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The reported donor site morbidity of the fibula free flap (FFF) is low; however, several uncommon complications have been reported with tibia fracture rarely being reported. We present a case of a pathological tibial fracture in the setting of chronic osteomyelitis after FFF. A 54-year-old female presented with a benign fibro-osseous lesion of the right mandible and was treated with mandibulectomy and reconstructed with a left FFF. Approximately 1 year following surgery, the patient presented to the emergency department. Imaging showed a pathological fracture of the distal third of the tibial shaft with persistent erythema and cellulitis of the lateral prior graft harvest site without signs of systemic infection. She was taken to the operating room for irrigation and debridement with culture and biopsy as well as external fixation of the tibial fracture. Intraoperative biopsy and culture demonstrated fracture site change with callus formation and negative culture. The patient was discharged on 6 weeks of IV vancomycin and ceftriaxone. In conclusion, tibial fracture following FFF is an uncommon complication, yet it can be exacerbated by chronic osteomyelitis. This report highlights the importance of close observation and comprehensive wound care of donor sites after free flap harvest for head and neck reconstruction., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Prophylactic intervention for impending pathological fractures (IF) is associated with improved survival in patients with long-bone metastasis. However, information regarding whether the tumor burden and/or physical status are associated with survival benefits of intervention for IF is lacking., Methods: This multicenter retrospective study investigated 121 patients who underwent surgery for 63 impending and 58 complete metastatic fractures of the proximal femur between 2008 and 2023. After matching for age, sex, body mass index, and Katagiri-New score, 42 patients with IF were compared with 42 patients with complete pathological fractures. The 1-year mortality rate was considered the primary outcome, and was compared and stratified by risk based on the Katagiri-New score. The 1-year mortality rate was evaluated according to the surgical method in the subgroup analysis of patients with IF., Results: The 1-year mortality rate was significantly lower in patients with IF with intermediate-to-high risk(p = 0.04), whereas no difference was observed in patients with low-to-high risk. IF was associated with a significantly higher rate of home discharge (p < 0.01) and improved post-operative ambulatory function (p = 0.07). The subgroup analysis of patients with IF revealed no difference in the survival rate between nailing and hemiarthroplasty., Conclusion: Patients with intermediate-to-high risk IF based on the Katagiri-New score had a lower mortality rate than those who underwent surgery for pathological fractures. A higher rate of home discharge was observed in patients with IF. Based on the Katagiri-New score, survival benefits can be obtained from prophylactic intervention for IF of the proximal femur in patients with intermediate-to high-risk., (© 2024. The Author(s).)

Background: Metastatic bone disease (MBD) and its complications have a significant impact on patients' quality of life. Pathological fractures are a particular problem as they affect patient mobility and pose a high risk of non-union. The pelvis is frequently affected by MBD and its fixation is challenging. We present a case series of three pathological sacral fractures treated with a new minimally invasive bilateral fixed angle locking system., Case Presentation: Case 1 and 2 suffered a pathological transforaminal sacral fracture without adequate trauma in stage 4 carcinomas (gastric cancer and breast cancer). Both were initially treated with non-surgical treatment, which had only a limited effect and led to imminent immobility. Both were operated on with fluoroscopic navigation and underwent transsacral SACRONAIL ® stabilisation according to CT morphology (S1 + S2 and S1 respectively). Immediately after the operation, pain decreased and mobilisation improved. Case 3 had a pathological transalar sacral fracture during the 2nd cycle of chemotherapy due to non-Hodgkin's lymphoma. He soon became immobile and could only move in a wheelchair. The operation was performed with CT navigation due to the very small corridors and an implant was inserted in S1 and S2. The patient reported immediate pain relief and his ability to walk improved over the following months. Despite continued chemotherapy, no wound complications occurred., Conclusions: The cases show the advantages of the minimally invasive bilateral fixed angle locking system SACRONAIL ® in the treatment of patients with pathological sacral fractures. It allows immediate full weight bearing and the risk of secondary surgical complications is low. All cases showed an improvement in pain scores and mobility., (© 2024. The Author(s).)

Background: As cancer survivorship continues to improve, the perioperative morbidity and mortality following surgical treatment of metastatic bone disease become an increasingly important consideration. The objective of this study is to identify risk factors for early postoperative complications and mortality following extremity prophylactic fixation and pathologic fracture stabilization., Methods: A single-centre retrospective review of 185 patients (226 total surgeries) who underwent prophylactic fixation or pathologic fracture stabilization for extremity metastatic bone disease between 2005 and 2020 was performed. Skull, spine, pelvic, and revision surgeries along with diagnosis of primary bone neoplasm were excluded. Univariate, multivariate, and subgroup analyses were performed to identify predictors and independent risk factors for 30-day postoperative morbidity and mortality., Results: Primary cancers included lung ( n  = 41), breast ( n  = 36), multiple myeloma ( n  = 35), prostate ( n  = 16), lymphoma ( n  = 11), renal cell carcinoma ( n  = 10), and other ( n  = 36). The 30-day postoperative complication and mortality rates were 32.30% ( n  = 73) and 17.26% ( n  = 39), respectively. The most common complications were pulmonary-related, cardiac events, surgical site infection, sepsis, and thromboembolism. Pathologic fracture, presence of extra-skeletal metastases, longer surgical duration, and blood transfusion requirements were associated with 30-day postoperative complications overall. A past medical history for cardiac disease was also associated with systemic but not local surgical complications. Pathologic fracture, presence of extra-skeletal metastases, lung cancer, blood transfusion requirements, and increasing pack-year smoking history were predictors for 30-day mortality. In the multivariate analysis, pathologic fracture ( p =0.016) and presence of extra-skeletal metastases ( p =0.029) were independent predictors of complications. For mortality, pathologic fracture ( p =0.014), presence of extra-skeletal metastases ( p =0.0085), and increased blood transfusion requirements ( p =0.048) were independent risk factors., Conclusions: The findings of this study provide additional guidance for perioperative risk assessment and patient counselling. Additionally, improving clinical assessment tools to identify and quantify patients at risk of pathologic fractures becomes increasingly important given the significant morbidity and mortality associated with pathologic fracture treatment., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2024 Patrick Qi Wang et al.)

Background: We examined the treatment outcomes following intramedullary nailing in patients with metastatic femoral tumors, excluding those from hematological malignancies., Methods: We retrospectively evaluated treatment outcomes following intramedullary nailing between patients who underwent preventative surgery compared with those who had surgery following pathological fracture. Patients who underwent preventative surgery (Mirels' score ≥8) were allocated to the impending fracture group (n = 11) and those who underwent surgery after pathological fracture were allocated to the completed fracture group (n = 20)., Results: Duration of surgery was significantly shorter in the impending fracture group than in the completed fracture group. Median blood loss was significantly less, and the median duration of hospital stay was significantly shorter in the impending fracture group than in the completed fracture group. Among patients who died following surgery, the median postoperative survival duration was significantly longer in the impending fracture group than in the completed fracture group. Significantly more patients regained walking function in the impending fracture group than in the completed fracture group. Regarding complications, infection occurred in one patient in the completed fracture group. No implant damage was observed in either group., Conclusions: Patients with metastatic femoral tumors who underwent intramedullary nailing in the impending fracture group had better postoperative survival and gait function, less blood loss, and shorter durations of surgery and hospital stay than those in the completed fracture group. These findings indicate the importance of early diagnosis and treatment and value of treatment prior to fracture occurrence., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest., (Copyright © 2023 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Introduction: Despite the benefits of intramedullary nailing (IMN) of impending or pathologic fractures in oncologic patients, literature on patient-reported outcomes (PROs) is scarce in patients treated with carbon fiber (CF) nails. Our study compared postoperative PROs after IMN with CF or titanium implants., Methods: We conducted a retrospective propensity score-matched cohort study of patients treated at our institution with CF or titanium nails for impending or pathologic fractures from metastatic bone disease. Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health Short Form (SF) Physical, Mental, and Physical Function 10a scores were collected. Pain was assessed using visual analog scale (VAS). Absolute and differential scores were compared between groups., Results: We included 207 patients, 51 treated with CF and 156 with titanium nails. One month postoperatively, patients had a one-point decrease in the pain VAS score while PROMIS scores did not improve. At 3 months, PROMIS SF Physical and SF 10a scores improved from preoperative values. Six months postoperatively, median PROMIS SF Physical, SF Mental, and SF 10a scores were higher than preoperative scores. Absolute and differential PROMIS and pain VAS scores were similar between groups at the 6-month and 1-year marks., Conclusion: Patient-reported outcomes were similar after intramedullary nailing with either CF or titanium implants., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Elastic stable intramedullary nailing (ESIN) internal fixation is used clinically to treat pathological fractures of bone cysts in children. However, one of the most important complications was removal difficulty. In this study, we aim to analyse the factors which can influence ESIN removal in healed bone cysts in children. From April 2014 to November 2020, the clinical data of 49 children who underwent elastic stable intramedullary nail removal for pathological fractures of the bone cysts in our hospital were retrospectively analysed. The following data, including age, sex, pathological fracture site, with bone graft, number of ESINs, ESIN indwelling time, and extraosseous length of ESIN were collected, and univariate analysis and logistic regression analysis was performed. The frequency of difficulty in ESIN extraction was 44.90% (22/49). The univariate logistic regression analysis showed that age,ESIN indwelling time,with bone garft and extraosseous length of ESIN may be correlated with the difficulty in removing ESIN (P < 0.05), while sex, pathological fracture site, number of ESIN may not be correlated with the difficulty in removing ESIN (P > 0.05).The multivariate logistic regression analysis showed that the ESIN indwelling time was the independent influencing factor for difficulty in removing ESIN (P < 0.05). The factors influencing the ESIN removal in healed bone cysts in children include over 11.79 years old, the long indwelling time of the ESIN(over 10.5 months),with bone graft and short extraosseous length of ESIN(≤ 0.405 cm). These factors influencing ESIN removal in healed bone cysts in children should be considered., (© 2024. The Author(s).)

BACKGROUND Unicameral bone cysts (UBCs) are benign tumor-like lesions that are the most common cause of pathological proximal femur fracture in children. This study aimed to present the outcomes of acute, unstable, pathological proximal femur fractures secondary to UBCs in children. MATERIAL AND METHODS We retrospectively reviewed data on 12 patients with a mean age of 9.3 years (7-12 years) who were initially treated with decompression and grafting, followed by stabilization using a 120° fixed-angle low-contact locking pediatric plate (LCLPP). The Musculoskeletal Tumor Society (MSTS) scores, Capanna classification of cyst repair, time to union, collodiaphyseal angle (CDA), and limb length discrepancy (LLD) were evaluated. RESULTS The mean follow-up was 33.1 months (range, 13-96 months). The mean union time was 9.5 weeks (8-14 weeks). The mean time for reparation of the cyst was 6.9 months (range 3-9 months). Four patients had Dormans type IB, while the remaining had type IIB fractures. According to the Capanna classification, repairs in 10 cases were grade I and in 2 cases grade II. At the last follow-up, the mean 120.8° of preoperative CDA was corrected to 140.9° (P<0.001) and there was no difference compared to the healthy side (P=0.214). The mean postoperative MSTS score was 97.1% (29.1 points). Two patients experienced LLD at the affected extremities, while the other 10 patients healed without any complications. CONCLUSIONS Fixation of acute unstable fractures secondary to UBCs with a 120° fixed-angle LCLPP is a reliable and successful option after decompression and grafting of the lesion.

Background: Pathological fracture of the humerus causes severe pain, limited use of the hand, and decreased quality of life. This study aimed to compare the outcomes of intramedullary nailing and locking plate in treating metastatic pathological fractures of the proximal humerus., Methods: This retrospective comparison study included 45 patients (22 male, 23 female) with proximal humerus metastatic pathological fractures who underwent surgical treatment between 2011 and 2022. All data were collected from medical records and were analyzed retrospectively. Seventeen cases underwent intramedullary nailing plus cement augmentation, and 28 cases underwent locking plate plus cement augmentation. The main outcomes were pain relief, function scores, and complications., Results: Among 45 patients with mean age 61.7 ± 9.7 years, 23 (51.1%) had multiple bone metastases, and 28 (62.2%) were diagnosed with impending fractures. The nailing group had significantly lower blood loss [100 (60-200) versus 500 (350-600) ml, p < 0.001] and shorter hospital stay (8.4 ± 2.6 versus 12.3 ± 4.3 days, p < 0.001) than the plating group. Average follow-up time of the nailing group was 12 months and 16.5 months for the plating group. The nailing group had higher visual analog scale (VAS) scores than the plating group, indicating greater pain relief with nailing [7 (6-8) versus 6 (5-7), p = 0.01]. Musculoskeletal Tumor Society functional scores [28 (27-29) versus 27 (26.5-28.5), p = 0.23] were comparable between groups. No complications, local recurrence, or revision surgery were reported until the last follow-up in either group. However, one case in the plating group had a humeral head collapse and fragmentation without needing revision surgery., Conclusions: Intramedullary nailing with cement augmentation is a viable option for treating proximal humerus metastatic pathological fracture, providing rigid fixation and better pain relief resulting in earlier mobility to optimize functional outcomes. Less invasive procedure with less blood loss and shorter hospital stay also benefits patients. Level of evidence Level II. Trial registration statement Not applicable., (© 2023. Societa Italiana di Ortopedia e Traumatologia (Italian Society of Orthopaedics and Traumatology SIOT).)

Background: Giant cell tumor of bone (GCTB) is a benign locally aggressive tumor frequently treated with intralesional curettage and cementation. The aim of this study was to investigate the long-term incidence of arthritic changes following curettage and cementation of GCTB around the knee., Materials and Methods: This study was a retrospective review of patients with GCTB around the knee treated with curettage and cementation with a minimum follow-up of 10 years. The functional results were assessed using the Musculoskeletal Tumor Society (MSTS) score. The arthritic changes were classified using the Kellgren-Lawrence (KL) classification system of osteoarthritis., Results: This study included 119 patients, 54 males and 65 females, with a mean age of 29.4 ± 9.2 years. There were 35 (29.4%) patients with pathological fractures. There were 84 (70.6%) patients with de novo lesions and 35 (29.4%) with recurrent lesions. The mean follow-up period was 13.2 ± 3.16 years. The mean MSTS score was 28.5 ± 1.9. Overall, 25 (21%) patients developed variable degrees of arthritis of KL grade 1 (n = 7), KL grade 2 (n = 11), KL grade 3 (n = 4), and KL grade 4 (n = 3). Ten patients showed progression of arthritis during the follow-up period. Age at presentation, gender, presence of pathological fracture, whether the tumor was de novo or recurrent, and tumor location were not associated with arthritis incidence., Conclusions: Curettage and cementation can be used safely to treat GCTB around the knee. Arthritis of the knee is a possible complication, but mild grades are expected in most cases. There was no association between arthritis incidence and age, gender, pathological fractures, tumor location, or recurrent tumors., Level of Evidence: Level IV., (© 2023. The Author(s).)

Background: In recent years, researchers have proposed a number of adjuvant methods for extended curettage of giant cell tumors of the bone. However, various schemes have significant differences in efficacy and safety. Therefore, this article will describe an empirical expanded curettage protocol, 'triple clear', in detail to show the effect of the efficient surgical protocol., Method: Patients with Campanacci grades II and III primary GCTB who were treated with either SR (n = 39) or TC (n = 41) were included. Various perioperative clinical indicators, including the therapy modality, operation time, Campanacci grade, and filling material were recorded and compared. The pain level was determined by the visual analog scale. Limb function was determined by the Musculoskeletal Tumour Society (MSTS) score. Follow-up time, recurrence rates, reoperation rates, and complication rates were also recorded and compared., Result: The operation time was 135.7 ± 38.4 min in the TC group and 174.2 ± 43.0 min in the SR group (P < 0.05). The recurrence rates were 7.3% in the TC group and 8.3% in the SR group (P = 0.37). The MSTS scores at three months after surgery were 19.8 ± 1.5 in the TC group and 18.8 ± 1.3 in the SR group. The MSTS scores at two years were 26.2 ± 1.2 in the TC group and 24.3 ± 1.4 in the SR group (P < 0.05)., Conclusion: TC is recommended for patients with Campanacci grade II-III GCTB and for those with a pathological fracture or slight joint invasion. Bone grafts may be more suitable than bone cement in the long term., (© 2023. The Author(s).)

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., (© 2023. The Author(s).)

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

Primary hyperparathyroidism (PHPT) with pathological fracture is rare, and the early symptoms of PHPT lack specificity, leading to misdiagnosis. Therefore, this study aimed to summarize the clinical characteristics and treatment of PHPT patients with pathological fractures and to improve the attention of orthopedic clinicians to PHPT. It is a retrospective study, 2226 patients with hyperparathyroidism in our hospital from 2009 to 2019 were screened, excluding secondary hyperparathyroidism and patients without limb fracture, and the remaining 20 patients with PHPT accompanied by pathological fractures were finally analyzed. Parathyroid hormone (PTH) and calcium levels were compared on the first postoperative day, and the prognosis of the patients was assessed by bone mineral density and Visual Analogue Scale scores at 3 and 12 months postoperatively. The early symptoms of PHPT patients in this study included urinary calculi (80%), bone pain (30%), and digestive tract symptoms (25%). Fourteen (70%) cases were misdiagnosed at the initial diagnosis. After parathyroidectomy, the blood calcium and PTH levels decreased significantly in all patients (P < .05). For the treatment of fracture, 9 of the patients underwent surgical treatment of the fracture, while the remaining patients received splint external fixation. The follow-up time was 4.60 ± 0.62 years (1-10 years). All patients recovered well from the fracture, the symptoms of systemic bone pain were markedly improved, and bone mineral density was significantly improved after surgery. Orthopedic surgeons need to avoid misdiagnosis and pay attention to the early symptoms in PHPT patients with pathological fracture, and better therapeutic effects can be obtained by combining parathyroidectomy with fractures fixation., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose.

Background: Pathologic fracture of the long bones is a common complication of bone metastases. Intramedullary nail stabilization can be used prophylactically (for impending fractures) or therapeutically (for completed fractures) to preserve mobility and quality of life. However, local disease progression may occur after such treatment, and there is concern that surgical instrumentation and the intramedullary nail itself may seed tumor cells along the intramedullary tract, ultimately leading to loss of structural integrity of the construct. Identifying factors associated with local disease progression after intramedullary nail stabilization would help surgeons predict which patients may benefit from alternative surgical strategies., Questions/purposes: (1) Among patients who underwent intramedullary nail stabilization for impending or completed pathologic fractures of the long bones, what is the risk of local progression, including progression of the existing lesion and development of a new lesion around the nail? (2) Among patients who experience local progression, what proportion undergo reoperation? (3) What patient characteristics and treatment factors are associated with postoperative local progression? (4) What is the difference in survival rates between patients who experienced local progression and those with stable local disease?, Methods: Between January 2013 and December 2019, 177 patients at our institution were treated with an intramedullary nail for an impending or completed pathologic fracture. We excluded patients who did not have a pathologic diagnosis of metastasis before fixation, who were younger than 18 years of age, who presented with a primary soft tissue mass that eroded into bone, and who experienced nonunion from radiation osteitis or an avulsion fracture rather than from metastasis. Overall, 122 patients met the criteria for our study. Three fellowship-trained orthopaedic oncology surgeons involved in the care of these patients treated an impending or pathologic fracture with an intramedullary nail when a long bone lesion either fractured or was deemed to be of at least 35% risk of fracture within 3 months, and in patients with an anticipated duration of overall survival of at least 6 weeks (fractured) or 3 months (impending) to yield palliative benefit during their lifetime. The most common primary malignancy was multiple myeloma (25% [31 of 122]), followed by lung carcinoma (16% [20 of 122]), breast carcinoma (15% [18 of 122]), and renal cell carcinoma (12% [15 of 122]). The most commonly involved bone was the femur (68% [83 of 122]), followed by the humerus (27% [33 of 122]) and the tibia (5% [6 of 122]). A competing risk analysis was used to determine the risk of progression in our patients at 1 month, 3 months, 6 months, and 12 months after surgery. A proportion of patients who ultimately underwent reoperation due to progression was calculated. A univariate analysis was performed to determine whether lesion progression was associated with various factors, including the age and sex of the patient, use of adjuvant therapies (radiation therapy at the site of the lesion, systemic therapy, and antiresorptive therapy), histologic tumor type, location of the lesion, and fracture type (impending or complete). Patient survival was assessed with a Kaplan-Meier curve. A p value < 0.05 was considered significant., Results: The cumulative incidence of local tumor progression (with death as a competing risk) at 1 month, 3 months, 6 months, and 12 months after surgery was 1.9% (95% confidence interval 0.3% to 6.1%), 2.9% (95% CI 0.8% to 7.5%), 3.9% (95% CI 1.3% to 8.9%), and 4.9% (95% CI 1.8% to 10.3%), respectively. Of 122 patients, 6% (7) had disease progression around the intramedullary nail and 0.8% (1) had new lesions at the end of the intramedullary nail. Two percent (3 of 122) of patients ultimately underwent reoperation because of local progression. The only factors associated with progression were a primary tumor of renal cell carcinoma (odds ratio 5.1 [95% CI 0.69 to 29]; p = 0.03) and patient age (difference in mean age 7.7 years [95% CI 1.2 to 14]; p = 0.02). We found no associations between local disease progression and the presence of visceral metastases, other skeletal metastases, radiation therapy, systemic therapy, use of bisphosphonate or receptor activator of nuclear factor kappa-B ligand inhibitor, type of fracture, or the direction of nail insertion. There was no difference in survivorship curves between those with disease progression and those with stable local disease (= 0.36; p = 0.54)., Conclusion: Our analysis suggests that for this population of patients with metastatic bone disease who have a fracture or impeding fracture and an anticipated survival of at least 6 weeks (completed fracture) or 3 months (impending fracture), the risk of experiencing local progression of tumor growth and reoperations after intramedullary nail stabilization seems to be low. Lesion progression was not associated with the duration of survival, although this conclusion is limited by the small number of patients in the current study and the competing risks of survival and local progression. Based on our data, patients who present with renal cell carcinoma should be cautioned against undergoing intramedullary nailing because of the risk of postoperative lesion progression., Level of Evidence: Level III, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

Radiolucent implants offer theoretical advantages of increased ability to evaluate the fracture site for healing and recurrence and potentially less effect on radiation treatment, avoiding scatter. Their clinical utility and outcomes have yet to be proven in a well-designed randomized trial or large cohort study, although studies based on other indications have shown relative safety and they are approved by the US Food and Drug Administration for treatment of pathologic fractures. Further research is necessary to better understand when and how these implants should be implemented in practice. [ Orthopedics . 2022;45(3):e115-e121.].

Background: Pathological examination of the femoral head after hip arthroplasty is often performed routinely. The cost-effectiveness of the examination with regard to identifying clinically relevant diagnoses has been a point of discussion. To date, recommendations on performing pathological examination based on patient characteristics, disease history or radiographic findings are scarce. The aim of this study was to gain insight in when to select a patient for pathological examination of the femoral head by means of the following research questions: "How many clinically relevant diagnoses does selective pathological examination identify?" "Which factors contribute to selection of the femoral head for conducting pathological examination?" "What are the costs of selective pathological examination for identifying clinically relevant diagnoses?", Hypothesis: Selective pathological examination of the femoral head results in higher ratios of identified clinically relevant diagnoses against substantially lower costs., Methods: A retrospective cohort study was performed over the period of 2010-2015. All pathological reports were collected from our hospital and screened for resected femoral heads after primary total hip arthroplasty (THA) or primary hemiarthroplasty (HA). The coherence between preoperative diagnosis and postoperative pathological diagnosis was defined as concordant, discrepant or discordant. The aim was to perform logistic regression analysis., Results: In total, 164 patients were included of 3998 hip arthroplasties performed during the study period with a mean age of 74±12.3 years including 54 (33%) male and 110 (67%) female of whom 112 (68%) underwent THA and 52 (32%) HA. A discrepancy in diagnosis was found in nine patients (6%) and discordance in three patients (2%). The most frequently reported reasons to perform pathological examination were malignancy in medical history n=86 (53%), avascular necrosis n=22 (13%), bone abnormality perioperatively n=19 (11%) and pathological fracture n=13 (8%). The factors that identified the unexpected clinically relevant diagnoses were pathological fracture (3 cases out of 13), bone abnormality perioperatively (2 out of 19), abnormalities on preoperative radiographs (1 out of 9) and to a lesser extent malignancy in history (2 out of 86). With costs of pathological examination of approximately €163 per femoral head, performed in 164 patients, the total costs of pathological examination resulted in €26,732. The cost per discrepant case (n=9) was €2970 and the cost per discordant case (n=3) was €8910., Conclusion: Selective pathological examination of the femoral head following hip arthroplasty results in higher ratios of discrepant and discordant cases against substantially lower costs. Factors that identify clinically relevant diagnoses are pathological fracture, perioperative bone abnormality, abnormalities on preoperative radiographs and to a lesser extent malignancy in history., Level of Evidence: III; retrospective cohort study., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

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., (© 2022. The Author(s).)

PURPOSE OF THE STUDY The paper focuses on the potential use of nail osteosynthesis in diaphyseal metastases of long bones. The purpose of the paper is to assess the outcomes of intramedullary osteosynthesis in pathologic and impending pathologic fractures, to evaluate patient survival and potential complications. MATERIAL AND METHODS The retrospective study evaluated a cohort of 42 patients (19 men and 23 women) in whom intramedullary osteosynthesis was performed for complete pathologic fracture (28 patients) or impending pathologic fracture (14 patients) between 2010 and 2019. Of the total number of 42 patients, 31 patients' lower limbs were affected, namely by 17 pathologic fractures and 14 impending fractures. There were 11 humerus fractures. The mean age was 61.8 years (range 41-84 years). In the followed-up cohort, the patient survival after osteosynthesis with intramedullary nails, complications occurred and post-operative mobility of the patient were assessed. The functional outcomes were evaluated using the Musculoskeletal Tumor Society (MSTS) scoring system. The unpaired Mann-Whitney test was used to test the significance of the difference in functional outcomes and survival between the followed-up groups. Survival longer than 6 months was evaluated using Fisher's exact test. The level of statistical significance used for the test was p 0.05. RESULTS The investigated indicator was patient survival, which was 11.3 months (range 1-50 months) on average. In the group of impending fractures, the mean survival was 13.5 months. In the group of pathologic fractures, the survival was 10 months. The functional outcome in 16 followed-up patients at three months after intramedullary osteosynthesis according to the MSTS score was 46.9% (30-66.7%). At the level of significance of p 0.05, the statistically significant difference in the functional outcomes between the group with preventive intramedullary osteosynthesis and the group with nail osteosynthesis of the pathologic fracture was not confirmed (p=0.952). When comparing the patient survival after nail osteosynthesis with impending pathologic fracture and the survival of patients with pathologic fracture, a statistically significant difference in survival between these two groups (p=0.520) was not confirmed. The patient survival of longer than 6 months was 71% in the group of impending fractures and 40% in the group of pathologic fractures. DISCUSSION The occurrence of pathologic fracture is associated with increased pain, loss of function, and according to some authors, a higher risk of death. Surgical treatment options include intramedullary osteosynthesis, plate osteosynthesis with cement filling, implantation of an intercalary spacer, and implantation of tumor endoprostheses. When deciding on a surgical procedure, an account is taken of the expected survival of the patient. In patients with an expected survival of up to 6 months, intramedullary osteosynthesis is indicated as a palliative surgical intervention. The most common complications include implant failure and metastatic progression. CONCLUSIONS Intramedullary osteosynthesis is the method of choice in treating pathologic fractures or impending pathologic diaphyseal fractures of long bones in patients with an expected predicted survival of up to 6 months. Intramedullary osteosynthesis aims to reduce pain and enable early verticalization. The study confirmed the importance of preventive intramedullary osteosynthesis and its effect on survival compared to the survival of patients with a pathologic fracture. Key words: skeletal metastases, diaphyseal metastases, intramedullary osteosynthesis, pathologic fracture, impending fracture.

Background: Racial disparities in outcomes after orthopaedic surgery have been well-documented in the fields of arthroplasty, trauma, and spine surgery; however, little research has assessed differences in outcomes after surgery for oncologic musculoskeletal disease. If racial disparities exist in the treatment of patients with pathologic long bone fractures, then they should be identified and addressed to promote equity in patient care., Questions/purposes: (1) How do wait times between hospital admission and operative fixation for pathologic fractures of long bones differ between Black and non-Hispanic white patients, after controlling for confounding variables using propensity score matching? (2) How does the proportion of patients with 30-day postoperative complication differ between these groups after controlling for confounding variables using propensity score matching?, Methods: Using the National Surgical Quality Improvement Program database, we analyzed 828 patients who underwent fixation for pathologic fractures from 2012 to 2018. This database not only provides a large enough sample of pathologic long bone fracture patients to conduct the present study, but also it contains variables such as time from hospitalization to surgery that other national databases do not. After excluding patients with incomplete data (4% of the initial cohort), 775 patients were grouped by self-reported race as Black (12% [94]) or white (88% [681]). Propensity score matching using a 1:1 nearest-neighbor match was then used to match 94 Black patients with 94 white patients according to age, gender, BMI, American Society of Anesthesiologists physical status classification, anemia, endstage renal disease, independence in performing activities of daily living, congestive heart failure, and pulmonary disease. The primary outcome of interest was the number of days between hospital admission and operative fixation, which we assessed using a Poisson regression and report as an incidence risk ratio. The secondary outcomes were the occurrences of major 30-day postoperative adverse events (failure to wean off mechanical ventilation, cerebrovascular events, renal failure, cardiovascular events, reoperation, death), minor 30-day adverse events (reintubation, wound complications, pneumonia, and thromboembolic events), and any 30-day adverse events (defined as the pooling of all adverse events, including readmissions). These outcomes were analyzed using a bivariate analysis and logistic regression with robust estimates of variance and are reported as odds ratios. Because any results on disparities rely on rigorous control of other baseline demographics, we performed this multivariable approach to ensure we were controlling for confounding variables as much as possible., Results: After controlling for potentially confounding variables such as age and gender, we found that Black patients had a longer mean wait time (incidence risk ratio 1.5 [95% CI 1.1 to 2.1]; p = 0.01) than white patients. After controlling for confounding variables, Black patients also had greater odds of having any postoperative adverse event (OR 2.1 [95% CI 1.1 to 3.8]; p = 0.02), including readmission (OR 3.3 [95% CI 1.5 to 7.6]; p = 0.004)., Conclusion: The racial disparities in pathologic long bone fracture care found in our study may be attributed to fundamental racial biases, as well as systemic socioeconomic disparities in the US healthcare system. Identifying and eliminating the racial, socioeconomic, and sociocultural biases that drive these disparities would improve care for patients with orthopaedic oncologic conditions. One possible way to reduce these disparities would be to implement standardized surgical care pathways for pathological long bone fractures across different institutions to minimize variation in important aspects of care, such as time to surgical fixation. Further insight is needed on the types of standardized care pathways and the implementation mechanisms that are most effective., Level of Evidence: Level III, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

Background: The high mortality rates seen within the first postoperative year after hip fracture surgery have remained relatively unchanged in many countries for the past 15 years. Recent investigations have shown an association between beta-blocker (BB) therapy and a reduction in risk-adjusted mortality within the first 90 days after hip fracture surgery. We hypothesized that preoperative, and continuous postoperative, BB therapy may also be associated with a decrease in mortality within the first year after hip fracture surgery., Methods: In this retrospective cohort study, all adults who underwent primary emergency hip fracture surgery in Sweden, between January 1, 2008 and December 31, 2017, were included. Patients with pathological fractures and conservatively managed hip fractures were excluded. Patients who filled a prescription within the year before and after surgery were defined as having ongoing BB therapy. The primary outcome of interest was postoperative mortality within the first year. To reduce the effects of confounding from covariates due to nonrandomization in the current study, the inverse probability of treatment weighting (IPTW) method was used. Subsequently, Cox proportional hazards models were fitted to the weighted cohorts. These analyses were repeated while excluding patients who died within the first 30 days postoperatively. This reduces the effect of early deaths due to surgical and anesthesiologic complications as well as the higher degree of advanced directives present in the study population compared to the general population, which allowed for the evaluation of the long-term association between BB therapy and mortality in isolation. Results are reported as hazard ratios (HR) with 95% confidence intervals (CI). Statistical significance was defined as a 2-sided P value <.05., Results: A total of 134,915 cases were included in the study. After IPTW, BB therapy was associated with a 42% reduction the risk of mortality within the first postoperative year (adjusted HR = 0.58, 95% CI, 0.57-0.60; P < .001). After excluding patients who died within the first 30 days postoperatively, BB therapy was associated with a 27% reduction in the risk of mortality (adjusted HR = 0.73, 95% CI, 0.71-0.75; P < .001)., Conclusions: A significant reduction in the risk of mortality in the first year following hip fracture surgery was observed in patients with ongoing BB therapy. Further investigations into this finding are warranted., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society.)

Background/aim: The surgical treatment of patients with bone metastasis of the extremities poses a set of unique challenges. We aimed to highlight common hazards when treating pathological fractures as well as hazards surrounding assumptions on metastatic status and life expectancy., Materials and Methods: This systematic literature review includes studies published from January 1, 1985 to May 7, 2021. Published articles were surveyed using PubMed. Of 99 studies, 32 original articles were found to meet the inclusion criteria. The PRISMA guidelines were used to select articles., Results: Current literature reports a variety of common pitfalls. In order to avoid pitfalls, it is essential to secure the diagnosis. Furthermore, life expectancy must be given consideration when planning surgical therapy. In addition, a well-functioning multidisciplinary team is needed to coordinate further options such as radiation or embolization., Conclusion: Despite the fact that the surgical principles for treating bone metastases of the extremities are often to the point, incorporating all the nuances of treatment is a meticulous procedure., (Copyright © 2021 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

We present a 73-year-old woman who presented with a pathological fracture of her right humerus. Further imaging and biopsy indicated a mucinous adenocarcinoma of the lung as the primary neoplasm. This represents the first published case of a mucinous adenocarcinoma of the lung presenting as a metastatic lesion of the humerus. Operative management of pathological fractures of the humerus has typically included either intramedullary nailing or the use of single-plating or double-plating techniques. The authors describe a novel technique using both intramedullary fixation augmented with a locking plate, steel cables and bone cement, with good outcome., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Lower lumbar osteoporotic vertebral compression fracture in extremely elderly patients can often lead to lumbosacral radiculopathy (LSR) due to delayed vertebral collapse (DVC). Surgical intervention requires posterior instrumented lumbar fusion as well as vertebral augmentation or anterior column reconstruction depending on the cleft formation and intravertebral instability. However, it is necessary to decide on surgery in consideration of the patient's frail status, surgical invasiveness, and rehabilitation. In the lower lumbar DVC without intravertebral instability, biportal endoscopic posterior lumbar decompression and vertebroplasty (BEPLD + VP) can be simultaneously attempted. This study aimed to assess the clinical outcomes of BEPLD + VP for the treatment of DVC-related LSR., Methods: This retrospective case series enrolled 18 consecutive extremely elderly (aged ≥ 75-year-old) patients (6 men and 12 women) who had lower lumbar (at or below L3) DVC-related LSR. Patients who require anterior column reconstruction, such as cleft formation accompanied by intravertebral instability and patients who have not been followed for more than 6 months, were excluded from this study. All patients underwent BEPLD + VP under epidural anesthesia. Clinical results were evaluated by the visual analog scale (VAS) score and the modified Japanese Orthopedic Association (mJOA) scores., Results: Most of the patients had DVC affecting level L4, with the deformation being a flat type or concave type rather than a wedge type. The VAS score (back and leg) significantly decreased from 7.78 ± 1.17 and 6.89 ± 1.13 preoperatively to 2.94 ± 0.64 and 2.67 ± 1.08 within 2 postoperative days (p < 0.001). The mJOA score significantly improved from 4.72 ± 1.27 preoperatively to 8.17 ± 1.15 in the final follow-up (p < 0.001). The mean recovery rate (RR) in the last follow-up was 56.07% ± 9.98. Incidental durotomy was reported in two patients and epidural hematomas in another two patients; however, all patients improved with conservative treatment, and no re-operation was required., Conclusions: BELPD + VP was a type of salvage therapy that reduces surgical morbidity, requires major spine surgery under general anesthesia and provides good clinical outcomes in extremely elderly patients with DVC-related LSR.

Objective: To explore the high-risk factors of augmented vertebra recompression after percutaneous vertebral augmentation (PVA) in the treatment of osteoporotic vertebral compression fracture (OVCF) and analyze the correlation between these factors and augmented vertebra recompression after PVA., Methods: A retrospective analysis was conducted on 353 patients who received PVA for a single-segment osteoporotic vertebral compression fracture from January 2017 to December 2018 in our department according to the inclusion criteria. All cases meeting the inclusion and exclusion criteria were divided into two groups: 82 patients in the recompression group and 175 patients in the non-compression group. The following covariates were reviewed: age, gender, body mass index (BMI), injured vertebral segment, bone mineral density (BMD) during follow-up, intravertebral cleft (IVC) before operation, selection of surgical methods, unilateral or bilateral puncture, volume of bone cement injected, postoperative leakage of bone cement, distribution of bone cement, contact between the bone cement and the upper or lower endplates, and anterior height of injured vertebrae before operation, after surgery, and at the last follow-up. Univariate analysis was performed on these factors, and the statistically significant factors were substituted into the logistic regression model to analyze their correlation with the augmented vertebra recompression after PVA., Results: A total of 257 patients from 353 patients were included in this study. The follow-up time was 12-24 months, with an average of 13.5 ± 0.9 months. All the operations were successfully completed, and the pain of patients was relieved obviously after PVA. Univariate analysis showed that in the early stage after PVA, the augmented vertebra recompression was correlated with BMD, surgical methods, volume of bone cement injected, preoperative IVC, contact between bone cement and the upper or lower endplates, and recovery of anterior column height. The difference was statistically significant (P < 0.05). Among them, multiple factors logistic regression elucidated that more injected cement (P < 0.001, OR = 0.558) and high BMD (P = 0.028, OR = 0.583) were negatively correlated with the augmented vertebra recompression after PVA, which meant protective factors (B < 0). Preoperative IVC (P < 0.001, OR = 3.252) and bone cement not in contact with upper or lower endplates (P = 0.006, OR = 2.504) were risk factors for the augmented vertebra recompression after PVA. The augmented vertebra recompression after PVP was significantly less than that of PKP (P = 0.007, OR = 0.337)., Conclusions: The augmented vertebra recompression after PVA is due to the interaction of various factors, such as surgical methods, volume of bone cement injected, osteoporosis, preoperative IVC, and whether the bone cement is in contact with the upper or lower endplates.

Background: Osteitis fibrosa cystica is the classic manifestation of primary hyperparathyroidism (PHPT), occurs after prolonged exposure of bone to high serum parathyroid hormone (PTH) level. It has become increasingly rare due to early detection of PHPT., Case Presentation: A 37-year-old woman was referred to our institution for fixation of multiple fractures of upper and lower extremities that had been reoccurring in the past 5 years. Her medical history showed right-shoulder, left-elbow, and right-femur fractures after a fall 5 years previously. One month ago, she sustained fractures of the right distal humerus, left tibia, and left femur without history of trauma. Upon arrival to our hospital, a thorough review of her plain radiographs demonstrated brown tumors at multiple sites, along with a salt-and-pepper appearance of the skull and a rugger-jersey spine, compatible with osteitis fibrosa cystica. Patient was diagnosed with PHPT, confirmed by high-corrected serum calcium (13.6 [8.6-10.0] mg/dl), low serum phosphate (2.2 [2.5-4.5] mg/dL), high serum alkaline phosphatase (1482 [35-105] U/L), and significantly elevated parathyroid hormone (PTH 3850 [15-65] pg/mL). A histologically confirmed, 2.5-cm parathyroid adenoma was removed by parathyroidectomy. Ten days later, closed reduction and internal fixation of the left proximal femoral shaft was performed. Pain and ambulation were significantly improved 6 months postoperatively. At the 1.5-year follow-up, fracture unions and complete mineralization of brown tumors were noted; the patient could ambulate with neither pain nor an assistive device., Conclusions: PHPT has become more asymptomatic in countries where routine calcium screening is performed. Nevertheless, the classic skeletal involvement, osteitis fibrosa cystica, should not be overlooked, particularly in young patients who present with a low-energy fracture.

Background: To describe the rate and predictors of pathologic fractures in benign neoplasms of the finger, as variables from prediction models for pathologic fractures of the long bones of the extremities are not necessarily applicable to the bones of the hand. Methods: In this retrospective chart review, 69 histologically confirmed neoplasms affecting the bones of the fingers, 49 phalanges and 20 metacarpals, were identified in patients presenting at 2 urban hospitals over a 24-year period. Different variables were studied as possible predictors of pathologic fractures. Results: Forty-nine percent of the tumors presented as a pathologic fracture. The small finger was independently associated with pathologic fractures compared to the other fingers. Tumors of the metacarpal bones were the least likely to fracture compared to other bones. Conclusions: Almost half of neoplasms affecting the bones of the fingers presented initially with a pathologic fracture, most commonly the small finger. Therefore, a lower threshold for surgical treatment of a bone neoplasm affecting the small finger may be reasonable.

Background: The aim of this retrospective study is to analyze history and treatment outcomes of pathological fracture (PF) in dedifferentiated chondrosarcoma (DdChS) of the limbs.., Methods: We retrospectively reviewed 175 adult patients with primary DdChS of the limbs.Disease-specific survival (OS) and local recurrence (LR) were analyzed., Results: Median age was 66 years (range, 29-91). Most DdChS (121, 69.1%) were localized in the femur. Forty-nine (28.0%) had metastasis at diagnosis; thirty-nine DdChS (22.3%) had a PF.OS rate was lower in patients with metastasis at diagnosis (8.6% Vs 41.0% at 10 years, p < 0.001). A similar OS was observed among patients with localized disease, whether with/without PF (p = 0.638), with/without chemotherapy (p = 0.543) and independently from the type of surgery (resection/amputation) (p = 0.877). Amputation reduces the risk of LR (80.0% vs 63.1% at 5 years, p = 0.039), particularly in the PF group.., Conclusion: Patients with metastases have a particularly poor prognosis in DdChS, but pathological fracture does not influence prognosis in terms of survival and local control. Initial curative resection is essential in order to reduce the chance of recurrences. Amputation might be an option in patients with localized disease and a PF to reduce the risk of LR.., (Copyright © 2020 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Impending and complete pathologic fractures often necessitate surgical fixation. Traditional orthopedic implants are commonly used, achieving clinically acceptable outcomes, but their metallic composition can impair radiographic evaluation and affect radiation treatments. Recognition of these concerns led to the development of radiolucent implants such as the minimally invasive Photodynamic Bone Stabilization System (PBSS; IlluminOss Medical Inc), featuring a light cured polymer contained within an inflatable balloon catheter. Two participating hospitals in one health care system reviewed cases using the PBSS implant. Twenty-five patients with 29 impending or pathologic fractures in the proximal radius or humerus from metastatic carcinoma, myeloma, lymphoma, and melanoma were identified. Clinical charts and imaging were reviewed to determine the status of the implant at final follow-up as well as complications. For analysis, a chi-square test was used for nominal variables and a t test was used for continuous variables. Eleven of the 25 patients were alive with disease at the time of analysis. Eight of 29 (27.5%) implants failed. Five of 25 (20%) patients required repeat surgery due to complications, including 3 revision open reduction and internal fixations, 1 open reduction and internal fixation for a periprosthetic fracture, and 1 screw removal. Five of the 9 cases (56%) ( P =.03) with lesions in the distal humeral shaft had breakage of the implant by final follow-up, compared with 3 of 20 cases (15%) ( P =.03) elsewhere in the humerus; no failures were seen in the radius. One of 4 patients (25%) also had failure in the surgical neck, although this did not reach significance. Five patients were noted to have progression of disease on follow-up radiographs, with 4 failures in patients with progression. The PBSS implants potentially allow improved surveillance of fracture healing and tumor recurrence along with decreased scattering of radiation during treatment. Unfortunately, there may be a higher rate of mechanical failures, particularly for lesions involving the distal humerus. This may be due to decreased cross-sectional area of the implant in this region as compared with the metaphyseal and proximal regions. Caution should be exercised when treating distal humeral pathologic fractures with large lytic lesions where the underlying disease process is not well controlled. [ Orthopedics . 2021;44(3):154-159.].

Background: Hemophilic pseudotumor (HPT)-related fracture is a rare but severe complication in patients with HPTs. These fractures often occur in femurs. There is no consensus on the standard surgical protocol for HPT-related femoral fracture. The present retrospective study evaluated the outcomes of these patients treated with surgical interventions., Methods: Ten patients with HPT-related femoral fractures who were treated with 14 surgical procedures due to 11 fractures in our hospital from January 2014 to April 2020 were evaluated retrospectively. Demographic data, fracture location, complications after surgery, and follow-up outcomes were recorded and analyzed. The mean follow-up period was 39.7 months., Results: The mean age at surgery was 31 years. Closed reduction external fixation (CREF) was originally performed in 2 patients, open reduction internal fixation (ORIF) was performed in 4 patients, screw fixation alone was performed in 1 patient, brace immobilization was performed in 1 patient, and amputation was performed in 3 patients. Bone union was observed in 5 patients, and an adequate callus was visible in 2 patients. Both patients with CREF had pin infections. Nonunion combined with external fixation (EF) failure occurred in 1 patient, and the plate was broken after ORIF. Three patients underwent autogenous or allogeneic cortical strut grafting. Three patients had HPT recurrence., Conclusions: It is necessary to perform surgery in patients with HPT-related femoral fractures. Surgical treatments must consider fracture stabilization and HPT resection. Internal fixation is preferable, and EF should only be used for temporary fixation. If the HPT erodes more than one third of the bone diameter, strut grafts are necessary for mechanical stability. Amputation is an appropriate curative method in certain situations.

Objective: This study aimed to assess the pain and functional status of patients who underwent various surgical interventions for the stabilization of selected multiple myeloma (MM) lesions in the extremities and pelvis and to investigate the rate of complications requiring reintervention., Methods: Patients with MM who underwent various surgical interventions for the extremity or pelvic lesions were retrospectively reviewed. Change in the pain intensity was assessed using visual analogous scale (VAS) preoperatively, at the time of discharge, and at the final follow-up. Functional status was assessed using the musculoskeletal tumor society (MSTS) scoring system for both upper and lower extremities preoperatively and at the final follow-up. Postoperative complications requiring reintervention, including dislocation, loss of fixation/aseptic loosening of prosthesis, mechanical insufficiency, periprosthetic fracture, infection, or progression of the local disease, were recorded., Results: A total of 49 (20 men and 29 women) previously (23) or newly (26) diagnosed patients with a mean age of 60.8±18.2 years were included in this study. Of these, 6 patients underwent multiple surgeries for different skeletal sites; in total, 57 procedures were performed. The mean follow-up was 47.7±21.63 months. The lesions were localized to the humerus (19), radius (1), pelvis (4), femur (30), and tibia (3). The surgical indications included therapy-refractory pain for 17 patients and pathological fractures due to progression of pre-existing lesions for 12 patients or newly diagnosed lesions with extensive bone destruction at initial presentation for 28 patients. Surgical procedures included prosthetic reconstruction in 32 patients, cement-augmented osteosynthesis in 9, and closed intramedullary nailing in 16. The mean VAS score decreased from 8.75±1.2 preoperatively to 3.21±1.56 at the time of discharge and 1.2±0.42 at the final follow-up. Although a significant decrease was detected between the preoperative and postoperative VAS scores at the time of discharge (p=0.0001), the decrease between the time of discharge and the final follow-up was statistically insignificant (p=0.086). The mean MSTS score significantly improved from 9.1%±6.4% (range: 0%-40%) preoperatively to 76%±14.9% (range: 40%-93.3%) at the final follow-up (p=0.0001). Significantly higher MSTS scores were obtained in the upper extremity than lower extremity/pelvis (p=0.04) and in isolated diaphyseal involvement than metaphyseal or articular involvement (p=0.032). A total of 11 complications requiring reintervention (19.2%) were observed, which included dislocation (3.5%), loss of fixation (5.2%), mechanical insufficiency (3.5%), infection (5.2%), and local tumor progression (1.7%). The rate of complications requiring reintervention was lower but statistically insignificant in the upper extremity (5%; 1/20) than lower extremity/pelvis (27%; 10/37) (p=0.076) and in isolated diaphyseal involvement (6.2%; 1/16) than metaphyseal or articular involvement (24.3%; 10/41) (p=0.079)., Conclusion: Although different types of surgeries can achieve pain relief and good function in different anatomical localizations, better functional results with lower complication rates may be obtained following surgical management of MM lesions in the upper extremities and in diaphyseal localizations., Level of Evidence: Level IV, Therapeutic Study.

A 65-year-old female patient has a history of malignant triton tumour of the right upper lobe of the lung. She underwent right upper lobectomy and lymphadenectomy in May 2018. She presented in November 2019 with pathological fracture of the left proximal femur. It was not associated with neurofibromatosis. We decided to do an excisional biopsy of the mass and proximal femoral replacement followed by radiotherapy. Four months later, she presented with local recurrence. We organised a multidisciplinary team between the orthopaedic, histopathology and oncology teams. Then, we decided to treat her with chemotherapy. After 2 months of follow-up, she responded well to the chemotherapy with no further deterioration of her condition., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Percutaneous vertebroplasty (PVP) is a routine operation for the treatment of osteoporotic lumbar compression fractures (OLCFs). As is well known, unilateral puncture is a common method. However, with the conventional transpedicular approach (CTPA), the cement may be asymmetrically dispersed, so some surgeons use the transverse process root-pedicle approach (TPRPA). The objective of this study was to compare the clinical results and bone cement distribution of PVP for OLCF with unilateral TPRPA and CTPA to identify the advantages and disadvantages of the two surgical options., Patients and Methods: From January 2016 to June 2019, seventy-two elderly patients who underwent unilateral PVP for single-level OLCF were retrospectively reviewed. Operation time, injection amount and type of bone cement distribution, and bone cement leakage and surgical complications were recorded. The visual analog scale (VAS) scores and Oswestry disability index (ODI) scores were used to evaluate the clinical results. All patients were followed up for more than 12 months, and the assessment was based primarily on clinical and radiological outcomes., Results: There were significant differences in the surgical time and the volume and the type of bone cement distribution and the lost of operative vertebra height between the two groups. However, there was no significant difference in bone cement leakage. Moreover, there were no significant differences in VAS and ODI between the two groups at 2 days and 12 months after the operation., Conclusions: Unilateral TPRPA and CTPA are practical and feasible methods in PVP for the treatment of OLCF, and they have similar clinical effects. However, TPRPA has the advantages of a better distribution of bone cement and a shorter operation time and a better maintenance effect of injured vertebra height, without increasing the rate of bone cement leakage.

Six days after a normal delivery, a 24-year-old woman with atraumatic lumbosacral pain radiating to the left groin was referred to the orthopaedic surgeon due to worsening pain and impossible load bearing on the left lower limb. Standard pelvic radiographs revealed an unstable displaced left neck of femur (NOF) fracture. A CT scanner and MRI showed diffuse osteopaenia of the left proximal femur and the corresponding acetabulum. A diagnosis of transient osteoporosis of the hip (TOH) complicated by a pathological displaced subcapital NOF fracture was established. The patient underwent total hip arthroplasty without complication and recovered excellent function after rehabilitation. Awareness of the differential diagnosis of TOH in pregnancy, a high index of suspicion and early MRI to make an early diagnosis and to prevent devastating fracture complications are mandatory., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

A 60-year-old man presented to our hospital with complaints of pain and deformity on his right thigh for the past 2 days following a history of accidental slip and fall. Radiological investigations suggested a pathological type 2 Seinsheimer subtrochanteric fracture of the right femur with a 'bone within bone' appearance, which posed a diagnostic dilemma as this radiological appearance is seen in a spectrum of conditions. Radiographic skeletal survey failed to identify a similar appearance elsewhere in the body. Laboratory investigations pointed in favour of bone mineral disease, and histopathological examination of the bone narrowed it down to Paget's disease. The fracture was fixed with a contralateral distal femur locking compression plate. The fracture site failed to show signs of union until 6 months postsurgery and hence the patient was advised for grafting procedure. The patient deferred surgery and remains without major complications until 18 months of follow-up., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Rationale: Angiosarcoma is a rare malignant tumors. The objective of this study is to report a patient who suffered from a progressive low back pain and left lower extremities radiation pain for about 8 months, After diagnoses, this was identified as an extremely rare case of primary multiple angiosarcoma of vertebra., Patient Concerns: A 54-year-old man with a history of 2-year hypertension and 8-year diabetes, both of which were well controlled by drug management. Lately, he suffered from a progressive low back pain and left lower extremities radiation pain for about 8 months., Diagnoses: Magnetic resonance imaging of lumbar showed a clear pathological fracture and primary multiple angiosarcoma of all vertebra. Postoperative pathology and High-throughput sequencing confirmed the diagnosis of primary multiple angiosarcoma of vertebra., Interventions: The patient underwent minimally invasive pedicle screw fixation combined with bone cement augmentation for the purpose of stabilizing the damaged vertebrae. Following operation, he received both radiotherapy and chemotherapy for a period of time., Outcomes: The operation has achieved positive results in relieving pain and stabilizing the spine. No wound problem or operative complications occurred after operation. The patient reported an obvious remission of low back pain and was only capable to perform restricted physiological activities. A long-term palliative radiotherapy and chemotherapy were performed after operation. Unfortunately, the patient died 18 months later., Conclusion: This article emphasizes primary multiple angiosarcoma of vertebra. Despite being rare, it should be part of the differential when the patient manifested back pain and radiculopathy. We recommended the minimally invasive pedicle screw fixation for angiosarcoma of vertebra. Osteoplasty by bone cement augmentation was also an ideal choice for surgical treatment. It also advocates the use of specific targeted radiotherapy drugs based on gene analysis of tumors.

Introduction: Peripheral skeletal metastasis (PSM) has a negative impact on quality of life. New treatments for the primary tumor or the osteolysis hold out hope of improved survival. The few published French series were small, and we therefore undertook a multicenter retrospective analysis of PSM surgery between 2005 and December 2016, with the aim of assessing: 1) rate and type of complications, 2) functional results, and 3) overall survival and corresponding risk factors., Hypothesis: The French data for clinical results, survival and complications are in agreement with the international literature., Materials and Method: The series comprised 391 patients with 434 metastatic locations. There was female predominance: 247 women (63%). Two sites were treated in 46 patients (12%), and three in 5. The main etiologies were breast cancer (151/391: 39%), lung cancer (103/391: 26%) and kidney cancer (52/391: 13%). There was synchronous visceral metastasis in 166 patients (42.5%), other peripheral locations in 137 (35%) and spinal location in 142 (39%). One hundred (27%) had ASA score>3; 61 (16%) had WHO score>3. The reason for surgery was pathologic fracture (n=137: 35%). Locations were femoral (274: 70%), acetabular (58: 15%), humeral (40: 0%), tibial (12: 3%) or other (7: 2%)., Results: There were surgery site complications in 41 patients (9.4%), including 13 surgery site infections, and general complications in 47 patients (11%), including 11 cases of thromboembolism, 6 of blood loss, 9 pulmonary complications and 6 perioperative deaths. Overall survival, taking all etiologies and sites together, was 10 months (range, 5 days to 9 years; 95% CI, 8-13 months), and significantly better in females (14 versus 6 months; p=0.01), under-65 year-olds (p=0.001), and in preventive surgery versus fractured PSM (p=0.001). Median survival was 22 months (95% CI, 17-28 months) after breast cancer, 3 months (95% CI, 2-5 months) after lung cancer, and 17 months (95% CI, 8-58 months) after kidney cancer. Preoperatively, walking was impossible for 143 patients (38%), versus 23 (6.5%) postoperatively; 229 patients (63.5%) could walk normally or nearly normally after surgery, versus 110 (28%) before. After surgery, 3 patients (6%) were not using their operated upper limb, versus 27 (45%) before; 30 patients (54%) had normal upper limb use after surgery, versus 8 (5%) before., Conclusion: The study hypothesis was on the whole confirmed in terms of survival according to type of primary and whether surgery was indicated preventively or for fracture., Level of Evidence: IV, retrospective study without control group., (Copyright © 2019. Published by Elsevier Masson SAS.)

Introduction: Long bone metastasis to the tibia is somewhat rare and has only been studied in a few publications with a limited number of cases. This led us to carry out a large multicenter, observational, retrospective study to 1) evaluate the clinical and radiological outcomes of surgical treatment at this location and 2) highlight the specific risks associated with this condition., Hypothesis: We hypothesized that the clinical outcomes and survivorship were comparable to those reported in the literature., Material and Methods: The case series included 15 men and 10 women with a mean age of 66±11.7 years. The most common primary cancers were kidney (10 patients) and lung (4 patients). Thirteen patients had a concurrent visceral metastasis and sixteen had metastasis in another bone. The tibial metastasis was the initial sign of cancer in seven patients. The surgical procedure was done to prevent an impending fracture in 19 patients and to treat a pathological fracture in 6 patients (initial sign of cancer in 4 patients). Osteolysis occurred in the proximal epiphysis/metaphysis in 12 patients, diaphysis in 9 patients and distal epiphysis/metaphysis in 4 patients. We performed fixation with a lateral cortex plate and cementoplasty in 14 patients, locked intramedullary nailing in 8 patients, cementoplasty only in 2 patients and knee arthroplasty in 1 patient., Results: Three surgical site infections, one pulmonary embolism and one cardiac rhythm disturbance occurred. Four patients died before the 3 rd month postoperative. At their best clinical status, 2 patients had not resumed walking, 10 could walk short distances with two canes or a walker, 3 had altered gait but could walk without aids and 6 could walk normally. The mean survival was 14±11.7 months (95% CI: 8.1-19.8) for all patients, 4±4 months (95% CI: 3-14) for those with a lung primary and 32±14 months (95% CI: 20-47) for those with a kidney primary. The survival was 15 months (95% CI: 4-29) after preventative treatment and 5 months (95% CI: 4-26) after fracture treatment., Conclusion: Our clinical outcomes are comparable overall to the three main published articles on this topic. The risk of infection and benefits of preventative fixation were apparent in our cohort., Level of Evidence: IV, retrospective study., (Copyright © 2019. Published by Elsevier Masson SAS.)

The goal of this study was to report the clinical outcomes of pathologic humeral shaft fractures treated with reamed or unreamed intramedullary nail fixation in an era of longer patient survival. A retrospective review was conducted of all patients who underwent intramedullary nail fixation performed by a single surgeon for pathologic humeral shaft fractures at a Level I trauma center from 2009 to 2017. Of the 25 patients who were identified, 9 were excluded. Groups were categorized according to whether they underwent reamed or unreamed fixation, and they were evaluated for evidence of union, complications, and reoperation. Of the patients, 11 underwent an unreamed procedure and 5 underwent a reamed procedure. Mean length of follow-up was 51.5 weeks. Of the patients who participated, 12 (75%) showed evidence of union and 2 patients (12.5%) showed evidence of nonunion, with no statistical difference between the groups. Five patients (31.3%) had complications. One nonunion occurred in the reamed group and did not require reoperation. In the unreamed group, complications consisted of 1 delayed union, 1 nonunion treated with revision intramedullary nail fixation, and 2 cases of disease progression that required reoperation. Intramedullary nail fixation of pathologic humeral shaft fractures achieves rates of union parallel to those seen with fixation in a healthy population. The length of follow-up in the current study was longer than the life expectancy reported by previous authors, which can be attributed to improvements in the treatment of cancer. The current authors argue that unreamed fixation is the optimal technique because it yields similar outcomes to a reamed approach and is faster and potentially safer. [Orthopedics. 2020;43(5):e389-e398.]., (Copyright 2020, SLACK Incorporated.)

Background: Surgical treatment for metastatic pathological femur fractures is associated with high mortality. Correct estimation of prognosis helps in determining the palliative value of surgical treatment and informs surgical decision. This study evaluates the risk factors for mortality in these patients who were surgically treated., Methods: This is a retrospective study of 112 patients with surgical treatment of metastatic pathological femur fractures. Risk factors evaluated included age, ASA status, Charlson comorbidity index, preoperative serum albumin and haemoglobin, primary tumour site, presence of visceral metastases, presence of spinal metastases, time from diagnosis of cancer to occurrence of pathological fracture, type of surgical procedure performed, lesion and whether treatment was received for an actual or impending fracture. A Cox regression model was used to determine if these factors were independent significant factors for survival., Results: Mortality at 2 years after surgical treatment of metastatic femoral fractures was 86%. Cox regression analysis of risk factors revealed that preoperative serum albumin and type primary tumour were independent risk factors for mortality. Presence of visceral metastases was strongly correlated to serum albumin levels., Conclusion: Preoperative serum albumin level and primary tumour site are independent risk factors of survival in patients treated for pathological femur fractures. Serum albumin level may be used as a prognostic tool to guide treatment in this cohort of patients with high mortality rates.

Background/objective: The purpose of this study is to analyze the effect of surgical methods on mortality and the relative risk of patients who underwent internal fixation (IF) or hemiarthroplasty (HA) after being diagnosed as a pertrochanteric fracture over 65 years old in a Korean nationwide cohort with a single insurance medical system., Methods: The Korean National Health Insurance Service-Senior cohort (NHIS-Senior, NHIS-2018-2-111) was used in this study. The eligibility criteria for incident hip fracture patients were the following: (1) first-time admission to acute care hospitals (index admission) with pertrochanteric fracture (ICD-10 S721), (2) three years of hip fracture-free period, (3) recipients of typical surgeries including IF, HA, (4) age between 65 and 99., Results: a total of 7223 patients were enrolled in the cohort. There were 1662 patients (23%) in the HA group and 5561 patients (77%) in the IF group. Mortality rates of the IF group and HA group were 13.46 and 17.94 cases per 100 person-years, respectively. In the multivariable-adjusted Cox proportional hazard model, the HA group had 1.22 times more hazard of all-cause mortality than IF group (aHR 1.22, 95% CI 1.13-1.32). In subgroup analysis, aged 65-79 and female patients showed a prominent association between surgery type and mortality (aHR 1.52, 95% CI 1.29-1.79)., Conclusions: In patients with pertrochanter fracture over 65 years, 1.22-fold mortality rate was observed when HA was performed compared to that of IF, and the difference in mortality was particularly prominent within 1-year after surgery., (Copyright © 2019. Published by Elsevier Taiwan LLC.)