Surgical treatment of metastatic disease of the femur

Nearly every malignant neoplasm has been described as having the capability to metastasize to bone. Of the estimated 1.2 million new cases of cancer diagnosed annually, more than 50% will eventually demonstrate skeletal metastasis. Advances in systemic and radiation therapy have led to a considerable improvement in the prognosis of patients with metastatic disease. As a result, orthopaedic surgeons are being asked with increasing frequency to evaluate and treat the manifestations of skeletal metastases. The femur is commonly the site of large impending lesions and complete pathologic fractures. Although the health status of some patients may preclude operative intervention, established pathologic fractures of the femur and metastatic lesions deemed likely to progress to imminent fracture generally should be treated surgically. A rational approach to selection of the proper treatment for these problems includes consideration of the patient's overall medical condition and the type, location, size, and extent of the tumor. Treatment principles are the same regardless of location. A construct should ideally provide enough stability to allow immediate full weight bearing with enough durability to last the patient's expected lifetime. All areas of weakened bone should be addressed at the time of surgery in anticipation of disease progression. To minimize disease progression and possible implant or internal fixation failure, postoperative external-beam irradiation should be considered.

Supracondylar fracture of the femur following total knee arthroplasty. Description of two clinical cases

The authors describe two cases of supracondylar fracture of the femur occurring following total knee arthroplasty. By reviewing the literature, they analyze causal factors indicating the constant presence, observed also in the cases presented, of an erroneous resection of the anterior cortex of the femur. In association with other predisposing factors, this condition favors an anomalous distribution of the load forces in this site, reducing torsion resistance of the femur by about 30%: what results is greater susceptibility for the risk of fracture for a long period of time, even for trauma of moderate entity.

[Fully implantable intramedullary distraction nail in shortening deformity and bone defects. Spectrum of indications]

Since the first clinical experiences with the fully implantable programmable distraction nail nearly ten years ago, the system has been improved in Munich and meanwhile used in 26 patients. During the first 10 cases there has been highest interest in the reliability of the system, while in the following the expansion of indications was more important. At the thigh a good indication beside shortening is the combination of shortening and axis deviation, even if the center of deviation is located near to the knee joint in the supracondylar area. According to preoperative planing the deformity correction can be done acutely while the lengthening procedure follows postoperatively automatically at night-time. If the stabilization with an intramedullary nail is possible, large bone defects can be treated by bone transport using this system also. The fully implantable intramedullary nail has proved its variable functions in cases of large bone defects combined with shortening of the femur. The system is able to perform the bone transport at first and the lengthening procedure automatically without any further operation thereafter.

Osteitis fibrosa cystica generalizata with adult T-cell leukaemia: a case report

We report on a 62-year-old female initially suffering from extreme pain in both her lower extremities. Plain radiographs revealed multiple osteolytic lesions. Laboratory analyses indicated high levels of serum calcium and parathyroid hormone related protein (PTHrP) and detected HTLV-1 antibody. Histological examination of biopsied specimens which were obtained from osteolytic lesions indicated osteitis fibrosa cystica (OFC) without tumour cells. After the initial biopsy, a subcutaneous mass developed in the left thigh. Microsections of the biopsied mass disclosed adult T-cell leukaemia (ATL) neoplastic cells. Immunohistochemical findings revealed that PTHrP secreted from ATL neoplastic cells induced the OFC.

Stabilisation of acute femoral fractures in Paget's disease

Eleven cases of acute femoral fractures in patients with Paget's disease are presented following stabilisation with the solid AO femoral nail. In three cases with severe deformity of the femur, reaming was required to enable implant insertion. No corticotomies were required. The median operation time was 55 (35-65) min. There was no operative mortality and no patient developed signs of acute respiratory distress syndrome/fat embolism. Skeletal stability was achieved in all cases. The reconstruction proximal locking option (spiral blade) was utilised in ten of the eleven cases. In all cases a 9 mm nail was inserted. One patient (pagetic sarcoma) died 23 months after surgery. Ten of the eleven fractures healed uneventfully. The mean time to union was 32 (26-42) weeks.

Design and application of combined hip-knee intramedullary joint replacements

Cases in which there is a total hip arthroplasty and a stemmed total knee arthroplasty in the same femur, with loosening of 1 or both components, with serious endosteal bone loss or even a fracture between the stems present a difficult reconstruction problem. We describe a reconstruction using a combined hip and stemmed knee, designed so that they could be rigidly connected during the surgical procedure. The advantages of this implant design are that the entire femur with its muscle attachments is preserved, and the inherent stability allows for immediate weight bearing. To determine the viability of the connection between the hip and the knee, a stress analysis was carried out using finite element analysis. Guidelines were thus provided for the required metal and cement thicknesses. Three case examples are presented with an average follow-up of 3 years. It was shown that the combined hip-knee implant could provide successful results for these difficult reconstructive problems in appropriately selected cases.

Distal femoral fractures after knee arthroplasty

In seven patients who sustained eight distal femoral fractures following knee arthroplasty all fractures were treated operatively. Seven with open reduction internal fixation and one with external fixation. Seven of eight fractures had an unsatisfactory result. This was due not only to bone quality and fracture comminution, but also to technical problems and choice of implant. Revision surgery is often required.

Ebb and flow rickets in a premature infant: the Afghan turban sign

The pattern of alternating dense and lucent bands, with straight outer edges, at the youngest metaphysis of long bones, the "Afghan turban" sign, occurs when incompletely treated rickets has recurred and been retreated. Recognition of this, and other, rickets patterns allows the radiologist to influence treatment, as described in a very low birth weight infant.

A fabric-dependent fracture criterion for bone

A fracture criterion for bone tissue is proposed. Bone material is considered to be anisotropic and its properties are described by invoking the concept of directional variation of porosity. The fracture criterion is expressed as a scalar-valued function of the stress tensor and it incorporates an orientation-dependent distribution of compressive/tensile strength. The proposed mathematical framework is applied to a numerical analysis of fracture in the proximal femur due to a fall from standing height. The risk of fracture is assessed in the context of two different porosity distributions, simulating a healthy and an osteoporotic bone.

Orthopedic problems in Lesch-Nyhan syndrome

Lesch-Nyhan syndrome is an X-linked disorder of purine metabolism. The orthopedic problems and results of treatment of nine Lesch-Nyhan patients are reviewed. Associated orthopedic problems included hip subluxation or dislocation (nine of 18 hips), fractures (three), autoamputation, infections (three), minor scoliosis, and contractures. Lesch-Nyhan patients can safely undergo orthopedic procedures and the results of surgery are satisfactory and similar to those of patients with spastic cerebral palsy. All of the seven operated-on hips maintained good reduction at 6-year mean follow-up. With adequate cast technique, fractures and hip subluxation/dislocation may be treated successfully. The treating orthopedist should be aware of the increased incidence of heterotopic ossification in this population, as well as the potential for serious complications such as hardware failure or femur fracture, if appropriate immobilization is not used.

Uncemented total hip arthroplasty in patients with rheumatoid arthritis

Total hip arthroplasty has become a successful way of treating the painful and destroyed hip joint in the patient with rheumatoid arthritis. Because of the underlying disease, it still is controversial whether the implants selected should be used with bone cement, or whether uncemented devices will give equally good results in this population. Fifteen patients suffering from rheumatoid arthritis underwent 21 hip arthroplasties. The followup period averaged 3.3 years (range, 2.5-6.8 years). All but one patient were taking medication at the time of surgery for their underlying disease. Clinical evaluation was based on a modified Harris hip score that showed significant improvement in pain and function preoperatively compared with pain and function at the most recent followup. Radiographic analysis revealed five cases of minor migration of the acetabular components, and three cases of distal migration of 2 mm or less in the femoral components. Complications consisted of heterotopic ossifications in one patient, and an intraoperative femoral fracture in one patient. There were no infections, and there were no deep vein thromboses. The results in these patients suggest that cementless total hip arthroplasty might become a successful way of treating the destroyed hip joint in the patient with rheumatoid arthritis.

Comparison of quantitative ultrasound in the human calcaneus with mechanical failure loads of the hip and spine

OBJECTIVE

Quantitative ultrasound of the calcaneus is used clinically for evaluating bone fracture risk, but its association with the mechanical properties at other skeletal sites is not well characterized. The objective was therefore to determine its predictive ability of the mechanical failure loads of the proximal femur and lumbar spine.

METHOD

In 45 human cadavers (29 males and 16 females, aged 82.5 +/- 9.6 years), we determined the speed of sound, broadband ultrasonic attenuation (BUA) and the empirical stiffness index, using a commercial quantitative ultrasound scanner. The proximal femora and the fourth vertebral body were excised and loaded to failure in a testing machine.

RESULTS

Femoral failure loads ranged from 933 to 7000 N and those of the vertebrae from 1000 to 7867 N, their correlation being 0.51 in females and -0.08 in males. Forty percent of the variability of femoral, but only 24% of the variability of the vertebral fracture loads could be predicted with calcaneal speed of sound. In the femur, a combination of speed of sound and BUA improved the prediction (r2 = 50-60%), but not in the spine.

CONCLUSIONS

The study provides experimental evidence that calcaneal quantitative ultrasound is capable of predicting mechanical failure at other skeletal sites and has potential to identify patients at risk from osteoporotic fracture. The different association of quantitative ultrasound with femoral and vertebral failure may result from the influence of the cortical bone and a higher microstructure-related similarity of the calcaneus and the femur.

Complications of the Bailey-Dubow elongating nail in osteogenesis imperfecta: 34 children with 110 nails

The Bailey-Dubow nail, inserted in the femur or tibia of 34 children with osteogenesis imperfecta (OI), was studied retrospectively. Comparing the various groups of OI, no significant difference was found. Location of the nail (tibia or femur) did not influence the complication rate significantly. The reoperation rate was 29%, a rate comparable to that reported in earlier studies. The part of the nail located around the knee had a significantly higher migration rate (P = 0.005 at obturator ends and P = 0.007 at sleeve ends). Migration of the nail was the reason to reoperate in 50% of the patients. Better anchoring of the T-piece will substantially decrease the complication rate. In consideration of the different functional capacities of the OI population, the complications are likely related more to the hardware than to the patient.

Repair of supracondylar femur fracture and unilateral knee replacement at the same surgery

In patients who are candidates for a total knee arthroplasty and suffer a periarticular fracture of the femur, the arthroplasty may be performed after bony union of the fracture or immediately, in conjunction with the fracture repair. Herein we present the case of a sixty-year-old female with rheumatoid arthritis and a supracondylar fracture of the right femur in whom total knee arthroplasty and retrograde nail insertion were addressed at one surgery; the outcome was favorable. The transverse extraarticular fracture pattern in this patient was advantageous for simultaneous procedures; had the fracture been more comminuted or intraarticular, it might not have been possible to perform both procedures at the same time.

[Use of Ilizarov fixator in the treatment of post-osteomyelitis pseudoarthroses in children]

PURPOSE OF THE STUDY

The aim of this study was to emphasize the importance of the distraction osteogenesis technique in the treatment of post-osteomyelitis nonunion. We report 12 cases.

PATIENTS AND METHODS

Mean patient age was 9.5 years. There were 7 cases of nonunion of the femur and 5 involving the tibia. Nonunion was associated with 5.9 cm shortening in 10 cases, 8.4 cm circumferential bone defect in 1 case, shortening and bone defects in 6 cases, and shortening and joint deformities in 2 cases.

RESULTS

Consolidation was obtained in 11 cases with an average delay of 11.6 months. Infection was eradicated in 75 per cent of the cases. Average residual shortening was 0.4 cm. Joint deformities and axial deviations were corrected at the same time in all cases.

DISCUSSION

The advantages of the Ilizarov technique are well known for the treatment of such deformities and musculoskeletal system disorders subsequent to osteomyelitis: nonunion, infection, shortening, joint deformities and malunion.

Indirect reduction with a condylar blade plate for osteosynthesis of subtrochanteric femoral fractures

Subtrochanteric fractures frequently occur as high energy trauma usually in younger patients and may lead to severe comminution of the medial cortex. The medial cortex of the proximal femur is exposed to high compressive forces which make fracture stabilization a difficult problem. Bone healing may be seriously compromised due to extensive comminution and fragment devitalization. This requires reduction techniques which do not cause additional damage to the vitality of the bone. With indirect reduction techniques and the use of a condylar blade plate the results have been significantly improved in these fracture types in our department (1). In this report the essential aspects of indirect reduction for subtrochanteric fractures using a condylar blade plate and the treatment results from our department from earlier years (1) and from the last 2 1/2 years will be presented. In the latter period, fifteen patients with a mean age of 49 years (19-87 years) were treated with this method. Fractures resulted from traffic incidents or falls from a great height in 11 cases (73%). Union was achieved in 14 cases (93%) with full weight-bearing after a mean of 3 months (1-4 1/2 months). Malunion was seen in two cases (13%) without the need for further surgery. Non union occurred in one patient (7%) with a III B open injury due to early infection. After repeated debridements, bone grafting and decortication, the fracture was stabilized with a replacement condylar blade plate and healed uneventfully.

Characteristics of male hip fracture patients

BACKGROUND AND AIMS

Among men, hip fracture is the most common outcome of osteoporosis. The aim of this study was to investigate the clinical characteristics, treatment, complications, short-term outcome and mortality of male hip fracture patients.

MATERIAL AND METHODS

Operation theatre logs of all hip fracture patients operated on (1124 patients) at Kuopio University Hospital in 1989-1993 were reviewed. Medical records of the 276 male patients who underwent surgery (25 % of all patients) were studied.

RESULTS AND CONCLUSIONS

233 hip fractures (86 %) in men were due to low energy trauma. Of these cases, 61 % of the fractures occurred at the femoral neck, 31 % were pertrochanteric and 8 % subtrochanteric. The vast majority (90 %) of these patients had some chronic medical condition, and in 66 % the condition influenced motory or sensory functions. Hemiarthroplasty was most often used for femoral neck fractures (64 %). Internal fixation was used for pertrochanteric (97 %) and subtrochanteric (94 %) fractures. 20 % of the men had post-operative complications during the 1.5 year follow-up. During primary hospitalisation mortality was 3 %. Within 1.5 years of the fracture 40 % of the men had died, resulting in a mortality three times higher than age matched Finnish male population.

[Percutaneous resection under computed tomography guidance of osteoid osteoma. Mid-term follow-up of 38 cases]

PURPOSE

To evaluate the mid-term outcome following CT-guided percutaneous resection of osteoid osteoma.

MATERIALS AND METHODS

38 patients who had been treated by CT-guided percutaneous resection were included. The mean follow-up of 3.7 years. Early and mid-term outcome and histology were analyzed.

RESULTS

Histological samples were adequate in 92% of cases and a diagnosis of osteoid osteoma was confirmed in 73.7% of cases. In 6 cases, the lesion was not an osteoid osteoma: 2 mucoid cysts, 1 benign fibrous dysplasia, 1 fibromucoid lesion, 1 focal osteochondritis, 1 osteomyelitis. Cure was achieved in 84.2% of patients. Minor transient complications occurred in 23.7% of cases. The most serious complications included: 1 intramuscular hematoma, 2 femoral fractures, and 1 case of S. aureus osteomyelitis.

CONCLUSION

This study confirms that CT-guided percutaneous resection of osteoid osteomas is effective and shows that other small lesions can also be treated using this technique.

Severe anorexia nervosa associated with osteoporotic-linked femural neck fracture and pulmonary tuberculosis: a case report

We report a case study of a 38-year-old woman who had been suffering from anorexia nervosa (AN) since the age of 26. Before admittance to our clinic, she weighed 23.8 kg (at a height of 164 cm, 8.8 body mass index [BMI]) but still carried out strenuous physical activities. After good psychotherapeutic response and weight gain (34.4 kg), she accidentally fell and broke her femoral neck-favored as it was by osteoporosis. The X-ray taken before dynamic hip screw implantation coincidentally showed signs of pulmonary tuberculosis (TB), which could then be proven by computed tomography (CT) scans and cultures from a bronchoscopy. Other than lack of appetite and loss of weight, which we attributed to AN, there were no other clinical or biochemical indicators which could have pointed to an earlier TB diagnosis. As a result, the need for screening procedures is discussed. The manifestation of TB during the first weight gain after 12 years of severe malnutrition, during which there were no serious infections, seems to endorse former observations that AN patients appear to be "resistant" to some extent against infectious diseases, a "protection" which may be lost with convalescence and weight gain.

Use of the fork plate for internal fixation of periprosthetic fractures and osteotomies in connection with total knee replacement

Six cases of periprosthetic fractures of the distal femur following total knee arthroplasty were treated with a newly developed fork plate. Instead of the blade of the condylar plate, this implant features two prongs that are adaptable in length. Because of the space between the prongs, the distal femoral fragment surrounds the anchorage pegs of the prosthesis and can be gripped near the joint line. The average patient age was 74 years. Follow-up ranged between 2 and 54 months. All patients were mobilized immediately postoperatively. Full weight bearing and bone consolidation was achieved by 9 weeks postoperatively.