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Twenty-one patients were treated with Zickel nail for neoplastic pathological fracture or impending pathological fracture: in the femoral neck in three, in the intertrochanteric region in three, and in the subtrochanteric region in fifteen. Nineteen patients were restored to bed-chain status by the third postoperative day, and twenty were able to walk. Failure of fixation did not occur and there were no infections.

Seventy-two pathological fractures associated with tumors other than carcinoma of the breast in the long bones of the extremities of sixty patients were treated over a five-year period at Roswell Park Memorial Institute. Pain was relieved in 91 per cent of the patients treated by internal fixation, in 59 per cent of those treated by irradiation, and in 45 per cent of those treated by other means. Among patients with lower-extremity fractures, 61 per cent of those treated by internal fixation became ambulatory, whereas only 23 per cent of those treated by other methods were able to walk. Internal fixation of these pathological fractures appeared to be the best treatment.

Methylmethacrylate was used adjunctively in the internal fixation of thirty-five pathological fractures and in sixteen patients in whom fractures were imminent. Effective fixation and stability were achieved after all procedures. Without the use of methylmethacrylate, twenty procedures associated with extensive destruction would not have achieved satisfactory fixation. Because stability of the osseous structure can be restored by the methylmethacrylate, extensive bone destruction is not a contraindication in the selection of patients. Relief of pain and functional improvement were rated as follows: good in thirty-eight cases, fair in six, and poor in seven. There were no failures of the fixation and no significant complications from the methylmethacrylate.

The Zickel intramedullary appliance was used without methylmethacrylate in forty-six patients to stabilize thirty-five fractures and eleven impending fractures associated with osseous lesions in the subtrochanteric region of the femur. Early mobilization or ambulation was possible in nearly all cases. The patients with actual fractures survived an average of 4.7 months, while those with lesions stabilized prophylactically survived an average of 13.8 months postoperatively. Fourteen of the thirty-five patients with fractures showed union after an average of 4.5 months.

In 167 consecutive pathological or impending fractures of the hip treated by endoprosthetic replacement from 1975 to 1978, there was dramatic relief of pain in all patients. Either a long-stem femoral endoprosthesis or a total prosthetic hip was used. The ambulatory status was significantly enhanced in those patients who were able to walk but it was not in the gravely ill. Cementing the prosthesis allowed stabilization of the entire femur as well as resection of diseased bone. The patients had a median survival time of 5.6 months. There were no dislocations, instances of loosening, or failures of the device, and the incidence of deep infection was 1.2 per cent. If the anticipated life of the patient exceeds one month, that constitutes an indication for prosthetic replacement for treatment of a pathological or impending fracture of the hip.

Twenty-eight bone specimens containing the implant beds of partial and total hip arthroplasties were studied. All cases of infection of the prosthesis bed and of pathological fractures due to metastasis were excluded. There was necrosis around the acrylic cement (up to three weeks postoperatively), followed by repair of the implant bed (up to two years postoperatively), and finally by bone remodeling (after completion of the repair). Microscopic acrylic pearls were found in the implant bed, documenting possible harmful alterations of the cement surface. Early and late loosening of the prosthesis may be associated with characteristic changes of the implant bed.

Sixteen hundred and seventy-seven melanoma patients were treated at Duke University Medical Center from 1956 to 1976. Osseous metastases were more common than previously reported and occurred in 116 patients (6.9 per cent), most often in the axial skeleton. Diagnosis was made by roentgenogram, bone scan, or both in the symptomatic patient. Seventy-five patients sustained pathological fractures, most of which were successfully treated conservatively. Nine of the ten patients with neurological symptoms were improved by laminectomy. The grave prognosis for melanoma patients with osseous metastases (mean survival, 3.6 months) led to conservatism even for an impending pathological fracture. Unstable pathological fractures of long bones were treated by internal fixation and irradiation.

An intramedullary rod for the femur was designed and compared with rods commonly used. Its bending strength was increased 40 to 80 per cent and its torsional rigidity was increased 230 to 3,000 per cent compared with the other devices tested. In forty patients with traumatic and pathological fractures and osteotomies of the femur, excellent fixation was achieved and very early weight-bearing was possible. In all fresh fractures and non-infected non-unions, union occurred very promptly and bone-grafting was not required in most instances. The stregth and rigidity of the device made it exceptionally useful for non-unions, pathological fractures of the femur, and resection-fusions of the knee.

The records were reviewed of 162 patients who had been admitted to the Hospital for Special Surgery since 1950 with compression fractures of the spine and demineralization. Fifty-seven of the patients were excluded from this study because the diagnosis was known at the time of admission, adequate trauma to cause fracture had occurred, or the diagnostic study or follow-up had been inadequate. In the remaining 105 patients, osteoporosis was thought to be responsible for the vertebral collapse in fifty-five patients, malignant bone disease in twenty-five, hypercorticism with rheumatoid arthritis in nine, and osteomalacia in six patients. Other conditions were responsible for vertebral collapse in ten patients. The chances of a patient having primary or metastatic malignant bone disease were markedly increased if fewer than three vertebrae were collapsed and the patient was less than fifty-five years of age. In the younger-age group especially, a variety of unusual conditions other than osteoporosis produced the demineralization. In order to make a final diagnosis, complete and, often, repeated studies are necessary. It is important to establish an exact diagnosis since some conditions that produce vertebral collapse respond to specific treatment.

1. Bone atrophy occurring in paraplegia is of an osteoporotic nature. 2. There is close association of urinary calculi and soft-tissue ossifications with the excessive calcium mobilization from the bones. 3. If calcium could be held in bone, urinary calculi, soft-tissue ossifications, and pathological fractures could be prevented. 4. Pressure produces bone matrix, thus allowing the deposition of calcium. 5. The only logical therapeutic agent which applies pressure intermittently is ambulation.

One extensive periosteal stripping of the femur and tibia from one epiphyseal plate to the other in dogs caused some increase in longitudinal growth on the stripped side as compared with the unstripped side in 63 per cent of paired bones. A second stripping operation performed one or two months later produced a statistically significant increase in growth after a single stripping operation in dogs. Two periosteal stripping operations in monkeys caused a slight increase in longitudinal growth in the long bones in 87.5 per cent of the cases. Pathological fractures of the femur or tibia occurred after two stripping procedures in five of the twenty-two dogs and in five of the ten monkeys.