier Inc. All rights reserved.

2. FIGURE 81.1 A, patient with Stage 3 bisphosphonate-associated osteonecrosis of the right maxilla. B, computed tomography scan of the same patient, coronal view. Source: courtesy of Dr. Salvatore Ruggiero. 2

3. Copyright © 2013 Elsevier Inc. All rights reserved. FIGURE 81.2 Anteroposterior (AP) radiographs showing an atypical femoral shaft fracture (A) pre- and (B) postoperatively, from the same individual. Note the oblique and transverse components (white arrow) and a medial “spike” (black arrow) on the preoperative view, and the lateral, transverse, lucent fracture line and associated focal cortical thickening with a “beaked” appearance (arrow) on the postoperative view. Source: courtesy of Thomas Einhorn, M.D. 3

4. Copyright © 2013 Elsevier Inc. All rights reserved. FIGURE 81.3 Conventional anteroposterior radiographs of the right (A) and left femurs (C) demonstrate subtle focal cortical thickening on both periosteal and endosteal surfaces, as well callus on the periosteal surface (arrows), while bone scintigraphy (B) demonstrates focal increased radionuclide uptake in the corresponding proximal lateral femoral cortices, findings consistent with early, evolving, bilateral, femoral insufficiency fractures. Source: courtesy of Piet Geusens, M.D. 4

5. Copyright © 2013 Elsevier Inc. All rights reserved. FIGURE 81.4 Conventional anteroposterior (AP) radiograph of the pelvis (A) shows bilateral focal cortical thickening from periosteal new-bone formation (arrows). Corresponding bone scintigraphy (B) demonstrates focal increased radionuclide uptake in the proximal lateral femoral cortices (arrows). Magnetic resonance images of the femurs (C) demonstrate subtle decreased signal on T1-weighted and increased signal on T-2 weighted images only of the right femur on this section. Similar findings on AP dual-energy x-ray absorptiometry (DXA) hip images (D) show focal bilateral cortical thickening consistent with early, evolving, femoral insufficiency fractures. Source: courtesy of Fergus McKiernan, M.D. 5

6. Copyright © 2013 Elsevier Inc. All rights reserved. FIGURE 81.5 A 76-year-old woman with osteoporosis who presented with an atypical femoral fracture. A, Anteroposterior radiograph of the right femur shows a displaced atypical femoral fracture characterized by both periosteal and endosteal beaking with an endosteal lesion (black arrow) superior to it. B, Anteroposterior radiograph of the left femur shows multifocal endosteal thickening (white arrowheads). Source: reprinted from Mohan etal. (213) [254], with permission. 6