Neoplastic pathologic hip fractures are associated with a higher risk of post-operative bleeding and thromboembolic events

INTRODUCTION

Surgical treatment of hip fractures leads to significant post-operative complications. Although pathologic fractures (PF) are associated with worse outcomes, most studies do not differentiate between etiology (neoplastic and non-neoplastic PF). We seek to compare 30-day complication rates between 1) native hip fractures and neoplastic PF, and 2) neoplastic and non-neoplastic PF.

MATERIALS AND METHODS

A total of 127,819 patients with hip fractures and 5104 with PF diagnosed from 2005 to 2021 were retrieved from the NSQIP database. We included 1843 patients with neoplastic PF and 3261 with non-neoplastic PF. Demographics, pre-operative labs and co-morbidities, and post-operative outcomes were analyzed. Propensity-score matching was conducted to control for confounders.

RESULTS

Patients with a neoplastic PF had a significantly higher rate of deep venous thrombosis (DVT) (4 % vs 1.2 %, p = 0.001) and pulmonary embolism (PE) (2.4 % vs 0.7 %, p < 0.001), than native hip fractures. Rates of post-operative bleeding were significantly higher in the neoplastic PF group (29.3 % vs 23.9 %, p < 0.001) than non-neoplastic PF. No differences in soft tissue complications were found. When comparing neoplastic and non-neoplastic PF, the former had a higher rate of PE (2.5 % vs 1.0 %, p = 0.015) and post-operative bleeding (27.6 % vs 22.0 %, p = 0.009). Unplanned readmission rates and 30-day mortality rate were also higher in the neoplastic PF group.

CONCLUSION

Neoplastic PF of the hip are associated with higher risk of thromboembolic event rates and post-operative bleeding than both native hip fractures and non-neoplastic PF. No differences in rates of soft tissue complications were found between groups.

Dual plating in the metastatic distal humerus: Benefits may outweigh the risks

Background

Impending and complete pathologic fractures of the distal humerus are rare complications of metastatic cancer. Surgical treatment aims to quickly restore function and minimize pain. Plate and screw fixation (PSF) is a common method for addressing these lesions, but unlike in orthopaedic trauma, there are no clear guidelines for best management. While dual PSF theoretically provides better support and reduces the chance of reoperation due to tumor progression, single PSF is currently the more common choice.

Materials and methods

Between March 2008 and September 2021, 35 consecutive patients who underwent PSF for distal humerus metastasis or multiple myeloma were retrospectively reviewed. The proportion of patients who developed various postoperative complications, including infection, nonunion, deep vein thrombosis, tumor progression, and radial nerve palsy, as well as those requiring reoperation, was calculated. Mann-Whitney U test, Pearson's chi-squared, and Fisher's exact test were used to investigate differences between the single and dual PSF groups with statistical significance defined as p ≤ 0.05.

Results

There was no significant difference (p = 0.259) in revision rate, although 3 of 21 (14.3 %) single PSF patients required reoperation compared to 0 of 14 (0.0 %) dual PSF patients. The revisions were performed in one patient due to refracture and in two patients due to tumor progression. Although not statistically significant, a larger percentage of single PSF patients developed a postoperative complication compared to dual PSF patients [odds ratio 0.42 (95 % confidence interval 0.071 to 2.5); p = 0.431]. Single PSF did lead to shorter operative time compared to dual PSF [p < 0.001].

Conclusion

Dual PSF is non-inferior to single PSF and potentially results in fewer reoperations and postoperative complications in distal humerus pathologic lesions, although it leads to longer operative time. The current study is limited by small sample size due to the rarity of distal humerus metastatic lesions.

Photodynamic bone stabilization for traumatic and pathologic fractures: a systematic review of utilization, complications, and patient-reported outcomes

INTRODUCTION

The photodynamic bone stabilization system (PBSS) was was developed in 2010, and in 2018 gained FDA approval in the United States. Given its relative novelty, our analysis sought to analyze the available literature exploring the indications, outcomes, and complications of the PBSS.

METHODS

We performed a systematic review (PROSPERO registration of study protocol: CRD42022363065, October 8th, 2022). PubMed, EBSCOHost, and Google Scholar electronic databases were queried to identify articles evaluating PBSS in the treatment of pathologic or traumatic fractures between January 1 2010 and 15 October 2022. The quality of the included studies was assessed using the Methodological Index for Nonrandomized Studies tool.

RESULTS

Our initial search yielded 326 publications, which were then screened for appropriate studies that aligned with the purpose of our review. A total of thirteen studies, comprising seven case series, four case reports, and two cohort studies. The total sample size of the included studies consisted of 345 patients, with 242 females (70%) and 103 males (30%). The implants were most commonly utilized in the humerus (41%), radius (12%), and metacarpal (12%). The most common complications were related to broken implants (5%) and dislocation (1%). Most studies reported complete fracture healing and return of full strength and range of motion.

CONCLUSION

Despite being a relatively novel technology, PBSS appears to be a viable option for fracture stabilization. Most studies included in our analysis reported complete fracture healing and return of function with minimal complications.

[Acetabular metastatic defect reconstruction using the modular revision support cup MRS-C]

OBJECTIVE

Stabilization of metastatic acetabular defects with a bone cement-augmented revision support cup for remobilization of oncological patients in advanced cancer stages.

INDICATIONS

Metastatic acetabular defects (Metastatic Acetabular Classification, MAC 2-4) in patients with a prognostic medium or long-term survival.

CONTRAINDICATIONS

Highly limited survival due to metastatic disease (< 6 weeks). Local bone or soft tissue infection. Primary bone tumor with curative treatment option. Advanced pelvic discontinuity. Recent wound compromising systemic therapy.

SURGICAL TECHNIQUE

Standard hip approach. Curettage of the metastatic defect and careful reaming of the acetabulum before insertion of the cup. Predrilling of the dome und flange screws before application of the bone cement through the center hole of the implant and filling of the acetabular defect. Complete insertion of the screws for compound osteosynthesis. Implant of a modular inlay or dual mobility system.

POSTOPERATIVE MANAGEMENT

Full weight bearing or mobilization with two crutches according to the level of pain. Adjuvant local radiation therapy after wound consolidation. Continuation of systemic therapy according to tumor board decision.

RESULTS

Between 2012 and 2019, we treated 14 patients with metastatic acetabular defects using the modular revision support cup "MRS-TITAN® Comfort", MRS-C, Peter Brehm GmbH, Weisendorf, Germany) at our institution. Mean Harris Hip Score improvement was 23.2 with a mean patient's survival of 9.7 months due to the reduced cancer-related prognosis; 13 of the 14 implants endured the patient's prognosis. One implant had to be removed due soft tissue defect-related periprosthetic joint infection.

Novel illuminoss photodynamic bone stabilization system: normal and post-operative complication imaging findings in the emergency setting

The mainstay orthopedic surgical technique for fracture fixation involves metal plates, screws, and rods. While these methods are effective, they exhibit high rates of complications within specific populations, particularly among patients with pathologic and insufficiency fractures. IlluminOss represents a novel photodynamic bone stabilization system, approved for use in multiple countries, that serves as an alternative to traditional fracture fixation approaches for patients experiencing pathologic, traumatic, and fragility fractures. Despite the initial success of the system in fostering fracture healing, no study has comprehensively examined the radiological attributes of the IlluminOss Stabilization system thus far. The emergency radiologist is often the first point of imaging identification and interpretation for patients presenting with suspected postoperative complications, requiring evolving knowledge of both expected and atypical appearances for novel surgical implants. This manuscript's objective is to delve into the design and clinical application of IlluminOss, scrutinize relevant normal imaging findings across various modalities, and delineate potential complications associated with the IlluminOss Stabilization system for traumatic, pathologic, and fragility fractures that are increasingly encountered in the emergency department setting.

Geriatric chronic recurrent multifocal osteomyelitis (CRMO) mimicking multifocal multiple myeloma: a first in an octogenarian

Chronic recurrent multifocal osteomyelitis (CRMO), an autoinflammatory bone disorder characterized by non-bacterial osteomyelitis causing recurrent multifocal bone lesions, is a well-known, yet uncommon pediatric condition that rarely affects adults; to date, it has never been diagnosed over the age of 75. The following report will discuss the first octogenarian diagnosed with CRMO and therefore represents an exceptionally rare presentation of a rare disease. An 83-year-old woman presented with progressive right shoulder, forearm, and hip pain, with associated weight loss and global weakness, requiring a wheelchair for mobility. Imaging revealed a pathologic right ulna fracture in addition to lytic lesions of the right proximal humerus and proximal femur. The clinical picture was thus that of a patient with probable multiple myeloma versus metastatic disease. After an extensive workup, however, the lesions were not malignant; histologic findings were instead suggestive of chronic osteomyelitis with negative cultures. Given the multifocal nature of this condition, combined with a lack of clinical symptoms of infection, a diagnosis of CRMO was rendered. The patient underwent intramedullary nailing of the right femur and splinting of the ulna, with a subsequent remarkable recovery to painless ambulation, complete union of the right ulna fracture, and resolution of the lytic lesions without receiving any targeted medical treatment. This case highlights the importance of maintaining CRMO on the differential for multifocal skeletal lesions, regardless of age. Performing a thorough workup with necessary imaging, biopsy, and culture are critical to establishing this diagnosis, which can only made as a diagnosis of exclusion.

Pathologic fractures of the humerus during adjuvant pembrolizumab in patients with renal cell carcinoma after radical nephrectomy: A case report

INTRODUCTION AND IMPORTANCE

Immune checkpoint inhibitors (ICIs) have noticeably enhanced oncologic outcomes associated with patient survival in different subtypes of metastatic cancer by enhancing cytotoxic T-cell activity. ICI-associated toxicities are often referred to as immune-related adverse events (irAEs) and occur in nearly every organ system. However, the effect of ICIs on the skeleton is poorly examined, and only a few case series have been published.

CASE PRESENTATION

A 37-year-old man who presented with pathologic fractures of the right proximal humerus during adjuvant pembrolizumab therapy following laparoscopic radical nephrectomy for right renal cell carcinoma.

CLINICAL DISCUSSION

ICIs are associated with various irAEs virtually affecting all host tissues, most of which have been described well by pharmacovigilance analyses. However, to date, very few studies have examined the effects of ICI on the skeleton.

CONCLUSION

Urologic oncologists and urologists should be aware of the rare but potentially fatal bone side effects of ICIs.

Subtrochanteric nonunion after intramedullary nailing due to pathological fracture: proximal femoral replacement as a salvage approach

PURPOSE

To assess proximal femoral replacement as a treatment solution for nonunion of pathologic subtrochanteric fractures after cephalomedullary nailing in patients with pathological fracture and previously irradiated bone.

METHODS

Retrospective review of five patients with pathological subtrochanteric femoral fractures that were treated with cephalomedullary nailing and developed a nonunion, which was revised with conversion to a proximal endoprosthetic replacement.

RESULTS

All five patients had previously been treated with radiation. One patient had the latest follow-up at 2 months postoperatively. At that time, the patient was walking with a walker for assistance, with no evidence of hardware failure or loosening on imaging. The remaining four patients had the latest follow-up ranging from 9 to 20 months after surgery. At their latest follow-up, three of the four patients were ambulatory with no pain, using only a cane for assistance with longer distances. The other patient demonstrated pain in his affected thigh, utilizing a walker for assistance with ambulation at latest follow-up, but not requiring further surgical interventions. There were no hardware failures or implant loosening through the follow-up period. None of the patients required revision, and there were no postoperative complications observed at their last follow-up.

CONCLUSIONS

In patients with pathological fractures in the subtrochanteric region that is treated with cephalomedullary nailing and developed a nonunion, treatment with conversion to a proximal femoral replacement with a mega prosthesis is a valuable treatment with good functional results and low risk for complications.

LEVEL OF EVIDENCE

Therapeutic level IV.

The Use of Photodynamic Bone Stabilization to Tamponade Bleeding in a Pathologic Humeral Shaft Fracture: A Case Report

Introduction

Hypervascular tumors such as renal and thyroid carcinoma have a significant risk of intraoperative bleeding. To help mitigate bleeding, interventional preoperative embolization is traditionally used; however, it is success is highly variable. This is the first case report to discuss using expandable balloon implants with a minimally invasive approach to achieve fracture fixation and tamponade acute intraoperative bleeding.

Case Report

A 48-year-old male with clear-cell renal cell carcinoma presented with a left humeral shaft pathologic fracture. The patient was scheduled to undergo open biopsy, curettage of tumor, and fracture fixation with an intramedullary device. Intraoperatively, during open biopsy and curettage, brisk bleeding was encountered, which ceased after inserting an intramedullary photodynamic bone stabilization implant (IlluminOss). The implant's balloon expanded to the diameter of the humerus allowing for tamponade, fracture stability, and a minimally invasive approach.

Conclusion

We present a possible intraoperative option for achieving control of bleeding in pathologic long bone fractures by deploying a photodynamic stabilization device. The method described can have applications in specific patients and obviate the need for pre-operative embolization for highly vascular tumors due to the implant's ability to create tamponade within the bone.

A solitary osteolytic lesion with pathological fracture in the cervical spine - a case report

BACKGROUND

Langerhans cell histiocytosis (LCH) is a rare disorder. The treatment options vary depending on how many organs are involved and how extensive the disease is. In this report, a case of LCH with isolated 6th cervical vertebra (C6) collapse was presented. This case was treated with anterior corpectomy and instrumented fusion, followed by local radiotherapy (RT), with a good clinical outcome up to postoperative six months.

CASE PRESENTATION

This was a 47-year-old female patient with a complaint of neck pain and bilateral shoulder pain for two months before consultation. She was initially treated with analgesics, but the pain was persistent. Further radiological evaluations revealed an osteolytic lesion within the C6 vertebral body with a pathological fracture. Magnetic resonance imaging (MRI) with contrast of the cervical spine revealed diffused hypointense signal changes on the T1-weighted images and hyperintense signal changes on the T2-weighted images in the C6 vertebral body, with significant contrast-enhanced infiltration signals. Furthermore, in positron emission tomography-computed tomography (PET-CT), focal hypermetabolism and abnormal uptake signals were seen only in the C6 vertebral body. The patient underwent an anterior cervical corpectomy with instrumented fusion. The histopathological results confirmed the diagnosis of LCH. The patient reported significant pain relief on postoperative day one. Moreover, she was treated by local RT at postoperative one month. Good clinical outcomes were achieved in the form of no pain and recovery in neck mobility up to postoperative six months. No evidence of recurrence was observed at the final follow-up.

CONCLUSIONS

This case report describes a treatment option for a solitary C6 collapse with LCH managed by anterior corpectomy and instrumented fusion, followed by local RT, with a good clinical outcome at postoperative six months. More studies are needed to elucidate whether such a treatment strategy is superior to surgery or RT alone.

Fully constrained acetabular liner vs. dual mobility hip joint in the surgical treatment of metastatic bone disease of the hip: study protocol for a randomized, open-label, two-arm, non-inferiority trial evaluating the post-operative hip dislocation rate

BACKGROUND

Patients receiving total hip arthroplasty (THA) due to metastatic bone disease of the hip (MBD) are at an increased risk of post-operative joint dislocation compared to other populations. Different joint solutions have been developed with the purpose of reducing the dislocation risk compared to regular THAs. One of these solutions, the constrained liner (CL), has been used increasingly at our department in recent years. This design, however, is prone to polyethylene wear and higher revision rates. An alternative is the dual mobility cup (DM), which has been shown to reduce the risk of dislocation in other high-risk populations. Few studies have investigated DM for THA due to MBD, and no studies have directly compared these two treatments in this population. We therefore decided to conduct a trial to investigate whether DM is non-inferior to CL regarding the post-operative joint dislocation risk in patients receiving THA due to MBD.

MATERIALS AND METHODS

This study is a single-center, randomized, open-label, two-arm, non-inferiority trial. We will include 146 patients with MBD of the hip who are planned for THA at the Department of Orthopedic Surgery, Rigshospitalet. Patients with previous osteosynthesis or endoprosthetic surgery of the afflicted hip, or who are planned to receive partial pelvic reconstruction or total femoral replacement, will be excluded. Patients will be stratified by whether subtrochanteric bone resection will be performed and allocated to either CL or DM in a 1:1 ratio. The primary outcome is the 6 months post-operative joint dislocation rate. Secondary outcomes include overall survival, implant survival, the rate of other surgical- and post-operative complications, and quality of life and functional outcome scores.

DISCUSSION

This study is designed to investigate whether DM is non-inferior to CL regarding the risk of post-operative dislocation in patients receiving THA due to MBD. To our knowledge, this trial is the first of its kind. Knowledge gained from this trial will help guide surgeons in choosing a joint solution that minimizes the risk of dislocation and, ultimately, reduces the need for repeat surgeries in this patient population.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05461313. Registered on July 15 2022. This trial is reported according to the items in the WHO Trial Registration Data Set (Version 1.3.1).

Clinical outcomes of pediatric osteomyelitis

BACKGROUND

Osteomyelitis in children may produce severe sequelae. However, the frequency and distribution of such complications by type of osteomyelitis (chronic or acute) is not well described.

METHODS

We searched the HealthFacts® database (containing medical information on 68 million individual patients in the United States) with 238 International Classification of Diseases (ICD) version 10 codes for acute osteomyelitis and chronic osteomyelitis appearing in 2015. Outcomes were recorded for each subject, including development of limb length discrepancies, pathologic fractures, mortality, and need for multiple surgeries or prolonged orthopedic care (one to two years following diagnosis). Gender, age and season of diagnosis were also assessed. Chi-square tests were used to compare differences between categorical variables, and t-tests between continuous variables.

RESULTS

Eight hundred sixty-nine subjects were included (57.4% male). Children with chronic osteomyelitis were older than those with acute osteomyelitis (median 9.5 years vs 12.0, respectively, p = .0004). Diagnoses were more common in winter (p = .0003). Four subjects died while hospitalized during the study period (two with acute osteomyelitis, two with chronic osteomyelitis). Limb length discrepancies were rare and similarly distributed between infection types (≤ 1.3% of subjects, p = .83). Subjects with chronic osteomyeltis were more likely to require long-term orthopedic follow-up (14.0% vs. 4.8% for acute osteomyelitis, p < .0001), suffer from pathologic fractures (1.5% vs < 1.0%, p = .003) and to require multiple surgeries (46.0% vs. 29.3%, p = .04).

CONCLUSIONS

Though infrequent, serious outcomes from osteomyelitis are more common with chronic osteomyelitis than acute osteomyelitis.

Modification to Mirels scoring system location component improves fracture prediction for metastatic disease of the proximal femur

BACKGROUND

Correctly identifying patients at risk of femoral fracture due to metastatic bone disease remains a clinical challenge. Mirels criteria remains the most widely referenced method with the advantage of being easily calculated but it suffers from poor specificity. The purpose of this study was to develop and evaluate a modified Mirels scoring system through scoring modification of the original Mirels location component within the proximal femur.

METHODS

Computational (finite element) experiments were performed to quantify strength reduction in the proximal femur caused by simulated lytic lesions at defined locations. Virtual spherical defects representing lytic lesions were placed at 32 defined locations based on axial (4 axial positions: neck, intertrochanteric, subtrochanteric or diaphyseal) and circumferential (8 circumferential: 45-degree intervals) positions. Finite element meshes were created, material property assignment was based on CT mineral density, and femoral head/greater trochanter loading consistent with stair ascent was applied. The strength of each femur with a simulated lesion divided by the strength of the intact femur was used to calculate the Location-Based Strength Fraction (LBSF). A modified Mirels location score was next defined for each of the 32 lesion locations with an assignment of 1 (LBSF > 75%), 2 (LBSF: 51-75%), and 3 (LBSF: 0-50%). To test the new scoring system, data from 48 patients with metastatic disease to the femur, previously enrolled in a Musculoskeletal Tumor Society (MSTS) cross-sectional study was used. The lesion location was identified for each case based on axial and circumferential location from the CT images and assigned an original (2 or 3) and modified (1,2, or 3) Mirels location score. The total score for each was then calculated. Eight patients had a fracture of the femur and 40 did not over a 4-month follow-up period. Logistic regression and decision curve analysis were used to explore relationships between clinical outcome (Fracture/No Fracture) and the two Mirels scoring methods.

RESULTS

The location-based strength fraction (LBSF) was lowest for lesions in the subtrochanteric and diaphyseal regions on the lateral side of the femur; lesions in these regions would be at greatest risk of fracture. Neck lesions located at the anterior and antero-medial positions were at the lowest risk of fracture. When grouped, neck lesions had the highest LBSF (83%), followed by intertrochanteric (72%), with subtrochanteric (50%) and diaphyseal lesions (49%) having the lowest LBSF. There was a significant difference (p < 0.0001) in LBSF between each axial location, except subtrochanteric and diaphyseal which were not different from each other (p = 0.96). The area under the receiver operator characteristic (ROC) curve using logistic regression was greatest for modified Mirels Score using site specific location of the lesion (Modified Mirels-ss, AUC = 0.950), followed by a modified Mirels Score using axial location of lesion (Modified Mirels-ax, AUC = 0.941). Both were an improvement over the original Mirels score (AUC = 0.853). Decision curve analysis was used to quantify the relative risks of identifying patients that would fracture (TP, true positives) and those erroneously predicted to fracture (FP, false positives) for the original and modified Mirels scoring systems. The net benefit of the scoring system weighed the benefits (TP) and harms (FP) on the same scale. At a threshold probability of fracture of 10%, use of the modified Mirels scoring reduced the number of false positives by 17-20% compared to Mirels scoring.

CONCLUSIONS

A modified Mirels scoring system, informed by detailed analysis of the influence of lesion location, improved the ability to predict impending pathological fractures of the proximal femur for patients with metastatic bone disease. Decision curve analysis is a useful tool to weigh costs and benefits concerning fracture risk and could be combined with other patient/clinical factors that contribute to clinical decision making.

Pediatric patient with a bilateral Salter-Harris II fracture and slipped capital femoral epiphysis secondary to autosomal recessive osteopetrosis

Treatment of femoral neck fractures secondary to osteopetrosis is an uncertain and puzzled decision. Experience in the treatment, especially in the pediatric population, is scarcely reported. The duration of conservative treatment is prolonged and poses the risks of non-union and development of coxa vara deformity. The recommended treatment is closed reduction and internal fixation; however, surgery on osteopetrotic bone is challenging due to defective bone marrow function, delayed consolidation and higher risk of intraoperative fractures. Slipped capital femoral epiphysis secondary to osteopetrosis is very rarely reported. This article presents the case of a 5-year-old female patient with rapidly deteriorating physical function due to bilateral proximal femoral Salter-Harris type II fractures with associated slippage of the growth plates secondary to confirmed autosomal recessive osteopetrosis. Operative treatment was performed in a tertiary level orthopedic center with closed reduction and internal fixation with cannulated screws. A loss of fixation with coxa vara deformity was seen on the left side 7 months postoperatively with increasing pain. A revision surgery with reosteosynthesis and a valgus osteotomy was thus performed which showed good subjective and objective results 1 year postoperatively with complete bony union.

Fracture of the Distal Radius by Tuberculous Osteomyelitis: A Case Report and Review of Literature

We report a 94-year-old patient with a fractured radius that was being managed conservatively. At 2 months, an abscess was observed overlying the fracture site. An MRI scan was done and samples obtained for microbiological and pathological analyses. The patient was diagnosed with tuberculous osteomyelitis. Surgical debridement of the fracture site was performed, and the bone defect was filled with bone cement impregnated with gentamicin and rifampicin. Anti-tuberculosis therapy was administered for 9 months and the patient made an uneventful recovery. Early diagnosis and correct medical treatment depend on sound evidence of tuberculous osteomyelitis. Surgical debridement is essential if abscesses are present in the bone. Level of Evidence: Level V (Therapeutic).

Prophylactic surgical treatment using CT-based rigidity analysis vs. after the fact fracture treatment of pathologic femoral lesions

Background

Accurate comparison of prophylactic surgical treatment (PST) to after fracture treatment (AF) of patients with femoral metastatic disease requires more accurately identifying patients for impending fracture, such as with CT-based structural rigidity analysis (CTRA). This study compares a more accurately defined PST group (of impending fractures defined by CTRA) to AF for metastatic femoral disease.

Methods

PST patients were enrolled and treated by the PI in a longitudinal multicenter study of impending pathologic fractures evaluated for accuracy by CTRA. The AF patients were also treated by the senior author and were identified by retrospective chart review. Fifty-five patients were treated surgically for metastatic femoral lesions and were divided into three groups for the purpose of this study: Group I (AF), Group II (PST-high), and Group III (PST-low). Demographic information, comorbidities, and clinical variables of interest were collected by retrospective chart review; cost data was collected by collaboration with our hospital financial personnel (office of the Chief Financial Officer).

Results

Survival showed statistically significant differences favoring Group II. Transfusions in Group I were nearly twice those of Groups II and III, but there was no statistically significant (NS) difference between groups. Estimated blood loss (EBL) was generally with NS difference. Similarly, there were NS differences in LOS between groups. Discharge disposition showed statistically significant differences between groups (P=0.012, global). Discharge to home was highest in Group II (76%) and lowest in Group I (27%). Discharge to rehab was lowest in Group II (24%) and highest in Group I (47%). There were no discharges to hospice or morgue in Group II, while both occurred in Group I. Mean direct and total costs were highest in Group I ($18,837 and $31,997, respectively) and lowest in Group II ($16,094 and $27,357) but the differences were NS.

Conclusions

This study shows benefits of PST over AF in a group of PST patients more accurately defined to have impending pathologic fractures by CTRA definition.

Postoperative outcomes of minimally invasive pedicle screw fixation for treatment of unstable pathologic neoplastic fractures

STUDY DESIGN

Retrospective Case Series.

OBJECTIVES

Minimally invasive techniques have emerged as a useful tool in the treatment of neoplastic spine pathology due to decrease in surgical morbidity and earlier adjuvant treatment. The objective of this study was to analyze outcomes and complications in a cohort of unstable, symptomatic pathologic fractures treated with percutaneous pedicle screw fixation (PPSF).

METHODS

A retrospective review was performed on consecutive patients with spinal stabilization for unstable pathologic neoplastic fractures between 2007 and 2017. Patients who underwent PPSF through a minimally invasive approach were included. Surgical indications included intractable pain, mechanical instability, and neurologic compromise with radiologic visualization of the lesion.

RESULTS

20 patients with mean Tomita Score of 6.3 ± 2.1 points [95% CI, 5.3-7.2] were treated with constructs that spanned a mean of 4.7 ± 1.4 [95% CI, 4.0-5.3] instrumented levels. 10 (50%) patients were augmented with vertebroplasty. Majority of patients (65%) had no complications during their hospital stay and were discharged home (60%). Four patients received reoperation: two extracavitary corpectomies, one pathologic fracture at a different level, and one adjacent segment disease.

CONCLUSION

Minimally invasive PPSF is a safe and effective option when treating unstable neoplastic fractures and may be a viable alternative to the traditional open approach in select cases.

LEVEL OF EVIDENCE

4.

Does surgical technique influence the burden of lung metastases in patients with pathologic long bone fractures?

BACKGROUND

The aims of this study are to (1) determine whether fixation of metastatic long bone fractures with an intramedullary nail (IMN) influences the incidence of lung metastasis in comparison to arthroplasty or ORIF (Arthro/ORIF); and (2) assess this relationship in primary tumor types; and (3) to assess survival implications of lung metastasis after surgery.

METHODS

Retrospective cohort study investigating 184 patients (107 IMN, and 77 Arthro/ORIF) surgically treated for metastatic long bone fractures. Patients were required to have a single surgically treated impending or established pathologic fracture of a long bone, pre-operative lung imaging (lung radiograph or computed tomography) and post-operative lung imaging within 6 months of surgery. Primary cancer types included were breast (n = 70), lung (n = 43), prostate (n = 34), renal cell (n = 37). Statistical analyses were conducted using two-tailed Fisher's exact tests, and Kaplan-Meier survival analyses.

RESULTS

Patients treated with IMN and Arthro/ORIF developed new or progressive lung metastases following surgery at an incidence of 34 and 26%, respectively. Surgical method did not significantly influence lung metastasis (p = 0.33). Furthermore, an analysis of primary cancer subgroups did not yield any differences between IMN vs Arthro/ORIF. Median survival for the entire cohort was 11 months and 1-year overall survival was 42.7% (95% CI: 35.4-49.8). Regardless of fixation method, the presence of new or progressive lung metastatic disease at follow up imaging study was found to have a negative impact on patient survival (p < 0.001).

CONCLUSIONS

In this study, development or progression of metastatic lung disease was not affected by long bone stabilization strategy. IM manipulation of metastatic long bone fractures therefore may not result in a clinically relevant increase in metastatic lung burden. The results of this study also suggest that lung metastasis within 6 months of surgery for metastatic long bone lesions is negatively associated with patient survival.

LEVEL OF EVIDENCE

III, therapeutic study.

Morbidity and mortality of surgically treated pathologic humerus fractures compared to native humerus fractures

BACKGROUND

Despite an increasing prevalence of patients sustaining pathologic fractures of neoplastic origin, few studies have investigated 30-day postoperative complication profiles after surgical treatment of pathologic humerus fractures. The purposes of this study were to use a large nationally representative database to determine short-term complication profiles after surgical treatment of pathologic humerus fractures and assess how these complications compared with more commonly studied native humerus fractures.

METHODS

Using the National Surgical Quality Improvement Program database, we identified 30,866 patients who underwent surgical treatment for either pathologic (n = 449) or native humerus fractures (n = 30,417) from 2007 to 2017. Thirty-day postoperative complication profiles were ascertained and compared between the 2 groups using χ² analyses. Three logistic regression models were then performed to determine which complications were primarily attributable to the pathologic fracture itself vs. the increased comorbidity burden faced by these patients.

RESULTS

Patients with pathologic humerus fractures experienced significantly higher rates of death (6.0% vs. 0.3%, P < .001), serious adverse events (12.2% vs. 3.7%, P < .001), minor complications (15.8% vs. 4.8%, P < .001), extended postoperative lengths of stay (42.3% vs. 21.3%, P < .001), discharge to facilities (22.3% vs. 13.5%, P < .001), and readmissions (14.8% vs. 3.4%, P < .001) compared with patients with native humerus fractures. With respect to specific complications, patients with pathologic fractures were at significantly higher risk of pulmonary complications (1.3% vs. 0.3%, P < .001), renal complications (0.7% vs. 0.2%, P = .007), thromboembolic complications (1.6% vs. 0.6%, P = .01), and transfusions (15.1% vs. 4.1%, P < .001).

CONCLUSION

After surgical treatment, patients with pathologic humerus fractures had significantly higher complication rates compared with native humerus fractures, suggesting that guidelines and treatment algorithms for native humerus fractures may not be generalizable for those of pathologic origin. These findings have significant implications for preoperative patient counseling and may be used to negotiate higher reimbursement rates for these patients given a significantly higher morbidity and mortality than was previously described in literature. Postoperatively, orthopedic surgeons should closely monitor patients with pathologic humerus fractures for deep vein thrombosis, renal complications, and pulmonary complications, use blood-sparing techniques, and employ a multidisciplinary approach to help manage and prevent a more heterogeneous profile of postsurgical complications.

Bony Lesions in Paediatric Acute Leukaemia

Teaching Point: Translucent metaphyseal lines in children warrant further analysis to rule out malignancy.

Retrospective evaluation of pathologic fractures in medication related osteonecrosis of the jaw

The aim of this study was to focus on the MRONJ-related pathologic fractures, their incidence, and to analyze possible causative factors for their occurrence. Pathologic fracture in patients suffering frm MRONJ were identified, examined in detail, and the patient characteristics were evaluated. In 116 patients (73 female and 43 male; mean age 62.08 ± 13.6 years), pathologic fracture incidence was found to be 4.31%. Zoledronic acid was the most commonly used anti-resorptive drug (77.8%). Median antiresorptive usage was 24 months. Five patients had pathologic fractures in the mandible. Four fracture patients had metastatic prostate cancer, and one had metastatic renal cell cancer. This case series study can provide clinical insight into which factors are associated with pathologic fractures. Cancer type, medical comorbidities, additive toxicity of the combination of antiresorptive and antiangiogenic drugs, specific pathogens, and dento-alveolar surgical procedures may be some of the important factors that need to be considered. Since MRONJ-related pathologic fracture management can be complicated, it may be good to focus on the causative factors and prevent occurrence with regular follow-up as often as possible in line with these factors.

[Femoral neck stress fractures and femoroacetabular impingement : A retrospective case study and literature review]

BACKGROUND

Femoroacetabular impingement (FAI) can lead to morphologic damage of both the acetabulum and the femoral neck. Recent reports have found an association between impingement deformities and the development of femoral neck stress fractures. The aim of this study was to report a series of patients with these findings and to update the current evidence on the topic.

MATERIAL AND METHODS

5 patients (6 cases) with atraumatic femoral neck fractures and FAI were identified in the Dresden hip registry from 2015 to 2018. Demographic data, comorbidities, radiographic results and bone metabolism results were described. A literature search was conducted using keywords related to femoral neck stress fractures and FAI syndrome.

RESULTS

The average age of the series was 39 (range: 22-52), 2 patients were female and 3 male. A total of 12 surgical procedures were performed. 4 of the 5 patients showed radiographic features of pincer and/or cam-FAI, whereas 3 patients had a decreased femoral antetorsion (-7° to +7° antetorsion). In 3 patients, magnetic resonance imaging revealed additional signs of avascular necrosis ARCO I. There was a lack of FAI-specific treatment recommendations in the available literature.

DISCUSSION

Radiographic results of the patients evaluated suggested that impingement-associated deformities of the hip may cause femoral neck stress fractures, which is in line with the available literature. This potential coincidence should be integrated in diagnostic algorithms and therapeutic approaches.

Reciprocal hematogenous osteomyelitis of the femurs caused by Anaerococcus prevotii: A case report

BACKGROUND

Haematogenous osteomyelitis is an extremely rare disease occurring in adults, especially in developed countries. It is clearly a systemic infection, because bacteraemia spreads over proximal and distal long bones or paravertebral plexuses, resulting in acute or chronic bone infection and destruction.

CASE SUMMARY

A 46-year-old Caucasian male was complaining of a left thigh pain. It is known from the anamnesis that the patient developed severe pneumonia three months ago before the onset of these symptoms. The patient was diagnosed with haematogenous osteomyelitis, which developed a turbulent course and required complex combination therapy. The primary pathogen is thought to be Anaerococcus prevotii, which caused pneumonia before the onset of signs of osteomyelitis. Unfortunately, due to the complexity of identifying anaerobes and contributing nosocomial infections, the primary pathogen was not extracted immediately. After the manifestation of this disease, pathological fractures occurred in both femurs, as well as purulent processes in the lungs and molars accompanied. The patient received broad-spectrum antibiotic therapy and countless amounts of orthopaedic and reconstructive surgeries, but no positive effect was observed. The patient underwent osteosynthesis using an Ilizarov’s external fixation apparatus, re-fixations, external AO, debridements, intrame-dullary osteosynthesis with a silver-coated intramedullary nail, abscessotomies. The right femur healed completely after the pathological fracture and osteomyelitis did not recur. Left femur could not be saved due to non-healing, knee contracture and bone destruction. After almost three years of struggle, it was decided to amputate the left limb, after which the signs of osteomyelitis no longer appeared.

CONCLUSION

To sum it all up, complicated or chronic osteomyelitis requires surgery to remove the infected tissue and bone. Osteomyelitis surgery prevents the infection from spreading further or getting even worse up to such condition that amputation is the only option left.

C-reactive protein and tumour diagnosis predict survival in patients treated surgically for long bone metastases

PURPOSE

Surgical options for long bone metastases include intramedullary nail fixation or prosthetic reconstruction. Patients with a short life expectancy may benefit from less invasive surgery such as intramedullary nail fixation, while patients with a long life expectancy could be treated with more invasive surgery such as prosthetic reconstruction. The purpose of our study was to analyze the survival of patients treated surgically for long bone metastases, determining the prognostic factors affecting survival and analyzing the surgical complications and reoperation rates. Based on our results, we developed a prognostic score that helps to choose the best treatment for these patients. In addition, we compared the performance of our prognostic score with other previous prognostic models.

METHOD

We investigated prospectively potential clinical and laboratory prognostic factors in 159 patients with metastatic bone disease who underwent surgery with intramedullary nail fixation or prosthetic reconstruction. Clinical data were collected, recording the following data: age and sex of patients, primary tumour and time of diagnosis, number (single or multiple) and presentation (synchronous or metachronous) of bone metastases, presence of visceral metastases. The following laboratory data were analyzed: hemoglobin, leukocyte counts, lymphocyte counts, platelets count, alkaline phosphatase, and C-reactive protein.

RESULTS

Our study showed that pathological C-reactive protein and primary tumour diagnosis were significant negative independent prognostic factors at 12-month survival. Based on our results, we created a score using C-reactive protein and primary tumour diagnosis, creating three different prognostic groups: (A) good prognosis primary tumour and physiological CRP with probability of survival at 12 months of 88.9 [80.1-98.5]; (B) bad prognosis primary tumour and physiological CRP or good prognosis primary tumour and pathological CRP with a probability of survival at 12 months of 56.7 [45.4-70.7]; (C) bad prognosis primary tumour and pathological CRP with a probability of survival at 12 months of 12.5 [5.0-28.3]. Using ROC multiple analysis, our score (AUC = 0.816) was the most accurate in predicting a 12-month survival compared to previous prognostic models.

DISCUSSION

Patients treated surgically for long bone metastases with a life expectancy over 12 months should be treated with more durable reconstruction, while patients with a life expectancy less than 12 months should be treated with less invasive surgery. The diagnosis of primary cancer and C-reactive protein are two very simple data which every orthopaedic surgeon in any community hospital can easily rely on for any decision-making in the surgical treatment of a complex patient as with a patient with skeletal metastases.

CONCLUSION

Our prognostic score based on only two simple variables (C-reactive protein and primary tumour diagnosis) was able to predict the 12-month survival of patients treated surgically for long bone metastases and could be helpful in choosing the best treatment for these patients.

Patient-specific computed tomography-based finite element analysis: a new tool to assess fracture risk in benign bone lesions of the femur

BACKGROUND

Most benign active and latent lesions of proximal femur do not predispose a patient to a pathologic fracture. Nonetheless, there is a tendency to perform internal fixation due to the lack of accurate clinical tools that may reliably confirm low risk of pathologic fracture. As many as 30% of these surgeries may be unnecessary. A patient-specific CT-based finite element analysis may quantify bone strength and risk of fracture under normal weight-bearing conditions.

METHODS

The clinical relevance of such finite element analysis was investigated in a retrospective study on a cohort of 17 patients. Finite element analysis results (high risk = indication for surgery, low or moderate risk = follow-up) were compared to actual clinical decisions (surgery vs follow-up). All patients predicted by the finite element analysis as high risk underwent internal fixation and had good outcomes (n = 6).

FINDINGS

Four of the 11 low- and moderate-risk finite element analysis patients (36%) were operated immediately, and seven (64%) were either operated after a delay of at least 6 months or were never operated. None sustained a pathologic fracture. Patients who were predicted as low fracture risk by finite element analysis remained fracture-free for a minimal period of 6 months. Prediction of high risk of pathologic fracture by finite element analysis was in complete agreement with the conventional clinical evaluation.

INTERPRETATION

We consider finite element analysis a promising decision support system for the management of patients with benign tumors of femur, and that it may reliably endorse the decision to withhold surgery for patients at low fracture-risk.

Solitary fibrous tumor of bone developing lung metastases on long-term follow-up

Solitary fibrous tumors are rare mesenchymal neoplasms of fibroblastic or myofibroblastic origin. Primary solitary fibrous tumors arising in bone are extremely rare and rarely metastasize. We present a case of solitary fibrous tumor where the diagnosis was delayed due to a failure to recognize the subtle, lytic lesion underlying a fracture of the left humerus. The patient underwent proximal humeral replacement and was followed closely with imaging of humerus and chest. A small lung metastasis was found on CT scan 38 months later and was resected. Two additional small metastases were found and resected 62 months after initial tumor resection. The purpose of this case report is both to highlight the radiologic challenges which can lead to overlooking a lytic lesion underlying a fracture and to show the importance of long-term follow-up in patients with solitary fibrous tumor.

Extended curettage versus en bloc resection for the treatment of grade 3 giant cell tumour of the knee with pathologic fracture: a retrospective study

PURPOSE

For the treatment of giant cell tumour of the bone (GCTB) around the knee, preserving the native joint confers advantages over scarifying it. But, there is a controversy about the efficacy of intralesional curettage versus en bloc resection for treatment of such lesions. In this study, we compared local recurrence, functional outcomes, and complications of extended curettage and en bloc resection in these lesions.

METHODS

Patients with grade 3 GCTB of the distal femur or proximal tibia who were presented with a pathologic fracture and treated with either en bloc resection (n = 22) or extended curettage (n = 20) were included. The mean follow-up of the patients was 6.4 ± 1.9 years in the resection group and 5.5 ± 2.4 years in the extended curettage group. The primary outcome was a local recurrence. Secondary outcomes were limb function evaluated by the Musculoskeletal Tumor Society (MSTS) score and rate of complications.

RESULTS

Local recurrence was seen in four (20%) patients of the curettage group and three (13.7%) patients of the resection group (P = 0.69). The mean MSTS score was 24 ± 1.9 in the resection group and 26.5 ± 1.3 in the curettage group (P < 0.001). The number of complications was not significantly different between the two study groups (P = 0.49). However, the number of complications that required revision surgery was significantly more in the resection group (P = 0.049).

CONCLUSION

In grade 3 GCTB around the knee with pathologic fracture, extended curettage results in comparable oncologic outcomes to en bloc resection, while providing better function and a lower rate of revision.

A pathologic mandibular fracture revealing a bifocal location of Langerhans cell histiocytosis

Introduction

Langerhans cell histiocytosis is a rare disease. When it occurs in the cranium/facial bones, the mandibular location is the most frequent.

Presentation of case

A 31 years-old man was referred to our department for a mandibular chronic discomfort during an acute exacerbation, spontaneous teeth mobility and an alteration of the dental occlusion revealing a pathologic mandibular fracture.The diagnosis was confirmed by a subsequent CT scan.The surgical procedure was performed under general anesthesia by a maxillo-facial senior surgeon. The therapeutic plan combined teeth extractions, enucleation of both the left maxillary and right mandibular cystic lesions and osteosynthesis of the pathologic mandibular fracture with a miniplate.Histological and immunohistochemistry analysis of the maxillary and mandibular cystic lesions pointed the diagnosis of a bifocal Langerhans cell histiocytosis of the oral cavity.Several investigations were done in order to find another location, showing no abnormalities.

Discussion

This is a case of rare single system LCH at two distinct locations: one at the mandibular bone and the other at the upper left maxilla. Both were uncovered by an acute exacerbation of a chronic discomfort secondary to a mandibular pathologic fracture. This should draw attention to the issues of the diagnosis.

Conclusion

An early LCH diagnosis and a multidisciplinary treatment plan allow the improvement of the patient 's prognosis and quality of life.

Dual energy CT can aid in the emergent differentiation of acute traumatic and pathologic fractures of the pelvis and long bones

PURPOSE

To determine whether dual energy CT (DECT) scanning can aid in the differentiation between acute traumatic and pathologic fractures of the pelvis and long bones.

METHODS

Retrospective review of 11 patients with 15 pathologic fractures proven by biopsy and/or other advanced imaging modalities. Age- and sex-matched patients with non-pathologic traumatic fractures were used as controls. Studies were reviewed by two readers on syngo.via software before and after the creation of virtual bone marrow color maps. Hounsfield units (HU) of the marrow space at the level of the fracture were recorded on both reviews. Differences between the HU of the bone marrow of traumatic and pathologic fractures were compared using two-tailed unpaired t-test.

RESULTS

A statistically significant difference was found in the HU of the affected bone marrow on DECT virtual noncalcium bone marrow color maps between the pathologic group (mean HU:4.89) and the non-pathologic group (mean HU: - 286.2) (p = 0.0177). HU measurements on the mixed kVp images were 150.4 for the pathologic and 94.1 for the non-pathologic fracture groups, respectively, with no statistical significance (p = 0.272).

CONCLUSIONS

DECT scanning can aid in the differentiation between hematoma at acute traumatic fracture sites and neoplasm at pathologic fracture sites. HU of the bone marrow is higher for pathologic fractures, and the difference in bone marrow attenuation is more evident on the virtual bone marrow color maps.

Recurrence of a primary xanthoma of the humerus in a 9-year-old normolipidemic child

Xanthomas are rare bone tumors that occur more often in patients with hyperlipidemia or metabolic disorders. We report the case of a 9-year-old child presenting with right shoulder pain after a trauma. A benign osteolytic lesion was found in the proximal humeral metaphysis. Curettage of the lesion was performed. Histologic findings confirmed intraosseous xanthoma. Although there was no evidence of dyslipidemia or metabolic disease, the patient suffered local recurrence at the 8-month follow-up, requiring a second surgery with bone grafting. This difficult and rare diagnosis must be kept in mind with osteolytic lesions.

Outcomes of knee arthroplasty for primary treatment of pathologic peri-articular fractures of the distal femur and proximal tibia

BACKGROUND

Treatment goals for pathologic fractures about the knee include pain relief and unrestricted weight bearing. In cases of condylar destruction, these fractures may not be amenable to internal fixation, and arthroplasty may be considered. The purpose of this study was to analyze the outcomes of knee arthroplasty for primary treatment of impending or pathologic fractures of the distal femur or proximal tibia.

METHODS

Fifteen (8 males and 7 females) patients, mean age 62 ± nine years, undergoing arthroplasty for management of a pathologic peri-articular distal femur (n = 11) or proximal tibia (n = 4) fracture between 2001 and 2017 were reviewed. Implants included tumour endoprostheses (n = 11) and rotating hinged total knees (n = 4). Pathology included metastatic disease (n = 14) and lymphoma (n = 1). Eight (53%) patients presented with a fracture while the remainder had large impending lesions.

RESULTS

Mean follow-up was 19 months. At final follow-up, 11 patients had died with overall five year survival of 33%. Two (13%) patients required re-operation; including wound irrigation and debridement (n = 1) and above knee amputation for local recurrence (n = 1). An additional two (13%) patients developed post-operative VTE. MSTS, KSS, and KSS-F scores improved from a mean 12 ± 16%, 30 ± 11, and 14 ± 24 pre-operatively to 69 ± 26%, 75 ± 16, and 67 ± 25 at final follow-up, respectively (P < 0.001). Thirteen (87%) patients had severe pain prior to surgery with no patients (0%, P < 0.001) reporting severe pain at last follow-up.

CONCLUSION

Knee arthroplasty provided improved function and full weight-bearing making it an effective treatment for pathologic periarticular fractures of the distal femur and proximal tibia.

Successful treatment of pathologic femoral shaft fracture associated with large arteriovenous malformations using a 3-dimensional external fixator and teriparatide: a case report

Background

Arteriovenous malformations (AVMs) are rare congenital vascular lesions associated with early quiescence, late expansion, and, ultimately, infiltration and destruction of local soft tissue and bone. The extremities are a common location. Incidence of bony involvement by AVM has been reported as high as 31%. However, there are few reports on management of pathologic fracture associated with AVM. Teriparatide is a recombinant parathyroid hormone (PTH) analogue consisting of the 1–34 fragment of PTH. Recently, some reports have shown the ability of teriparatide to improve fracture healing. Here, we present a case of pathologic femoral shaft fracture associated with large AVMs that was treated successfully by external fixation and teriparatide.

Case presentation

A 68-year-old Japanese woman, previously diagnosed as having large AVMs, sustained a right femoral shaft fracture due to a fall. At the time of admission, she presented with massive swelling and venous varicosities of the right thigh. Plain radiography of the right thigh revealed femoral shaft fracture with bony erosion and calcification of soft tissue. We planned closed reduction and intramedullary nailing with a unilateral external fixator following embolization of the feeding artery. However, closed reduction using the fracture table was difficult. When we attempted open reduction, massive bleeding (1000 mL) after incision of subcutaneous tissue occurred. Finally, we carefully applied a Taylor Spatial Frame. Fracture displacement was corrected successfully and bony union was obtained with administration of teriparatide 15 months after the initial surgery. The patient is able to walk using 1 cane.

Conclusion

We present the first report of pathologic fracture associated with large AVMs that achieved bony union using a 3-dimensional external fixator and teriparatide.

Progression of dialysis-related amyloidoma towards pathologic fracture

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

Cutaneous Metastasis via Surgical Planes After Lumbar Spinal Reconstruction for Spinal Metastatic Disease

BACKGROUND

Cervical squamous cell carcinoma is the second most common cancer in women worldwide and the third most common cause of female cancer mortality. It frequently metastasizes to the osseous spine and has been rarely reported to cause cutaneous metastases at gynecologic surgical scars.

CASE DESCRIPTION

A 63-year-old woman with known metastatic cervical squamous cell carcinoma presented with a pathologic fracture of the L2 vertebra, unrelenting back pain, bilateral lower extremity weakness, and inability to ambulate. The patient elected to undergo an L2 corpectomy with intervertebral cage placement via the right-sided retroperitoneal approach followed by percutaneous L1-L4 pedicle screw instrumentation in the same operative setting. Her immediate postoperative course was uneventful. Eight weeks after surgery, both her flank and posterior incisions became painful and swollen. She underwent irrigation and debridement of the right flank incision due to elevated inflammatory markers and concern for surgical site infection. Multiple intraoperative cultures were obtained and were ultimately negative for bacterial or fungal growth. Several weeks later, the patient presented with worsening painful growths of her incisions. Excisional biopsy and debulking of the masses in the operating room revealed squamous cell carcinoma with areas of cystic change and tumor necrosis consistent with progression of the patient's metastatic cervical cancer.

CONCLUSIONS

Cervical squamous cell carcinoma can metastasize regionally via surgical planes and manifest as cutaneous lesions. Local metastasis should be included in the differential in cases of postoperative wound complications.

Imaging of Acute Low Back Pain

Acute low back pain, defined as less than 6 weeks in duration, does not require imaging in the absence of "red flags" that may indicate a cause, such as fracture, infection, or malignancy. When imaging is indicated, it is important to rule out a host of abnormalities that may be responsible for the pain and any associated symptoms. A common mnemonic VINDICATE can help ensure a thorough consideration of the possible causes.

Right iliac bone pathological fracture mimicking acute appendicitis

Simple bone cyst (SBC) also known as unicameral bone cyst is a benign, radiolucent bone lesion that is seen commonly in childhood. These lesions are usually found incidentally although pain and swelling can be seen. The most common complication is a pathological fracture, and this is often the cause of presentation. Here, we present a 22-year-old male with right lower quadrant pain due to SBC related pathological fracture of right iliac bone which is mimicking acute appendicitis.

Treatment of pathologic fractures of the proximal femur

BACKGROUND

Metastatic lesions to the proximal femur occur frequently and require special consideration due to the high risk of pathologic fractures. Type of surgery might influence patient survival considering the growing concept of oligometastases. In fact, the use of modular tumor megaprosthesis is increasing in the last decades compared to intramedullary nailing. Aim of this study was to evaluate oncological and functional results of treatment in patients with pathologic or impending fracture of the proximal femur, with patient survival being the primary, complications the secondary, and functional results the tertiary endpoint.

METHODS

Between 2016 and 2017, 40 patients with pathologic fracture (29 cases) or impending fracture according to the Mirels score (11 cases) of the proximal femur, were treated in our Institute and prospectively collected. There were 29 females (72.5%) and 11 males (27.5%), with a mean age at diagnosis of the metastasis of 63.6 years (range 35 to 92 years). Patients were treated due to bone metastases (commonly develop from breast cancer) or hematologic malignancies. Considering number of lesions, 17 patients had less than three bone metastases. Surgical procedures included intramedullary nailing (7 patients), conventional endoprosthesis (4 patients) and modular endoprosthetic replacement (29 patients). Adjuvant treatments included chemotherapy (13 cases), radiation therapy (8 cases) or both (15 cases), and selective arterial embolization (6 pre-op). Oncological results were evaluated considering the survival of patients. Functional results were assessed as pain intensity in VAS score and MSTS score.

RESULTS

The mean follow-up of patients was 10.2 months (range 6-26.3 years). At the latest evaluation, 23 patients were alive with disease, 3 patients were alive without evidence of disease and 14 patients were dead with disease. There was a significant better survival in patients treated with PFR compared to IMN and EPR groups (p = 0.0080). No differences in term of survival were found comparing impending vs actual pathological fracture and oligo vs multiple metastases. After surgery, all patients experienced improvement in quality of life resulting from reduction in pain. Mean MSTS score was 22.4. The overall complications rate was 22.5%. The most frequent complication was dislocation followed by wound dehiscence and deep infections.

CONCLUSION

Modular tumour prosthesis for proximal femur replacement provides good functional outcome, relative low incidence of complications and higher life quality in the medium term. Oncologic results were influenced by type of surgery, biased by the correct indications for resection and nailing. Preoperative general health condition, life expectancy and ambulatory capacity may influence treatment strategy. With the numbers available, the patients with actual pathologic or impending fracture of the proximal femur treated with resection had a significantly higher survival, especially those with metastases from renal carcinoma or multiple myeloma.

A scoping review on the surgical management of metastatic bone disease of the extremities

Background

Management of metastatic bone disease of the extremities (MBD-E) is challenging, and surgical directions pose significant implications for overall patient morbidity and mortality. Recent literature reviews on the surgical management of MBD-E present a paucity of high-level evidence and global inconsistencies in study design. In order to steer productive research, a scoping review was performed to map and assess critical knowledge gaps.

Methods

The Arksey and O’Malley framework for scoping studies was followed. A comprehensive literature search identified a large body of literature pertaining to the surgical management of MBD-E. Study data and meta-data was extracted and presented using descriptive analytics and a thematic framework. Literature gaps were identified and analyzed.

Results

Three hundred eighty five studies from 1969 to 2017 were included. Studies were categorized into 11 separate themes, with the majority (63%) falling into the “surgical fixation strategies” theme, followed by “complications” at 7% and “prognosis and survival” at 6.2%. Less than 3% of studies were categorized in “patient related outcomes” or “epidemiology” themes. 89% of studies were retrospective and only 6 studies were of level 1 or 2 evidence. We identified a temporal increase in publication by decade, and all studies published on interventional radiology techniques or economic analyses were published after 2007 or 2009, respectively. 64.9% of studies were published in Europe and 20.3% were published in North America. Average patient age was 62 (± 5.2 years), and breast was the most common primary tumour (28%), followed by lung (17%) and kidney (15%). In terms of surgical location, 75% of operations involved the femur, followed by the humerus at 22% and tibia at 3%.

Conclusions

We present a descriptive overview of the current published literature on the surgical management of MBD-E. Critical knowledge gaps have been identified through the development of a thematic framework. Consolidation of literary gaps must involve bolstered efforts towards patient and family-engaged research initiatives and assessment of patient-related surgical outcomes. Multi-disciplinary engagement in developing prospective research will also help guide evidence-based personalized practice for these patients. By building on existing comprehensive patient databases and registries, knowledge on survival and prognostic parameters can be greatly improved.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2210-8) contains supplementary material, which is available to authorized users.

Palliative Percutaneous Cryoablation and Cementoplasty of Acetabular Metastases: Factors Affecting Pain Control and Fracture Risk

PURPOSE

To characterize the response of patients with acetabular metastases following combined cryoablation and cementoplasty (CCC) for pain palliation and fracture risk reduction, based on completeness of ablation and the presence of pre-existing pathologic fracture.

MATERIALS AND METHODS

Thirty-nine consecutive acetabular CCC procedures were performed in 37 patients (24 M:13F, age 66 ± 8 years). Pain was assessed using a 0-10 numeric rating scale. Development of new or progression of pre-existing fractures and local tumor progression (LTP) were determined on follow-up imaging. Pain score reduction and fracture development rates were compared by ablation completeness and the presence of pre-existing fractures.

RESULTS

Twenty-three of 27 (85%) patients with evaluable pain scores had reduced pain, decreasing from 7.5 ± 2.1 to 3.6 ± 2.6 (p < 0.0001). Of 39 tumors, 28 (72%) were completely ablated with no significant difference in pain reduction after complete versus incomplete ablations (p = 0.9387). Six of 30 (20%) patients with follow-up imaging demonstrated new/progressive acetabular fractures. Four of 5 (80%) patients with LTP developed new/progressive fractures compared to 2 of 25 (8%) without tumor progression (p = 0.0003). Pre-existing fracture was not associated with subsequent fracture/fracture progression (p = 0.2986). However, patients with prior acetabular radiation therapy or surgery had increased fractures following treatment (p = 0.0380).

CONCLUSION

Complete acetabular tumor ablation during CCC was not associated with superior pain relief compared to subtotal ablation but did result in improved fracture stabilization. Pre-treatment pathologic fractures were not associated with fracture progression, but new/progressive fractures were more frequent in patients with prior radiation therapy or surgery.

Stabilization of Tumor-Associated Craniovertebral Junction Instability: Indications, Operative Variables, and Outcomes

BACKGROUND

Whether primary or metastatic, tumors of the craniovertebral junction (CVJ) are rare and challenging.

OBJECTIVE

To examine the surgical indications, operative variables, and outcomes in patients with tumors of the CVJ undergoing occipitocervical (OC) stabilization.

METHODS

A single-institution, retrospective case series was performed from a prospectively maintained spine database. Patients with primary or metastatic tumors of the CVJ who underwent OC stabilization were identified. Out of 46 patients who underwent OC fusion, 39 were for tumor. Paired t -tests and Wilcoxon rank-sum tests were performed to assess for postoperative changes.

RESULTS

Ten patients (26%) harbored primary tumors, and the remaining 29 (74%) had metastatic disease. Of the metastatic patients, 14 had a neurological deficit, 10 had severe neck pain, and 5 were deemed mechanically unstable. Postoperative visual analog pain scores were significantly reduced at all 3 follow-up times ( P < .001, 95% confidence interval [CI; 3.2, 6.0]; P = .001, 95% CI [2.6, 7.7]; P = .020, 95% CI [0.6, 5.5]). The percentage of patients who were ambulatory and neurologically improved or intact remained stable postoperatively with no significant declines. There were 2 perioperative mortalities (5%), and 13 patients (33%) experienced a major complication.

CONCLUSIONS

In patients with primary or metastatic tumor of the CVJ, OC stabilization using a cervical screw-rod system affixed to a midline-keel buttress plate, with or without posterior decompression, is a reliable method for CVJ stabilization in the oncologic setting. Improvement in pain and preservation of neurological function was seen.

The role of postoperative radiation and coordination of care in patients with metastatic bone disease of the appendicular skeleton

Metastatic bone disease affects approximately 300,000 people in the United States, and the burden is rising. These patients experience significant morbidity and decreased survival. The management of these patients requires coordinated care among a multidisciplinary team of physicians, including orthopaedic surgeons. This article reviews the role of radiation therapy after orthopaedic stabilization of impending or realized pathologic extremity fractures. Orthopaedic surgeons have an opportunity to benefit patients with metastatic bone disease by referring them for consideration of post-operative radiation therapy. Further research into rates of referral and the effect on clinical outcomes in this population is needed.

Pathologic Fractures Extended to the Metacarpal Head Related with Enchondromas at the Metacarpal Neck

We present two cases of pathologic fractures extended to the metacarpal head related with enchondromas at the metacarpal neck treated by surgery. The timing of surgery varied between the two cases. The first was operated without delay, using tumor curettage and β-TCP (tricalcium phosphate) packing in the cavity, followed by internal fixation of the fracture using a screw and Kirshner wires. In the second case, tumor curettage and β-TCP packing was performed after fracture union. Favorable clinical outcomes were obtained for both cases.

Case series of patients with pathological dyaphiseal fractures from metastatic bone disease

INTRODUCTION

Fractures on pathologic bone have major impact on life quality. The appropriate treatment is not standardized, but the current literature delineates that surgery must provide adequate stabilization for the life expectancy. We aimed to review the epidemiology, treatment outcomes and survival in our department.

MATERIAL AND METHODS

The electronic database from a major referral centre was searched for patients treated for tumours and fractures by the corresponding ICM-10 codes over five years. Eighty-nine patients were identified. Eleven females and nine males, with an average age of 64 years underwent 23 operations during the selected timeframe. Six fractures were subtrochanteric, five at the femoral neck and five at the femoral diaphysis. Seventeen cases were metastatic carcinomas, out of which five mammary, three pulmonary and seven carcinomas of undetermined origin without immunohistochemistry.

RESULTS

Fourteen types of surgical intervention were osteosynthesis with intramedullary nails and six were partial hip replacements of which one had proximal femur resection and revision stem hemiarthroplasty. Four patients had single metastatic lesions which underwent resection and defect filling using PMMA cement (polymethylmethacrylate). The follow-up period ranged between two and seven years or until death. Only five patients (25%) were alive at the last follow-up. Local recurrence appeared in one patient. There was one immediate post-operative complication (dehiscent wound) and one implant failure after five years and was replaced with a larger diameter (exchange nailing).

CONCLUSION

Both hip arthroplasty and femoral nailing are safe and routine procedures that are performed with relatively technical ease and low surgical stress and few peri-operative complications for the patient. They allow for immediate mobilization and weight-bearing with moderate and rapidly decreasing pain and discomfort.

Intramedullary Nailing for Pathological Fractures of the Proximal Humerus

BACKGROUND

Endoprosthetic reconstruction is widely applied for pathological fractures of the proximal humerus; however, functional impairment is usually unsatisfactory. The aims of the current study are to evaluate the reliability of interlocking intramedullary (IM) nailing with cement augmentation as a fixation method in proximal humeral lesions and to assess functional outcomes.

METHODS

We reviewed 32 patients with pathological fractures of the proximal humerus who underwent interlocking IM nailing and cement augmentation. Functional scores and pain relief were assessed as outcomes.

RESULTS

The mean follow-up period was 14.2 months. The mean Musculoskeletal Tumor Society functional score and Karnofsky performance status scale score were 27.7 and 75.6, respectively. Improvement of pain assessed using the visual analogue scale was 6.2 on average. Thirty-one patients (97%) experienced no pain after surgery. The mean ranges of forward flexion and abduction were 115° and 112.6°, respectively. All patients achieved stability and had no local recurrence without failure of fixation until the last follow-up.

CONCLUSIONS

Proximal interlocking IM nailing with cement augmentation appears to be a reliable treatment option for pathological or impending fractures of the proximal humerus in selected patients with metastatic tumors, even with extensive bone destruction.

Pathologic fracture and healthcare resource utilisation: A retrospective study in eight European countries

BACKGROUND

Skeletal-related events (SREs; pathologic fracture [PF], spinal cord compression and radiation or surgery to bone) are common complications of bone metastases or bone lesions and can impose a considerable burden on patients and healthcare systems. In this study, the healthcare resource utilisation (HRU) associated with PFs in patients with bone metastases or lesions secondary to solid tumours or multiple myeloma was estimated in eight European countries.

METHODS

Eligible patients were identified in Austria, the Czech Republic, Finland, Greece, Poland, Portugal, Sweden and Switzerland. HRU data were extracted from hospital charts from 3.5 months before the index PF (defined as a PF preceded by a 6.5-month period without a SRE) until 3 months after the last SRE during the study period. Changes from baseline in the number and duration of inpatient stays, number of outpatient visits and number of procedures provided were recorded.

RESULTS

Overall, 118 patients with PFs of long bones (those longer than they are wide, e.g. the femur) and 241 patients with PFs of other bones were included. Overall, HRU was greater in patients with long bone PFs than in those with PFs of other bones. A higher proportion of patients with long bone PFs had multiple SREs (79.7%), and more of their SREs were considered to be linked (73.4%) compared with patients with PFs of other bones (51.0% and 47.2%, respectively).

CONCLUSION

The increased number and duration of inpatient stays for PFs of long bones compared with those for PFs of other bones may be due in part to the requirement for complicated and lengthy rehabilitation in patients with long bone PFs. Implementing strategies to delay or reduce the number of PFs experienced by patients with bone metastases or lesions may therefore reduce the associated HRU and patient burden.

The Carbofix™ "Piccolo Proximal femur nail": A new perspective for treating proximal femur lesion. A technique report

Metastases to proximal femur are common and surgery is often suggested to prevent fractures; otherwise it is necessary in cases where this has already occurred. Adjuvant radiotherapy is necessary to reduce the risk of local progression. Nevertheless, the success or failure of radiation therapy treatments depends upon the accuracy in which target identification is correct and dose prescription is fulfilled. Unfortunately, the use of titanium nails consistently limits radiation dose; indeed, the presence of ferromagnetic artifacts interferes with target identification. We present the technique for implant a new carbon fiber nail useful to reduce the ferromagnetic artifacts which allows a better adjuvant radiotherapy.

[Pathological fracture rate due to proximal femur metastasis at a referral hospital]

OBJECTIVE

To report the incidence of pathological fractures secondary to metastasis at a national referral hospital during a 5-year period.

METHODS

Total admissions to our center were recorded, together with the patients who met the requirement of having a proximal femur fracture in a pathological area. The potential number of beneficiaries was estimated based on official figures and the hospitals area of influence. The annual incidence rate and the incidence density were calculated using the latter data.

RESULTS

98 fractures were identified in 95 patients. The calculated incidence density was 0.70/100,000 population during the observation period. Fifty-four female patients and 41 male patients were included. Mean age was 65.3 years, with a very wide age range (18-90 years). Most patients had metastasis of solid tumors. Twenty-nine percent of patients were treated conservatively and the rest of them required surgery that included from osteosynthesis to prosthetic arthroplasty. The mean length of stay was over one week.

CONCLUSIONS

The reported incidence of this type of fractures is relatively low. We found a wide variety of anatomical origins and locations. As of now, it is not possible to generalize the treatment or predict the survival.