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Assessment of pathological fracture risk is critical to optimize the use of prophylactic orthopedic fixation to prevent pathological fractures. Better prediction of pathological fracture risk is needed. We evaluated if quantitative measures of FDG avidity can assess femoral pathological fracture risk in patients with metastatic breast cancer (MBC).A Health Insurance Portability and Accountability Act-compliant retrospective case-control study was performed under institutional review board waiver. Patients with MBC who received an FDG PET/CT from January 2008 to December 2014 and had pathological fracture of the proximal femur within 3 months of PET/CT were selected as cases. Patients with MBC who had an FDG PET/CT in 2013 were sequentially screened in reverse chronological order to identify patients with proximal femoral metastases on PET/CT but no subsequent pathological fracture to serve as a control group. The prespecified goal was to have twice the number of controls as cases. Target lesions in the proximal femur, from femoral head to 5 cm below the lesser trochanter, were analyzed on FDG PET/CT for SUVmax, SUVmean, metabolic tumor volume, and total lesion glycolysis. Wilcoxon rank sum test was used to compare continuous variables in cases and controls. A nonparametric receiver operating characteristic analysis was performed to assess the ability of quantitative FDG measurements to differentiate between cases and controls.In 27 cases with pathological fracture and 55 controls without pathological fracture, all 4 quantitative measures of FDG avidity were statistically different between cases and controls (P0.001). A total lesion glycolysis of 81 could differentiate between fracture and nonfracture patients with accuracy, sensitivity, and specificity of 0.83, 0.85, and 0.80, respectively.Quantitative measures of FDG avidity may help identify breast cancer patients at high risk of subsequent pathological fracture of the proximal femur.

OBJECTIVES The femur is the most common long bone affected by cancerous metastasis. Femoral tumor defects are known to induce pain and functional impairment in patients. Although prior studies exist evaluating the clinical and biomechanical effect of tumor defect size, no biomechanical studies have experimentally examined the risk of pathological fracture with respect to the anterior, posterior, medial, and lateral surfaces on which a proximal tumor defect is located on the femur. METHODS Circular tumor-like defects of 40-mm diameter were created proximally in the subtrochanteric region on the Anterior (n = 5), Posterior (n = 5), Medial (n = 5), and Lateral (n = 5) sides of 20 synthetic femurs. Intact femurs served as a control group (n = 4). Femurs were tested for lateral, "offset" torsional, and axial stiffness, as well as axial strength. RESULTS Lateral stiffnesses (range, 121-162 N/mm) yielded no differences between groups (P = 0.069). "Offset" torsional stiffnesses (range, 135-188 N/mm) demonstrated that the Medial group was less stiff than the Intact, Anterior, and Lateral groups (P ≤ 0.012). Axial stiffnesses (range, 1057-1993 N/mm) showed that the Medial group was less stiff than the Intact group (P = 0.006). Axial strengths (range, 3250-6590 N) for the Medial group were lower than Anterior (P = 0.001) and Posterior (P = 0.001) specimens, whereas the Lateral group had a lower strength than Anterior specimens (P = 0.019). No other statistical differences were noted. Axial failure of Medial and Lateral specimens involved the tumor-like defect in 100% of cases, whereas 100% of Intact femurs and 80% of Anterior and Posterior femur groups failed only through the neck. CONCLUSIONS In 2 of 3 test modes, the Medial tumor-like defect group resulted in statistically lower stiffness values compared with Intact femurs and had lower strength than Anterior and Posterior groups in axial failure.

Magnetic resonance imaging is the imaging modality of choice as a conjunctive study to radiography for imaging bone tumors of the foot. However, there will be cases where computed tomography (CT) is performed, and CT is superior in evaluating the bone cortex and identifying pathological fractures, periosteal reaction, or matrix mineralization. This article reviews osseous foot neoplasms. Clinical and imaging findings are discussed, as well as applications where CT provides valuable information.

This report deals with the advantages and disadvantages associated with the most commonly used methods of stabilization after a pathologic fracture of the humerus shaft.A total of 39 patients with 41 metastatic lesions and pathologic fractures of the humerus, treated surgically between 1992 and 2007, were retrospectively analyzed.The rate of local complications was 14.6% (6 of 41). Radial nerve injury was the only local complication and was exclusively observed in patients who underwent open reduction and plate fixation. The overall rate of osteosynthesis failure was 12.2% (5 of 41). Two failures were observed in 21 patients with open reductions and plate fixations, compared with three failures in 20 procedures involving closed reductions and intramedullary stabilization. The 1- and 2-year survival rates were 0.35 and 0.2 in ORIF and 0.07 and 0 in patients with IM fixation retrospectively.Intramedullary stabilization is a reliable method for fixation of pathologic fractures of the humerus diaphysis for patients in the advanced stage of metastatic disease. ORIF are preferable to IM fixations for the treatment of metaphyseal fractures and for those patients with a solitary metastasis in the humerus or those with a better prognosis.

Pathological fractures are common in pediatric neuromuscular disorders. Dual-energy x-ray absorptiometry has become the most accepted technique for the measurement of bone mineral density (BMD) in adults and children. Limited data are available on BMD in pediatric neuromuscular diseases except Duchenne muscular dystrophy.We retrospectively analyzed the results of all dual-energy x-ray absorptiometry scans done in a period of 23 months at a tertiary care pediatric neuromuscular center. BMD was performed on spine region L1-4. Osteopenia was classified as mild if the Z scores were between 0 and -1.5, moderate if Z scores were between -1.5 and -2.5, and severe if Z scores were-2.5 standard deviation scores.Eighty-four dual-energy x-ray absorptiometry scans were performed on 79 patients between the ages of 4 months and 18 years with the mean age of 8 years. Z scores were used to compare their BMDs. BMD was lowest in patients with spinal muscular atrophy (SMA) with Z score of -2.25 +/- 0.31 standard deviation scores. The Z score for patients with Duchenne muscular dystrophy was -1.72 +/- 0.1. The BMD in nonambulatory patients with SMA was significantly decreased compared with ambulatory patients with SMA (P0.05).We conclude that osteopenia is common in children with neuromuscular disorders. Patients with SMA have the lowest BMD.

Aspergillus osteomylyelitis in immunocompetent hosts is a rare disease. In this article, we report a case of Aspergillus vertebral osteomyelitis in an immunocompetent woman who presented with pathological fractures of the thoracic vertebrae. We reviewed medical literature to find the optimal regimen, and in our case, we elected to start the patient on voriconazole and intended to treat for a minimum of 6 months. Our patient responded nicely to voriconazole and showed clinical and radiological resolution of osteomyelitis after 6 weeks of therapy.

A retrospective study was made of 37 patients with 54 fractures that occurred without significant trauma. The morbidity and causes of these pathological fractures in patients with cerebral palsy were analyzed. The major causes for the fractures were long and fragile lever arms and stiffness in major joints, particularly the hips and knees. An additional factor was severe osteoporosis following a long period of postoperative immobilization. Seventy-four percent of the fractures occurred in the femoral shaft and supracondylar region. Stress fractures were rare (7%) and involved only the patella. Conservative treatment was sufficient in most cases but surgical fixation provided a good alternative for fractures of the femoral shaft. Intraarticular fractures with joint incongruity resulted in a decreased level of activity of the patient. Since osteoporosis is a major risk factor, patients with cerebral palsy should bear weight to prevent pathological fractures. Any stiffness of major joints and extended periods of immobilization should be avoided.

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.