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Primary hyperparathyroidism (PHPT) is usually seen in females above the age of 50 years, with a prevalence of 21/1000 whereas the incidence in patients aged 12-28 years is <5%. A solitary adenoma is responsible for 80% of cases of PHPT. PHPT is most commonly asymptomatic. The young age of the patient and her presentation with osteoporosis and bone fractures make this an extremely rare presentation of parathyroid adenoma (PTA). Here, we report a case of PTA in a young female presented with pathological fracture of tibia and humerus. The case was diagnosed as PTA based on clinical symptoms and investigations. Surgical intervention, i.e. parathyroidectomy was performed under GA. [ABSTRACT FROM AUTHOR]

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Background: Pathological fracture of the humerus causes severe pain, limited use of the hand, and decreased quality of life. This study aimed to compare the outcomes of intramedullary nailing and locking plate in treating metastatic pathological fractures of the proximal humerus. Methods: This retrospective comparison study included 45 patients (22 male, 23 female) with proximal humerus metastatic pathological fractures who underwent surgical treatment between 2011 and 2022. All data were collected from medical records and were analyzed retrospectively. Seventeen cases underwent intramedullary nailing plus cement augmentation, and 28 cases underwent locking plate plus cement augmentation. The main outcomes were pain relief, function scores, and complications. Results: Among 45 patients with mean age 61.7 ± 9.7 years, 23 (51.1%) had multiple bone metastases, and 28 (62.2%) were diagnosed with impending fractures. The nailing group had significantly lower blood loss [100 (60–200) versus 500 (350–600) ml, p < 0.001] and shorter hospital stay (8.4 ± 2.6 versus 12.3 ± 4.3 days, p < 0.001) than the plating group. Average follow-up time of the nailing group was 12 months and 16.5 months for the plating group. The nailing group had higher visual analog scale (VAS) scores than the plating group, indicating greater pain relief with nailing [7 (6–8) versus 6 (5–7), p = 0.01]. Musculoskeletal Tumor Society functional scores [28 (27–29) versus 27 (26.5–28.5), p = 0.23] were comparable between groups. No complications, local recurrence, or revision surgery were reported until the last follow-up in either group. However, one case in the plating group had a humeral head collapse and fragmentation without needing revision surgery. Conclusions: Intramedullary nailing with cement augmentation is a viable option for treating proximal humerus metastatic pathological fracture, providing rigid fixation and better pain relief resulting in earlier mobility to optimize functional outcomes. Less invasive procedure with less blood loss and shorter hospital stay also benefits patients. Level of evidence Level II. Trial registration statement Not applicable. [ABSTRACT FROM AUTHOR]

Background: Bone metastases can cause severe pain, pathological fractures, and spinal cord paralysis, which interrupt treatment for tumors and cause patients to be bedridden. In this study, we aimed to clarify therapists' problems in the rehabilitation of patients with bone metastases and their countermeasures using the results of questionnaires to therapists and recommend safer and more rational rehabilitation. Methods: Questionnaire forms were sent to 21 therapists in our department. The questionnaire was conducted anonymously about problems during the rehabilitation procedure such as the risk of pathological fractures and paralysis. Results: All of the therapists had strong anxiety (43%) or some anxiety (57%) about the risk of pathological fractures or paralysis during a procedure. However, no therapist responded that this had ever occurred. Many of the respondents had changed a procedure to a milder one (81%) or interrupted a procedure (48%) due to the patient's condition on the day. Therapists chose many options to reduce the risk of pathological fractures and paralysis during the procedure. Among them, "pre-rehabilitation referral to orthopedic surgeon" (86%), "consultation with a doctor about changes in patient's symptoms and findings" (86%), and "regular cooperation between multiple occupations" (67%) were frequently selected. Conclusions: Our questionnaire survey of therapists regarding the treatment of patients with bone metastases found that there was considerable anxiety about the risk of pathological fractures and paralysis during treatment. Our findings suggest that it is necessary to strengthen cooperation with multiple occupations, especially those in the orthopedic field. [ABSTRACT FROM AUTHOR]

Primary hyperparathyroidism (PHPT) is usually seen in females above the age of 50 years, with a prevalence of 21/1000 whereas the incidence in patients aged 12–28 years is

Introduction: Adenoid cystic carcinoma (ACC) is a rare head and neck malignancy and is likely to be diagnosed in the major salivary glands. It's also known for its slow clinical course and prolonged survival unless no distant metastasis occurs. Even after a long period from the detection of the primary tumor, metastasis to the lung, brain, liver, and bone has a tendency to occur. Case presentation: We report a 53-year-old man who presented with a pathological femur fracture thirteen years after the presentation of submandibular ACC. Our patient reported an improved patient-reported outcome after undergoing resection hemiarthroplasty for his bone metastasis. Conclusion: We tried to accentuate the importance of periodical visits for the probability of distant metastasis and the work-up if it's necessary in such a rare case. It should be kept in mind that proper management of bone metastasis may lead to improvements in the quality of life.

Abstract Background Pediatric proximal femoral tumors often present with accumulative and severe bone destruction and are often complicated by pathological fractures and malunion. Such tumors are treated clinically by lesion scraping and graft reconstruction with autologous iliac bone alone or in combination with artificial bone. This study aimed to determine the efficacy of the Locking Compression Pediatric Hip Plate™ in treating pediatric proximal femoral tumors. Methods From 2012–2017, the Locking Compression Pediatric Hip Plate™ was applied for internal fixation in 28 children in the Department of Pediatric Surgery. The complications were pathological fractures in 19 patients and multiple lesions in 5 patients. Tumors were removed by tumor curettage and reconstruction with autogenous iliac bone or artificial bone graft. The Locking Compression Pediatric Hip Plate™ was then applied. Postoperative pathological examination confirmed the diagnosis. Results The cohort comprised 20 males and 8 females (mean age 7.8 ± 2.9 years). The mean follow-up duration was 26.1 ± 8.1 months (range 18–48 months). Post-treatment radiography showed that the lesions and local pathological fractures were healed in 3.2 ± 0.4 months (range 3–4 months), with no complications. Four patients continued to receive antineoplastic therapy postoperatively. Four patients experienced recurrence in situ, while another four developed distant metastases. The radiographic and joint function findings indicated that the affected limbs had excellent function. The mean Enneking score was 28.7 ± 1.0 points (range 27–30 points). Conclusions Internal fixation with the Locking Compression Pediatric Hip Plate™ in children achieves good therapeutic effects. Moreover, the Locking Compression Pediatric Hip Plate™ resolves the shortcomings of external fixation by traditional plaster casts and internal fixation by Kirschner wires and elastic intramedullary screws.

Brown tumors are rare destructive bone lesions caused by hyperparathyroidism. As their clinical symptoms, radiographic findings, and laboratory results closely mimic those of metastatic tumors or multiple myeloma, the diagnosis may often be mistaken. We report a case of a 61-year-old woman with brown tumors in both femurs due to parathyroid carcinoma. The patient presented with multiple osteolytic lesions that caused pain in the right thigh. Whole-body computed tomography (CT), including the neck, suspected a parathyroid tumor, and a biopsy of the bone lesion revealed no malignancy. Following parathyroidectomy, she was diagnosed with a brown tumor with hyperparathyroidism due to a very rare parathyroid carcinoma. Although the right femoral lesion was indicated as an impending fracture, conservative treatment was performed because of the instability of her general condition after parathyroidectomy and her wishes. Bone remodeling of the right femur progressed, and the patient was ambulatory; however, 9 months postoperatively, the patient fell, developed a pathological fracture, and underwent internal fixation. When multiple osteolytic bone lesions are present, CT imaging of the neck should be performed to determine the possibility of a brown tumor due to parathyroid disease. Bone lesions of brown tumors are known to be naturally cured after treatment for hyperparathyroidism. However, when the lesion of a brown tumor in the femur is an impending fracture, prophylactic internal fixation is recommended aggressively if the patient’s general condition permits.

Abstract Background Thrombotic complications are synergistic and associated with orthopedic procedures, trauma, and malignancy. Because cancer enhances coagulation activity and vice versa, we assessed preoperative biomarkers for survival and complications after treatment of pathologic fractures in non-spinal skeletal metastases. Patients/methods Our study population comprised 113 actual or impending pathologic fractures in 100 patients admitted to two referral centers. Laboratory variables were collected retrospectively from patient records and analyzed related to incidence of pulmonary embolism (PE) and mortality (Kaplan-Meier and Cox regression analyses and biomarker quartiles). Results Preoperative coagulation variables were high without exceptions. PE occurred in 12 patients at 36 post-operative days at incidence of 11% in the lower and 13% in the upper extremity fractures. Patients with fibrinogen exceeding 5 g/l (log-rank 0.022) developed PE earlier (5 to 15 days postoperatively) than others. Also, mean patient survival with normal fibrinogen range (2–4 g/l) was 34 months, whereas it halved upon elevated fibrinogen (log-rank p = 0.009). Survival in patients with FVIII levels under 326 IU/dl (Q3) was 22 months, but only 7 months if FVIII exceeded 326 IU/dl (log-rank p = 0.002). Combined elevated fibrinogen and FVIII predicted survival: for patients with levels below threshold limits was 22 months versus only 7 months when both variables exceeded the ranges (log-rank p

Marcos R Gonzalez,1 Mayte Bryce-Alberti,1 Juan Pretell-Mazzini2 1Facultad de Medicina Universidad Peruana Cayetano Heredia, Lima, Peru; 2Miami Cancer Institute, Division of Orthopedic Oncology, Baptist Health System South Florida, Plantation, FL, USACorrespondence: Juan Pretell-Mazzini, Chief of Orthopedic Oncology, Miami Cancer Institute – Plantation, Baptist Health System South Florida, Plantation, FL, 333324, USA, Tel +1 (954)-837-1490, Email juan.pretell@baptisthealth.netAbstract: Bones are the third most common site of metastatic disease. Treatment is rarely curative; rather, it seeks to control disease progression and palliate symptoms. Imaging evaluation of a patient with symptoms of metastatic bone disease should begin with plain X-rays. Further imaging consists of a combination of (PET)-CT scan and bone scintigraphy. We recommend performing a biopsy after imaging workup has been conducted. Metastatic bone disease is managed with a combination of systemic treatment, radiotherapy (RT), and surgery. External beam RT (EBRT) is used for pain control and postoperatively after fracture stabilization. Single-fraction and multiple-fractions schemes are equally effective achieving pain control. Adequate assessment of fracture risk should guide the decision to stabilize an impending fracture. Despite low specificity, plain X-rays are the first tool to determine risk of impending fractures. CT scan offers a higher positive predictive value and can add diagnostic value. Surgical management depends on the patient’s characteristics, tumor type, and location of fracture/bone stock. Fixation options include plate and screw fixation, intramedullary (IM) nailing, and endoprostheses. Despite widespread use, the need for prophylactic stabilization of the entire femur should be individually analyzed in each patient due to higher complication rates of long stems.Keywords: bone metastasis, pathological fracture, radiotherapy, surgery

The aim of the study was to look for the effectiveness of percutaneous balloon kyphoplasty in the management of vertebral compression osteoporotic and pathological fracture. A retrospective analysis of 112 patients with 198 symptomatic wedge vertebral compression fractures who were treated by percutaneous balloon kyphoplasty was done. Visual Analogue pain (VAP) scale, Oswestry Disability index (ODI) and Short Form (SF-36) were used to look for the outcome. Pre-operative median VAS score was (8.0, IQR 2.0) which decreased to (4.0, IQR 3.0) at 12 months. Pre-operative median ODI score was (66, IQR 22) which at 12 months follow up decreased to (28, IQR 31). Short-form 36 showed improvement in all quality of life sub-domains. The physical component summary (PCS) improved from 33.0 ± 5.0 to 37.4 ± 6.1. The Mental component summary (MCS) improved from 17.1 ± 8.6 to 23.5 ± 18.9. The results were statistically significant (p < 0.001). Percutaneous balloon kyphoplasty alleviates pain and improves function, disability, and quality of life in osteoporotic and pathological fracture. [ABSTRACT FROM AUTHOR]

Humeral shaft fractures are relatively common injuries and are classified according to location and fracture morphology. Epidemiological studies improve understanding of injury patterns and lay foundations for future research. There are only a few published larger epidemiological studies on humeral shaft fractures. We retrospectively analyzed the medical records of adult patients having sustained a humeral shaft fracture treated in the Helsinki University Hospital between 2006 and 2016. We recorded patient and fracture characteristics, timing and mechanism of injury, associated injuries, and 1-year mortality. We identified 914 patients (489 females, median age = 61.4 years; 425 males, median age = 50.4 years) with 936 fractures. Over 60% of these fractures were sustained from simple falls. The patient age distribution was bimodal, with highest fracture rates in elderly females and young males. We divided the fractures into typical traumatic, periprosthetic, and pathological fractures. Of the 872 typical traumatic fractures, 3.0% were open. In addition, there were 24 (2.6%) periprosthetic and 40 (4.3%) pathological fractures. An associated injury was found in 24% of patients, with primary radial nerve palsy (PRNP) being the most common (10%). PRNPs were more common in distal shaft fractures and high energy injuries. The 1-year mortality was 9.2%. In this study, the most common injury mechanism was a simple fall. The most common associated injury was PRNP. The observed bimodal fracture distribution is consistent with previous literature. [ABSTRACT FROM AUTHOR]

We aimed to investigate the relationship between central sarcopenia and survival in patients with pathological fracture. We reviewed records of patients who were treated for pathological fracture of axial and appendicular skeleton in our clinic between 2011 and 2020. We used the psoas: lumbar vertebral index (PLVI) on axial computer tomographic evaluation to assess for central sarcopenia. A multivariate Cox algorithm was applied to recognize these factors independently associated with one month, six months, one year, and overall survival. A total of 147 patients [61 (41.4%) male and 86 (58.6%) female] were included, with an average age of 62.4 years. During the study, 108 (73.4%) patients died, and 39 (26.6%) were alive. The survival rates at 1 month, 6 months, and 1 year after surgery were 94.6%, 68.7%, and 53.1%, respectively. PLVI values ranged from 0.21 to 1.20 with a mean of 0.536 and a median of 0.520. According to the median value of PLVI, 68 patients with sarcopenia had low PLVI and 79 patients without sarcopenia had high PLVI. For the first month, only the preoperative albumin level was identified as a prognostic factor. Eastern Cooperative Oncology Group Performance Status (ECOG), American Society of Anesthesia (ASA) scores and primary malignancy (rapid grade) were strong predictor of poor survival. The PLVI was independent significant predictor of first month (HR, 0.083 [95% CI, 0.011–0.649], p = 0.018) and overall survival (HR, 0.129 [95% CI, 0.034–0.492], p = 0.003). The PLVI was a strong predictor of first year, and overall survival in patients with pathological fracture. - The PLVI was a strong predictor of first year, and overall survival. - Primary malignancy (rapid grade) was independently associated with poor survival. - ECOG PS and ASA scores were strong predictor of first year, and overall survival. [ABSTRACT FROM AUTHOR]

Introduction: Procedures like kyphoplasty or vertebroplasty have become an established treatment option for vertebral compression fractures (VCF). The transpedicular approach used during these procedures allows to take biopsies from the affected vertebral body. The aim of this study was to systematically summarize the existing knowledge on the value of routine transpedicular biopsies during kyphoplasty or vertebroplasty for vertebral compression fractures. Methods: A systematic review of the literature using PubMed/Medline databases with the goal of finding all articles describing the value trans-pedicular biopsies for detecting primary bone tumors, metastases, bone diseases, or spondylitis in patients with vertebral compression fractures was performed. Search terms were (*biopsy/ OR biops*.ti,ab.) AND (vertebral compression fracture*.ti,ab.). Results: Sixteen articles met the inclusion criteria, among these were six prospective and ten retrospective case series. Publication dates ranged from 2005 to 2020. A total of 3083 patients with 3667 transpedicular biopsies performed were included. Most biopsies confirmed osteoporosis as the dominant underlying pathology of VCFs. Transpedicular biopsies revealed an unexpected malignant diagnosis in 0.4–6% of the cases. Conclusion: Routine transpedicular biopsies during kyphoplasty or vertebroplasty detect unexpected malignant lesions in 0.4–6% of the patients, even though the definition of "unexpected" varies among the analyzed studies. The evidence to support a routine biopsy is inconsistent. Nevertheless, routine biopsies can be considered, especially when sufficient preoperatvie imaging is not available or radiological findings are unclear. [ABSTRACT FROM AUTHOR]

Giant cell tumor of bone is a histologically benign bone neoplasia that clinically has an aggressive course. In rare cases, it can give "benign" lung metastases or undergo malignant transformation. The World Health Organization defines this neoplasia as an "aggressive, potentially malignant lesion". Herein, we present a rare case of a neglected long-term pathologic fracture of the distal femur in a 20-year-old female patient. After a biopsy, a giant cell tumor of bone was diagnosed. The patient was treated with intralesional curettage, osteoplasty and plate fixation of the fracture. Eight months postoperatively, no local recurrence or metastasis of the tumor was observed.

Fracture callus formation is a dynamic stage of bone activity and repair with precise, spatially localized gene expression. Metastatic breast cancer impairs fracture healing by disrupting bone homeostasis and imparting an altered genomic profile. Previous sequencing techniques such as single-cell RNA and in situ hybridization are limited by missing spatial context and low throughput, respectively. We present a preliminary approach using the Visium CytAssist spatial transcriptomics platform to provide the first spatially intact characterization of genetic expression changes within an orthopedic model of impaired fracture healing. Tissue slides prepared from BALB/c mice with or without MDA-MB-231 metastatic breast cancer cells were used. Both unsupervised clustering and histology-based annotations were performed to identify the hard callus, soft callus, and interzone for differential gene expression between the wild-type and pathological fracture model. The spatial transcriptomics platform successfully localized validated genes of the hard (Dmp1, Sost) and soft callus (Acan, Col2a1). The fibrous interzone was identified as a region of extensive genomic heterogeneity. MDA-MB-231 samples demonstrated downregulation of the critical bone matrix and structural regulators that may explain the weakened bone structure of pathological fractures. Spatial transcriptomics may represent a valuable tool in orthopedic research by providing temporal and spatial context.

Objective: We report the unorthodox use of a retrograde intramedullary nail via antegrade technique for the treatment of a subtrochanteric pathological femur fracture in the presence of significant coxa vara. No similar use has been documented previously in literature. Methods: A standard approach to the proximal right femur was performed and standard antegrade technique used to introduce a guide wire into the proximal femur after which the femoral shaft was reamed. A 38-cm long 10 mm diameter retrograde nail was attached to the retrograde insertion and targeting device as if to perform a left sided retrograde femoral nailing. The nail was then inserted antegrade into the proximal right femur and locked. Results: The patient made a good recovery without complications and was followed up regularly at the clinic until complete healing of the fracture. Conclusion: We believe that a retrograde intramedullary nail inserted antegrade, enabling proximal locking with screws passing into the femoral head, provides a mechanically sound fixation of a subtrochanteric fracture, where a reduced neck-shaft angle precludes the use of a standard cephalo-medullary nail.

Aims Due to their radiolucency and favourable mechanical properties, carbon fibre nails may be a preferable alternative to titanium nails for oncology patients. We aim to compare the surgical characteristics and short-term results of patients who underwent intramedullary fixation with either a titanium or carbon fibre nail for pathological long-bone fracture. Methods This single tertiary-institutional, retrospectively matched case-control study included 72 patients who underwent prophylactic or therapeutic fixation for pathological fracture of the humerus, femur, or tibia with either a titanium (control group, n = 36) or carbon fibre (case group, n = 36) intramedullary nail between 2016 to 2020. Patients were excluded if intramedullary fixation was combined with any other surgical procedure/fixation method. Outcomes included operating time, blood loss, fluoroscopic time, and complications. Fisher’s exact test and Mann-Whitney U test were used for categorical and continuous outcomes, respectively. Results Patients receiving carbon nails as compared to those receiving titanium nails had higher blood loss (median 150 ml (interquartile range (IQR) 100 to 250) vs 100 ml (IQR 50 to 150); p = 0.042) and longer fluoroscopic time (median 150 seconds (IQR 114 to 182) vs 94 seconds (IQR 58 to 124); p = 0.001). Implant complications occurred in seven patients (19%) in the titanium group versus one patient (3%) in the carbon fibre group (p = 0.055). There were no notable differences between groups with regard to operating time, surgical wound infection, or survival. Conclusion This pilot study demonstrates a non-inferior surgical and short-term clinical profile supporting further consideration of carbon fibre nails for pathological fracture fixation in orthopaedic oncology patients. Given enhanced accommodation of imaging methods important for oncological surveillance and radiation therapy planning, as well as high tolerances to fatigue stress, carbon fibre implants possess important oncological advantages over titanium implants that merit further prospective investigation. Level of evidence: III, Retrospective study Cite this article: Bone Jt Open 2022;3(8):648–655.

Hypothesis: The aim of this study was to investigate the reproducibility, reliability, and accuracy of Mirels’ score in upper limb bony metastatic disease and validate its use in predicting pathologic fractures. Methods: Forty-five patients with upper limb bony metastases met the inclusion criteria (62% male 28/45). The mean age was 69 years (SD 9.5), and the most common primaries were lung (29%, 13/45), followed by prostate and hematological (each 20%, 9/45). The most commonly affected bone was the humerus (76%, 35/45), followed by the ulna (6.5%, 3/45). Mirels’ score was calculated in 32 patients; with plain radiographs at index presentation scored using Mirels’ system by 6 raters. The radiological aspects (lesion size and appearance) were scored twice by each rater (2 weeks apart). Intraobserver and interobserver reliability were calculated using Fleiss’ kappa test. Bland-Altman plots compared the variances of both individual components and the total Mirels’ score. Results: The overall fracture rate of upper limb metastatic lesions was 76% (35/46) with a mean follow-up of 3.6 years (range 11 months-6.8 years). Where time from diagnosis to fracture was known (n = 20), fractures occurred at a median 19 days (interquartile range 60-10), and 80% (16/20) occurred within 3 months of diagnosis.Mirels’ score of ≥9 did not accurately predict lesions that fractured (fracture rate 11%, 5/46, for Mirels’ ≥ 9 vs. 65%, 30/46, for Mirels’ ≤ 8, P

Background: Gaucher disease (GD) is a rare condition commonly associated with skeletal symptoms. At the advanced stage, it can lead to aseptic bone necrosis (AVN) and pathological fractures. The medical treatment by enzymatic replacement therapy (ERT) has considerably improved a patient's quality of life, but without being able to avoid bone-related complications. The handling of these patients in terms of orthopedic surgery is quite specific, and very few publications discussed the surgical management of this disorder in the literature. Case report: We are reporting a rare case of a 50-year-old female who presented with a pathologic fracture on a deformed femur with an Ehrlenmeyer flake aspect. She underwent surgical treatment by percutaneous nailing using an MRI-compatible Titanium implant. Conclusion: Through this paper, we are trying to briefly define GD, summarize his bone-related manifestations, and outline the appropriate measures and precautions that should be considered by orthopedic surgeons when dealing with skeletal complications of this rare disease.

Primary bone lymphoma (PBL) is a rare extranodal presentation within lymphomas and primary bone malignancies. Pathologic fracture (PF) is a common complication of metastatic bone disease but is, rarely, the presentation of a primary bone tumor. We report a case of an 83-year-old man with a history of untreated prostate cancer, presenting with atraumatic fracture of his left femur after months of intermittent pains and weight loss. Radiographic workup revealed a lytic lesion suspicious for PF secondary to metastatic prostate cancer; however, initial core biopsy results were inconclusive for malignancy. A complete blood count with differential and complete metabolic panel was within normal limits. During surgical fixation and nailing of the femur, a reaming biopsy was performed as a repeat measure and revealed diffuse large B-cell lymphoma. Staging with positron emission tomography and computed tomography found no evidence of lymphatic or visceral involvement and chemotherapy was promptly initiated. This case highlights the diagnostic workup challenges for PF secondary to PBL, especially in the setting of concurrent malignancy. Because of the nonspecific presentation of a lytic lesion on imaging associated with atraumatic fracture, we highlight PBL as an important diagnostic consideration. [ABSTRACT FROM AUTHOR]

Introduction: Solitary bone cysts in the calcaneus (calcaneal bone cysts) are often asymptomatic. Pathological fractures are rare, and few reports are available concerning its risk assessment. Therefore, the indication for operative interventions remains debatable, and further discussion on the treatment of symptomatic cysts and pathological fractures in calcaneal bone cysts is necessary. Materials and methods: Clinical data of 21 patients with calcaneal bone cysts (16 men and five women) was retrospectively reviewed. The average age was 13.3 (range, 7–23) years. Clinical data, such as concerning symptoms, radiological findings, pathological findings and outcomes, were investigated, and the pathogenesis of symptomatic cysts was studied. Results: Thirteen cysts were symptomatic, and eight were incidentally discovered. Computed tomography revealed no fracture in 12 cases, microfracture in eight and complete fracture in one. The areas under the curves of the receiver operating characteristic curves calculated to establish an association between cyst size and symptoms and cyst size and pathological fractures (microfracture and complete fracture) were 0.78 and 0.71, respectively. Symptomatic cysts and pathological fractures were associated with the cyst ratio (cyst size/calcaneus ≥ 0.20). On magnetic resonance imaging (MRI), fluid levels were observed in 11 of 21 (52%) patients. At the time of surgery, blood from the haemorrhage was aspirated from 15 of 21 (71%) cysts. Conclusions: Orthopaedic surgeons should be aware that the cyst ratio is associated with clinical symptoms and pathological fractures. MRI and gross findings revealed haemorrhage in the cystic fluid. In calcaneal bone cysts, repeated microfractures and spontaneous healing might occur. [ABSTRACT FROM AUTHOR]

PURPOSE OF THE STUDY The aim of the study was to determine the incidence of primary malignancies metastasizing to the area of the proximal femur, to evaluate the localization of the lesions and fractures, to compare the results of the selected surgical therapy, survival time of the patients and postoperative complications. MATERIAL AND METHODS We retrospectively evaluated the group of patients operated on from 2012 to 2021. The study included 45 patients (24 women and 21 men) with a pathological lesion or a pathological fracture in the area of the proximal femur. The average age was 67 years (38–90). There were 30 (67%) cases of pathological fracture and 15 (33%) cases of pathological lesions in the cohort. In each patient, the perioperative biopsy or resected sample was sent for histological examination. The type of primary malignancy with the localization of lesions and fractures was assessed. Furthermore, we evaluated the outcomes of the surgical method chosen and its complications. We monitored the patients' functional score using the Karnofsky performance status and survival interval. RESULTS The most common primary malignancy was multiple myeloma in 10 cases (22%), followed by seven cases (16%) of breast and lung cancer and 6 cases (13%) of clear cell renal cell carcinoma. Internal fixation was used in 15 cases (33%). Tumor resection with hip joint replacement was performed in 29 patients (64%). One patient was treated with percutaneous femoroplasty. Out of a total of 45 patients, 10 patients (22%) survived for less than three months. The survival rate of more than one year was observed in 21 patients (47%). A total of seven complications occurred in six patients (15%). Fewer complications occurred in the group of patients with a pathological fracture compared to the group with an impending fracture. DISCUSSION Pathological lesions in the bone or an already existing pathological fracture are signs of advanced cancer. Better outcomes are reported in patients who underwent prophylactic surgery, which was, however, not confirmed by our study. The incidence of individual primary malignancies, the postoperative complications and the patient survival corresponded to the statistical data reported by the other authors. CONCLUSIONS In patients with a pathological lesion of the proximal femur, operative treatment will increase the quality of life, either when choosing osteosynthesis or joint replacement, while prophylactic treatment is usually associated with a better prognosis. As a less invasive procedure with lower blood loss, osteosynthesis is indicated for palliative therapy in patients with a limited expected survival time or in patients with a prognosis of healing of the lesion. Reconstruction of the joint with an arthroplasty is indicated in patients with a better prognosis or in cases excluding safe osteosynthesis. Our study confirmed good outcomes with the use of an uncemented revision femoral component. [ABSTRACT FROM AUTHOR]

Primary hyperparathyroidism (PHPT) is a disease commonly seen in postmenopausal women. We report two cases of pathological fractures following trivial injuries in two different age groups; the middle and teen age group presented as PHPT due to parathyroid adenoma. PHPT usually presents with symptomatic hypercalcemia and target organ damage. Biochemical manifestations in both cases are similar i.e. hypercalcemia, elevated serum intact parathyroid hormone (iPTH), and mass in the parathyroid gland. Histopathological examination is consistent with parathyroid adenoma. We highlighted these two cases due to long delay before the PHPT diagnosisisconfirmedbecause of various investigations commenced in these patients to rule out other diagnoses. [ABSTRACT FROM AUTHOR]

Introduction: An increasing number of patients sustaining a fragility hip fracture (FHF) have either an active diagnosis or a history of cancer. However, little is known about the outcomes of non-malignant related FHF in this group of patients. We aimed to evaluate the mortality and complications rates during hospitalization, as well as at 1-year follow-up within this population. Methods: A retrospective cohort study of patients 65 years of age and above, who underwent surgery for the treatment of proximal femoral fractures between January 2012 and June 2016 was conducted. Patients diagnosed with malignancies, both solid (Carcinomas) and a hematological neoplasias (Lymphomas, Multiple Myeloma) were included, along with consecutive controls without a diagnosis of cancer in the 5 years prior to the study period. Demographic, clinical and radiographic parameters were recorded and analyzed. Results: Seven hundred and fifty-two patients with FHF were included, of whom 51 had a malignancy diagnosis within the 5-year period preceding the fracture (18% metastatic disease). The mean time from malignancy diagnosis to FHF was 4.3 ± 4.8 years. Time to surgery did not differ between groups, and the vast majority of patients from both groups (over 87%) were operated within the desirable 48 h from admission. Patients with malignancy had a higher probability of being admitted to an internal medicine department both pre and post-surgically (p < 0.001), and were more susceptible to pre-operative anemia (p = 0.034). In-hospital mortality did not differ between groups, yet 1-year mortality was higher for the malignancy group (41.2% vs 19.5%, p < 0.001). At 1-year post-operatively, orthopedic complications were similar between groups. Conclusion: Patients with a history of malignancy in the 5-years prior to a non-neoplastic FHF, showed similar mortality and complications rates during admission but increased 1 year mortality rate when compared to patients without cancer undergoing surgical treatment of a non-neoplastic proximal femoral fracture. [ABSTRACT FROM AUTHOR]

Introduction: Solitary bone metastasis of colorectal carcinoma (CRC) without other metastasis sites is extremely rare and can be found in less than 1% of patients with CRC. Aim: In the present study, we report the first case of a solitary tibia metastasis and its pathologic fracture as the first presenting feature of a colorectal adenocarcinoma. Material and methods: A 78-year-old female patient presented to our emergency department due to atraumatic pretibial swelling. Plain radiography did not detect any pathology. The swelling was incised and serous-bloody collection was evacuated, and the patient was discharged. On the 17th postoperative day, during a regular walk, the patient fell down and broke her leg, which transpired to be a pathologic fracture of the proximal tibial diaphysis, confirmed by X-ray. A biopsy of the altered bone tissue from the fracture site revealed metastatic colorectal adenocarcinoma. On colonoscopy, a circular mass in the upper rectum was found. Conclusions: Solitary bone metastases are most commonly found in bones that are related to venous drainage via the paravertebral plexus of Batson - the pelvis, vertebrae, and sacrum. Long bones are extremely rare localizations of solitary CRC metastases, with only few cases published so far in medical literature. In our case, the patient's first symptom was related to the osseous tibial metastasis - leg swelling. No tumour was suspected until the pathologic fracture occurred. It is important to consider osseous metastasis in every patient with unexplained swelling, haematoma, or pain of the extremities and make a bone scan to recognize the metastasis early. [ABSTRACT FROM AUTHOR]

Background: We report the successful conservative management of a pathological mandibular fracture resulting from chronic osteomyelitis in a super-elderly patient. Case Presentation: A 90-year-old woman was admitted because of an external dental fistula with purulent drainage. Radiographs showed extensive bone destruction in the mandible. Long-term antibiotic therapy and chin cap immobilization resulted in satisfactory bone healing 1 year after treatment initiation, which suggests that a conservative approach is alternative or complementary to surgical resection for a mandibular fracture, especially in older patients at high risk of severe postoperative complications. Conclusion: As the population ages, the number of such cases will rise; therefore, minimally invasive therapeutic strategies must be developed. [ABSTRACT FROM AUTHOR]

Background. Recent studies have shown that a combination of surgery with chemotherapy and radiotherapy can signifcantly improve survival in patients with primary and metastatic bone tumors. Reconstruction of bone defects after resection of long bones is critical for successful functional limb salvage. The choice of the reconstruction technique depends on the tumor location, tumor extension, presence of pathological fracture, and somatic status of the patient. Reconstruction of bone defects in cases with diaphyseal tumor location can pose a surgical challenge. For the reconstruction of diaphyseal bone defects, endoprostheses, alloimplants, and autologous bone grafts are used. To achieve stability of the affected segment of the limb, various options for osteosynthesis are used. Modern technological achievements provide the emergence of materials with characteristics close to those of human bone tissue, however, without the disadvantages inherent in allo- and autologous implants. The purpose of the study was to improve surgical treatment outcomes in patients with long tubular bone tumors. Material and Methods. For the reconstruction of postoperative long bone defects, we used carbon nanostructured implants (СNI) in combination with intramedullary osteosynthesis with a blocked pin. A total of 25 patients underwent surgery (including 9 patients with a pathological fracture), 24 of them had metastases. Results. There were no intraoperative and postoperative complications. All patients had a signifcant decrease in pain 1 month after surgery. At 3 months after surgery, functional outcomes were satisfactory. None of the patients had a local recurrence, instability of the operated limb segment, or a reaction of rejection of a carbon nanostructured implant. Conclusion. Reconstruction of postoperative defects with carbon nanostructured implants after resection of long tubular bones for metastatic cancer provides good functional results and satisfactory local control.

Purpose: to conducted a systematic analysis of data available in the current literature, modern diagnosticalgorithms, prognostic factors, survival and options for surgical treatment of metastases in the spine andlong bones of the extremities.Material And Methods. The review included data from randomized clinical trials evaluating various diagnostic algorithms for detecting bone metastases, the frequency of metastases to the vertebral column and long bones, their number, and options for surgical or radiation treatment published over the past 10 years. The review also evaluated various prognostic factors that can be used to determine the patient’s life expectancy.Results. Diagnostic algorithms and scales that help choose treatment strategy, taking into account prognostic factors, were published. The treatment outcomes in patients with spine and long bone metastases were shown to be improved due to personalized surgical treatment strategies.Conclusion. Further studies are needed to identify new prognostic factors determining the oncological outcomes in patients with bone metastases. This will lead to the optimization of surgical treatment methods and the development of new algorithms for choosing the extent of surgery in patients with bone metastases.

Intraosseous hemangiomas are uncommon slow-growing benign bone tumors. Most of these lesions are located in the spine or skull and long bone location is rare. Here we present the case of a 63-year-old female with a pathological fracture of the left proximal humerus through an intraosseous hemangioma. Imaging features can be highly unspecific when these tumors are found in the long bones. In this case a pathological fracture obscured the diagnosis even further, prompting the need for tissue sampling to exclude an underlying malignancy.

Objective To describe the epidemiological and clinical characteristics of fibrous dysplasia of bone admitted to a single center in the past 30 years. Methods We analyzed the clinical features of 744 patients with bone fibrous dysplasia diagnosed by pathology, including age, gender, disease location, monostotic or polyostotic lesions, pathological fracture and malignant transformation. Results There were 1183 lesions in 744 patients. The mean age at admission was 31.1±13.5 years old. The ratio of male to female was close to 1:1. The most common site was the lower extremities (916(77.4%)), followed by the upper extremities (106(9.0%)). The most common sites of lower extremities were the femur (645(54.5%)) and the tibia (224(18.9%)). Polyostotic cases accounted for 25.4%, and monostotic cases accounted for 74.6%. Pathological fracture occurred in 163 (13.8%) patients. There were 6 (0.8%) patients with malignant transformation. The mean age was 40.5 years old. The mean time of malignant transformation was 7.7 years. Conclusion Fibrous dysplasia of bone is a rare group of benign bone tumors, with typical epidemiological and clinical features.

Huali Gu,1 Yizhuo Wang,1 Dongsheng Huang,1 Xunda Ji,2 Yi Zhang,1 Jianmin Ma,3 Mei Li,4 Weiling Zhang,1 Huimin Hu,1 Jing Li,1 Pinwei Zhang1 1Department of Pediatrics, Beijing Tongren Hospital, Capital Medical University, Beijing, People’s Republic of China; 2Department of Ophthalmology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China; 3Department of Ophthalmic Oncology, Beijing Tongren Hospital, Capital Medical University, Beijing, People’s Republic of China; 4Department of Nuclear Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, People’s Republic of ChinaCorrespondence: Dongsheng Huang, Department of Pediatrics, Beijing Tongren Hospital, Capital Medical University, West South Road 2, Yizhuang Economic and Technological Development Zone, Daxing District, Beijing, 100176, People’s Republic of China, Tel +86 01058266032, Email hds5180@sina.com Xunda Ji, Department of Ophthalmology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Kong Jiang Road 1665, Shanghai, 200092, People’s Republic of China, Tel +86 15921670980, Email jixunda@xinhuamed.com.cnPurpose: Retinoblastoma (RB) is the most common intraocular malignancy in infancy and childhood. This study evaluated the clinical and imaging features, treatment, and prognosis of patients with recurrent RB with limb bone metastases and without central nervous system involvement.Patients and Methods: The clinical data of five patients with RB with limb bone metastases who were diagnosed at the Department of Pediatrics in Beijing Tongren Hospital between January 2015 and January 2021 were analyzed retrospectively.Results: Three males and two females were included (seven eyes: four group E and one each of group D, C, and B). The most common symptom was pain. Three patients had bone marrow and lymph node metastases. Three patients had single and two had multiple skeletal lesions. The main bones that were involved were the femur, humerus, talus, and ulna. The simultaneous involvement of the bone marrow and cortex was also observed. Serum neuron-specific enolase (NSE) levels were significantly elevated in four cases and slightly elevated in one case; primary intravenous chemotherapy resulted in a decrease in NSE levels and the gradual resolution of the bone lesions. Two patients died at the time of follow-up and three were in complete remission. The results of the statistical analysis showed that anterior chamber invasion was correlated with prognosis, and there was significant difference in the decrease in the serum NSE levels after intravenous chemotherapy.Conclusion: Regular lifelong follow-up of patients with RB is warranted to identify bone metastases earlier. Anterior chamber invasion may be a risk factor. The simultaneous involvement of the bone marrow and cortex is characteristic manifestations in images of RB with bone metastases. Multidisciplinary treatment especially intravenous chemotherapy is useful, at least at the beginning.Keywords: recurrent, NSE, SRE, pathological fracture, pamidronate, osteoclast inhibitors

Introduction A pathological fracture in patients with primary bone sarcomas is a complication that requires specific management with the prognosis affecting the disease. The treatment strategy of the patients with pathological fracture remains controversial. The aim was to explore the effect of a pathological bone fracture on treatment of pediatric bone sarcoma. Material and methods The study included 141 children with bone sarcomas, residents of Moscow. A pathological fracture was observed in 17 (12.1 %) cases accompanied by osteosarcoma in 10 (58.8 %) cases and Ewing's sarcoma in 7 (41.2 %) cases. Long bones were most common location of the fracture seen in 15 (88.2 %) cases. Results Errors in establishing the diagnosis of bone sarcomas occurred in children with/without a fracture with no statistically significant differences (p = 0.239). There were no statistically significant differences in the volume of surgical interventions, functional assessment using the Musculoskeletal Tumor Society System (MSTS), and 5-year survival in children with/without a fracture (p ≥ 0.05). Discussion Treatment of pathological fractures in children should be produced after obtaining biopsy and the histological diagnosis. The frequency of local recurrence and functional outcome does not depend on the fracture. Conclusion Pathological process is to be ruled out in the presence of a fracture, and adequate visualization using MRI to be followed by a biopsy in a specialized institution would be needed if a pathological focus is suspected.

Brown tumors are non-neoplastic reactive tissue with osteoclasts multinucleated giant cells, and vascular and proliferative fibrous tissue. Hemorrhage results in significant bone resorption caused by hyperparathyroidism. This study provides information about the diagnosis challenge for brown tumor cases. We report four cases that experience pathological fractures with moderate pain, multiple lytic lesions, severe hypercalcemia, increased ALP (Alkaline Phosphatase), and PTH (Parathyroid Hormone). Abnormal parathyroid mass was found in ultrasound. A bone scan described increasing radio uptake in various bones, a whole body scan, or parathyroid scintigraphy with 99mTc- MIBI. Eventually, in all cases, the diagnosis of the brown tumor was confirmed through histopathological examination, which showed multiple nucleated giant cells with a deposit of hemosiderin pathognomonic for the brown tumor, and the diagnosis of primary hyperparathyroidism (PHPT) was confirmed in all cases. These cases show that initial misdiagnosis of brown tumors as other bone tumors. A definitive diagnosis of brown tumors requires more than just histological confirmation. A comprehensive evaluation encompassing laboratory tests, imaging studies, clinical symptoms, and a multidisciplinary orthopedic-oncology board discussion is essential. Observations show that treating hyperparathyroidism alleviates the osteolytic lesions caused by brown tumors, despite the lack of clinical guidelines. Based on a review of the literature and our clinical experience, we recommend screening serum calcium, phosphorus, and PTH levels in patients presenting with multiple lesions and widespread bone pain. This screening aims to rule out multiple bone lesions caused by PHPT. • Misdiagnosis of multiple lytic lesions • The diagnostic challenge of brown tumors • MIBI scan still useful to diagnose brown tumors [ABSTRACT FROM AUTHOR]

Pathological mandibular fractures occur in regions with previously damaged bone structure due to different etiologies. The purpose of the study is to present a retrospective review of patients with pathological mandibular fractures who passed through the Clinic of Oral and Maxillofacial Surgery of St. George University Hospital, Plovdiv, for the period 2005-2019 and to compare the results with published literature. Material and methods: The study includes1328 patients with pathological fractures of the mandible with different etiology. Data were collected on age, gender, pre-existing bone damage and lesions, history of any interventions of the lower jaw and treatment approach. Results: Patients with pathological mandibular fractures are 5,1% of all patients who passed through the clinic for this period. Two hundred of them are associated with benign or malignant bone tumors, 161 with osteomyelitis, 202 with other causes: third molar extraction, implant placement, osteonecrosis. Conclusion: Pathological mandibular fractures have different etiologies. Diagnosis and treatment of this condition are challenging, and the treatment plan should be decided individually, according to the underlying disease.

Introduction: Long-standing hematomas may expand and are called chronic expanding hematomas. These may produce complications from their pressure effect on the surrounding structures. In addition, a variety of their presentations and similarity to benign or locally aggressive tumors present a diagnostic dilemma and surgical challenge to manage. Case presentation: We report a case of a pathological fracture of the proximal left femur in a 62-year-old male. He was on anticoagulation therapy for the past mitral valve surgery. He presented with a long history of pain and swelling in the left thigh. The pain suddenly worsened with an inability to bear weight on the left lower limb. He had sustained a pathological fracture of the left proximal femur. There was an erosion of the femur and obliterated medullary canal from the compression effect of a chronic expanding hematoma in his left thigh. The hematoma was evacuated, and the fracture was internally fixed with a dynamic compression screw and plate. The fracture fixation was augmented with an autologous fibular strut graft and extended immobilization. At one and half year follow-up, the fracture had united, with graft incorporationwith no signs of erosion and recurrence.The patient was pain-free and could mobilize full weight-bearing. Conclusion: Chronic expanding hematomas should form part of the differential diagnosis in the work-up of soft tissue tumors in adults. These can result in erosion of bone with resultant pathological fractures. In addition, they may be challenging to diagnose due to their rarity and present a surgical challenge because of their size, bone defects it produces.

Hemangioendothelioma (HE) is a vascular malignancy which shows a borderline biological behavior. Spindle cell HE (SCHE) is a type of hemangioendothelioma, first described by Weiss and Enzinger in 1986. We present a case of 58-year-old male, who presented with fracture right femur. The biopsy showed necrotic bone with features of soft-tissue SCHE. Immunohistochemistry showed diffuse positivity of cluster of differentiation 31 in the tumor cells. Although SCHE has been pondered as a low-grade/borderline malignancy, few cases have been reported as locally aggressive and invasive behavior in the literature. The overall prognosis is excellent and no metastases from this locally aggressive tumor have been reported till date.

Pathologic fractures are common complications of metastatic bone disease in patients with breast cancer. Fractures involving the proximal femur generally cause significant pain that is exacerbated by ambulation. Due to excessive stress on the weight-bearing hip joint, these fractures present a significant burden on the quality of life among patients. Here we describe a case of a 38-year-old female patient who was found to have a pathologic fracture of the proximal femur missed on imaging studies that underwent spontaneous union. Pathologic fractures rarely heal on their own, since a tumor at the fracture site interferes with bone healing and most fractures have to be managed with surgical intervention. Fractures can be missed on imaging studies in the setting of extensive metastatic disease. Physicians should be cognizant of this fact and maintain a high level of suspicion to recognize fractures with unusual presentations where patients may not present with the typical findings of acute onset of pain and inability to ambulate or bear weight.

Despite the significant achievements of modern medical science, oncological diseases pose great difficulties regarding the etiology, timely diagnosis, treatment and prevention of these ailments. Early diagnosis of tumors is the main task facing doctors. Our clinical observations over the past 5 years have shown that all children with tumors sought medical help late with advanced forms. Therefore, our task is to convey to a wide range of pediatric specialists, and not only, information that will help to recognize tumors as early as possible. Time is of crucial importance - whether the child will live or not. The given typical clinical cases should alert you to the recognition of tumors. Unfortunately, the markers of osteogenic sarcoma have not been developed at the moment, so clinical signs play an extremely important role in recognizing this disease.

Primary bone lymphoma (PBL) is a rare extranodal presentation within lymphomas and primary bone malignancies. Pathologic fracture (PF) is a common complication of metastatic bone disease but is, rarely, the presentation of a primary bone tumor. We report a case of an 83-year-old man with a history of untreated prostate cancer, presenting with atraumatic fracture of his left femur after months of intermittent pains and weight loss. Radiographic workup revealed a lytic lesion suspicious for PF secondary to metastatic prostate cancer; however, initial core biopsy results were inconclusive for malignancy. A complete blood count with differential and complete metabolic panel was within normal limits. During surgical fixation and nailing of the femur, a reaming biopsy was performed as a repeat measure and revealed diffuse large B-cell lymphoma. Staging with positron emission tomography and computed tomography found no evidence of lymphatic or visceral involvement and chemotherapy was promptly initiated. This case highlights the diagnostic workup challenges for PF secondary to PBL, especially in the setting of concurrent malignancy. Because of the non-specific presentation of a lytic lesion on imaging associated with atraumatic fracture, we highlight PBL as an important diagnostic consideration.

Background: Pediatric proximal femoral tumors often present with accumulative and severe bone destruction and are often complicated by pathological fractures and malunion. Such tumors are treated clinically by lesion scraping and graft reconstruction with autologous iliac bone alone or in combination with artificial bone. This study aimed to determine the efficacy of the Locking Compression Pediatric Hip Plate™ in treating pediatric proximal femoral tumors. Methods: From 2012–2017, the Locking Compression Pediatric Hip Plate™ was applied for internal fixation in 28 children in the Department of Pediatric Surgery. The complications were pathological fractures in 19 patients and multiple lesions in 5 patients. Tumors were removed by tumor curettage and reconstruction with autogenous iliac bone or artificial bone graft. The Locking Compression Pediatric Hip Plate™ was then applied. Postoperative pathological examination confirmed the diagnosis. Results: The cohort comprised 20 males and 8 females (mean age 7.8 ± 2.9 years). The mean follow-up duration was 26.1 ± 8.1 months (range 18–48 months). Post-treatment radiography showed that the lesions and local pathological fractures were healed in 3.2 ± 0.4 months (range 3–4 months), with no complications. Four patients continued to receive antineoplastic therapy postoperatively. Four patients experienced recurrence in situ, while another four developed distant metastases. The radiographic and joint function findings indicated that the affected limbs had excellent function. The mean Enneking score was 28.7 ± 1.0 points (range 27–30 points). Conclusions: Internal fixation with the Locking Compression Pediatric Hip Plate™ in children achieves good therapeutic effects. Moreover, the Locking Compression Pediatric Hip Plate™ resolves the shortcomings of external fixation by traditional plaster casts and internal fixation by Kirschner wires and elastic intramedullary screws. [ABSTRACT FROM AUTHOR]

Background: Thrombotic complications are synergistic and associated with orthopedic procedures, trauma, and malignancy. Because cancer enhances coagulation activity and vice versa, we assessed preoperative biomarkers for survival and complications after treatment of pathologic fractures in non-spinal skeletal metastases. Patients/methods: Our study population comprised 113 actual or impending pathologic fractures in 100 patients admitted to two referral centers. Laboratory variables were collected retrospectively from patient records and analyzed related to incidence of pulmonary embolism (PE) and mortality (Kaplan-Meier and Cox regression analyses and biomarker quartiles). Results: Preoperative coagulation variables were high without exceptions. PE occurred in 12 patients at 36 post-operative days at incidence of 11% in the lower and 13% in the upper extremity fractures. Patients with fibrinogen exceeding 5 g/l (log-rank 0.022) developed PE earlier (5 to 15 days postoperatively) than others. Also, mean patient survival with normal fibrinogen range (2–4 g/l) was 34 months, whereas it halved upon elevated fibrinogen (log-rank p = 0.009). Survival in patients with FVIII levels under 326 IU/dl (Q3) was 22 months, but only 7 months if FVIII exceeded 326 IU/dl (log-rank p = 0.002). Combined elevated fibrinogen and FVIII predicted survival: for patients with levels below threshold limits was 22 months versus only 7 months when both variables exceeded the ranges (log-rank p < 0.001). Multivariate analysis to control confounders supported an independent role of fibrinogen and FVIII for survival. Conclusions: Our study has established fibrinogen and FVIII as potential preoperative contributors of survival and complications after treatment of metastatic fractures. These results highlight the need for novel anticoagulation and thromboprophylaxis strategies among these patients. [ABSTRACT FROM AUTHOR]

Introduction: There are several studies in the literature about pathological fractures but almost no information about patients whose pathological fracture caused by a malignant lesion misdiagnosed and treated as a simple fracture. The aim of this study was to investigate patient and fracture characteristics, and outcomes in cases where fractures occurred in the presence of a malign pathology but were treated as simple fractures.Patients and Methods: Cases of malign bone lesions between 2000 and 2020 were retrospectively reviewed. Patients with a final diagnosis of malign bone lesion but whose pathological fractures were treated ignoring the underlying malign bone disease were included. Demographic, clinical and outcome data were collected from patient's medical records and analyzed.Results: Six patients met the inclusion criteria. Three of the patients were female and the cohort mean age was 56.8 ± 21.8 years at the time of admission. Patient diagnoses were: renal cell carcinoma metastasis (n = 1); colon cancer metastasis (n = 1); chondrosarcoma (n = 2); osteosarcoma (n = 1); and undifferentiated pleomorphic sarcoma of bone (n = 1). In all cases surgical management differed from those that should have been applied if the pathological fracture had been identified. Furthermore, surgical management after definitive histological diagnosis were more aggressive compared to if the malignancy had been identified at first admission. All patients died after a mean follow-up of 16.67 ± 11.7 months and the complication rate was 100%.Conclusion: When a pathological fracture is misdiagnosed and managed as a simple bone fracture, outcomes are extremely poor. In these situations, remedial surgery is more extensive, with increased complication rates and there is poor life expectancy. [ABSTRACT FROM AUTHOR]