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BACKGROUND Various etiologies contribute to pathological fractures, including bone infections. Recently, non-tuberculosis Mycobacterium-related bone infections among patients with anti-interferon-gamma autoantibody-induced adult-onset immunodeficiency has raised concerns in Southeast Asia, with the common presentations including osteomyelitis. However, it also rarely manifests as traumatic fractures, as reported in this case. CASE SUMMARY A diabetic female fractured her humerus after a traumatic accident and received fixation surgery. Abnormal necrotic bone tissue and abscess formation were noted, and she was diagnosed with a pathological fracture due to non-tuberculosis Mycobacterium infection. Multiple bone involvement was also revealed in a bone scan. Anti-interferon-gamma autoantibodies were then checked due to an unexplained immunocompromised status and found to be positive. Her humerus fracture and multiple bone infections healed after steroid and anti-non-tuberculosis Mycobacterium medication treatment following fixation surgery. CONCLUSION Comprehensive preoperative evaluations may help identify pathological fractures and guide the treatment course.

Unicameral bone cysts (UBC) are reported to be the underlying lesion in 40% of pathological femoral neck fractures in skeletally immature patients. They are typically asymptomatic and incidentally found on imaging. However, when symptomatic, it commonly may present with pathologic fracture that causes pain, swelling, or deformity. The purpose of this study was to assess the natural history of the pediatric proximal femoral unicameral bone cyst, risk factors for pathological fracture and recurrence. Medical records were retrospectively reviewed of patients with pediatric proximal femoral UBCs who underwent surgery between 2004 and 2018. We included 51 consecutive patients with pediatric proximal femoral UBC (36 impending fractures/15 pathological fractures). The patients were evaluated regarding the localization of the UBC and the activity of the cyst. The cyst parameters were measured, and the patients were further assessed regarding the presence of pathological fracture and applied treatment. The pathological fracture group was compared to the impending fracture group using radiological cyst parameters, management options, healing, recurrences, and other related complications. The most commonly affected localizations were combined involvement of femoral neck and intertrochanteric (n=21) The number of latent lesions was 27 and active lesions were 24. The mean cyst index in our series was 3.8±1.2 (1.2-7.2). The cyst index in our series was correlated with pathological fractures. (p=0.048) There were significantly higher cyst index values in recurrent cases. (p=0.016) The cyst extension below the trochanter minor level was found as a risk factor for pathological fractures. (p=0.021) The most common treatment in our series was curettage, graft packing, and plate fixation with 27 patients. The treatment method showed no correlation with consolidation or recurrence rate. According to the healing criteria for UBCs at final follow-up, 36 cysts were completely consolidated, 13 were evaluated as incomplete healing and two were persistent. The recurrence rate was significantly high in UBCs who were operated on at [Med-Science 2021; 10(3.000): 670-8]

An immature canine was attacked by another dog in a kennel facility and sustained multiple wounds to the lateral right forelimb and cranial right lateral thoracic region. General surgical and antimicrobial therapies were instituted immediately. The patient battled with recurrent infections and subsequent delayed healing. After approximately 35 days from the initial injury, the patient became acutely lame and febrile. The persistently open wounds were cultured and returned positive for Salmonella spp. Within the following days, the patient became painful, and the lameness progressed significantly. Radiographs confirmed pathologic humeral fracture, and the patient was referred for specialty evaluation. Zoonotic preventative protocols were adopted at the specialty facility upon arrival. Complete forequarter limb amputation was curative in this patient., An immature canine was attacked by another dog in a kennel facility and sustained multiple wounds to the lateral right forelimb and cranial right lateral thoracic region. The patient battled with recurrent infections and subsequent delayed healing and after approximately 35 days from the initial injury, the patient became acutely mildly lame and febrile. Open wounds and draining tracts were cultured and returned positive for Salmonella spp.; within the following days, the patient became painful, and the lameness progressed significantly, with radiographic confirmation of a pathologic humeral fracture.

BACKGROUND Fracture risk assessment in children with benign bone lesions of long bones remains poorly investigated. AIM To investigate the risk factors for pathological fracture in children with benign bone lesions and to propose a modified scoring system for quantitative analysis of the pathologic fracture risk. METHODS We retrospectively reviewed 96 pediatric patients with benign bone lesions. We compared radiographic and clinical features between 40 patients who had fractures through a benign bone lesion and 56 who had no fracture. Information including histological diagnosis, anatomical site, radiographic appearance, severity of pain, and lesion size was recorded for the patients. A modified scoring system was proposed to predict the risk of fracture. RESULTS The univariate comparisons showed a significant difference between the fracture and non-fracture groups in terms of lesion type, pain, lesion-to-bone width, and axial cortical involvement of the patients (P < 0.05). Lesion type, pain, lesion-to-bone width, and axial cortical involvement were independently correlated with an increased risk of fracture. The mean score of the fracture group was 7.89, whereas the mean score of the non-fracture group was 6.01. The optimum cut-off value of the score to predict pathological fracture was 7. The scoring system had a sensitivity of 70% and a specificity of 80% for detecting patients with fractures. The Youden index was 0.5, which was the maximum value. The area under the receiver operator characteristic was 0.814. CONCLUSION Lesion type, pain, lesion-to-bone width, and axial cortical involvement are risk factors for pathological fracture. The modified scoring system can provide evidence for clinical decision-making in children with benign bone lesions. A bone lesion with a total score > 7 indicates a high risk of a pathologic fracture and is an indication for prophylactic internal fixation.

Aims Hydroxyapatite (HA)-coated collars have been shown to reduce aseptic loosening of massive endoprostheses following primary surgery. Limited information exists about their effectiveness in revision surgery. The aim of this study was to radiologically assess osteointegration to HA-coated collars of cemented massive endoprostheses following revision surgery. Methods Retrospective review of osseointegration frequency, pattern, and timing to a specific HA-coated collar on massive endoprostheses used in revision surgery at our tertiary referral centre between 2010 to 2017 was undertaken. Osseointegration was radiologically classified on cases with a minimum follow-up of six months. Results In all, 39 patients underwent radiological review at mean 43.5 months; 22/39 (56.4%) showed no osseointegration to the collar. Revision endoprostheses for aseptic loosening were less likely to show osseointegration compared with other indications for revision. Oncological cases with previous or current infection were more likely to show osseointegration to ≥ 1 collar side than those without evidence of prior infection. Conclusion This seven-year review identified osseointegration of HA-coated collars after revision surgery is less likely (43.6%, 17/39) than after primary surgery. Young patients who undergo revision surgery following initial oncological indication may benefit the most from this collar design. Use in revision oncological cases with a history of infection may be beneficial. HA-coated collars showed limited benefit for patients undergoing revision for failed arthroplasty with history of infection. Cite this article: Bone Jt Open 2021;2(6):371–379.

Background: The aim of this retrospective study is to analyze history and treatment outcomes of pathological fracture (PF) in dedifferentiated chondrosarcoma (DdChS) of the limbs. Methods: We retrospectively reviewed 175 adult patients with primary DdChS of the limbs.Disease-specific survival (OS) and local recurrence (LR) were analyzed. Results: Median age was 66 years (range, 29–91). Most DdChS (121, 69.1%) were localized in the femur. Forty-nine (28.0%) had metastasis at diagnosis; thirty-nine DdChS (22.3%) had a PF.OS rate was lower in patients with metastasis at diagnosis (8.6% Vs 41.0% at 10 years, p < 0.001). A similar OS was observed among patients with localized disease, whether with/without PF (p = 0.638), with/without chemotherapy (p = 0.543) and independently from the type of surgery (resection/amputation) (p = 0.877). Amputation reduces the risk of LR (80.0% vs 63.1% at 5 years, p = 0.039), particularly in the PF group. Conclusion: Patients with metastases have a particularly poor prognosis in DdChS, but pathological fracture does not influence prognosis in terms of survival and local control. Initial curative resection is essential in order to reduce the chance of recurrences. Amputation might be an option in patients with localized disease and a PF to reduce the risk of LR..

AimsAneurysmal bone cysts (ABCs) are locally aggressive lesions typically found in the long bones of children and adolescents. A variety of management strategies have been reported to be effective in the treatment of these lesions. The purpose of this review was to assess the effectiveness of current strategies for the management of primary ABCs of the long bones.MethodsA systematic review of the published literature was performed to identify all articles relating to the management of primary ABCs. Studies required a minimum 12-month follow-up and case series reporting on under ten participants were not included.ResultsA total of 28 articles meeting the eligibility criteria were included in this review, and all but one were retrospective in design. Due to heterogeneity in study design, treatment, and outcome reporting, data synthesis and group comparison was not possible. The most common treatment option reported on was surgical curettage with or without a form of adjuvant therapy, followed by injection-based therapies. Of the 594 patients treated with curettage across 17 studies, 86 (14.4%) failed to heal or experienced a recurrence. Similar outcomes were reported for 57 (14.70%) of the 387 patients treated with injection therapy across 12 studies. Only one study directly compared curettage with injection therapy (polidocanol), randomizing 94 patients into both treatment groups. This study was at risk of bias and provided low-quality evidence of a lack of difference between the two interventions, reporting success rates of 93.3% and 84.8% for injection and surgical treatment groups, respectively.ConclusionWhile both surgery and sclerotherapy are widely implemented for treatment of ABCs, there is currently no good quality evidence to support the use of one option over the other. There is a need for prospective multicentre randomized controlled trials (RCTs) on interventions for the treatment of ABCs. Cite this article: Bone Jt Open 2021;2(2):125–133.

Introduction: Giant cell tumors (GCTs) of the bone are uncommon primary bone neoplasms that occur mainly in the epiphysis of long bones. GCT of the femoral head is rarely encountered. Case Report: We report a rare case of GCT of the femoral head in a 20-year-old female. The patient presented with pathological fracture. The patient underwent total hip arthroplasty (THA). The aim of this paper is to present a case study with pathological fracture of the femoral head and to report the results of a literature review. Conclusion: The treatment of choice for GCT of the proximal femur is a hip arthroplasty with either a standard THA for small confined tumors or endoprosthesis insertion for more extensive tumors. Joint preserving procedures have a high revision rate (47.06%). Denosumab has been tried as a neoadjuvant treatment with some success in certain cases. Keywords: Giant cell tumor, pathological fracture, arthroplasty.

Introduction: Of the largest series on osteoarticular tuberculosis (TB) by Tuli et al. involving 1074 cases, only seven involved clavicle. It is also noted that the lateral end of the clavicle has been less frequently involved by tubercular disease than the medial end. We present a case of primary tubercular involvement of the lateral end of the clavicle and discuss its management by an innovative modification of the Weaver-Dunn procedure. Case Report: Twenty-five-year-old working women came with complaints of swelling in her left shoulder for the past 2 months. On examination, swelling with restricted shoulder movements was noted. Radiological evaluation revealed an osteolytic lesion with a pathological fracture in the lateral end of the clavicle. With a provisional diagnosis of giant cell tumor, we proceeded with fine-needle aspiration cytology which was inconclusive. Blood parameters were within normal limits. We proceeded with the excision biopsy of the lateral end of the clavicle and stabilization with a modified Weaver-Dunn procedure involving the reconstruction of the coracoclavicular ligament and augmentation with an Endobutton loop. Biopsy reported the lesion to be of tuberculous etiology. The patient made a good recovery without any complications. Conclusion: Primary TB of the clavicle is a rarity that mimics other diseases like a tumor; hence, clinicians should be aware of a wide range of presentations to diagnose such an entity. Although antitubercular treatment remains the mainstay of treatment, surgical resection is justified in cases of uncertain diagnosis or disease not responding to conservative lines of management and in cases that need the removal of the sequestrum. Keywords: Primary tuberculosis, clavicle, modified Weaver-Dunn procedure, osteoarticular tuberculosis, pathological fracture.

Background Fibrous dysplasia (FD) is a rare bone disorder in which normal intramedullary bone is replaced by fibro-osseous tissue, which is complicated by the progression of Shepherd’s crook deformity. How to predict the progression of Shepherd’s crook deformity is still a challenging for the orthopedic surgeon. Methods A total of 159 cases were reviewed in the retrospective study between January 2000 and September 2016. Clinical and monitoring data were collected. We analyzed the correlationship between the bone turnover markers and other parameters (age, gender, FD type, deformity, BMI, and lesion location). Results Age, gender, lesion location, lesion type, and shepherd’s crook deformity had a close relationship with preoperative ALP level in the univariate analysis, and the multivariate analysis showed age, gender, lesion type, and shepherd’s crook deformity had the significant relationship with the preoperative serum ALP level. The surgery could remove the bone lesion and suppressed the abnormal bone metabolism. Furthermore, the preoperative ALP level of FD patients with the shepherd’s crook deformity was obviously higher than that without deformity, and the preoperative calcium and phosphorus levels of FD patients with deformity were significantly lower than that without deformity. Notably, for some patients with progression of the shepherd’s crook deformity during the follow-up, ALP increased to the high level and at that time X-ray showed the shepherd’s crook deformity severely progressing. Conclusions PFD with higher serum ALP level has obvious tendency to progress severely, and risk factors of progression to the deformity are the condition of bony metabolism and FD type. The deformity of PFD may be related to high speed of bone turnover, which is exactly reflected by the levels of serum ALP and calcium. Evaluation of patients with FD should include a thorough evaluation of calcium/phosphate metabolism and bone turnover.

Symptomatic metastatic bone disease affects a large proportion of patients with malignant tumours and significantly impairs patients' quality of life. There are still controversies regarding both surgical indications and methods, mainly because of the relatively few high-quality studies in this field. Generally, prosthetic reconstruction has been shown to result in fewer implant failures and should be preferred in patients with a good prognosis. Survival estimation tools should be used as part of preoperative planning. Adjuvant treatment, which relies on radiotherapy and inhibition of osteoclast function may also offer symptomatic relief and prevent implant failure. In this review we discuss the epidemiology, indications for surgery, preoperative planning, surgical techniques and adjuvant treatment of metastatic bone disease.

Traumatic avulsion fractures of the lesser trochanter are usually seen along with fractures of the proximal femur and with young adolescents involved in high-intensity sporting injuries. Atraumatic isolated lesser trochanter avulsion in adults are most commonly associated with malignancy. We describe a case of a female in her sixties who was previously fit and healthy with no systemic illness and no history of trauma presenting with groin pain. The X-ray demonstrated an isolated lesser trochanter avulsion fracture. Further imaging including MRI and a staging CT scan of the neck, chest, abdomen and pelvis revealed a pulmonary tumour. Biopsy later confirmed this as a non-small cell carcinoma of the lung. At the time of publication, she had been started on palliative chemotherapy (afatinib) with encouraging results.

Background and purpose: Patients with advanced cancer may develop painful bone metastases, potentially resulting in pathological fractures. Adequate fracture risk assessment is of key importance to prevent fracturing and maintain mobility. This study aims to validate the clinical reliability of axial cortical involvement with a 30 mm threshold on conventional radiographs to assess fracture risk in femoral bone metastases.Materials and methods: All patients with bone metastases who received radiotherapy for pain included in two multicentre prospective studies were selected. Conventional radiographs obtained at a maximum of two months prior to radiotherapy were collected. Three experts independently measured lesions and scored radiographic characteristics. Sensitivity, specificity, positive (PPV) and negative predictive value (NPV) were calculated.Results: Hundred patients were included with a median follow-up of 23.0 months (95%CI: 10.6-35.5). Two fractures occurred in lesions with axial cortical involvement = 30 mm. Sensitivity, specificity, PPV and NPV of axial cortical involvement for predicting femoral fractures were 86%, 50%, 20% and 96%, respectively. Patients with lesions >= 30 mm had a 5.3 times higher fracture risk than patients with smaller lesions.Conclusion: Our validation study confirmed the use of 30 mm axial cortical involvement to assess fracture risk in femoral bone metastases. Until a more accurate and practically feasible method has been developed, this clinical parameter remains an easy method to assess femoral fracture risk to aid patients and clinicians to choose the optimal individual treatment modality. (C) 2019 Elsevier B.V. All rights reserved.

Simple Summary Major progress has been achieved in stage-IV bone metastatic patients to control over the disease progression, thereby resulting in longer survival. Self-autonomy and return to physical activity are now frequent. Thus, assessment of the strength of tumoral bone has becoming an issue, especially with the rapid variations of bone tumoral aspect (from lytic to sclerosing and vice versa), that we can observe on treatment. This review will explain the current available imaging techniques, the limits of the existing fracture risk scores in bone metastasis and the new numerical simulation technics arising in biomechanics. Abstract Major progress has been achieved to treat cancer patients and survival has improved considerably, even for stage-IV bone metastatic patients. Locomotive health has become a crucial issue for patient autonomy and quality of life. The centerpiece of the reflection lies in the fracture risk evaluation of bone metastasis to guide physician decision regarding physical activity, antiresorptive agent prescription, and local intervention by radiotherapy, surgery, and interventional radiology. A key mandatory step, since bone metastases may be asymptomatic and disseminated throughout the skeleton, is to identify the bone metastasis location by cartography, especially within weight-bearing bones. For every location, the fracture risk evaluation relies on qualitative approaches using imagery and scores such as Mirels and spinal instability neoplastic score (SINS). This approach, however, has important limitations and there is a need to develop new tools for bone metastatic and myeloma fracture risk evaluation. Personalized numerical simulation qCT-based imaging constitutes one of these emerging tools to assess bone tumoral strength and estimate the femoral and vertebral fracture risk. The next generation of numerical simulation and artificial intelligence will take into account multiple loadings to integrate movement and obtain conditions even closer to real-life, in order to guide patient rehabilitation and activity within a personalized-medicine approach.

Pathological fractures usually occur in patients with known malignancies, though pathological fracture may be the first sign of cancer. Malignant pathological fractures most commonly represent metastatic lung, breast, kidney, thyroid, or prostate cancer and typically occur in the spine, pelvis, femur, and humerus. We present the case of a 71-year-old female with an atraumatic tibial fracture in which further imaging was not pursued. Five months later, she was diagnosed with non-Hodgkin’s lymphoma. Pathological proximal tibial fracture is an exceedingly rare presentation of lymphoma; however, diagnostic delay could likely have been avoided if a thorough workup had been pursued. Our case highlights the importance of careful examination of all patients presenting with a low-energy fracture, particularly when constitutional symptoms suggestive of cancer are present. All patients with pathological fractures should receive a thorough physical examination that includes lymph node palpation.

We report the case of a male child, aged three years, with no particular pathological history, who has presented for three months with isolated evasive lameness complicated two weeks before his admission by a total functional impotence of the right lower limb following a fall from his height. The clinical examination on admission found a child in good general condition, afebrile, with functional impairment of the right lower limb, associated with painful limitation of ipsilateral hip flexion. The blood count and C-reactive protein are normal. A frontal and lateral view of the right femur was performed (A, B) which revealed a proximal metaphyseal-diaphyseal lesion of the right femur, osteolytic (Ladwic type 2 geographic osteolysis), fairly well limited oval, containing thin partitions delimiting multiple cubicles. This gap blows the cortex which is partially ruptured on the external face of the bone with detachment of a thin cortical lamella intra-lesional testifying to a secondary fracture (clearly visible on the face X-ray). There are no other bone abnormalities or soft tissue detectable. A computed tomography (CT) scan of the right hip was prescribed as an adjunct and revealed an eccentric metaphyseal-diaphysealosteolytic lesion breaking the cortical without periosteal reaction (C).

Background Postoperative adverse events after intramedullary nailing have been reported in patients with metastatic pathological and non-pathological femoral fractures. Other consequences to be considered are readmission and reoperation. Few studies have compared the risks of postoperative adverse events, reoperation, and readmission after intramedullary nailing of pathological and non-pathological femur fractures. This study was designed to test the hypothesis that patients with pathological femoral fractures had more adverse events, readmission, and reoperation following surgical fixation than non-pathological femoral fractures. Methods This was a retrospective observational cohort study, conducted at an academic medical center in Thailand. The data from patients with femoral shaft fractures undergoing long intramedullary nailing, from June 1, 2006, to June 30, 2020, were included. Patients who had a pathological fracture from a primary bone tumor, metabolic bone disease, or inadequate/missing information were excluded. Patients with pathological fractures from metastatic bone disease were assigned to be the pathological group whereas those with traumatic fractures were assigned to be the non-pathological group. The primary outcome was the risk of inpatient adverse events as compared between the two groups. The secondary outcome was the risk of consequences after discharge as compared between the two groups. Outcomes were analyzed by using multivariate logistic regression analysis. Results The total number of patients was 48 in the pathological fracture group and 185 in the non-pathological group. There were significantly higher rates of surgical and medical adverse events in patients with pathological fractures compared to patients with non-pathological fractures. After adjusting for potential confounding factors in multivariate regression analysis, patients with pathological fractures had higher odds of both adverse surgical (adjusted OR 2.43, 95 % CI 1.15–5.13) and medical adverse events (adjusted OR 2.81, 95 % CI 1.13–7.03). Conclusions Patients with metastatic pathological femoral shaft fractures undergoing intramedullary nailing were more likely to experience postoperative adverse events than patients with non-pathological fractures.

Non-ossifying fibroma (NOF) is a frequently occurring benign tumor of children and adolescents. In the long bones, it appears as an eccentric, expanded lesion in the metaphyseal diaphyseal area. Most cases are asymptomatic and resolve at a later age while others might become symptomatic and have a high risk of fracture. We present a case of a 15-year-old boy who is known to have lactose intolerance, suffered a pathological fracture following trauma, and was diagnosed with non-ossifying fibroma of the proximal tibia. The etiology of these lesions is not well-known. However, there might be a relation between tendons and NOF. This reported case of NOF is in the proximal tibia, which is a common site of the lesion beside the distal femur. Our reported case was treated by open curettage and grafting, which is the recommended classical treatment. On follow-up, full union was achieved without complications.

Secondary hyperparathyroidism is a complication arising from untreated end-stage renal disease (ESRD). It can invariably lead to osteoporosis and subsequently cause pathological neck of femur (NOF) fracture. Despite being young, osteosynthesis in neck of femur fractures of these patients often leads to nonunion and implant failure due to severely osteoporotic bone. We present our experience in managing three young patients with ESRD and secondary hyperthyroidism who sustained NOF fractures. All three patients were successfully treated and showed no complication at one year post-operation. Based on our experience and literature review, we propose a simple algorithm to guide the management of these patients.

Objective To evaluate the short-term effectiveness of using a three-dimensional (3D)-printed custom-made prosthesis to repair unicondylar femoral defects. Methods We retrospectively reviewed 26 patients with a primary pathological fracture of the distal femur caused by a giant cell tumor. All patients had unicondylar defects involving the articular surface. Twelve patients were treated with a 3D-printed custom-made prosthesis to repair the unicondylar defect (3D-printed group). The other 14 patients were treated with total knee replacement (TKR group). The operation time, blood loss, Musculoskeletal Tumor Society score, range of motion, local recurrence, and complications were statistically compared. Results The operation time was significantly shorter and the blood loss was significantly less in the 3D-printed group than in the TKR group. The Musculoskeletal Tumor Society scores were significantly higher in the 3D-printed group than in the TKR group from 3 to 24 months postoperatively. The range of motion was significantly better in the 3D-printed group than in the TKR group at 6 and 9 months postoperatively. Conclusions 3D-printed custom-made prostheses provide better short-term functional results than does TKR.

Background Chondroblastoma is a rare primary bone tumor of young people that generally occurs in the epiphyseal plate of long bones. To date, only 13 cases of patella with pathological fracture in chondroblastoma have been previously published. Case presentation A 15-year-old male patient presented with acute pain in the left knee after an injury occurred while playing basketball. Plain radiographs and computed tomography showed a pathological fracture of the left patella with an osteolytic lesion (1.5 × 2 × 3 cm). Magnetic resonance imaging revealed an expansile lesion within the patella with a slightly high signal on the T1-weighted image, a high signal on the T2-weighted image and soft tissue swelling in front of the patella. A m99Tc bone scintigraphy revealed moderate uptake. The preoperative diagnosis was chondroblastoma. This patient underwent intralesional meticulous extended curettage, adjuvant high-speed burr, 95% alcohol and electrotome treatment, autogenous iliac crest bone grafting, and internal fixation. A postoperative pathological diagnosis was chondroblastoma. The patient’s function was satisfactory, and there was no sign of tumor recurrence. The internal fixator was good, with no loosening or migration observed at the last follow-up at 20 months after surgery. Conclusions Rarely, chondroblastoma of the patella can present with acute pain due to pathological fracture. We present the 14th such case in the literature to associate patellar chondroblastoma with pathological fracture. The patient was treated with curettage, inactivation, autogenous bone grafting, and internal fixation. A satisfactory therapeutic effect was obtained. This case may be beneficial to the diagnosis and treatment of chondroblastoma patella.

Understanding the epidemiology of extremity skeletal metastasis and the factors deciding the treatment decision-making are essential in developing a diagnostic and treatment strategy. This leads to optimum care and reduces disease-related burden. With the evolution of medical, radiation therapy, and surgical methods, cancer care has improved the quality of life for patients with improved survival and functional status in patients with skeletal metastasis. Based on the currently available literature, we have described a step-wise evaluation and management strategy of metastatic extremity bone disease. The present review article addresses various aspects and related controversies related to evaluation, staging, and treatment options in the management of extremity bone metastasis. This article also highlights the role of multidisciplinary involvement in management of extremity skeletal metastasis.

Background and Purpose: Health professions that previously focused on treatment of patients are now focusing on prevention and health provision by improving lifestyle and eliminating factors that somehow have a negative impact on human health. Some people have strong skeleton genetically, but others do not. So far, medical science has not been able to change the genetic characteristics of individuals; however, lifestyles can be changed to reach the maximum bone mass. The aim of this study was to investigate the association between lifestyle and pathologic fractures in patients admitted to surgery departments of selected Hospitals in 2014–2015. Materials and Methods: In this descriptive (correlational) study, using the Cochran sampling formula, 350 patients with fractures were selected by stratified sampling in surgery departments of selected hospitals affiliated to Alborz University of Medical Sciences. Data were collected using the standard lifestyle questionnaire, which was validated through the test–retest method. The qualitative data of this project were analyzed using SPSS 20 software at a significance level of 0.05. Results: Most of the subjects were in the age group of 72–85 years which included 103 (26.8%) people. In all, 187 (48.6%) subjects were male and 198 (51.4%) subjects were female. A total of 83 (21.6%) participants were in the healthy group, 123 (32.0%) subjects were in the osteoporosis group, 113 (29.3%) subjects were in the bone infection group, and 66 (17.1%) individuals were in the general bone disease group. Conclusion: All studied components including smoking, physical activity, and nutrition directly affect pathologic fractures.

BACKGROUND: This study aimed to determine the prevalence of pathological neck of femur (NOF) fractures at a tertiary referral hospital through histological examination of specimens in all NOF fracture patients undergoing hip arthroplasty. A secondary aim was to determine whether the current practice of sending all femoral heads for histological evaluation, to avoid missing unsuspected malignancies, is financially warranted. METHODS: A retrospective folder review of patients who underwent arthroplasty for NOF fractures was conducted. Patients with suspected pathological fractures were managed by the divisional Bone Tumour Unit while fragility traumatic fractures were managed by the Arthroplasty Unit. All femoral heads were sent for histological analysis regardless of suspicion of pathological fracture. Quotes from the public and private sector were sought to determine cost implications of sending femoral head specimens for histology. RESULTS: A total of 311 patients were included. Of these, 11 patients (4%) had suspected pathological fractures, with fragility/traumatic fractures being diagnosed in the remaining 300 patients (97%). Histology results were available for 195 patients (63%), including all the patients with suspected pathological fractures. No unexpected malignant histological results were observed, while nine of the suspected pathological fracture group had pathological fractures, confirmed with histology. CONCLUSION: Pathological lesions were identified in 3% of patients undergoing arthroplasty for NOF fractures in our population, which is higher than other reports in the literature. Routine histological screening of femoral heads to exclude pathological fracture might not be necessary and cost effective, as pathological lesions can accurately be identified by clinical and radiographic evaluation. Level of evidence: Level 4 Keywords: femoral head histology, pathological fracture, neck of femur fracture, metastases, hip arthroplasty

Salmonella osteomyelitis is usually seen in patients with hemoglobinopathies and immunodeficient individuals. However, it is a rare clinical entity in an immunocompetent person with very few cases reported in clinical literature usually caused by non-typhoid Salmonella. Here, we report a case of S. typhi osteomyelitis of the right tibia in a 40-year-old immunocompetent lady. She developed a pathological fracture of the right tibia during the course of her treatment. It was then managed successfully by debridement and external fixation using a rail fixator. Salmonella osteomyelitis does not present with unique clinical or radiological signs. High index of suspicion with appropriate testing will help in determining the causative agent correctly and thus aid in its successful management.

Purpose The purpose of this study was to retrospectively assess the safety profile of percutaneous image-guided screw fixation (PIGSF) for insufficiency, impending or pathological fractures. Materials and methods From July 2012 to April 2020, all consecutive patients who underwent PIGSF were retrospectively included in the study. Patient characteristics, fracture type, procedural data and complications were analyzed. Complications were divided into per-procedural, early (< 24 hours) and delayed (> 24 hours) and classified into minor (grade 1-2) and major complications (grade 3-5) according to Common Terminology Criteria for Adverse Events (CTCAE) v5.0. Results A total of 110 fractures (40 insufficiency [36%], 53 pathological [48.5%] and 17 impending [15.5%] fractures) in 94 patients (48 women, 46 men; mean age, 62.7 ± 12.7 [SD] years; age range: 32–88 years) were treated with PIGSF during 95 procedures. Twenty-four-hours follow-up was available for all patients, and > 24-hours follow-up was available for 79 (79/110; 71.8%) fractures in 69 (69/94; 73.4%) patients. Per-procedural complications occurred in 3/110 fractures (2.7%, all minor). Early complications were reported in 4/110 fractures (3.6%, 1 major and 3 minor) and delayed ones in 14/79 fractures (17.7%, 5 major and 9 minor). The most frequent major delayed complication was infection (3/79; 3.8%). Conclusion The rate of per-procedural and early (within 24 hours) complications following PIGSF is extremely low with most complications being minor, with major complications being delayed ones (> 24 hours).

Introduction Langerhans cell histiocytosis (LCH) is a rare neoplastic hyperplasia with an unknown etiology. It is clinically rare for patients with solitary rib lesion and pathological fracture; moreover, its diagnosis and treatment are quite difficult. The purpose of this study is to present a case for the pathogenesis, clinical features, imaging, and treatment of this disease. Case presentation A 52-year-old female patient complained of left chest pain for one week. CT showed a fracture in the left 5th rib. The rib tumor was then resected and the surrounding muscles and soft tissues were accordingly resected. The patient was diagnosed with pathological rib fracture, and the patient was pathologically diagnosed with LCH. After surgery, no local recurrence or distant metastasis was reported during the two-year follow-up. Conclusions LCH should be treated by observation, chemotherapy, radiotherapy, or surgery, or using a combination of several methods. Moreover, primary tumor should be considered when rib fracture without trauma and tumor metastasis.

Bone disease is an important complication of hyperparathyroidism. We herein report a rare case of severe bone disease caused by primary hyperparathyroidism. A 33-year-old man presented with pain and restricted mobility in his right upper limb and right hip due to a fall 3 days previously. X-ray examination showed a fracture of the proximal and distal humerus. Computed tomography examination showed a supracondylar fracture of the right humerus, a fracture of the right femoral neck, a fracture of the right sciatic branch, and multiple brown tumors. Ultrasonography showed a 3.5- × 1.6-cm hypoechoic mass below the left lobe of the thyroid. The patient was diagnosed with primary hyperparathyroidism based on increased serum calcium and parathormone concentrations, pathological fractures, and multiple brown tumors. He therefore underwent bilateral lower parathyroidectomy. Pathological examination revealed a parathyroid adenoma. The patient recovered well after surgery and was followed up for 6 months with no symptoms of hyperparathyroidism. This case report suggests that clinicians should be aware of the possibility of severe bone disease secondary to primary hyperparathyroidism. Active and early diagnosis and surgical treatment are important in such cases.

Pathological fracture of the proximal femur represents a challenging situation for orthopedic surgeons because of the high risk of non-union, varus union, and avascular necrosis (AVN) of the femoral head. This study aims to investigate the efficacy of ESINs for the treatment of proximal femoral fractures caused by simple bone cysts (SBCs).All the patients with a diagnosis of proximal femoral fracture secondary to SBC treated with ESINs combined with bone grafting between January 2008 and January 2018, were analyzed retrospectively.In all, 11 patients were included in the Double ESINs group (5.1 ±â€Š0.8 years, 5 male, 6 female) and 27 patients were included in the Triple ESINs group (9.1 ±â€Š2.1 years, 11 male, 16 female). There was no significant difference between the 2 groups concerning the patients demographic parameters, including sex and affected side. However, the age in the Double group was significantly younger than those in the Triple group (P 

Purpose Unicameral bone cysts (UBCs) are most often found when accompanied by a pathological fracture. In these cases, the doctor must determine the optimal timing for the surgery. The purpose of this study was to evaluate the outcome of immediate surgery as compared with delayed surgery in paediatric pathological fractures due to UBCs. Methods This retrospective study assessed the medical records of 65 patients between January 2012 and September 2016. Group A included 34 patients who underwent immediate surgery, including curettage, demineralized bone matrix and fixation with elastic stable intramedullary nailing. Group B included 31 patients who underwent the same surgery several months later. The outcome evaluations included the radiological changes, brace fixation time, cyst healing time, at the first-, third- and sixth month, and final visit. Results The mean brace fixation time was 26.3 days (sd 5.7) for group A and 53.8 days (sd .1) for group B (p = 0.012). According to radiological evaluations, 3/34 patients in group A and 5/31 in group B had recurrence after the first surgery. A second surgery was performed in all cases of recurrence, and all fractures were healed at the last visit. There was no significant difference in the recurrence rate between the two groups (p = 0.4631), and healing times were also similar (p = 0.6033). Conclusion Both the immediate and delayed surgery were safe for the treatment of UBCs with fractures. We suggest immediate surgery for shorter fixation time and early activity. Level of evidence IV

Unicameral bone cyst (UBC) is a benign fluid-filled lesion, mainly located in the metaphyses of long bones in children and adolescents. Elastic stable intramedullary nail (ESIN) is adopted in our institute for UBCs since 2010, and bone grafting was performed simultaneously. This study aims to evaluate the efficacy of ESIN decompression combined with different bone graft materials. All patients with the diagnoses of UBCs of the humerus, treated with ESINs and bone grafting between January 2010 and June 2018, were analyzed retrospectively. The bone grafting included injectable calcium sulfate, a mixture of the autologous iliac bone and allogeneic bone. All patients were categorized into 2 groups: ICS (injectable calcium sulfate) group and MIX (a mixture of the autologous iliac bone and allogeneic bone, ratio: 1:3) group. All the information was collected from the Hospital Database. In all, 17 patients (8.8 ± 2.3-year-old, male 8, female 9) in the ICS group and 19 patients (8.9 ± 1.9-year-old, male 10, female 9) in the MIX group were included in this study. Patients in both groups were followed up for more than 2 years (average, 3.4 ± 1.3 years). No recurrence was observed in either group. There was no significant difference between the two groups concerning the patient's demographic parameters, including sex, age, and affected side. All patients in both groups displayed excellent and good shoulder function, and there was no significant difference between the 2 groups (P = .29). As for the Capanna classification, there was no significant difference between these 2 groups (P = .78). Intramedullary nailing has the advantage of a minimally invasive procedure, immediate stability, and continuous decompression. ICS showed similar results as a mixture of the autologous iliac bone and allogeneic bone.

Objectives To evaluate whether curettage with adjuvant microwave therapy was successful in the treatment of giant cell tumor of the bone (GCTB) in extremities, especially for GCTB with pathological fractures and GCTB of the distal radius. Methods This was a retrospective study of 54 cases of GCTB of the extremities treated by curettage with adjuvant microwave therapy between 2007 and 2019. Five patients were lost to follow up and excluded from the study. A total of 33 male and 21 female patients were included in this study. Patients were aged 15–57 years (mean 29.72 ± 10.48 years). Among these patients, there were 10 cases of GCTB with pathological fractures and eight cases of GCTB of the distal radius; one of these cases was combined with a pathological fracture. Comprehensive imaging examinations (X‐rays [including lesion site and chest], CT, MRI, emission computed tomography, and pathology examination) of all patients were reviewed. The clinical staging of these patients were evaluated radiologically using the Campanacci classification system based on the extent of spread of the tumor. All patients underwent curettage with adjuvant microwave therapy. Clinical and imaging evaluations were performed in all cases to check for recurrence or metastasis. Lower limb and upper limber function were assessed using the Musculoskeletal Tumor Society score (MSTS), and wrist function was assessed according to the disabilities of the arm, shoulder and hand (DASH) score. Data on surgical‐related complications were recorded. Results All cases were followed up for 24–126 months (mean 60.69 ± 29.61 months). There were 24 patients with a Campanacci grade of 3 and 30 with a Campanacci grade of 2. The 52 patients were continuously disease‐free. The local recurrence rate was 3.70% (2 patients). One patient had recurrence in the proximal femur, and the other developed in soft tissue of the calf muscle. No recurrence occurred for GCTB of the distal radius. One recurrence occurred in a GCTB with pathological fractures. The intervals were 9 and 28 months, respectively. The cases of recurrence all had a Campanacci grade of 3 (8.33%). The median MSTS among the 54 patients was 27.67 ± 3.81. The mean wrist function DASH score was 8.30 ± 2.53. The mean MSTS was 28.67 ± 1.63 and 26.71 ± 5.49 for patients with GCTB of the distal radius and for those with pathological fractures, respectively. In comparing patients with and without pathological fractures, there was no significant difference in the MSTS functional score. Five patients had complications after the surgery. Conclusion Curettage with adjuvant microwave ablation therapy provided favorable local control and satisfactory functional outcomes in the treatment of GCTB, especially for cases with pathological fractures and those with GCTB of the distal radius., Schematic diagrams of giant cell tumor in proximal tibia are shown to illustrate the heating and monitoring. (A) Microwave ablation probe. (B) Temperature probe in knee joint, adjacent to the lesion. (C) Flow of cryogenic saline cools the articular cavity to protect the normal structure, including cartilage, meniscus, and cruciate ligament. (D) Gauze soaked with ice brine isolates the vascular and nerve bundle from the tumor lesion. Sometimes we placed our hand between the tumor lesion and the important vascular nerve to prevent damage to the vascular nerve. The orange region represents the heating range of the microwave.High fever may cause damage to normal surrounding tissue. a series of protective measures were taken during the operation. the gauze soaked with ice brine isolates the posterior vascular and nerve bundle, the cooled sterilized water was injected into the knee joint to protect the the structure in the knee joint. In the meantime, continuous multi‐point temperature measurement can play a important role in monitoring.

Parathyroid carcinoma is a rare cause of primary hyperparathyroidism. It often presents with unspecified clinical manifestation that leads to misdiagnosis. We report a case of a 36-year-old woman who suffered from multiple bone tumours and recurrent bone fracture for 3 years ago, and misdiagnosis as only a giant cell tumours of the bone. Then, the patient continued to develop another mass in the neck that kept growing and the mass move on swallowing. The clinician diagnosed her as a colloid goitre based on cytological examination from fine-needle aspiration biopsy. Elevated parathyroid hormone level, hypercalcemia, and suspected parathyroid adenoma in the Sestamibi Parathyroid scan led the clinician to perform a frozen section in this patient with subsequent histopathological of diagnosis as parathyroid carcinoma. The diagnosis of parathyroid carcinoma continues to be a challenge. Understanding the pathogenesis and multidisciplinary collaboration is important to define an accurate diagnosis and treatment.

Intrahepatic cholangiocarcinoma (ICC) is the second most common tumor of the liver and accounts for 3% of all gastrointestinal tumors. Bone metastasis due to ICC is extremely rare. In this case report, a patient with pathological clavicle fracture as the first presentation of ICC was reported. A lytic mass causing a fracture in the middle part of the left clavicle was detected in a 75-year-old female patient who had sudden and severe pain in her left shoulder while getting up from her seat. Blood tests were normal except gamma-glutamyl transferase 575 U/L (0-38 U/L), alkaline phosphatase 259 U/L (0-105 U/L), direct bilirubin 5.1 mg/dl (0-0.2 mg/dl) and carcinoembryonic antigen 5.1 ng/ml (0-5 ng/ml). Positron emission tomography (PET-CT) revealed a mass in the liver and metastasis to the proximal femur and peritonei carcinomatosis. Pathological clavicle fracture was treated surgically and liver biopsy was performed by an interventional radiologist in the same session. The pathology result was reported as ICC. During the follow-up of the patient, a pathological proximal femur fracture also occurred. This fracture was also treated with total tumor hip replacement. Metastasis of ICC to the bone is extremely rare and should be kept in mind in the differential diagnosis in patients presenting with pathological bone fracture and liver mass.

Background Most patients suffering from distal femoral unicameral bone cysts (UBCs) are adolescents that require an early return to normal activities, including school attendance and sports exercises. However, the optimal choice of implants for such patients remains controversial. This study evaluated the application of pediatric physeal slide-traction plate (PPSP) in the treatment of pathological distal femoral fracture caused by UBCs. Methods Between Jan 2014 and Jan 2016, 11 (male = 6, female = 5) patients were reviewed retrospectively. Age, sex, operative time, limb-length discrepancy (LLD), and valgus angulation were all recorded for every patient. Results The average age of 11 patients was 12.2 ± 1.1 years. The operating time was 94.8 ± 7.8 min. The postoperative hospital stay was 5 to 7 days. The epiphyseal morphology in the operative leg was nearly normal. The plate was removed in an average of 19.5 ± 3.1 months. The knee range of motion (ROM) was normal in 9 patients, whereas 2 female patients reported a loss of less than 10 degrees of ROM as compared to the contralateral knee joint. Breakage of plates or refracture did not occur in our cases. All patients had a follow-up of at least 24 months. At the latest follow-up visit, all patients walked without a limp. None of the patients manifested obvious LLD and valgus deformity. Conclusion PPSP combined with curettage and bone grafting allows early mobilization and produces satisfactory outcomes for pathological fracture of distal femur secondary to UBCs in adolescents.

OBJECTIVESevere lytic cancerous lesions of the spine are associated with significant morbidity and treatment challenges. Stabilization and restoration of the axial load capability of the vertebral body (VB) are important to prevent or arrest vertebral collapse. Percutaneous stent screw–assisted internal fixation (SAIF), which anchors a VB stent/cement complex with pedicular screws to the posterior vertebral elements, is a minimally invasive, image-guided, 360° internal fixation technique that can be utilized in this patient cohort. The purpose of this study was to assess the feasibility, safety, and stabilization efficacy of VB reconstruction via the SAIF technique in a cohort of patients with extensive lytic vertebral lesions, who were considered to have an unstable or potentially unstable spine according to the Spinal Instability Neoplastic Score (SINS).METHODSThis study was a retrospective assessment of a prospectively maintained database of a consecutive series of patients with neoplastic extensive extracompartmental osteolysis (Tomita type 4–6) of the VB treated with the SAIF technique. VB reconstruction was assessed on postprocedure plain radiographs and CT by two independent raters. Technical and clinical complications were recorded. Clinical and imaging follow-ups were assessed.RESULTSThirty-five patients with extensive osteolytic metastatic lesions of the VB underwent 36 SAIF procedures. SAIF was performed as a stand-alone procedure in 31/36 cases and was associated with posterior surgical fixation in 5/36 (4/5 with decompressive laminectomy). In 1 case an epidural cement leak required surgical decompression. VB reconstruction was categorized as satisfactory (excellent or good rating) by the two raters in 34/36 cases (94.5%) with an interrater reliability of 94.4% (Cohen’s kappa of 0.8). Follow-up, ranging from 1 to 30 months, was available for 30/36 levels. Long-term follow-up (6–30 months, mean 11.5 months) was available for 16/36 levels. Stability during follow-up was noted in 29/30 cases.CONCLUSIONSSAIF provides 360° nonfusion internal fixation that stabilizes the VB in patients with extensive lytic lesions that would otherwise be challenging to treat.

Purpose To determine whether patient-specific finite element (FE) computer models are better at assessing fracture risk for femoral bone metastases compared to clinical assessments based on axial cortical involvement on conventional radiographs, as described in current clinical guidelines. Methods Forty-five patients with 50 femoral bone metastases, who were treated with palliative radiotherapy for pain, were included (64% single fraction (8 Gy), 36% multiple fractions (5 or 6 x 4 Gy)) and were followed for six months to determine whether they developed a pathological femoral fracture. All plain radiographs available within a two month period prior to radiotherapy were obtained. Patient-specific FE models were constructed based on the geometry and bone density obtained from the baseline quantitative CT scans used for radiotherapy planning. Femoral failure loads normalized for body weight (BW) were calculated. Patients with a failure load of 7.5 x BW or lower were identified as having high fracture risk, whereas patients with a failure load higher than 7.5 x BW were classified as low fracture risk. Experienced assessors measured axial cortical involvement on conventional radiographs. Following clinical guidelines, patients with lesions larger than 30 mm were identified as having a high fracture risk. FE predictions were compared to clinical assessments by means of diagnostic accuracy values (sensitivity, specificity and positive (PPV) and negative predictive values (NPV)). Results Seven femurs (14%) fractured during follow-up. Median time to fracture was 8 weeks. FE models were better at assessing fracture risk in comparison to axial cortical involvement (sensitivity 100% vs. 86%, specificity 74% vs. 42%, PPV 39% vs. 19%, and NPV 100% vs. 95%, for the FE computer model vs. axial cortical involvement, respectively). Conclusions Patient-specific FE computer models improve fracture risk assessments of femoral bone metastases in advanced cancer patients compared to clinical assessments based on axial cortical involvement, which is currently used in clinical guidelines.

Study Design: Single-center, retrospective cohort study. Purpose: We aimed to evaluate and compare the clinical outcomes in patients who underwent palliative posterior instrumentation (PPI) versus those who underwent corpectomy with cage reconstruction (CCR) for thoracolumbar pathological fracture. Overview of Literature: The requirement for anterior support after corpectomy has been emphasized in the treatment of pathological fractures of the vertebrae. However, for patients with a relatively short life expectancy, anterior reconstruction may not be required and posterior instrumentation alone may provide adequate stabilization. Methods: A total of 43 patients with metastases of the thoracolumbar spine underwent surgery in the department of orthopaedic and traumatology of Istanbul University Faculty of Medicine from 2003 to 2016. Surgical outcomes were assessed on the basis of survival status, pre- and postoperative pain, complication rate, and operation time. Results: PPI was performed for 22 patients and CCR was performed for 21 patients. In the PPI group, the follow-up period of the five surviving patients was 32 months. The remaining 17 patients died with a mean survival duration of 12.3 months postoperatively. In the CCR group, the five surviving patients were followed up for an average of 14.1 months. The remaining 16 patients died with a mean survival duration of 18.7 months postoperatively. No statistically significant difference (p=0.812) was noted in the survival duration. The Visual Analog Scale scores of the patients were significantly reduced after both procedures, with no significant difference noted on the basis of the type of surgical intervention (p>0.05). The complication rate in the CCR group (33.3%) was higher compared with that in the PPI group (22.7%); however, this difference was not noted to be statistically significant (p=0.379). The average operation time in the PPI group (149 minutes) was significantly shorter (p=0.04) than that in the CCR group (192 minutes). Conclusions: The PPI technique can decompress the tumor for functional improvement and can stabilize the spinal structure to provide pain relief. WOS:000462917400019 30481977

Background Currently, there are no known reports on the aetiology of local giant cell tumour (GCT) recurrence in the proximal fibula following en bloc resection. We analysed 21 cases of proximal fibular GCT, focusing on the presence of residual bone in the tibiofibular joint, its causes and its impact on postoperative recurrence. Methods We retrospectively analysed 21 cases with proximal fibular GCT occurring between 2000 and 2017. Results There were 14 males and 7 females. The average patient age was 25.0 years. Seventeen patients were diagnosed and treated at our facility, while 4 were referred after local recurrence. Six patients presented with residual bone fragments in the tibiofibular joint during their first month of follow-up. Patients with residual bone fragments had a higher local recurrence rate (83.3%) than those without (0%, p = 0.0003). Upon further analysis, patients with a preoperative Campanacci grade III tumour (p = 0.0055) and pathological fractures (p = 0.0109) were at a higher risk of exhibiting postoperative residual bone fragments. Conclusions The presence of residual bone fragments in the tibiofibular joint was the main cause of postoperative local recurrence. The presence of residual bone fragments may be related to the preoperative Campanacci grade and pathological fractures. Therefore, close attention should be paid to postoperative follow-up examinations, and if recurrence is suspected, surgical resection should be planned.

Purpose To reinvestigate the functional recovery after combined treatment with surgery and postoperative irradiation of complete or impending pathologic fractures of long bones. Methods We retrospectively evaluated the results of external beam radiation therapy (EBRT) carried out after 68 orthopedic stabilization procedures (femur, n = 55, 80.8%; humerus, n = 13, 19.2%) for actual or impending pathological fracture of long bone in 61 patients with skeletal metastases. The mean normalized total dose was 34.7 ± 7.8 Gy. Endpoints were patient’s functional status (FS; 1 = normal pain free status; 2 = normal use with pain; 3 = significantly limited used; 4 = nonfunctional status), a need for a secondary procedure to the same site and overall survival following surgery. Results Overall, 75% of patients achieved normal functional status (FS 1–2) within 12 weeks after surgery. Functional recovery in surviving patients reached 93%. Median survival was 17 months (95% confidence interval 13.7–20.2). Secondary surgical intervention at the same location was necessary in 3 patients (4.4%). On multivariate analysis, only general status (p = 0.011) and growing potential of primary tumor (p = 0.049) were associated with achieving normal functional status within 12 weeks after surgery and radiotherapy. The applied radiation schemes demonstrated a comparable impact on functional recovery. Conclusions Our results confirm the effectiveness of stabilizing surgery and fractionated postoperative radiotherapy in terms of functional recovery, supporting prior results assessing postsurgical radiotherapy versus follow-up. The patient’s general status is a strong prognostic factor for functional recovery. Rapidly growing tumors may hinder achievement of a normal functional status.

Background The most appropriate treatment of pathological fractures from metastatic disease depends on several factors, one of the most important being predicted life expectancy. The aim of this study was to identify the variables that influence prognosis and utilise these to develop a novel scoring system to better predict life expectancy post-pathological fracture. Methods The records of all patients that presented with metastatic pathological fractures over a 10-year period from the only tertiary orthopaedic departments in Western Australia were retrospectively examined. Variables assessed were primary cancer type, fracture site, fixation method, cement augmentation, pre-morbid level of physical functioning, complication rate, treatment with chemotherapy or radiotherapy and appendicular, spinal and visceral metastatic load. Results A total of 233 patients were included. Median survival from fracture to death was 4.1 months. Median time from cancer diagnosis to pathological fracture was 14.2 months. There was a statistically significant association between patient survival and primary cancer type, physical functional score, spinal metastatic burden and use of chemotherapy or radiotherapy. Conclusion A novel scoring system has been developed that offers a survival probability based on patient’s individual circumstances. This can guide specialist management and offer patients a more accurate expectation of functional outcome and survival time.

ObjectiveThis study was performed to determine the most common causes, locations, and treatments of metastasizing primary tumors through evaluation of patients with metastatic bone tumors who were admitted to our clinic.MethodsIn total, 96 patients with metastatic bone tumors who were admitted to our clinic from 2000 to 2016 were included in the study.ResultsThe breast (30 patients, 31.3%) and lung (18 patients, 18.8%) were the most commonly metastasized primary organs. The femur was the most commonly metastasized bone.ConclusionsBone tumors in patients of advanced age are, unless otherwise proven, considered to be metastatic, and the development of specific diagnostic and treatment algorithms is needed. Clinicians should attempt to improve the general condition of patients with tumors exhibiting bone metastasis to increase the patients’ quality of life by providing early mobilization. Thus, appropriate patient selection and proper internal fixation are essential.

Background Renal cell carcinoma account for 3% of all cancers, with peak incidence between 60 and 70 years of age predominantly affecting male population. Renal carcinoma is the most common malignancy of kidney constitutes for 80–90% of renal neoplasm with an overall 45% five years survival rate. Majority are diagnosed incidentally during investigation for other disease process of abdomen. Classical triad of gross hematuria, pain and palpable mass in abdomen is rare accounting to only 6–10%. Treatment of early stages of disease i.e. localized disease is partial or radical nephrectomy. Most common metastasis in RCC occurs to lung, followed by bone involvement in 20–35%, lymph nodes, liver, adrenal gland and brain. In metastatic disease median survival rate of patient is about eight months with 50% mortality rate within first year of life, five years survival rate is 10%. Skeletal metastasis are very destructive in patients with renal cell carcinoma compromising bone integrity leading to skeletal related events including pains, impending fractures, nerve compressions, hypercalcemia and even pathological fractures which may require surgical interventions and other therapy. In addition to skeletal complications, presence of bone metastases in RCC has negative impact on progression free survival and overall survival of patients treated with systemic therapies. Objective In this review we discuss pathophysiology of tumor metastasis, diagnosis, management and Case examples of metastatic renal cell carcinoma. Conclusion Incidence of metastatic renal carcinoma is increasing. Overall prognosis of patient with advanced RCC is poor, emphasizing the importance of early detection and prompt treatment of primary lesion in its early stage. Advancement in targeted therapy in recent decades had made some improvement in treatment of SREs and has helped in improving patent's quality of life but still we are in need of further improvement in treatment modalities to cure disease thereby decreasing morbidity and mortality., Highlights • Renal cell carcinoma account for 3% of all cancers. • It is a very destructive that may compromise bone integrity. • Most common metastasis in renal cell carcinoma occurs to lung, followed by bone , lymph nodes, liver, adrenal gland and brain. • Most common metastasis in renal cell carcinoma occurs to lung, followed by bone involvement in 20–35%, lymph nodes, liver, adrenal gland and brain. • In metastatic disease median survival rate of patient is about eight months with 50% mortality rate within first year of life, five years survival rate is 10.

Langerhans cell histiocytosis (LCH) is a rare disease in which Langerhans cells, which are bone marrow-derived antigen-presenting cells, proliferate in single or multiple organs. We successfully treated a patient with unifocal LCH of the mandible with malocclusion due to a severe pathological fracture, using reconstruction with a vascularised free bone.

Giant cell tumor (GCT) or osteoclastoma is a benign, locally aggressive tumor with a tendency to recur. Involvement of the axial skeleton is very rare and majority of them are seen in the sacrum. The authors report a rare case of a 19-year-old female who presented with a C2 dens GCT with a pathological fracture and atlantoaxial dislocation. The patient was operated in two stages: first stage, with posterior instrumentation and stabilization followed by the second stage, tumor resection by anterior transoral approach. The residual tumor cavity was packed with autologous corticocancellous bone grafts. At a 5-year follow-up, computed tomography scan showed a C1-C2 fusion mass. There was no radiological or clinical evidence of tumor recurrence with the patient having good functional outcome without any neurological deficit.

Hypothesis: This study assessed, if there was a difference in surgical decision making for metastatic humeral lesions based on; orthopaedic subspecialty, tumor characteristics.Study type: Cross sectional survey study.Materials and methods: Twenty-four case scenarios were created by combining: tumor type, life expectancy, fracture type, and anatomical location. Participants were asked for every case: what treatment would you recommend? Participants were 78 (48%) orthopaedic oncologists and 83 (52%) orthopaedic surgeons that were not regularly involved in the treatment of bone tumors.Results: There was a difference between orthopaedic oncologists and other subspecialty surgeons in recommendation for specific treatments: intramedullary nailing was less often recommended by orthopaedic oncologists (53%, 95%CI: 47-59) compared to other surgeons (62%, 95%CI: 57-67) (p = 0.023); while endoprosthetic reconstruction (orthopaedic oncologists: 8.8% [95%CI: 6.6-11], other surgeons: 3.6%[95%CI: 2.3-4.8], p Discussion: Subspecialty training and patient and tumor characteristics influence the decision for operative management and the decision for a specific implant in metastatic humeral fractures. (C) 2017 Elsevier Masson SAS. All rights reserved.

Reconstruction of bone defects following femoral diaphyseal tumor resection is challenging. Segmental allograft (SA) and intercalary prosthesis (IP) are the most common reconstruction methods for femoral diaphyseal metastatic tumors with pathological fracture. However, whether the complications and functional outcomes differ between SA and IP remains unclear. To compare the clinical outcomes and complications for patients treated with SA reconstruction or IP replacement for femoral shaft tumors, 34 patients who had undergone intercalary resection for metastatic tumor with pathological fracture in the femoral diaphysis were evaluated. Of these, 18 had received SA and 16 IP. There were 11 males, and 24 females, with a mean age of 64.5±11.3 years. The most common sites of primary metastases were lung (26.5%), breast (17.6%) and liver (14.7%). The visual analog scale (VAS), implant-related complications and the Musculoskeletal Tumor Society (MSTS) scores for each patient were collected. The follow-up period for patients ranged from 2 to 27 months. At the most recent follow-up, 28 patients had succumbed to mortality, with a mean survival time of 6.9±3.7 months for the IP group and 7.4±3.0 months for the SA group. Patients with IP had a significantly shorter time to full weight bearing and hospitalization time than those who received SA (P=0.003 and P=0.002, respectively). The rates of overall complications and implant-related complications were significantly lower for IP as compared with SA (18.8 vs. 66.7%, P=0.007; 12.5 vs. 55.6%, P=0.013). The reoperation rate of the SA group was higher than that of the IP group (38.9 vs. 12.5%), however the difference between the two groups was statistically insignificant (P=0.125). MSTS scores were significantly higher for the IP group as compared with the SA group at one month after surgery (IP, 26.7±1.6 vs. SA, 20.3±1.5; P

Introduction Combined limb-sparing surgery and radiation therapy are considered the standard of care for higher grade soft tissue sarcomas (STS) of the extremities. The risk of post-radiation fracture after this treatment modality is well known, but still underestimated, and can end in serious long-term secondary problems years later. Presentation of case We reviewed the records of three patients with pathological femur fractures years after wide local excision of an STS of the proximal lower extremity. All patients received more than 50 Gy (Gy) to the entire femur circumference. During surgery, all patients had bone exposure, and in two patients with stripping of the periosteum. The median time from surgery to fracture was 116 months (range from 84 to 156 months). The median age at the time of diagnosis was 66 years old. Despite standard operative fracture treatment, all three patients developed a non-union. One patient later died due to uncontrolled pulmonary metastasis independent from the femoral non-union. In the second case, an exarticulation at hip level due to an uncontrolled infected non-union had to be performed. The third patient finally achieved fracture union after two years of treatment. Discussion Our study confirms the high occurrence rate of postoperative complications and difficulties one encounters in treating these pathologic fractures. Only in one patient, following several revisions with intramedullary nailing, the fracture healed. In pathologic femur shaft fractures we recommend a minimal invasive procedure using intramedullary nailing devices. Conclusion The risk of pathological fractures at the former treatment site is high, even years later. The rate of non-unions after a difficult fracture treatment in this particular clinical situation seems to be very high and may be associated with severe complications., Highlights • 3 patients with pathological femur fractures after excision of sarcoma are reviewed. • Risk of post-radiation fracture after this treatment modality is underestimated. • Despite standard operative fracture treatment, rate of non-unions is very high. • We recommend a minimal invasive procedure using intramedullary nailing devices.

Intraosseous gouty tophus as the cause of pathological fracture is a seldom encountered condition. Not only does the tophus lesion affect the bone, but recent literature has also demonstrated a correlation between bone health in relation to gout as a disease entity, and showed the importance of medical treatment to improve the bone quality in patients with gout. We present a rare case of a pathological fracture due to an intraosseous gouty tophus as the presentation of gout, which imposed a diagnostic challenge, and illustrates the importance of multidisciplinary management in such conditions.

Background Primary hyperparathyroidism revealed by a pathological fracture is very uncommon; in the majority of cases the discovery of lytic bone lesions on imaging examinations evokes in the clinician first a neoplastic etiology and a metabolic origin is often omitted. This case report adds to the existing literature as it describes an unusual presentation of primary hyperparathyroidism. Case presentation We report a case of a 50-year-old Moroccan man, without any known tumor, who presented a fracture of his left clavicle with multiple osteolytic lesions on computed tomography suggesting bone metastases. However, bone scintigraphy oriented the diagnosis to a metabolic pathology by showing a metabolic bone “super scan” with increased tracer uptake in the left clavicle; parathyroid scintigraphy was able to localize pathological right parathyroid tissue. Conclusions Whenever multiple osteolytic lesions are found in a patient without any known tumor, metabolic bone diseases including hyperparathyroidism should be highly considered.