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Introduction: Surgical treatment of hip fractures leads to significant post-operative complications. Although pathologic fractures (PF) are associated with worse outcomes, most studies do not differentiate between etiology (neoplastic and non-neoplastic PF). We seek to compare 30-day complication rates between 1) native hip fractures and neoplastic PF, and 2) neoplastic and non-neoplastic PF., Materials and Methods: A total of 127,819 patients with hip fractures and 5104 with PF diagnosed from 2005 to 2021 were retrieved from the NSQIP database. We included 1843 patients with neoplastic PF and 3261 with non-neoplastic PF. Demographics, pre-operative labs and co-morbidities, and post-operative outcomes were analyzed. Propensity-score matching was conducted to control for confounders., Results: Patients with a neoplastic PF had a significantly higher rate of deep venous thrombosis (DVT) (4 % vs 1.2 %, p = 0.001) and pulmonary embolism (PE) (2.4 % vs 0.7 %, p < 0.001), than native hip fractures. Rates of post-operative bleeding were significantly higher in the neoplastic PF group (29.3 % vs 23.9 %, p < 0.001) than non-neoplastic PF. No differences in soft tissue complications were found. When comparing neoplastic and non-neoplastic PF, the former had a higher rate of PE (2.5 % vs 1.0 %, p = 0.015) and post-operative bleeding (27.6 % vs 22.0 %, p = 0.009). Unplanned readmission rates and 30-day mortality rate were also higher in the neoplastic PF group., Conclusion: Neoplastic PF of the hip are associated with higher risk of thromboembolic event rates and post-operative bleeding than both native hip fractures and non-neoplastic PF. No differences in rates of soft tissue complications were found between groups., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Purpose: To determine whether synthetic grafts are a satisfactory treatment option for pathological proximal femoral fractures in children., Methods: Paediatric patients treated for pathological fractures of the proximal femur between 2013 and 2020 were evaluated retrospectively. 17 patients with a mean age of 10.7 years (range 6-16 years) were assessed. The definitive histopathological diagnoses were SBC (simple bone cyst) (12) and ABC (aneurysmal bone cyst) (5). The median duration of follow-up was 37 months (range 12-70 months)., Results: All patients returned to their normal daily routine within 3-8 months following surgery. The mean post-op recovery time was 3.2 months (range 3-6 months). Graft was incorporated at approximately 12 months. No significant radiographic healing was observed in 2 patients. In the remaining 15 patients, the mean duration of healing was 14 months (range 8-24 months)., Conclusion: Synthetic grafts are a satisfactory treatment option for pathological proximal femoral fractures in children., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The proximal femur is the most common location of metastases in the appendicular skeleton. Data on pathologic hip fractures, however, are sparse despite it is the most frequently operated pathologic fracture. The aim of this study was to investigate the ability of orthopaedic surgeons to identify pathologic hip fractures in an acute setting and secondly to validate the underlying cause of the pathologic fractures reported to Norwegian Hip Fracture Register (NHFR)., Methods: In the NHFR dataset between 2005 and 2019, we identified 1484 fractures reported to be pathologic possibly secondary to a malignancy. These fractures were thoroughly validated by reviewing X-rays, the patient journal, the operation description for date, side, why there had been suspicion of pathologic fracture, and implant choice. Pathology reports were reviewed once a biopsy had been performed. Based on this validation, information in the NHFR was corrected, whenever necessary., Results: Of the 1484 fractures possible secondary to malignancy, 485 (32.7%) were not a pathologic fracture. When reviewing the 999 validated pathologic fractures, 15 patients had a pathologic fracture secondary to a benign lesion. The remaining 984 patients had a pathologic fracture secondary to malignancy. The underlying diagnosis reported was corrected in 442 of the 999 patients. The true rate of pathologic hip fractures secondary to malignancy in our material was 0.8%, and most patients had underlying prostate (30%), breast (20%), or lung (17%) cancer., Conclusion: Orthopaedic surgeons in Norway failed to report correct data on pathologic fractures and the corresponding cancer diagnosis in an acute setting in many patients. The corrected data on pathologic fractures in the NHFR from 2005 to 2019 can now be a valid resource for further studies on the subject., (© 2023. The Author(s).)

PURPOSE OF THE STUDY Exploring the therapeutic potential of pathological fractures treatment of the proximal femur in childhood with LCP paediatric hip plate system according to the principles of AO. MATERIAL AND METHODS Six children with pathological fractures of the proximal femur and with an unicameral bone cyst have undergone surgery in our institution, in the period between June 2018 up until December 2020. All patients were young boys with a mean age of 11.83 ± 3.43 years. According to the classification of Delbet-Colonna, three of the fractures were Type IV - intertrochanteric fractures and three were Type III - basocervical fractures. ccording to the AO Trauma classification, one of the fractures was complete transtrochanteric multifragmentary (31-M/3.2.III), two were complete transtrochanteric simple (31-M/3.1.III), one was Complete basocervical multifragmentary (31-M/3.2.II) and two were complete basicervical simple (31-M/3.1.II). All patients have undergone open reposition and osteosynthesis with a 130° LCP pediatric hip plate system (DePuy Synthes Pediatric LCP Plate System). In four of the patients, one or two of the proximal locking screws pass through the growth plate, to ensure more stability. The anatomical correction of the proximal femur has been measured through the cervico-diaphyseal angle, consolidation of the fracture, the spontaneous reparation of the cyst according to the Capanna classification and cystic index, presence of avascular necrosis of the epiphysis, shortening of the extremity, and functional grading by the Musculoskeletal Tumor Society (MSTS) staging system. The Mann-Whitney (Wilcoxon W) test was used for data processing. RESULTS The mean timing of the follow-up after the surgery was 22 months (range 6-32). A radiographically supported consolidation of the fracture has occurred at an average timing of 4.8 months (range 3-6) in all patients. There is no clinical or radiological evidence of postoperative avascular necrosis in any of the patients. According to the classification of Capanna, in five of the six patients a spontaneous reparation of the cyst has occurred. In one of the cases, the reparation is classified as grade II with a pathological cystic index of 2.27. A postoperative correction of the varus fracture deformity of the proximal femur has been achieved in all children. The cervical-diaphysary angle of 112.50° preoperatively has been corrected to 137.17° (p=0.002). The achieved correction is lasting and the average value of the CDS at the final follow-up is 138.17° (p=0.794). Intraoperative correction, statistically equal to the CDA of the healthy side (p=0.942) is achieved with this operative technique. Data from the MSTS show functional correction on the third postoperative month with 38.33% of the norm (p=0.002) and 85% on the final follow-up (p=0.002). A contralateral distal femoral surgical epiphysiodesis by the method of Métaizeau has been used for the correction of the difference in the length of the extremities (with an average of 2.9 cm). CONCLUSIONS Osteosynthesis with an LCP paediatric hip plate system gives the opportunity for anatomical correction of the proximal femur with a low risk of avascular necrosis and achieving optimal functional results in pathological basocervical and intertrochanteric fractures in childhood. The use of 5mm plates and penetration of the proximal screw through the growth plate holds an increased risk of growth disruption. Key words: LCP paediatric hip plate system, pathological fracture, unicameral bone cysts, proximal femur.

A 60-year-old man presented to our hospital with complaints of pain and deformity on his right thigh for the past 2 days following a history of accidental slip and fall. Radiological investigations suggested a pathological type 2 Seinsheimer subtrochanteric fracture of the right femur with a 'bone within bone' appearance, which posed a diagnostic dilemma as this radiological appearance is seen in a spectrum of conditions. Radiographic skeletal survey failed to identify a similar appearance elsewhere in the body. Laboratory investigations pointed in favour of bone mineral disease, and histopathological examination of the bone narrowed it down to Paget's disease. The fracture was fixed with a contralateral distal femur locking compression plate. The fracture site failed to show signs of union until 6 months postsurgery and hence the patient was advised for grafting procedure. The patient deferred surgery and remains without major complications until 18 months of follow-up., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Amyloidosis is the extracellular deposition of amyloid protein fibrils, and this condition may be hereditary or acquired. Patients undergoing long-term hemodialysis are particularly at risk for developing acquired amyloidosis. A rare form of amyloidosis is an amyloidoma or amyloid tumor, which occurs when amyloid focally deposits in a section of the musculoskeletal system, most commonly in the osteoarticular system. Here, we present a case of a hemodialysis-related amyloidoma of the left femoral neck in an 80-year-old woman with end-stage renal disease on hemodialysis for 8 years. The purpose of this report is to provide an account of the unique clinical, imaging, and histopathologic manifestation of a dialysis-related amyloidoma that progressively enlarges over a 2-year period. This report also highlights some prophylactic measures that may reduce the risk of developing an associated pathologic fracture.

Objectives: FRAX is a computer-based algorithm developed by the World Health Organisation for estimation of the 10-yr risk of a hip or major osteoporotic fracture. Inclusion of femoral neck bone mineral density (BMD) in the estimation is optional. The study aimed to investigate the intra-individual agreement between FRAX fracture risk calculated with and without BMD in patients with rheumatoid arthritis (RA)., Methods: Clinical data and BMD results from 50 RA patients registered in the Danish rheumatology registry (DANBIO) were used for analysis. Using the Bland-Altman method, lower and upper 95% limits of agreement [LLoA;ULoA] between intraindividual assessments of fracture risk with and without BMD and the bias (mean of individual differences) were calculated. Categorization of patients according to the National Osteoporosis foundation (NOF) treatment thresholds were also assessed with and without BMD., Results: Mean age was 63.6 ± 11.7 yr, mean disease activity score (DAS28-CRP) 3.3 ± 3.5 and mean femoral neck T-score -1.43 ± 1.15. The mean 10-yr risk of a major fracture and a hip fracture calculated with BMD was 22.9 ± 15.8% and 8.5 ± 10.8%, respectively. The LLoA and ULoA [bias] calculated without vs with BMD were -14.5 and 20.4 percent point (pp) [2.9 pp] for major fracture risk and -14.0 and 23.2 pp [4.6 pp] for hip fracture. NOF treatment categorization was only dependent on BMD in 4% of the patients., Conclusion: The FRAX fracture risk estimated with and without BMD may disagree substantially in individual patients with RA but this seems to have only little impact on treatment categorization based on the NOF guidelines., (Copyright © 2018. Published by Elsevier Inc.)

Hip fractures are uncommon in childhood and adolescence. A high-energy injury is the most common cause. Low-energy trauma may result in a pathological hip fracture or stress fracture of the femoral neck, on the grounds of a preexisting skeletal disease, a tumor, or a tumor-like lesion. Surgical or conservative treatment may be provided based on underlying disease and/or age, Delbet and/or Colona classification, and displacement of the fracture. We present a case series of 13 children with pathological hip fracture. Mean age of patients was 7 years, and average follow-up was 3 years. There were types I and II, 3 type III, and 10 type IV fractures according to Delbet/Colona classification. Patients were treated conservatively, by open reduction and internal fixation or by minimally invasive surgery. In 11 children (84.5%), the outcome was satisfactory; one child (7.75%) presented with nonunion and refracture after minimally invasive surgery, and another (7.75%) presented with refracture after conservative treatment. Both patients were treated with open reduction and internal fixation. Pathological hip fractures are rare in children and should be treated properly. Surgical treatment with open reduction, internal fixation, and bone grafting is preferred in displaced fractures. In nondisplaced fractures, the choice between conservative and surgical treatment should be based on Delbet/Colona classification and patient profile.

Background: Although cephalomedullary nail fixation is often used for metastatic peritrochanteric lesions of the femur, there is concern regarding the durability of the implant in comparison to endoprosthetic reconstruction. Previous studies have reported the proportion of patients who undergo reoperation for loss of stability, but the adequacy of the construct has not been critically evaluated in a competing risk analysis that incorporates death of the patient in the calculation., Questions/purposes: (1) What is the cumulative incidence of reoperation of cephalomedullary nails with death as a competing risk for metastatic lesions of the proximal femur? (2) What is the survival of patients with metastases to the proximal femur after cephalomedullary nailing? (3) What clinical factors are associated with implant stability in these patients?, Methods: Between 1990 and 2009, 11 surgeons at one center treated 217 patients with cephalomedullary nails for metastatic proximal femoral lesions. This represented 40% (217 of 544) of the patients undergoing surgery for metastases in this location during the study period. In general, we used cephalomedullary nails when there was normal bone in the femoral head, no fracture in the neck, and a moderate-sized lesion; we favored bipolar hemiarthroplasty for femoral neck fractures and disease affecting the femoral head; finally, we used proximal femoral endoprosthetic replacement for large lesions with severe bone destruction. A retrospective study was conducted of 199 patients with cephalomedullary nails for peritrochanteric metastases from 1990 to 2009. Pathologic fracture, defined as a breach in cortex with a clear fracture line either with or without displacement, was present in 61 patients. The most common primary cancers were breast (42 of 199 patients [21%]), lung (37 of 199 patients [18%]), and renal cell (34 of 199 patients [17%]). A competing risk analysis was performed to describe the cumulative incidence of implant revision. Patient overall survival was assessed by Kaplan-Meier survivorship. A univariate analysis was performed to determine whether there was an association between revision surgery and various patient factors, including tumor histology, pathologic fracture, cementation, and radiation., Results: Loss of implant stability necessitating revision surgery occurred in 19 of 199 patients (10%). In a competing risk analysis with death of the patient as the competing event, the cumulative incidence of revision surgery was 5% (95% confidence interval [CI], 3%-9%) at 12 months and 9% (95% CI, 5%-13%) at 5 years. Using Kaplan-Meier analysis, the overall patient survival was 31% (95% CI, 25%-37%) at 12 months and 5% (95% CI, 3%-9%) at 60 months. Patients with lung cancer had the shortest overall survival of 11% (95% CI, 1%-21%) at 12 months, and patients with multiple myeloma had the longest overall survival of 71% (95% CI, 49%-94%) at 12 months (p < 0.001). Duration of patient survival beyond the median 7 months was the only factor associated with a greater likelihood of revision surgery. Factors not associated with revision included tumor histology, pathologic fracture, closed versus open nailing, cementation, gender, age, and postoperative radiation., Conclusions: The competing risk analysis demonstrates a relatively low cumulative incidence of reoperation and suggests that cephalomedullary nailing is reasonable for patients with moderate-sized proximal femoral metastasis not affecting the femoral head. For the large majority of patients, the construct achieves the goal of stabilizing the femur for the duration of the patient's life. Longer patient survival was associated with greater risk of revision surgery, but no particular tumor histology was found to have a greater cumulative incidence of reoperation. Future work with a larger number of patients and stricter surgical indications may be needed to corroborate these findings., Level of Evidence: Level III, therapeutic study.

The incidence of atypical femoral fractures (AFFs) was 2.95% among 6644 hip and femoral fractures. Independent risk factors included the use of bisphosphonates (BPs), osteopenia or osteoporosis, rheumatoid arthritis, increased femoral curvatures, and thicker femoral cortices. Patients with AFFs and BP treatment were more likely to have problematic healing than those with typical femoral fractures (TFFs) and no BP treatment., Introduction: To determine the incidence and risk factors of atypical femoral fractures (AFFs), we performed a multicenter case-control study. We also investigated the effects of bisphosphonates (BPs) on AFF healing., Methods: We retrospectively reviewed the medical records and radiographs of 6644 hip and femoral fractures of patients from eight tertiary referral hospitals. All the radiographs were reviewed to distinguish AFFs from TFFs. Univariate and multivariate logistic regression analyses were performed to identify risk factors, and interaction analyses were used to investigate the effects of BPs on fracture healing., Results: The incidence of AFFs among 6644 hip and femoral fractures was 2.95% (90 subtrochanter and 106 femoral shaft fractures). All patients were females with a mean age of 72 years, and 75.5% were exposed to BPs for an average duration of 5.2 years (range, 1-17 years). The use of BPs was significantly associated with AFFs (p < 0.001, odds ratio = 25.65; 95% confidence interval = 10.74-61.28). Other independent risk factors for AFFs included osteopenia or osteoporosis, rheumatoid arthritis, increased anterior and lateral femoral curvatures, and thicker lateral femoral cortex at the shaft level. Interaction analyses showed that patients with AFFs using BPs had a significantly higher risk of problematic fracture healing than those with TFFs and no BP treatment., Conclusions: The incidence of AFFs among 6644 hip and femoral fractures was 2.95%. Osteopenia or osteoporosis, use of BPs, rheumatoid arthritis, increased anterior and lateral femoral curvatures, and thicker lateral femoral cortex were independent risk factors for the development of AFFs. Patients with AFFs and BP treatment were more likely to have problematic fracture healing than those with TFFs and no BP treatment.

Background: The proximal femur represents the most common site of metastatic bone disease in the appendicular skeleton, and associated pathologic pertrochanteric femur fractures contribute to cancer-related morbidity and mortality. Controversy exists as to whether these injuries are best managed with intramedullary nailing (IMN) or with arthroplasty., Methods: A systematic review of the literature was performed using a PubMed search following PRISMA guidelines to identify studies performed within the last 20 years regarding treatment of proximal femur metastatic lesions with either nailing or arthroplasty with a reported reoperation rate. Sixteen studies were selected for inclusion containing 1414 patients. Pooled estimates and 95% confidence intervals (CIs) for reoperation rates associated with IMN and endoprosthetic reconstruction (EPR) were separately calculated., Results: The pooled estimate for reoperation for IMN was a median of 9% (95% CI, 5%-14%) and the pooled estimate for reoperation for EPR was a median of 7% (95% CI, 5%-11%). Significant heterogeneity was present in studies reporting on both treatment modalities: for IMN, I 2  = 55%, and for EPR, I 2  = 51%., Conclusion: This systematic literature review identified 16 eligible, nonrandomized, retrospective studies that reported on the results of surgical treatment for proximal femur metastatic disease. The pooled estimate of reoperation was similar between patients treated with IMN and EPR. Inconsistencies among follow-up and the study designs used limited evidence-based conclusions. As the oncologic care of patients with metastatic disease continues to evolve and improve, patient-specific needs must be carefully considered when selecting an optimal treatment strategy., Level of Evidence: Level III., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Patients who have lytic bone lesions in their proximal femurs are at risk for pathological fracture. Lesions with high fracture risk are surgically treated using prophylactic osteosynthesis, whereas low-risk lesions are treated conservatively. However, it is difficult to discriminate between high- and low-risk lesions based on clinical and radiographic findings. The computed tomography (CT)-based finite element (FE) models are useful for predicting the fracture load on proximal femoral lytic lesions., Materials and Methods: FE models were constructed from the quantitative CT scans of the femurs using software that created individual bone shapes and density distributions. Three independent observers measured the lesion size, Mirels' score, and thickness of the proximal femur along the horizontal plane. The predictive risk values of the proximal femur measured using the CT-based FE analysis were statistically compared., Results: The patients were divided into two groups (high and low risk). The mean fracture load was significantly higher in the high-risk group than in the low-risk group (5395 ± 525 N, 2622 ± 364 N, respectively, p = 0.0003). No significant differences in age, body weight, lesion size or Mirels' score were observed between groups. However, the thickness of the medial cortex in the high-risk group according to the FE analysis was significantly thinner than that in the low-risk group. Furthermore, the medial cortex thickness was positively correlated with the predicted fracture load. An optimal cut-off value of 3.67 mm for the thickness of the inner cortex resulted in 100% sensitivity and 75.1% specificity values for classifying the patients based on their fracture risk., Conclusions: Our findings indicate that the FE method is useful for the prediction of the pathological fracture. This method shows a versatile potential for the prediction of pathological fracture and might aid in judging the optimal treatment to prevent fracture., (Copyright © 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Objective: To determine the rate ratios of hip and distal radius fractures in patients with rheumatoid arthritis (RA), hip osteoarthritis (OA), and knee OA., Methods: Cohort study using healthcare data (1998-2012) covering the entire population of the Skåne region of Sweden., Results: We found an increased rate of hip fracture in both female [standardized fracture rate ratio (SFR) 1.54, 95% CI 1.40-1.70] and male patients with RA (SFR 1.81, 95% CI 1.51-2.17). The hip fracture rate in female OA was reduced by 10-20%, and trochanteric fracture tended to have a higher rate ratio compared with the cervical., Conclusion: The 50-80% increased rate of hip fracture adds to the total burden of RA while the shifted distribution of cervical/trochanteric fractures in OA is in support of subchondral bone alterations.

Objectives: To compare intracapsular (IC) and extracapsular (EC) hip fractures (HIF) in elderly patients in order to determine if they are different pathologies., Subjects and Methods: Longitudinal, observational, descriptive, analytical prospective design, using a non-probabilistic sample from a full sample collection with 647 subjects (male and female), of 60 or more years old, admitted with HIF to the Department of Orthopedics and Traumatology of the Hospital, between January 1, 2010 and December 31, 2012. Follow-up was for 1 year post HIF. Socio-demographic, etiological, developmental, therapeutic and prognostic variables are compared., Results: This is the first study on this subject with Latin American population. EC HIF incidence was superior to IC, contrary to that published in European/American populations. There are significant differences in etiological variables (χ(2)=6.34, p<0.042), with traumatic etiology in EC and non-traumatic in IC. There are also differences in therapeutic interventions performed (osteosynthesis for EC, arthroplasty for IC), with the decision on not to operate being lower in IC (both p<0.0000). The variables associated with the decision on not to perform surgery are age, etiology and postoperative mortality., Discussion: The results are similar to other studies, adding the IC association with non-traumatic origin, in particular the trend of statistical association between IC and non-primary osteoporotic pathology (neoplasms, renal osteodystrophy, primary hyperparathyroidism). A further analysis was performed on the differences between Latin American and European/American populations in the incidence of either type of HIF. There are important etiological and therapeutic differences between IC and EC HIF; therefore it would be advisable to consider them as distinct disease entities., (Copyright © 2014 SECOT. Published by Elsevier Espana. All rights reserved.)

Background: The FRAX tool allows calculate the 10 year probability of fracture risk in men and women., Objective: To compare the 10 years fracture risk calculated with the FRAX tool using or not bone densitometry., Material and Methods: A prospective, cross-sectional, open a comparative study was done with 40-80-year-old women, who were evaluated with bone densitometry. To calculate the fracture risk the FRAX tool was used with and without bone densitometry in each patient. Both results were compared with Mann-Whitney U test., Results: The mean age was 54.2 ± 8.7 years. The median of the FRAX calculated risks without using bone densitometry was for major fracture 2.4 (1-12) and hip 0.3 (0-5.2). The calculated risks using bone densitometry was for major fracture 2.3 (1.2-11) and for hip 0.2 (0-3.6), without statistically significant differences among them. The calculated T score with FRAX was -1.0 (-2.7 ± 1.9)., Conclusions: The results obtained with the FRAX tool using or not bone densitometry were similar. These findings will allow using this instrument in a greater number of patients.

Background: New methods for diagnosing osteoporosis and evaluating fracture risk are being developed. We aim to study the association between low-frequency (LF) axial transmission ultrasound and hip fracture risk in a population-based sample of older women., Methods: The study population consisted of 490 community-dwelling women (78-82 years). Ultrasound velocity (V(LF)) at mid-tibia was measured in 2006 using a low-frequency scanning axial transmission device. Bone mineral density (BMD) at proximal femur measured using dual-energy x-ray absorptiometry (DXA) was used as the reference method. The fracture history of the participants was collected from December 1997 until the end of 2010. Lifestyle-related risk factors and mobility were assessed at 1997., Results: During the total follow-up period (1997-2010), 130 women had one or more fractures, and 20 of them had a hip fracture. Low V(LF) (the lowest quartile) was associated with increased hip fracture risk when compared with V(LF) in the normal range (Odds ratio, OR = 3.3, 95% confidence interval (CI) 1.3-8.4). However, V(LF) was not related to fracture risk when all bone sites were considered. Osteoporotic femoral neck BMD was associated with higher risk of a hip fracture (OR = 4.1, 95% CI 1.6-10.5) and higher risk of any fracture (OR = 2.4, 95% CI 1.6-3.8) compared to the non-osteoporotic femoral neck BMD. Decreased VLF remained a significant risk factor for hip fracture when combined with lifestyle-related risk factors (OR = 3.3, 95% CI 1.2-9.0)., Conclusion: Low V(LF) was associated with hip fracture risk in older women even when combined with lifestyle-related risk factors. Further development of the method is needed to improve the measurement precision and to confirm the results.

We report the rare case of a 75-year-old man who was hospitalised following referral by his general practitioner with a 4-day history of worsening groin pain. Initial radiographs demonstrated an isolated avulsion fracture of the lesser trochanter. There were associated bony changes indicating pathological bone disease, likely secondary to bony metastasis. Further investigation revealed a renal mass almost certainly consistent with a renal cell carcinoma. This case emphasises the importance of having a high index of suspicion for neoplastic pathology when low impact injuries result in fractures., (2014 BMJ Publishing Group Ltd.)

Accumulating evidence shows that type 2 diabetes and chronic kidney disease (CKD) enhance fracture risk mainly by deteriorating bone quality. Vertebral fracture on X-ray films and hip fracture in past history in subjects of 50 years old or more are hallmarks to start medication for osteoporosis. Patients with diabetes or CKD who have no fracture could undergo drug treatments if their bone mineral density is osteopenic, considering the established link between these disorders and fracture risk.

Introduction: Endometrial cancer is the most common malignancy among females in developed countries. Abnormal uterine bleeding is the leading symptom in approximately 90 % of cases. The incidence of stage IV disease is approximately 5-10 % with a 5-year overall survival of less than 10 %., Materials and Methods: A rare case presented with femoral pathological fracture and underlying endometrial cancer. We discuss the diagnosis, management and literature review for this extremely rare entity which can be present even in the absence of vaginal bleeding., Results: Literature search revealed 28 cases with primary bone metastasis and all were symptomatic at the time of diagnosis. Eighty percent of them had tumour on the lower limb and the majority did not have vaginal bleeding. The predominant histopathological type was endometrioid (72.4 %) and grade 1-2 (59 %). Treatment had been individualised and 57 % of the cases underwent surgery with removal of uterus and adnexa and only three patients (10.7 %) received pelvic radiotherapy. Bone tumour was treated with radiotherapy in 80 % of the cases, alone (28 %), or combined with primary surgery (12 %) or chemotherapy (40 %). Overall, 54 % of patients received chemotherapy and 46 % received hormone therapy. The mean survival of patients who presented with single-bone metastasis was significantly better than those with multiple extrauterine metastatic sites: mean 85.7 months (SE: 9.2) versus 22.9 months (SE: 5.2), p < 0.003, CI 95 %. These two different survival patterns are more likely to reflect two different biological disease behaviours. Those with advanced local and widespread disease progress quicker, in contrast to those with a single-bone extrauterine metastatic site and local disease limited to the uterus, which continues to behave as early stage endometrial cancer., Conclusions: Although extremely rare, endometrial cancer can present as initial bone pathology. Endometrial biopsy should be included in the patient's workup when investigating for metastatic bone adenocarcinoma of unknown origin, even when gynaecological symptoms are lacking, as this rare presentation of stage IVb endometrial cancer appears to have good survival outcomes.

Pathological fracture is a rare but serious complication of radiotherapy. We report on a 44-year-old man who presented with a subtrochanteric femoral fracture 15 years after radiotherapy for a soft-tissue sarcoma in the thigh. We discuss its potential causes, a scoring system to identify high-risk patients for prophylactic intramedullary nailing of the femur, and radiographic signs to identify an impending insufficiency fracture.

A 74-year-old woman with refractory IgG-κ multiple myeloma developed massive melena caused by hemorrhagic submucosal tumors in the duodenum and middle jejunum. A biopsy revealed the tumor to be marked AL amyloid deposition. Treatment with bortezomib did not improve the melena or the underlying disease. The patient also developed multiple amyloidomas in the bilateral femoral heads, which caused a fracture in the left femoral head. Treatment with lenalidomide, as the final therapeutic option, resolved the intractable melena and improved both the intestinal lesions and myeloma. This case shows that successful treatment of multiple myeloma leads to marked improvement of accompanying AL amyloidosis.

Objective: Low bone mineral density (BMD) is a major risk factor for fragility fractures in osteoporosis. In recent studies, its use with clinical risk factors has been shown to enhance prediction of fragility fractures. The present study was done to assess BMD in Indian patients with fragility fractures using digital X-ray radiogrammetry (DXR-BMD)., Methods: A total of 228 patients (64 male and 164 female) admitted to an Orthopedic Hospital for management of fragility fracture were recruited. For each patient, DXR-BMD was obtained from an anteroposterior radiograph of the non-dominant hand., Results: The number of subjects with hip fracture was 104 (40 male, 64 female). Vertebral fractures were seen in 67 patients (11 male, 56 female) and distal radial fracture in 57 patients (13 male, 44 female). The DXR-BMD (g/cm(2)) was significantly lower in subjects with any fragility fracture (0.51 vs. 0.58 in men and 0.41 vs. 0.54 in women). When compared to the age-matched normative reference data by decade, all subjects with fragility fracture had significantly lower DXR-BMD except male subjects in the age decade of 40-49 years., Conclusion: This study confirms lower DXR-BMD in Indian subjects with fragility fractures. This may have a potential role in fracture prediction when used with clinical risk factors in the Indian population.

The present case describes an atypical femur fracture in a patient, who had not previously been treated with bisphosphonate. The patient fulfilled the specific characteristics for an atypical fracture that have recently been suggested by an international expert group. For 15 years after her menopause the patient had been treated with oestrogen. Prospective studies to determine the frequency and pathogenesis of these fractures in patients treated with bisphosphonate and in bisphosphonate naïve patients are suggested.

Bisphosphonates reduce fractures risk in patients with osteoporosis. A new pattern of fractures is now being noted in patients on prolonged bisphosphonate therapy. We report a case of an atypical femoral fracture with preceding pain and highlight the characteristics of these fractures.

Unlabelled: Non-traumatic fractures at typical osteoporotic sites are associated with increased mortality across all age groups, particularly in men. Furthermore, in certain age subgroups of women and men, this rate remained elevated beyond 5 years for fractures of the hip, vertebrae, humerus, and other sites., Introduction: Increased mortality rates have been documented following non-traumatic hip, vertebral, and shoulder fractures. However, data are lacking as to the duration of excess mortality and whether there is increased mortality following fractures at other sites. We determined mortality up to 15 years following incident fractures at typical osteoporotic sites., Methods: Using healthcare databases for the Province of Manitoba, Canada, we identified individuals 50 years and older with an incident non-traumatic fracture between 1986 and 2007. Each fracture case was matched to three fracture-free controls. Generalized linear models were used to test for trends in mortality and to estimate the relative risk for cases after adjusting for co-morbidity and living arrangements., Results: During the study period, we identified 21,067 incident fractures in men followed by 10,724 (50.1%) deaths and 49,197 incident fractures in women followed by 22,018 deaths (44.8%). Seventy-six percent of the fractures were at sites other than the hip and vertebrae. After adjustment for age, number of co-morbidities, and level of dependence in living arrangements, the risk of death in cases, relative to controls, was increased in both sexes for hip, vertebral, humerus, wrist (in men only), and other fracture sites. Post-fracture mortality was higher in men than women. Relative mortality was the highest in the younger age groups across the spectrum of fracture sites., Conclusions: Fractures at typical osteoporotic sites are associated with increased mortality across all age groups, particularly in men. Better understanding of factors associated with increased post-fracture mortality should inform the development of management strategies.

We report on the survival of 145 patients presenting to a single centre with a pathological metastatic fracture of the proximal femur. The single surviving patient had a follow-up of 17.7 years. Mean survival for the 144 patients who died was 332 days (range 2 to 3053 days), being longest for those with myeloma (662 days), lymphoma (> 633 days) and breast tumours (477 days) and lowest for lung tumours (110 days). The most common sites for the primary tumour were breast (36%), prostate (23%) and lung (17%). 47% of fractures were intracapsular, 28% trochanteric and 25% subtrochanteric. 99% of the fractures were treated surgically with a mean hospital stay of 19 days. The commonest fracture healing complication was further fracture of the femur around or immediately below the implant which occurred after 9/144 (6.2%) of operations. The difference in survival of patients related to the primary tumour site is of relevance in planning surgical treatment and discussing prognosis with patients.

We examined prospectively collected data from 6782 consecutive hip fractures and identified 327 fractures in 315 women aged ≤65 years. We report on their demographic characteristics, treatment and outcome and compare them with a cohort of 4810 hip fractures in 4542 women aged > 65 years. The first significant increase in age-related incidence of hip fracture was at 45, rather than 50, which is when screening by the osteoporosis service starts in most health areas. Hip fractures in younger women are sustained by a population at risk as a result of underlying disease. Mortality of younger women with hip fracture was 46 times the background mortality of the female population. Smoking had a strong influence on the relative risk of 'early' (≤ 65 years of age) fracture. Lag screw fixation was the most common method of operative treatment. General complication rates were low, as were re-operation rates for cemented prostheses. Kaplan-Meier implant survivorship of displaced intracapsular fractures treated by reduction and lag screw fixation was 71% (95% confidence interval 56 to 81) at five years. The best form of treatment remains controversial.

Objective: To evaluate the clinical features and outcome of inpatients with hip fracture and to investigate the clinical variables associated with the risk of medical complications., Methods: Prospective study of hip fracture patients aged 65 or more, admitted to the Department of Orthopaedic Surgery of the Xeral-Calde Hospital, in Lugo, Spain, in 2008. The different clinical and biochemical variables as regards the baseline health status and presentation features of the hip fracture and its complications were all recorded. The factors associated with the development of medical inpatient complications, including death, were determined, using univariate and multivariate analyses., Results: A total of 258 patients were studied. The mean age was 82.2 (9.5) years, and 76% were women. The fracture was osteoporotic in 96.8%, and 92.6% were treated surgically. The mean Barthel index was 72.9 (25.7) and the age adjusted Charlson comorbidity index was 5.2 (1.5). A total of 63.9% patients had a major medical complication during their hospital stay. Mortality was 5.8%. The following variables were associated with the development of medical inpatient complications: Barthel index (OR=2.21; 95% CI, 1.1-4.25; p=0,01), age (OR=1.09; 95% CI, 1.02-1.12; p=0.006), haemoglobin at admission (OR=0.76; 95% CI, 0.62-0.93; p=0.01)., Conclusions: Patients with hip fracture are fragile elderly with a high degree of functional dependence and comorbidity. Those with a high risk of developing medical inpatient complications can be identified at admission., (Copyright © 2010 SECA. Published by Elsevier Espana. All rights reserved.)

Risk factors for bone loss among the elderly are largely unknown. The objective of the study was to examine longitudinal bone loss in the hip in one-hundred and sixty-two 75-year-old women. Bone mineral density (BMD, g/cm(2)) was measured with dual X-ray absorptiometry (DXA) at baseline and after 4 years. The relationship between changes in BMD during follow-up and the following factors; baseline BMD, baseline weight, weight change, baseline lean and fat body mass (measured with DXA), serum values of biochemical markers and hormones, nutritional and lifestyle factors according to a questionnaire was assessed. The annual mean (SD) change in femoral neck BMD was -0.31% (1.38) in total trochanter -0.35% (1.15) and total hip -0.34% (1.10) and did not differ significantly between measurement sites. Bisphosphonate users had a 2.9%, 1.7% and 1.9% mean adjusted increase in femoral neck, total trochanter and total hip BMD respectively, different from none-users (p<0.05). Subjects with more than three weekly physical activity sessions had less femoral neck bone loss than less active women (p<0.05). The proportion of the variance in BMD changes explained by multivariate models (R(2)) was 12-13%. Women gaining weight had less loss of BMD than those losing weight in the trochanter and the total hip (p<0.001), and in the femoral neck (p=0.055). Elderly women should be advised to maintain their body weight and participate in physical activity. Despite the large number of variables examined in this study, bone loss occurring with increased age is not thoroughly explained., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Bone strength is determined not only by BMD, but also by many other bone quality relating factors such as bone structure etc.. Hip fractures are the most serious fragile fractures, considering that controlling their risk factors will successfully prevent these fractures. Recently Hip structure (strength) analyses have become available during standard DXA measurements. Bending strength and stability of the bone can be determined by their obtained parameters such as section modulus, cross sectional area and buckling ratio. These parameters shift towards fragile by aging, especially remarkably reduce after 70 years. It has been reported that both anti-resorptive agents and anabolic PTH increase bone strength in different manner. Further progressed 3 dimensional femoral neck strength analysis using CT scanning are now under development.

Hip fractures are a burden to both society and the individual. The aim of this study was to describe the frequency of osteoporosis and the in-hospital treatment costs of patients with hip fractures admitted to Hacettepe University Faculty of Medicine Hospital. Patients with a hip fracture who were admitted to the Orthopedics and Traumatology wards between April 2003 and December 2006 were interviewed and 50 of them were enrolled prospectively in the study protocol. Patient characteristics, predisposing factors for fractures and hospital costs were recorded as well as laboratory test results and bone mineral density measurements. The mean age was 74.2 years and 72% of the patients were women. Sixty-four percent of them presented with an intertrochanteric fracture. The patient population was significantly debilitated with a high prevalence of vitamin D insufficiency and secondary hyperparathyroidism. No association was shown with T scores and dietary habits and lifestyle characteristics of patients. In 34% of patients in whom measurements were available, no osteoporosis could be documented. The mean hospital expenditure was $5983. Factors affecting the total cost were age and functional status of the patient and the duration of hospital stay, independent of the type of fracture and surgical procedure used., (Copyright (c) 2009 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Osteoporosis is a major cause of low-energy hip fractures. Although there are pharmacologic agents available for both prevention and treatment, less than 10% of hip fracture cases initiate anti-osteoporotic treatment., Material and Methods: In 1995 and 2008, questionnaires were sent to all Danish orthopaedic surgery departments treating patients with low-energy hip fractures, asking them to explain a) whether patients with osteoporosis are identified, b) whether the patients identified are treated for osteoporosis, and c) whether physicians need more information about osteoporosis., Results: 56 departments (97%) returned the questionnaires in 1995 and 25 (95%) in 2008. 40% of the departments did (12% in 1995) refer any patients with low-energy fractures to bone densitometry. 84% treated (11% in 1995) patients with hip fractures with calcium and D vitamin. In 2008, 28% (0% in 1995) of the departments used bisfosfonates after hip fractures (none used yearly zoledronate). More than 80% (54% in 1995) of the departments informed the patients about in the advantages of lifestyle changes. Half of the departments' doctors wanted more information about osteoporosis in 1995 compared with only 16% in 2008. In 2008, 48% of the departments informed the GPs that their patient with a low-energy fracture may have osteoporosis and that further evaluation and treatment may be needed., Conclusion: Medical treatment after fractures was more widespread in 2008 than in 1995. About half of the Danish departments with orthopaedic surgery functions refer patients to further investigation. There is, however, still room for improvement.

Evidences of reduction in fracture risk have been accumulated increasingly in patients with osteoporosis. More than ten pharmaceutical agents have been shown to be effective to vertebral fracture risk, and six agents are also effective to reduce hip fracture risk as well. Recent analyses are revealing that the uses of agents to prevent fracture are cost-effective, if the agents potently reduce both vertebral and hip fractures. Pharmaceutical intervention, when combined with appropriate nutritional support and low intensity exercise, is currently eligible to be the primary strategy in subjects with increased risk of fracture in the health care of aged persons to maintain their daily activity and quality of life.

Objective: To characterize a population with osteoporotic proximal femur fractures in a Portuguese Hospital., Material and Methods: retrospective study, by clinical report consultation of all patients 50 years and older, hospitalized at the Orthopedic department in 3 consecutive years (from 2004 to 2006) at the Caldas da Rainha Hospital due to proximal femur fracture after a low impact fall. Database with: demographic; data about fracture and its treatment; follow up after discharge; previous osteoporosis diagnosis; reference to previous or simultaneous fractures; concomitant medication; other diseases; osteoporosis medication., Results: 272 hospitalizations of 267 patients in 3 years, 76% of which were women. Incidence rate of osteoporotic proximal femur fractures of 0.09%. The majority of patients had between 71 and 90 years old, median age of 80.2 years. Median ingress duration was 15.6 days. Only in 7% cases was registered the previous diagnosis of osteoporosis. Fall localization was referred in only 28% cases, in almost all cases occurred at home. There was a reference to other osteoporotic fractures in 16% cases. The majority of patients had between 1 and 5 simultaneous diseases. Fifty nine percent of patients were taking 4 or more medications. In no single case was ordered a densitometry nor registered the prescription of anti-osteoporotic treatment. The total cost of these 272 hospitalizations was 1,458.220.67 euros. There were 39 (14.6%) registered deaths in the first year after the proximal femur fracture., Conclusions: Osteoporosis and the risk of fractures were apparently under-diagnosed in this high risk population: old, polimedicated and with diseases that potentially facilitate falls and fractures. Apparently, there was no secondary prevention of osteoporotic fractures in these patients. The proximal femur fracture incidence and associated mortality were inferior to other literature references.

Bisphosphonates such as alendronate and risedronate effectively reduce hip fracture risk, and thus are suitable for the elderly people in whom this fracture is most likely to happen. Bisphophonates should be administered when patients meet the guideline made by Japanese bone society, which picks up prevalent fractures, low bone mineral density, and established risk factors as features for starting osteoporosis treatment. Long-term alendronate administration may inhibit normal repair of microdamage arising from severe suppression of bone turnover (SSBT), which, in turn, results in accumulation of microdamage. This process would lead to brittle bone and the occurrence of unexpected stress fractures, characteristically at the subtrochanter of femur. A large-scale study suggests that for more women, discontinuation of alendronate after 5 years for up to 5 more years does not significantly increase fracture risk. Thus, alendronate treatment might be stopped for a while after 5 years to prevent SSBT and subsequent stress fractures.

Introduction: The incidence of osteoporotic hip fractures in Singapore as well as in Asia will gradually increase with an ever ageing population. The objectives of this study were to understand the costs of hip fractures in our community and to analyse the various factors that lead to higher inpatient costs for hip fractures., Methods: We prospectively reviewed 80 elderly patients with osteoporotic hip fractures. The relevant patients' clinical data was correlated with the inpatient hospitalisation costs. We reviewed the cost and management practices of hip fractures published in the literature and compared them with our findings., Results: We found that our patients treated surgically incurred lower costs and had a shorter inpatient stay compared to those treated conservatively. The mean hospitalisation cost for patients treated surgically was S$10,515 and the mean length of stay was 16 days. We found that the length of stay, a longer delay to surgery, male gender, having ASA 3 score, and development of postoperative complications led to higher inpatient hospital costs., Conclusion: With the identification of various clinical factors that are associated with high inpatient costs, we can further shorten our hip fracture patients' stay as well as reduce the hospitalisation costs.

Background: The number of people living more than 90 years is increasing. This population is at high risk of osteoporotic hip fracture and the rates of a good outcome after surgical treatment are lower than in younger patients. The aim of this study was to evaluate psychophysical status and survival time following hip fracture surgery in nonagenarians., Material and Methods: Forty-two nonagenarian patients included in the study were assessed retrospectively using our own 16-point scale. Evaluation was made on several occasions: prior to injury, at discharge from the hospital and during a follow-up examination, at least 6 months after surgery. Medical data were obtained from medical records and from telephone information given by patients, their family members, carers or social welfare employees. Statistical analyses were performed using average point values and standard deviations., Results: 48% of the operated patients died within 1-9 months after surgery. Considerable deterioration of psychophysical status following surgery was reported for 24% of patients., Conclusions: Operative treatment in patients 90 years of age and over with hip fractures was associated with a good outcome, i.e. the recovery of psychophysical status comparable to that prior to the injury, only in 36% of the patients.

Background: The orthopaedic unit at a university teaching hospital hired an osteoporosis coordinator to identify patients with a fragility fracture and to coordinate their education, assessment, referral, and treatment of underlying osteoporosis. We report the results of an analysis of the cost-effectiveness of the use of a coordinator (in comparison with the use of no coordinator) in avoiding future costs of subsequent hip fracture., Methods: A one-year decision-analysis model was developed. The health outcome was subsequent hip fracture; only direct hospital costs were considered. With use of patient-level data from a previously described coordinator program and data from the literature, the expected annual incidence of subsequent hip fracture was calculated, on the basis of the type of index fracture (wrist, hip, humerus, other), attribution to osteoporosis, age, and gender. The rate of patient referral, the initiation of osteoporosis treatment, and adherence to therapy were modeled to modify the expected incidence of future hip fracture in the presence of a coordinator (with use of data from the program) and in the absence of a coordinator (with use of data from the literature). Sensitivity analysis modeling techniques were used to assess variable uncertainty and to evaluate coordinator cost-effectiveness., Results: Deterministic cost-effectiveness analysis showed that a tertiary care center that hired an osteoporosis coordinator who manages 500 patients with fragility fractures annually could reduce the number of subsequent hip fractures from thirty-four to thirty-one in the first year, with a net hospital cost savings of C$48,950 (Canadian dollars in year-2004 values), with use of conservative assumptions. Probabilistic sensitivity analysis indicated a 90% probability that hiring a coordinator costs less than C$25,000 per hip fracture avoided. Hiring a coordinator is a cost-saving measure even when the coordinator manages as few as 350 patients annually. Greater savings are anticipated after the first year and when additional costs such as rehabilitation and dependency costs are considered., Conclusions: Employment of an osteoporosis coordinator to manage outpatients and inpatients who have fragility fractures is predicted to reduce the incidence of future hip fractures and to save money (a dominant strategy). A probabilistic sensitivity analysis showed a high probability of cost-effectiveness of this intervention from the hospital cost perspective.

Background and Objective: Hypovitaminosis D is frequent in the elderly, and it is especially prevalent among patients with hip fracture. The prevalence of vitamin D deficiency and its related factors are not well known in our population. The objective of this study was to determine the prevalence of hypovitaminosis D in patients with osteoporotic hip fracture and to analyze which factors are associated with this deficit., Patients and Method: Transversal study. Inclusion of all consecutive patients older than 65 years, admitted in our hospital with osteoporotic hip fracture during the period of March 2002-February 2003. The prevalence of hypovitaminosis D and secondary hyperparathyroidism were analysed. Sunlight exposure, functional and nutritional status, and presence of comorbidity were investigated., Results: 324 patients were included. Mean (standard deviation) age was 83 (7) years, and 80% were female. Vitamin D deficiency was observed in 217 cases (67%; 95% confidence interval [CI], 62-72%); and 57% of these patients had secondary hyperparathyroidism. A low nutritional status -albumin < 4 g/l (odds ratio [OR] = 4.5; 95% CI, 1.3-16; p = 0.019)- and a low functional status (Barthel index < 60; OR = 3; 95% CI, 1.3-6.7; p = 0.008) - were factors independently associated with hypovitaminosis D. However, an active sunlight exposure was a protective factor (OR = 0.09; 95% CI, 0.02-0.5; p = 0.004)., Conclusions: The prevalence of hypovitaminosis D is high in patients with osteoporotic hip fracture, and in more than a half of the cases a secondary hyperparathyroidism is observed. The vitamin D deficiency is especially prevalent among patients with low sunlight exposure and low nutritional and functional status.

Increased bone turnover may produce a disturbance in bone structure which may result in fracture. In cortical bone, both reduction in turnover and increase in hip bone mineral density (BMD) may be necessary to decrease hip fracture risk and may require relatively greater proportionate changes than for trabecular bone. It should also be noted that increased porosity produces disproportionate reduction in bone strength, and studies have shown that increased cortical porosity and decreased cortical thickness are associated with hip fracture. Continued studies for determining the causes of bone strength and deterioration show distinct promise. Osteocyte viability has been observed to be an indicator of bone strength, with viability as the result of maintaining physiological levels of loading and osteocyte apoptosis as the result of a decrease in loading. Osteocyte apoptosis and decrease are major factors in the bone loss and fracture associated with aging. Both the osteocyte and periosteal cell layer are assuming greater importance in the process of maintaining skeletal integrity as our knowledge of these cells expand, as well being a target for pharmacological agents to reduce fracture especially in cortical bone. The bisphosphonate alendronate has been seen to have a positive effect on cortical bone by allowing customary periosteal growth, while reducing the rate of endocortical bone remodeling and slowing bone loss from the endocortical surface. Risedronate treatment effects were attributed to decrease in bone resorption and thus a decrease in fracture risk. Ibandronate has been seen to increase BMD as the spine and femur as well as a reduced incidence of new vertebral fractures and non vertebral on subset post hoc analysis. And treatment with the anabolic agent PTH(1-34) documented modeling and remodelling of quiescent and active bone surfaces. Receptor activator of nuclear factor kappa B ligand (RANKL) plays a key role in bone destruction, and the human monoclonal antibody denosumab binds to RANKL, inhibiting its action and thus improving BMD significantly.