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The article reported the results of osteosynthesis in 65 patients with pathological fractures on the background of metastatic bone lesions. We have applied such methods of osteosynthesis: perosseous osteosynthesis with external fixation device — in 33 (50.8 %) patients, reinforced osteosynthesis — in 32 (49.2 %). Osteosynthesis has been applied in comprehensive treatment using polychemotherapy, radiation therapy, hormone therapy, immunotherapy and bisphosphonates. Due to the use of osteosynthesis techniques in complex treatment regimens, complications occurred in 2 (3.1 %) patients, recurrences of metastatic tumors — in 3 (4.6 %) patients, new foci of metastatic lesions in bones and visceral organs during the treatment were detected in 35 ( 53.8 %) patients. The three-year overall survival rate of patients was 28.60 ± 1.32 %, five-year — 14.40 ± 1.96 %. The use of osteosynthesis techniques in the comprehensive treatment in patients with metastatic lesions of long bones helps to restore the function and support ability of the limb, to reduce pain and therefore to improve the quality of life of these patients.

Metastatic bone disease of the distal extremities, also known as acrometastasis, is very rare. Thus, there is very limited information regarding the clinical manifestations and methods of surgical treatment. The current available literature shows that acrometastases are often encountered in the context of advanced disease and are thus associated with poor patient survival. As metastatic bone disease is generally uncurable, the goal of surgical treatment is to provide the patient with good function with as few complications as possible. In this article, we discuss the clinical manifestation of acrometastases, the methods of surgical intervention, and the expected clinical outcome. Non-surgically managed pathological fractures generally remain ununited; therefore, conservative treatment is reserved for patients with poor general condition or dismal prognosis. The current evidence suggests that in lesions of the lower arm and leg, osteosynthesis (plate and screw fixation or intramedullary nail) is the most common method of reconstruction, whereas local excision or amputation are more commonly used in cases of more distal lesions (such as ankle, foot and hand). Following surgery most patients receive adjuvant radiotherapy, even though its role is poorly documented. Close collaboration between orthopedic surgeons and medical oncologists is necessary to improve patient care and treatment outcome. Further studies are needed in order to provide stronger clinical evidence and improve decision-making, in an effort to optimize the patients’ quality of life and avoid the need for revision surgery.

To compare the clinical outcomes of external fixator + elastic stable intramedullary nail (EF+ESIN) vs. external fixator (EF) in the treatment for open tibial shaft fracture in overweight adolescents.Patients of open tibial shaft fractures younger than 14 years old with body weight over 50 Kg treated with EF + ESIN or EF at our institute from 2010 to 2018 were reviewed. Patients with Gustilo Type III open fractures, pathological fractures, previous fracture or instrumentation in the operative leg were excluded. Baseline information and clinical data were collected from the hospital database and during out-patient visits.Forty-six patients, including 27 males and 19 females, were included in the EF group, whereas 35 patients, including 18 males and 17 females, were included in the EF + ESIN group (p = 0.527). The incidence of superficial infection was higher in the EF group (26/46, 56.5%) than the EF + ESIN group (12/35, 34.3%), p 0.001. The frontal and sagittal angulation was higher in the EF group (p 0.001), but the degrees in both groups were within the acceptable range. The union time was longer in the EF group (68.0 ± 12.7, d) than the EF + ESIN group (61.9 ± 11.9), p 0.001. The retaining of EF (11.9 ± 3.2, w) was longer in the EF group than the EF +ESIN group (5.7 ± 1.2, w), p 0.001.EF+ESIN is a safe and alternative choice for selected overweight adolescents with open tibial shaft fracture.

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.

Pathologische Frakturen und Instabilitaten der Wirbelsaule sind am haufigsten durch Primarien verursacht, die hamatogen in die Wirbelsaule metastasieren. Hierzu zahlen v. a. das Mamma‑, Prostata‑, Nierenzell- und Bronchialkarzinom. Eine weitere haufige Entitat stellt das multiple Myelom dar. Primare Tumoren der Wirbelsaule sind entsprechend selten und machen nur einen geringen Anteil aller malignen Prozesse der Wirbelsaule aus. Das Leitsymptom Schmerz ist in diesem Zusammenhang prognostisch ungunstig und geht haufig mit drohenden Instabilitaten oder pathologischen Frakturen einher. Zur Objektivierung des therapeutischen Vorgehens mussen u. a. der neurologische Status, eine onkologische Beurteilung, die biomechanische Stabilitat und der (systemische) Allgemeinzustand (NOMS[Neurologic, Oncologic, Mechanical Stability, and Systemic disease]-Kriterien) des Patienten einbezogen werden. Ein weiterer wesentlicher Faktor ist die Strahlensensibilitat des Tumors. Zur Beurteilung der Stabilitat wird der Spinal Instability Neoplastic Score (SINS) empfohlen. Unabhangig davon, ob eine konservative oder operative Therapie durchgefuhrt wird, muss eine interdisziplinare Zusammenarbeit zwischen den Fachkliniken gewahrleistet sein, um die adaquate Behandlung fur den Patienten zu erreichen. Wird ein kurativer Ansatz verfolgt, muss eine individualisierte und interdisziplinare Operationsstrategie zum Erreichen einer R0-Resektion meist als Spondylektomie angestrebt werden. Handelt es sich um eine palliative Behandlung, mussen die Ziele der chirurgischen Therapie die Schmerzreduktion, Stabilitat und Vermeidung bzw. Wiederherstellung von neurologischen Defiziten sein. Hierzu sind Stabilisierungen in perkutaner oder offener Technik, ggf. in Kombination mit einer Dekompression und einem lokalen Tumor-Debulking, notwendig.

One of the most severe complications of metastatic lesion of the skeleton is the development of a pathological fracture, which not only affects the quality of life, makes it difficult to carry out adequate systemic treatment, but also has a negative effect on survival. In case of a pathological fracture, the main method of treatment is a surgical method. The main goal of the correction is to achieve stability and reduce metastatic pain in the area of damage or fracture. Today, the most popular organ-preserving operations for metastatic lesions of the femur in combination with pathological fractures are endoprosthesis and intramedullary osteosynthesis. In this paper, a comparative analysis of the results of their use is carried out, the advantages and disadvantages of each of the methods are described.

Osteoradionecrosis of the jaw can be treated using both conservative treatment and surgery. External fixation may be used to bridge large resection defects after sequestrectomy for stabilisation and before secondary mandibular reconstruction. We designed a retrospective analysis of 70 patients with osteoradionecrosis treated between the years 2014 and 2018, and found that the use of external fixation greatly improves their outcomes. Patients were grouped according to Notani's classification: those who had Notani I disease were treated surgically but without external fixation; and those with Notani II and Notani III disease were eligible for external fixation. In those with Notani II disease, there was a significant reduction in the number of pathological fractures that occurred with external fixation. In those with Notani III disease, the success rate of primary sequestrectomy was only 1:14; however, those treated with external fixation all successfully healed after their first operation. It was hypothesised that although external fixation would improve outcome, it would come at a detriment to their quality of life (QoL). However, in a subset of these patients, we showed that in addition to increasing successful healing, patients' QoL with the external fixator was no worse than when they had an active osteonecrotic lesion. The treatment of osteoradionecrosis is cumbersome and advanced stages are associated with more complications. The use of an external fixator significantly reduces the probability of pathological fractures and increases the rate of successful healing in patients after mandibular resection. It does this without greatly interfering with patients' lives, while improving their condition sufficiently to allow for subsequent mandibular reconstruction.

To compare reamed intramedullary nailing (RIM) versus un-reamed intramedullary nailing (URIM) for the treatment of impending and pathological fractures of the humeral shaft in terms of 24-h postoperative pain, blood transfusion requirements, surgical time, surgical complications, medical complications, length of stay and consolidation rates. A retrospective comparative study between January 2013 and December 2018 was conducted. Student’s t test, Mann–Whitney U and Chi-square tests were used to detect differences within the two study groups. Multiple linear regression was done to adjust for possible confounders. A total of 53 patients (33 RIM vs. 20 URIM) underwent humeral nailing. Fifteen (28%) were impending fractures (7 RIM vs. 8 URIM). Multiple myeloma (49%) and metastatic carcinoma (39.6%) were the most common etiologies. Pain score (5.13 ± 0.68 RIM vs. 6.78 ± 0.62 URIM; p = 0.082) and total dose of opioids (33.125 ± 27.6 RIM vs. 33.3 ± 22.28 URIM; p = 0.462) showed similar results. Blood transfusion was more prevalent within RIM group (34.48% RIM vs. 20% URIM; p = 0.044) with a clinical tendency of higher blood loss (207.86 ± 150.83RIM vs. 127.00 ± 179.98 URIM; p = 0.092). There was a consolidation rate of 71.05% (27/38) with no statistical difference (73.08% (19/26) RIM vs. 66.67% (8/12) URIM; p = 0.685). Our study suggests possible benefit of URIM in terms of less blood transfusions with no difference in consolidation rates. Even though without significance, a tendency to less blood loss, less events of systemic complication and lower length of stay was observed with URIM. Despite its limitations, this study can be used to design future prospective ventures that quantify patient-reported outcomes and provide more clear evidence.

A 69-year-old man developed pulmonary metastases following vertebroplasties for pathological fractures of vertebrae T12–L4. The fractures developed due to spinal metastases from castrate-resistant prostate cancer. A CT scan performed 1 month prior indicated no evidence of pulmonary malignancy. However, CT scans performed 2 months after the vertebroplasties demonstrated intravascular pulmonary metastases distributed similarly to embolized polymethylmethacrylate. Vertebroplasty is a well-established procedure for symptomatic management of vertebral compression fractures. However, studies have demonstrated an increase in circulating tumor cells following vertebroplasties, theoretically increasing the risk of distant metastases. In this case, the chronicity and radiological findings suggest that the pulmonary intravascular metastases may have resulted from the vertebroplasties.

Epithelioid haemangioendothelioma (EHE) of bone often presents as a multifocal tumour with an affinity for cortical bone. Therefore, pathological fractures are common at presentation. They can be confused initially for metastatic carcinoma, given their potential to express cytokeratins. However, the diagnosis can now be clarified with to the discovery of a unique translocation that is found in the majority of EHE tumours.

The congenital pseudoarthrosis of the tibia is a rare pathology that may be associated with type I neurofibromatosis. A case of congenital pseudoarthrosis of the tibia is presented for every two hundred and fifty thousand people. It is suspected when they present multiple pathological fractures. The approach is multidisciplinary, for its early detection and the diagnosis of associated pathologies; to improve the quality of life of patients. We present the case of a patient of three years and seven months with a diagnosis of congenital pseudoarthrosis of the tibia associated with neurofibromatosis type I.

The author observed 1 patient with APGS-1 type. The disease was manifested by autoimmune damage of peripheral glands (hypoparathyroidism, adrenal insufficiency, hypothyroidism, hypogonadism), destructive keratitis and candidiasis. With a minor injury, pathological fractures of radial bones in the lower third of the forearm have been reported over last 14 years. Within a year, it was not possible to consolidate these fractures completely. The author suggests that the the diversity of the signs can be explained only by the presence of another genetic disease - imperfect osteogenesis. A complex of measures for the correction of APGS-1 and acceleration of consolidation of pathological fractures is proposed.

Surgery of long bone metastases is associated with a significant risk of perioperative blood loss, which may necessitate blood transfusion. Successful embolization (> 70% obliteration of vascularity) can be achieved in 36–75% of cases. The reported rate of embolization-related complications is 0–9%. Three out of six level III evidence studies showed a reduction in perioperative blood loss and/or blood transfusion requirement after preoperative embolization of renal cell carcinoma metastasis in long bones; three out of six studies did not. One level III evidence study did not show a reduction in perioperative blood loss and/or transfusion requirement after preoperative embolization of hepatocellular carcinoma metastases in long bones. There were no studies found that support preoperative embolization of thyroid metastases or other frequent long bone metastases (e.g. mamma carcinoma, lung carcinoma, or prostate carcinoma). The clinical level of evidence of the studies found is low and randomized studies taking into account primary tumour, location of metastases and type of surgery are therefore desired. Cite this article: EFORT Open Rev 2020;5:17-25. DOI: 10.1302/2058-5241.5.190013

Management of pathological fractures of the proximal femur is often challenging. Compound double-plate osteosynthesis has been specifically developed for surgical treatment of these pathological fractures. To our knowledge, this study represents the largest series to date of double-plate compound osteosynthesis with the longest follow-up. Using our institutional digital database, we identified 61 procedures in 53 patients at the proximal femur. Patients were divided into two groups. A ‘primary’ group with all cases in which a double-plate compound osteosynthesis was performed as initial procedure (n = 46) and a ‘revision’ group with all cases in which a double-plate compound osteosynthesis was performed as revision procedure after failed previous attempts of internal fixation (n = 15). (1) The survivorship of the hip was calculated using the Kaplan–Meier survivorship analysis. (2) Complications were graded using Sink’s classification. (3) The functional outcome was quantified with the Merle d’Aubigne and Postel score. (4) Risk factors were identified based on a multivariate Cox-regression analysis. The cumulative Kaplan–Meier survivorship of the primary group was 96% at 6 months, 90% at 1 year, 5 years and thereafter and 83% at 6 months, 74% at 1 year, 53% at 2 years for the ‘revision’ group (p = 0.0008). According to the classification of Sink et al., the rate of grade III and IV complications was significantly lower in the primary group (p

La osteogénesis imperfecta (OI) pertenece al grupo de enfermedades raras, dada su baja incidencia mundial. Esta dolencia consiste en una formación inadecuada del hueso, cuya principal consecuencia, desde el punto de vista clínico, es la tendencia a fracturas patológicas por excesiva fragilidad ósea, lo que lleva, muchas veces, a una calidad de vida limitada en las personas afectadas, con deformidades e invalidez. Para el diagnóstico prenatal de esta enfermedad, se emplean procedimientos invasivos, y no invasivos que permiten realizar el diagnóstico a edades gestacionales tempranas. Presentaremos el caso de una paciente vista en el Hospital de Rivera, de 35 años, portadora de osteogénesis imperfecta tipo IV, que curso su segunda gestación, con sospecha prenatal y confirmación diagnóstica al nacimiento de misma patología en el recién nacido. Osteogenesis imperfecta (OI) belongs to the group of rare diseases due to its low incidence in the world population. It is a disorder which involves an inadequate bone formation that, from the clinical point of view, mainly leads to pathological fractures caused by extremely brittle bones. This frequently causes affected people to have a limited quality of life because of deformities and disability. Before birth, there are both invasive and noninvasive procedures that allow us to diagnose the disorder at early gestational ages. This is the case of a 35-year-old patient treated at the Hospital de Rivera, who had OI type IV and was pregnant with her second child. The same condition was suspected prenatally in the baby and subsequently confirmed at birth.

Background: Pathological fracture complications such as impaired clinical features is suspected to increase the mortality in MBD. In Indonesia, the habit of delayed seeking of medical treatment was common and potentially led to pathological fracture. Aim: This study compared the clinical features between MBD with and without pathological fracture. Methods: This was a retrospective study of MBD at Dr. Soetomo General Hospital in 2011-2015. We compared the clinical features by pain in Visual Analog Scale (VAS); general health presentation represented by laboratory findings; and the history of non-medical treatments. Results: 64 patients had MBD were included in this study. 37 (57.8%) of them presented with pathological fractures, and 27 (42.2%) without. Pain was the most common chief complaint (76.5%). No significant difference found between the MBD with and without pathological fracture in all variables (p=0.122; p=0.64; p=0.823; p=0.417, p=1.000 for VAS, hemoglobin, albumin, calcium, and history of non-medical treatment respectively). This probably associated with the therapy and a variety of primary tumors underlying the MBD. However, 6 out of 10 patients with history non-medical treatment presented with fractures. Conclusion: There's no significant difference in clinical features of MBD from both groups, while those with fractures had worse conditions. Keywords: Metastatic bone disease, Pathological fracture, Clinical features

Cancer metastasis to bone is a frequent observation in malignancy that may result in complications such as pathological fractures and spinal cord compression. Monitoring treatment effects is the main concern in oncology; however, the evaluation of treatment response in bone is particularly challenging as it lacks well-established criteria. In addition, bone metastases have traditionally been considered non-measurable manifestations of cancer. Magnetic resonance imaging (MRI) is one of the most specific and sensitive methods for imaging skeletal metastases. The aim of this article is to highlight the diagnostic performance of MRI in the treatment monitoring of bone metastases, to review the current literature, and to provide an overview of recommendations for the evaluation of treatment response in bone.

Zur Behandlung pathologischer Frakturen an langen Rohrenknochen stehen im Wesentlichen Platten und Nagel als 2 prinzipiell unterschiedliche Systeme zur Verfugung, die hinsichtlich der chirurgischen Versorgung miteinander konkurrieren. Auf dem unfallchirurgischen Implantatmarkt wird zwar eine grose Zahl solcher Osteosynthesemittel angeboten; diese sind jedoch auf die Behandlung des gebrochenen, aber biologisch gesunden Knochens gerichtet. Hiervon unterscheidet sich die Behandlung des drohenden Knochenbruchs bei metastatisch bedingten Osteolysen oder des bereits gebrochenen Knochens in einigen wesentlichen Aspekten. Die Besonderheiten der metastatisch bedingten Frakturen machen die Entwicklung neuer Technologien wunschenswert. Ein neuer Ansatz in der Behandlung ist die Stabilisierung der inneren Knochenrohre mithilfe eines zylindrischen Ballonimplantats, das nach Applikation mit einem zahflussigen Kunststoffmonomer aufgefullt und anschliesend ausgehartet werden kann (IlluminOss™, IlluminOss Medical, Inc., East Providence, RI, USA). Viele bekannte Nachteile herkommlicher Stabilisierungstechniken mit Metallplatten und -nageln konnen so weitgehend vermieden werden. Insbesondere ist es mithilfe der Ballontechnik moglich, den unregelmasigen naturlichen Markraum formfullend zu beschicken. Mit der dadurch bewirkten Verzahnung erreicht das Implantat Torsionsstabilitat ohne zusatzliche Verriegelungsnotwendigkeit. Die Anwendung eines solchen „Kunststoffnagels“ zeichnet sich u. a. durch einen schonenden operativen Zugang und die Moglichkeit einer Kombinationsosteosynthese mit einer herkommlichen Metallplatte aus. Im Ergebnis zeigt sich in den meisten Fallen eine hohe Primarstabilitat bei der Versorgung von pathologischen Schaftfrakturen, wobei im Einzelfall eine zusatzliche Plattenosteosynthese erfolgen kann.

Objective: To determine the incidence and causes of pathological fractures in paediatric bone tumours and tumour-like lesions, and to determine if they are predictive of benign lesions. Methods and materials: Retrospective review of children with suspected bone tumours referred to a specialist musculoskeletal oncology service between September 2019 and August 2020. Data recorded included patient age and gender, lesion location, the presence of a pathological fracture on the initial plain radiograph, and the final diagnosis made either by image-guided biopsy/curettage or based on typical imaging features. Results: 231 patients were included with 233 lesions (138 males and 93 females with mean age 10.5 years, range 3 months–18 years). Final diagnosis was based on histology in 85 (36.5%) cases and imaging in 148 (63.5%) cases, 52 (22.3%) lesions classed as non-neoplastic, 139 (59.7%) as benign and 42 (18%) as malignant. Pathological fractures were seen in 41 cases (17.6%) at presentation, involving the humerus in 19 (46.3%), the femur in 14 (34.1%), the tibia in 3 (7.3%), the fibula and radius in two each (4.9%) and the second toe proximal phalanx in 1 (2.4%) (p < 0.001). The commonest underlying lesions included simple bone cyst (n = 17; 41.5%) and non-ossifying fibroma (n = 10; 24.4%). Only 4 cases (9.75%) were malignant, one case each of osteosarcoma, Ewing sarcoma, leukaemia and BCOR undifferentiated round cell sarcoma. Pathological fracture occurred in 27.7% of non-malignant lesions and 9.5% of malignant lesions, this difference being statistically significant (p < 0.001). Conclusion: Pathological fractures were seen in 17.6% of paediatric bone tumours, tumour-like lesions, being significantly associated with humeral location and non-malignant diagnosis. Advances in knowledge: Demonstrates the frequency, location and underlying diagnosis of pathological fractures in paediatric bone tumour and tumour-like lesions.

Background: This study aimed to evaluate the patient and implant survival, clinical and functional outcomes, and the rate of complications resulting in reconstruction failure following endoprosthetic reconstruction (EPR) of extensive proximal femoral metastases associated with actual or impending pathological fractures. Methods: A total of 111 patients with actual or impending pathological fractures due to metastatic disease of the proximal femur were treated with EPR between 2003 and 2018. Staged surgery, bilateral EPR, was performed in 3 cases. The patients comprised 51 females and 60 males with a mean age of 52.1 ± 12.3 years. The patient and implant survival were recorded. Clinical and functional outcomes were assessed by using the visual analogue scale (VAS), Musculoskeletal Tumour Society (MSTS) functional scoring, and Karnofsky Performance Scale (KPS). The different types of abductor mechanism repair were evaluated by functional tests and existence of Trendelenburg gait at postoperative follow-ups. The complications resulting in reconstruction failure were investigated. Results: The mean follow-up was 23.1 ± 17.9 months. The overall survival of patients after EPR was 89% at 6 months, 72% at 1 year and 10% at 5 years. The estimated 1- and 5-year overall implant survival was 100% and 97.3% (95% CI, 0.95–0.98), respectively, as the endpoint was defined as complete removal of the prosthesis. Median VAS score before endoprosthetic replacement was 8 and after 3 months 4. Before surgery, the median MSTS score was 40 (30–56.6%) and the median KPS score was 40 (30–50). Postoperative third month, the median MSTS score was 56.6 (53.3–86.6%) and the median KPS score was 60 (40–70). Functional scores were superior in trochanter major split osteotomized group compared to trochanter major removed group. Trendelenburg gait was seen in 20 (17.5%) patients postoperatively. There were 10 (8.7%) complications resulting in reconstruction failure. Conclusion: Endoprosthetic replacement can provide a durable fixation with high implant survival rate and good clinical and functional results in extensive proximal femoral metastases associated with a pathological fracture.

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.

Non-ossifying fibromas (NOFs) are common lesions most frequently found in the growing bones of children and adolescents. Although NOFs are benign, their presence as incidental findings often triggers further investigation as they are sometimes mistaken for more sinister bone lesions such as aneurysmal bone cysts. NOFs can also pose an increased risk of pathological fractures. However, there are currently no guidelines on the follow-up of NOFs. We present a case series of five patients from Addenbrooke’s Hospital with NOFs illustrating their morphological features on plain radiographs and highlighting specific characteristics to support clinicians in diagnosing and managing NOFs.

Background: Multiple myeloma bone disease(MMBD) is indicative of multiple myeloma (MM), and it will reduce patient life quality. In addition to oncological, antineoplastic systemic therapy, surgical therapy in patients with MM represents an essential treatment pillar within the framework of supportive therapy measures and is the task of orthopedic tumor surgery. Nevertheless, there are few reports about applying intramedullary (IM) nailing in treating MM-induced proximal humeral fracture to prevent fixation loss. This paper aims to describe a case of pathological fracture of the proximal humerus caused by multiple myeloma effectively treated with IM nailing without removal of tumors and review the current literature.Case presentation: This study reported a 64-year-old male patient complaining of serious left shoulder pain and limited movement. X-ray films showed left proximal humeral fracture accompanying with osteoporosis and bone destruction. During the preoperative examinations, tumor markers, whole-body bone imaging and bone marrow biopsy were performed. The patient was finally diagnosed with multiple myeloma (IgAλ, IIIA/II). After the treatment of pathological fracture with IM nailing, the patient's function recovered and the pain was relieved rapidly. The visual analogue scale (VAS) reduced by 7 points to 2 points postoperatively compared with that preoperatively. Histopathological examination results presented plasma cell myeloma. Next, the patient received chemotherapy in the hematology department. Humeral fracture displayed good union in the 40-month follow-up, with complete healing of fracture, and the clinical outcome was still satisfactory.Conclusion: The pathological fracture of proximal humerus caused by multiple myeloma should be treated by surgery early. IM nail can be used for this kind of fracture without removal of tumors, bone cement augmentation for bone defect or local adjuvant therapy was also employed. Under the combined treatment, the proximal humerus fracture can eventually heal.

Paget’s disease of bone is very common in older people, secondary to an altered remodeling, deforming bone structure. X-rays are characteristic. Most cases are asymptomatic, but can attain pathological fractures and long term infrequent cases of secondary sarcomas.

Die pathologische tumorassoziierte Fraktur ist insgesamt selten. Sie kann in jedem Alter und Knochen auftreten. Obwohl tumorbedingte Frakturen nur einen geringen Anteil der Knochenfrakturen ausmachen, sind das rechtzeitige Erkennen der Frakturursache und die onkologisch leitliniengerechte Behandlung fur den betroffenen Patienten von enormer Bedeutung. Fehlbehandlungen sind haufig mit weitreichenden negativen Konsequenzen hinsichtlich des Erkrankungsverlaufs assoziiert. Die grose Herausforderung ist nicht die zugige operative Versorgung, sondern vielmehr die adaquate Diagnostik und das Einbinden der lokalen Frakturversorgung in ein interdisziplinares onkologisches Gesamtkonzept.

Pathological fractures refer to the fracture that occurs on the basis of pathological changes to bone, which is usually seen in middle-aged and elderly patients. The older the patient is, the more likely the malignant lesion presents. Fractures caused by benign and malignant bone tumors are mostly in the metaphysis of the long bone, while those caused by non-neoplastic bone diseases are mainly in the diaphysis. Furthermore, pathological fractures are more common in the lower limb than the upper, which is due to the higher morbidity of bone tumors in the lower limb and an increased weight-bearing. For instance, femoral and tibia are the most common areas for pathological fractures. In addition, benign bone tumors generally have no obvious symptoms, or only dull pain, intermittent discomfort, or pain after exertion.

Pathological fractures are caused by many reasons such as osteomyelitis, bone tumors, and osteoporosis. They are common in clinics; however, misdiagnosis can be often occurred especially with bone tumors. If they are treated as an ordinary fracture, the best treatment time may be delayed. Malignancy bone tumor could potentially disseminate by blood, resulting in local recurrence and a failure in limb salvage.

Bone is one of the preferential sites of distant metastases from malignant tumors, with the highest prevalence observed in breast and prostate cancers. Patients with bone metastases (BMs) may experience skeletal-related events, such as severe bone pain, pathological fractures, spinal cord compression, and hypercalcemia, with negative effects on the quality of life. In the last decades, a deeper understanding of the molecular mechanisms underlying the BM onset has been gained, leading to the development of bone-targeting agents. So far, most of the research has been focused on the pathophysiology and treatment of BM, with only relatively few studies investigating potential predictors of risk for BM development. The ability to select such “high-risk” patients could allow early identification of those most likely to benefit from interventions to prevent or delay BM. This review summarizes several evidences for the potential use of specific biomarkers able to predict early the BM development.

Background: Osteitis fibrosa cystica is one of the classic manifestations of primary hyperparathyroidism (PHPT), yet it has become increasingly rare due to early detection of PHPT. Clinical case: A 37-year-old woman was referred to our hospital for fixation of multiple fractures. Before transferring to our hospital, she was admitted to a local hospital due to right distal humerus and left tibial fractures without history of trauma. During the hospitalization, a new fracture at left femur had occurred. Her past medical history was significant for fractures of right shoulder, left elbow and right femur when she fell on the ground 5 years ago and treated by fixation. She had a history of kidney stones in the remote past. She denied family history of calcium or skeletal disorders. Clinical examination revealed gross deformities at right elbow, left thigh and painful swelling of the left tibia. On HEENT examination, there were no palpable neck masses. Upon review of plain radiographs from outside hospital, we found not only fractures but diffuse osteopenia and brown tumors at multiple sites including shaft of right humerus, right proximal radius, left proximal femoral shaft and left tibia. Skull X-ray showed salt-and-pepper appearance. There were prominent subendplate densities at multiple lumbar spines (Rugger-jersey spine). These findings were consistent with osteitis fibrosa cystica which prompted further laboratory investigation for PHPT. The patient had a high corrected serum calcium level of 13.6 (8.6-10.0) mg/dl, low serum phosphate of 2.2 (2.5-4.5) mg/dL, serum creatinine of 1.16 (0.51-0.95) mg/dL, glomerular filtration rate (GFR) of 60.29 ml/min, high serum alkaline phosphatase of 1,482 (35-105) U/L. The serum parathyroid hormone (PTH) level was significantly high at 3,850 (15-65) pg/mL. Vitamin D level was low at 5.98 (≥30) ng/mL. The patient was diagnosed with PHPT. The left lower parathyroid adenoma was identified by 99mTc-Sestamibi scan with single photon emission computed tomography and neck ultrasound. Given severe skeletal manifestations and extremely elevated PTH level, urgent parathyroidectomy was performed. A 2.5-cm parathyroid adenoma was removed which was histologically confirmed by a pathologist. Postoperatively, she developed a hungry bone syndrome which resolved 10 months after. Clinical lesson: In current practice, skeletal manifestation of PHPT is uncommon with a reported incidence of 1.4% in US. Osteitis fibrosa cystica is a radiographic feature of PHPT characterized by demineralized skeleton, salt-and-pepper appearance of the skull, subperiosteal resorption of the phalanges, bone cysts, and brown tumors. Although PHPT has evolved to asymptomatic disease in majority of patients, the classic skeletal involvement should not be overlooked, particularly in young patients who present with multiple pathological fractures.

StreszczenieLeczenie dolegliwości bólowych będących konsekwencją przerzutów nowotworowych w układzie kostnym stanowi ważny problem kliniczny z uwagi na istotne obniżenie jakości życia chorego onkologicznego. Towarzyszące zaawansowanej chorobie nowotworowej zmiany przerzutowe oprócz bólu, są także przyczyną złamań patologicznych oraz upośledzenia funkcji ruchowych pacjenta, a nieleczone mogą być przyczyną krytycznych dla życia chorego powikłań. Zastosowanie leczenia radioizotopowego jako jednej z form terapii paliatywnej, jest ważnym i efektywnym sposobem zapobiegania komplikacjom zdrowotnym związanym z rozwojem przerzutów do układu szkieletowego.Abstract Palliative therapy in patients’ suffering from metastatic bone lesions is an important clinical problem due to a significant reduction in the quality of life of an oncological patient. The metastatic bone lesions regardless pain are also the cause of pathological fractures and impairments of the patient's motor functions and untreated can affect mortality more often than primary neoplastic disease. The palliative therapy using radioisotopes seems to be an important and effective method which might prevent the critical health complications caused by the skeletal tumors.

Objetivo: Notificar un caso de hiperparatiroidismo primario sintomático secundario a un adenoma de paratiroideo. Caso: Femenina de 34 años con cuadro de 4 años de evolución con múltiples fracturas patológicas, pérdida de peso, astenia. Los exámenes revelaron hipercalcemia, hipofosfemia y PTH elevada (968 pg/ml). Se hospitalizó para manejo de dolor articular severo asociado a multiples fracturas de fragilidad, realizándose niveles de PTH reportando niveles elevados (968 pg/mL) y gammagrama y Spect de paratiroides material 25mci 99m MIBI que evidencio patrón sugestivo de adenoma paratiroideo inferior izquierdo. Para lo cual se realiza exéresis del adenoma. Discusión: Hiperparatiroidismo primario (PHPT), un trastorno endocrino común caracterizado por hipercalcemia y niveles elevados o inadecuadamente normales de PTH, su diagnóstico se base en una evaluación bioquímica. Un de las principales causas es el adenoma o hiperplasia de paratiroides.

Introduction: Pathological fractures are frequent skeletal-related events among lung cancer patients, which result in high morbidity and decreased overall survival and make operative treatment decisions challenging. Objectives: To identify risk factors associated with the occurrence of pathological fractures in patients with lung cancer and to determine survival. Methods: We conducted a retrospective cohort study with 407 lung carcinoma patients diagnosed between 2006 and 2015. The prevalence of bone metastases and pathological fractures was calculated. Statistical analysis was conducted using a chi-squared test, and the odds ratio and 95% confidence interval were calculated. Overall survival was determined using the Kaplan-Meier method and differences were compared using the log-rank test. Results: The prevalence of bone metastases and pathological fractures was 28.2% (n = 115) and 19.1% (n = 22), respectively. Pathological fractures were more frequent among patients with bone metastases at the time of diagnosis of lung cancer (24.7% [n = 20] vs. 5.9% [n = 2]; p < 0.05). The median overall survival following the diagnosis of lung cancer, bone metastases, and pathological fracture was 6, 4, and 2 months, respectively. Conclusions: Pathological fracture was associated with synchronous bone metastases and overall survival times were considerably reduced. Level of Evidence IV, Case Series. RESUMO Introdução: Fratura patológica é um evento esquelético frequente em pacientes com câncer de pulmão, resultando em alta morbidade e sobrevida global reduzida que torna a decisão de tratamento cirúrgico desafiadora. Objetivos: Identificar fatores de risco associados à ocorrência de fraturas patológicas em pacientes com câncer de pulmão e determinar a sobrevida. Métodos: Conduzimos um estudo retrospectivo de coorte com 407 pacientes diagnosticados com carcinoma pulmonar entre 2006 e 2015. A prevalência de metástase óssea e fratura patológica foi calculada. Análise estatística foi conduzida usando o teste X2, e razão de chances e o intervalo de confiança de 95% foi calculado. A sobrevida global foi determinada usando o método de Kaplan-Meier e as diferenças foram comparadas usando o teste do log-rank. Resultados: A prevalência de metástases ósseas e fraturas patológicas foi de 28,2% (n = 115) e 19,1% (n = 22), respectivamente. Fraturas patológicas foram mais frequentes em pacientes com metástases ósseas ao diagnóstico do câncer de pulmão (24,7 % [n = 20] vs. 5,9% [n = 2]; p < 0.05). A sobrevida global média após o diagnóstico do câncer de pulmão, da metástase óssea e da fratura patológica foram 6, 4 e 2 meses, respectivamente. Conclusão: Fratura patológica foi associada à metástase óssea sincrônica e a sobrevida global consideravelmente reduzida. Nível de Evidência IV. Série de Casos.

Background Currently, there are no known reports on the aetiology of local giant cell tumour (GCT) recurrence in the proximal fibula following en bloc resection. We analysed 21 cases of proximal fibular GCT, focusing on the presence of residual bone in the tibiofibular joint, its causes and its impact on postoperative recurrence. Methods We retrospectively analysed 21 cases with proximal fibular GCT occurring between 2000 and 2017. Results There were 14 males and 7 females. The average patient age was 25.0 years. Seventeen patients were diagnosed and treated at our facility, while 4 were referred after local recurrence. Six patients presented with residual bone fragments in the tibiofibular joint during their first month of follow-up. Patients with residual bone fragments had a higher local recurrence rate (83.3%) than those without (0%, p = 0.0003). Upon further analysis, patients with a preoperative Campanacci grade III tumour (p = 0.0055) and pathological fractures (p = 0.0109) were at a higher risk of exhibiting postoperative residual bone fragments. Conclusions The presence of residual bone fragments in the tibiofibular joint was the main cause of postoperative local recurrence. The presence of residual bone fragments may be related to the preoperative Campanacci grade and pathological fractures. Therefore, close attention should be paid to postoperative follow-up examinations, and if recurrence is suspected, surgical resection should be planned.

Die chronische lymphatische Leukamie (CLL) ist die haufigste leukamische Erkrankung in Mitteleuropa. Pathologische Frakturen bei CLL-erkrankten Patienten sind nach wie vor eine Seltenheit. Die Diagnose ist in den meisten Fallen ein Zufallsbefund, da die CLL haufig uber die Jahre asymptomatisch verlauft. Der Fallbericht handelt von einem 65-jahrigen Patienten, der sich in unserer Klinik bei seit 5 Jahren bekannter asymptomatischer CLL mit einer huftgelenknahen Fraktur und einer proximalen Radiusfraktur vorstellte. Im Verlauf kam es zu multiplen pathologischen Frakturen mit nachgewiesener CLL-Infiltration der Osteolysen und einem akuten Schub der CLL, die chemotherapeutisch mit einer Kombinationstherapie behandelt wurde.

ObjectiveThis study was performed to determine the most common causes, locations, and treatments of metastasizing primary tumors through evaluation of patients with metastatic bone tumors who were admitted to our clinic.MethodsIn total, 96 patients with metastatic bone tumors who were admitted to our clinic from 2000 to 2016 were included in the study.ResultsThe breast (30 patients, 31.3%) and lung (18 patients, 18.8%) were the most commonly metastasized primary organs. The femur was the most commonly metastasized bone.ConclusionsBone tumors in patients of advanced age are, unless otherwise proven, considered to be metastatic, and the development of specific diagnostic and treatment algorithms is needed. Clinicians should attempt to improve the general condition of patients with tumors exhibiting bone metastasis to increase the patients’ quality of life by providing early mobilization. Thus, appropriate patient selection and proper internal fixation are essential.

Incidence of new cases of a severe form of unchecked primary hyperparathyroidism is decreasing day by day. Here, we report the case of a 40-year-old female patient of primary hyperparathyroidism with a maiden visit to the hospital with multiple osteolytic lesions and multiple pathological fractures. The diagnosis was installed and managed accordingly.

According to the literature, prophylactic consolidation of lytic metastasis located in the proximal femur is recommended when the Mirels' score is above 8. Osteoplasty alone provides inadequate consolidation but various devices have been used in association for better consolidation. The aim of this review is to detail the augmented osteoplasty techniques published in the literature and to report their safeties and their efficacies to prevent pathological fracture of the proximal femur. A Pubmed research found 5 studies that evaluated augmented osteoplasty of the proximal femur in cancer patients. All devices demonstrate adequate safety and low rate of secondary pathological fractures.

Background and purpose Impending or pathological fractures due to bone metastases may require surgical fixation. Postoperative radiation is often recommended to reduce local progression and prevent prosthesis displacement, hence reducing the need for second surgery. The objectives of this study were to investigate the need for second surgery, and to report on rates of re-irradiation, tumor progression and prosthesis displacement following postoperative radiation. Materials and methods Data were collected from 65 patients who received postoperative radiation to 74 sites in the extremities in a palliative radiation clinic between January 2009 and January 2017. Descriptive statistical analyses were performed. Results Only 2 patients required a second surgery (2.7%) at 9 and 10months after postoperative radiation. Increase in pain requiring re-irradiation was reported in 7 patients (9.5%), at a median time of 9.3months after the delivery of radiation. Of the 47 patients who had radiological imaging available post-radiation, local progression of bone metastases was seen in 8 patients (17.0%) and displacement of the prosthesis in 1 patient (2.1%). Conclusion Rates of prosthesis displacement and progression of bone metastases at site of surgery were low after postoperative radiation. There were few incidences of second surgery and re-irradiation observed in the cohort. These findings provide support for the benefit of postoperative radiation.

Materials & Methods: In this prospective, randomized study of 40 cases with clavicle fracture 20 patients were treated conservatively and 20 with IMN and were followed up at 4th, 8th and 12th week and 6th and 12th month. Time for fracture union was measured radiographically and Functional Outcome was assessed using Constant Murley Shoulder score. Patients with pathological fractures, open fractures, comminuted fractures, segmental fractures and fractures associated with neurovascular injury were excluded.

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.

Osteoporosis, a major global health problem of ageing population is most commonly present with complications like pathological fractures of bone. Hence to avoid complication as bhagna, the option is to stop degenerative pathology. Modern science use oral calcium supplementation, which may lead to calculus formation. Hence the aim of therapy of osteoporosis should be to stop degenerative changes without complications. This can be achieved by working with principles of ayurveda. Osteoporosis in which bones become brittle and weak can be co-related with asthisoushirya i.e Asthimajjadhatukshaya. Acharya Charaka advised to treat asthimajjadhatukshaya by kshir, ghrita, basti and tikta dravyas.1 Vagbhata has also treated asthishula with kshir, ghrita and tiktabasti.2Panchatiktaghritguggulu is described in Bhaishajyaratnavali for asthimajjagata vata in kushtha chikitsa prakarana which gives idea about similar opinion regarding tiktarasa in the management of asthimajjadhatu.3 Therefore the aim of the study was to evaluate the efficacy of panchatiktakshirbasti and Panchatiktaghritguggulu in asthisoushirya (osteoporosis). 30 patients of Asthimajjadhatukshaya were treated with panchatiktakshirbasti and Panchatiktaghritguggulu orally. The results were observed on various parameters like pain, tenderness, stiffiness, dosh-dhatu lakshanas. After the study the results were statistically analyzed. Patients treated with panchatiktakshirbasti and Panchatiktaghritguggulu showed improvement in symptoms of asthimajjadhatukshaya without any side effect. So we can conclude that treatment with panchatiktakshirbasti and panchatiktaghritguggulu gives speedy recovery by its action on vatavriddhi and asthimajjadhatukshaya.