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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.)

Objective: To optimize orthopedic care in patients with complicated course of metastatic lesions of the long bones., Material and Methods: There were 201 patients (72 men and 129 women) who underwent orthopedic care for metastatic lesions of the long bones for the period from 2006 to 2019. Breast cancer metastases were diagnosed in 71 (35%) cases, kidney cancer - 56 (28%) patients, prostate cancer - 19 (9%) cases, metastases without a primary identified focus - 15 (8%) patients. Other forms were observed in 40 (20%) patients. All patients were divided into two groups. The first group included 136 patients (68%) who underwent segmental resections with bone replacement. Of these, 100 (73%) patients had secondary lesions of the lower limb bones and 36 (27%) patients with metastatic lesions of the upper limb bones. A threat of pathologic fracture was in 63 (46%) cases, fracture - in 73 (54%) patients. The second group consisted of 65 (32%) patients who underwent immersion osteosynthesis. Of these, 47 (72%) patients had metastatic lesions of the lower limb bones and 18 (28%) patients had secondary lesions of the upper limb bones. A threat of pathologic fracture was in 24 (37%) patients, fracture - in 41 (63%) patients., Results: In the first group, mean surgery time was 140 min, in the second group - 120 min. Mean blood loss in the first group was 600 ml, in the second group - 300 ml. Patients were activated on the 3 rd postoperative day in both groups. We analyzed surgical, anatomical and functional results in both groups using MSTS, Watkins and Karnofsky's scales., Conclusion: Oncological replacement and osteosynthesis are the main methods of surgical treatment of secondary lesions of the long bones. However, our data emphasize advisability of bone replacement, since this method ensures the most adequate stabilization, pain syndrome relief and long-term improvement of the quality of life.

Purpose: For the treatment of giant cell tumour of the bone (GCTB) around the knee, preserving the native joint confers advantages over scarifying it. But, there is a controversy about the efficacy of intralesional curettage versus en bloc resection for treatment of such lesions. In this study, we compared local recurrence, functional outcomes, and complications of extended curettage and en bloc resection in these lesions., Methods: Patients with grade 3 GCTB of the distal femur or proximal tibia who were presented with a pathologic fracture and treated with either en bloc resection (n = 22) or extended curettage (n = 20) were included. The mean follow-up of the patients was 6.4 ± 1.9 years in the resection group and 5.5 ± 2.4 years in the extended curettage group. The primary outcome was a local recurrence. Secondary outcomes were limb function evaluated by the Musculoskeletal Tumor Society (MSTS) score and rate of complications., Results: Local recurrence was seen in four (20%) patients of the curettage group and three (13.7%) patients of the resection group (P = 0.69). The mean MSTS score was 24 ± 1.9 in the resection group and 26.5 ± 1.3 in the curettage group (P < 0.001). The number of complications was not significantly different between the two study groups (P = 0.49). However, the number of complications that required revision surgery was significantly more in the resection group (P = 0.049)., Conclusion: In grade 3 GCTB around the knee with pathologic fracture, extended curettage results in comparable oncologic outcomes to en bloc resection, while providing better function and a lower rate of revision.

A 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.

Case: Spine reconstruction after en bloc spondylectomy is challenging and may require multidisciplinary intervention. En bloc spine tumor resection with embolization of local recipient vessels for tumor control limits reconstructive options. Herein, we describe a case where combined efforts from orthopaedic, general, and plastic surgery teams permitted the successful reconstruction of a multilevel lumbar vertebral defect., Conclusion: A fibula-free flap within a titanium cage construct anastomosed to the left gastroepiploic vessels via a pedicled omental flow-through flap is a viable and novel method for reconstruction of a multilevel vertebral defect., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B312)., (Copyright © 2020 by The Journal of Bone and Joint Surgery, Incorporated.)

Fibular free flap reconstruction remains the workhorse of postmandibulectomy reconstruction. Dental implantation to support a dental prosthesis is a sought-after outcome when the area of resection involves tooth-bearing zones. Chronic perisoft tissue pedicle hyperplasia with secondary infection leading to gradual bone loss is a simple complication to manage in the general population, but it becomes a serious issue in the fibula mandibular reconstruction patient in that it can lead to pathological fracture of the fibula. A case of a patient with a near fracture of his fibula mandibular reconstruction, and its management via a minimally invasive approach is presented., (© 2020 by the American College of Prosthodontists.)

The osseous pelvis is a frequent site of metastases. Alteration of bone integrity may lead to pain but also to functional disability and pathological fractures. Percutaneous image-guided minimally invasive procedures, such as cementoplasty and screw fixation, have emerged as a viable option to provide bone reinforcement and fracture fixation, as stand-alone or combined techniques. Understanding the biomechanics of the osseous pelvis is paramount to tailor the treatment to the clinical situation. The purpose of the present review is to present the biomechanics of the osseous pelvis and discuss its implication for the choice of the optimal consolidative treatment.

Introduction: 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., Materials and Methods: 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'Aubigné and Postel score. (4) Risk factors were identified based on a multivariate Cox-regression analysis., Results: 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 < 0.0001). The mean Merle d'Aubigné score was 14 ± 7 at 0-3 months, 13 ± 3 at 3-6 months, 15 ± 3 at 6-12 months and 15 ± 4 thereafter (p = 0.54). The only multivariate negative predictor was previous surgery with a hazard ratio of 9.2 (p < 0.006)., Conclusion: Double-plate compound osteosynthesis is a valuable treatment option for pathological fractures in proximal femur with good functional results.

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.)

Notable advances in hip arthroplasty implants and techniques over the past 60 years have yielded excellent survivorship of fully cemented, hybrid, and reverse hybrid total hip replacements as demonstrated in joint registries worldwide. Major advances in noncemented implants have reduced the use of cement, particularly in North America. Noncemented implants predominate today based on procedural efficiency, concern related to thromboembolic risk, and a historic belief that cement was the primary cause of osteolysis and implant loosening. With the decline of cemented techniques, press-fit fixation has become common even in osteoporotic elderly patients. Unfortunately, there is a troubling rise in intraoperative, as well as early and late postoperative periprosthetic fractures associated with the use of noncemented implants. Despite the success of noncemented fixation, an understanding of modern cement techniques and cemented implant designs is useful to mitigate the risk of periprosthetic fractures. Cemented acetabular components can be considered in elderly patients with osteoporotic or pathologic bone. Cemented stems should be considered with abnormal proximal femoral morphology, conversion of failed hip fixation, inflammatory arthritis, patient age over 75 (especially women), osteoporotic bone (Dorr C), and in the treatment of femoral neck fractures.

Case: A 29-year-old man was admitted with acute atraumatic left hip pain and inability to bear weight. Subsequent workup revealed an intracapsular pathologic fracture of the femoral neck secondary to a high-grade spindle cell sarcoma. A unique method of extra-articular resection and reconstruction using a 3-dimensional (3D)-printed custom cutting jig and a custom acetabular component was pursued. Wide margins were achieved without violating the joint capsule but preserving pelvic integrity, allowing a return to an active lifestyle., Conclusion: Three-dimensional-printed custom resection guides and implants can help achieve adequate resection margins while preserving pelvic integrity and function.

Case: A 76-year-old woman without a personal or family history of gout presented with complaints of left hip pain after a mechanical fall from her wheelchair. Advanced imaging revealed a nonspecific lesion and nondisplaced fracture of the femoral neck. Intraoperative biopsy from the lesion/fracture demonstrated tophaceous gout., Conclusion: Fractures resulting from osseous manifestations of the gout are rare with this report describing a hip fracture secondary to tophaceous gout. We emphasize the importance of including this potential etiology in the differential diagnosis of elderly patients presenting with hip pain, with or without a known history of gout.

Case: A 64-year-old man suffered a pathologic left femoral neck fracture. Biopsy demonstrated metastatic urothelial cancer with a nonmuscle invasive bladder cancer primary confirmed by cystoscopy. The patient underwent hemiarthroplasty, chemotherapy, radiation, and eventually, a conversion to total hip arthroplasty. Today, over a decade from the initial surgery, the patient remains alive and highly functional. To our knowledge, this is the only report of bone metastatic bladder cancer with over 10-year survival., Conclusion: Combined chemotherapy, radiation, and surgical resection of metastasis with reconstruction may confer a survival benefit in bony oligometastatic bladder cancer.

Case: In this case, we report on a carbon-fiber-reinforced polyetheretherketone plate failure 4 months after implantation, radiation therapy, chemotherapy, and protective weight-bearing in a 75-year-old woman who sustained a nontraumatic pathological distal femur fracture due to lymphoma., Conclusion: Although carbon-fiber composite implants are regularly used and, to date, there have been no reports of early clinical failures, the longevity of the implant's structural integrity after high-dose radiation and/or chemotherapy treatment has not been fully explored. Therefore, we deem it too early to conclude that carbon-fiber-reinforced polyetheretherketone implants are superior to conventional implants in treating (pathological) fractures.

Case: A 10-year-old boy experienced a pathologic diaphyseal femur fracture through a large cyst encompassing 40% of femoral length. At age 5, he had had a traumatic ipsilateral diaphyseal femur fracture, treated with flexible nailing. Biopsy at age 10 revealed a simple bone cyst with components of aneurysmal bone cyst. Curettage, antegrade nailing, and allograft resulted in successful osseous healing., Conclusion: Post-traumatic cysts of long bones are rare and have not been reported to cause pathologic fracture in children. This case highlights that close scrutiny of follow-up radiographs of long bone fractures may identify clinically important post-traumatic cysts.

Background: Interest around carbon/PEEK plates and nails has been raising. The elastic modulus close to the bone, the high load-carrying capacity and radiolucency make CFR/PEEK materials a potential breakthrough. In the literature, there are abundant data about CFR/PEEK plates in the treatment of proximal humerus, distal radius and distal fibula fractures. In patients affected by bone metastasis, CFR/PEEK nails were proved effective and safe with 12 months of follow-up. Very little is known about performances of CFR/PEEK nails in patients affected by other pathologies., Purposes: The aim of the study was to evaluate safety and efficacy of CFR/PEEK nails in the treatment of various pathological conditions. It was also investigated whatever radiolucency of this nails could lead to a more objective evaluation of bone callus or disease site., Patients and Methods: In the study group were included 20 patients (22 bone segments) who underwent CFR/PEEK nail implantation (eight humerus, one tibia, nine femur and four knee arthrodesis). They were affected by pathological fractures, and in four cases, they required an arthrodesis of the knee. They were retrospectively evaluated considering nail failures and bone callus or disease progression (RUSH scores). Mean follow-up time was 11 months (min 6.8-max 20.3). In the control group were included patients treated with titanium nails in the same institution for the same pathologies. An interclass correlation coefficient (ICC) analysis was performed in both groups considering RUSH scores by two expert surgeon from two institution to assess whether radiolucency could lead to a more objective evaluation of disease or bone callus site., Results: The ICC of mean values between RUSH scores was 0.882 (IC 95%: 0.702-0.953) in the CFR/PEEK group, while it was 0.778 (IC 95%: 0.41-0.91) in the titanium group. Observers' evaluation showed a significantly higher obscuration by titanium nails than by CFR/PEEK nails. No osteosynthesis failures were reported in both groups., Conclusions: Our results confirm the safety of CFR/PEEK nails in the short-medium term. The radiolucency of these materials led our observers to perform more objective evaluations of bone callus formation or disease progression compared to the titanium group given the higher ICC., Level of Evidence: III Case-control therapeutic study.

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.)

Background: Delayed time to surgery of at least 2 days after hospital arrival is well known to be associated with increased complications after standard hip fracture surgery; whether this association is present for pathologic hip fractures, however, is unknown., Questions/purposes: (1) After controlling for differences in patient characteristics, is delayed time to surgery (at least 2 days) for patients with pathologic hip fractures independently associated with increased complications compared with early surgery (fewer than 2 days)? (2) What preoperative factors are independently associated with major complications and mortality after surgery for pathologic hip fractures?, Methods: A retrospective study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database of pathologic hip fractures (including femoral neck, trochanteric, and subtrochanteric fractures) from 2007 to 2017. This database was chosen over other databases given the high-quality preoperative medical history and postoperative complication (including readmissions, reoperations, and mortality) data collected from patient medical records through the thirtieth postoperative day. Patients were identified using Common Procedural Terminology codes for hip fracture treatment (THA, hemiarthroplasty, proximal femur replacement, intramedullary nail, and plate and screw fixation) with associated operative diagnoses for pathologic fractures as identified with International Classification of Diseases codes. A total of 2627 patients with pathologic hip fractures were included in this study; 65% (1714) had surgery within 2 days and 35% (913) had surgery after that time. Patient demographics, hospitalization information, and 30-day postoperative complications were recorded. Differences in characteristics between patients who underwent surgery in the early and delayed time periods were assessed with chi-square tests for categorical variables and t-tests for continuous variables. Delayed-surgery patients were more medically complex at the time of admission than early-surgery patients, including having higher American Society of Anesthesiologists classification (mean ± SD 3.18 ± 0.61 versus 2.94 ± 0.60; p < 0.001) and prevalence of advanced, "disseminated" cancer (53% versus 39%; p < 0.001). Propensity-adjusted multivariable logistic regression analyses were performed to assess the effect of delayed time to surgery alone on the various outcome measures. Additional independent risk factors for major complications and mortality were identified using backwards stepwise regressions., Results: After controlling for baseline factors, the only outcome associated with delayed surgery was extended postoperative length of stay (odds ratio 1.94 [95% CI 1.62 to 2.33]; p < 0.001). Delayed surgery was not associated with any postoperative complications, including major complications (OR 1.23 [95% CI 0.94 to 1.6]; p = 0.13), pulmonary complications (OR 1.24 [95% CI 0.83 to 1.86]; p = 0.29), and mortality (OR 1.26 [95% CI 0.91 to 1.76]; p = 0.16). Histories of chronic obstructive pulmonary disease (OR 2.48), congestive heart failure (OR 2.64), and disseminated cancer (OR 1.68) were associated with an increased risk of major complications, while dependent functional status (OR 2.27), advanced American Society of Anesthesiologists class (IV+ versus I-II, OR 4.81), and disseminated cancer were associated with an increased risk of mortality (OR 2.2; p ≤ 0.002 for all)., Conclusions: After controlling for baseline patient factors, delayed time to surgery was not independently associated with increased 30-day complications after surgical treatment of pathologic hip fractures. These results are in contrast to the traditional dogma for standard hip fractures that surgery within 2 days of hospital arrival is associated with reduced complications. Although surgery should not be delayed needlessly, if the surgeon feels that additional time could benefit the patient, the results of this study suggest surgeons should not expedite surgery because of the risk of surgical delay observed for standard hip fractures., Level of Evidence: Level III, therapeutic study.

Objective: While percutaneous osteoplasty is common for the treatment of vertebral fractures, low strength of fixation remains a major challenge for use in metastatic weight-bearing bones. With stent, wire, and cement augmentation, this study explores the feasibility of percutaneous reinforced osteoplasty for use in correcting long bone fractures., Materials and Methods: Fifteen explanted swine femora were randomly assigned into three groups. Group 1 (n = 5) was native (intact) bones without any intervention (control), group 2 (n = 5) received cementoplasty, and group 3 (n = 5) received stent and wire scaffolding ("rebar") in addition to cementoplasty. All treatment procedures were performed under fluoroscopic guidance. Mechanical strength of fracture fixation was quantified by peak load to failure, stiffness, work done to fracture, and fatigue testing with four-point bend test., Results: Percutaneous osteoplasty with or without reinforcement was successfully achieved in all specimens. The respective peak load at failure, flexural stiffness, and work done to fracture (mean ± SEM) for group 1 was 2245 ± 168 N, 14.77 ± 1.3 Nm/degree, and 4854 ± 541 Nmm; group 2 was 468 ± 81 N, 3.9 ± 0.5 Nm/degree, and 401 ± 56 Nmm; and group 3 was 594 ± 90 N, 4.42 ± 0.4 Nm/degree, and 522 ± 54 Nmm. The mean cyclic displacement for groups 1, 2, and 3 were 0.15, 0.58, and 0.48 mm, respectively, at 220-240 N loading., Conclusions: While percutaneous reinforced osteoplasty with stent, wire, and cement augmentation resulted in improved mechanical strength in restored bones, it did not differ significantly from specimens that underwent exclusive cementoplasty. With the improvement of fracture strength, the concept may be applicable for prevention or treatment of pathological fractures.

Introduction: Over the last several decades, both percutaneous kyphoplasty (PKP) and percutaneous vertebroplasty (PVP) have been used for pain relief in patients with osteoporotic vertebral compression fractures. The purpose of our study was to use citation analysis to identify and review the top 100 most-cited publications regarding PKP and PVP., Methods: All databases of the Web of Science were searched using the keywords "kyphoplasty" and "vertebroplasty." All publications with >100 citations were identified and the results were ranked in descending order of citations. The 100 most-cited publications were included for analysis., Results: A total of 6271 publications on PKP and PVP were identified. The number of citations of the 100 most-cited studies ranged from 735 to 109, with a mean of 225.3 citations per study. The most productive period was 2001-2010, which produced 79 of the top 100 publications. Thirteen journals published these 100 studies, with Spine publishing the largest number (23) of studies. Most of the identified articles originated in the United States, with France and Switzerland found to be the next most heavily represented countries of origin of the 11 countries that produced them. Most of the studies focused on treatment of osteoporotic vertebral compression fractures, followed by pathologic fractures caused by tumors., Conclusions: We identified the 100 most-cited publications on PKP and PVP and performed a bibliometric analysis characterizing distinguishing features of these studies. This list can help guide clinical decision making and future research directions as clinicians and researchers continue to explore these controversial therapeutic techniques., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The femur is the most common site of metastasis in the appendicular skeleton, and metastatic bone disease negatively influences quality of life. Orthopaedic surgeons are often faced with deciding whether to prophylactically stabilize an impending fracture, and it is unclear if prophylactic fixation increases the likelihood of survival., Questions/purposes: Is prophylactic femur stabilization in patients with metastatic disease associated with different overall survival than fixation of a complete pathologic fracture?, Methods: We performed a retrospective, comparative study using the national Veterans Administration database. All patient records from September 30, 2010 to October 1, 2015 were queried. Only nonarthroplasty procedures were included. The final study sample included 950 patients (94% males); 362 (38%) received prophylactic stabilization of a femoral lesion, and 588 patients (62%) underwent fixation of a pathologic femur fracture. Mean followup duration was 2 years (range, 0-7 years). We created prophylactic stabilization and pathologic fracture fixation groups for comparison using Common Procedural Terminology and ICD-9 codes. The primary endpoint of the analysis was overall survival. Univariate survival was estimated using the Kaplan-Meier method; between-group differences were compared using the log-rank test. Covariate data were used to create a multivariate Cox proportional hazards model for survival to adjust for confounders in the two groups, including Gagne comorbidity score and cancer type., Results: After adjusting for comorbidities and cancer type, we found that patients treated with prophylactic stabilization had a lower risk of death than did patients treated for pathologic femur fracture (hazard ratio = 0.75, 95% CI, 0.62-0.89; p = 0.002)., Conclusions: In the national Veterans Administration database, we found greater overall survival between patients undergoing prophylactic stabilization of metastatic femoral lesions and those with fixation of complete pathologic fractures. We could not determine the cause of this association, and it is possible, if not likely, that patients treated for fracture had more aggressive disease causing the fracture than did those undergoing prophylactic stabilization. Currently, most orthopaedic surgeons who treat pathological fractures stabilize the fracture prophylactically when reasonable to do so. We may be improving survival in addition to preventing a pathological fracture; further study is needed to determine whether the association is cause-and-effect and whether additional efforts to identify and treat at-risk lesions improves patient outcomes., Level of Evidence: Level III, therapeutic study.

The association between hyperparathyroidism and sarcoma is extremely rare with other reported cases describing the development of osteosarcoma and chondrosarcomas in middle-aged adults. This case describes an adolescent male with hyperparathyroidism and a pathologic fracture of a biopsy-proven brown tumor in the distal right femur. The fracture healed but later developed an undifferentiated pleomorphic sarcoma of the bone at the site of the known brown tumor. Although in vitro and in vivo studies have demonstrated the risks of elevated parathyroid hormone with development of sarcomas, there is limited evidence of a human association. The effects of elevated parathyroid hormone on the skeletally immature bone in the setting of sarcoma formation are currently not well understood without current description of adolescent hyperparathyroidism-associated sarcomas. This case highlights a sarcoma originating at a pathologically proven brown tumor within an adolescent male, discusses the association of sarcoma with hyperparathyroidism, and reviews the other nine reported cases in the literature., Competing Interests: None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Herrmann, Dr. Stanborough, Dr. Chrisinger, and Dr. Jennings., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: Vertebral osteomyelitis manifesting as a compression fracture misdiagnosed in the setting of steroid-induced or senile osteoporosis is very rare, although such patients are prone to infection or reactivation, as their immune system is exhausted. Spondylodiscitis occurring at adjacent levels following instrumented spinal fusion leading to pathologic fracture and proximal junctional failure, especially caused by tuberculosis, to our knowledge, has not been discussed in the literature., Methods: In case 1, a 61-year-old woman with osteoporotic T12 collapse was treated with corpectomy, anterior reconstruction, and posterior fixation from T9-L2. Initial biopsy and culture were normal. She presented 4 months later with compression fracture of T8; T8 corpectomy with anterior reconstruction and proximal extension of the construct was performed. In case 2, a 65-year-old woman with multiple comorbidities and osteoporotic L1 compression fracture was treated with L1 corpectomy, anterior reconstruction, and posterior instrumentation from T11-L3. She presented 4 months later with T10 vertebral body acute collapse; 2-stage anterior corpectomy and reconstruction was performed. In both cases, probing the affected vertebral body yielded pus. Pus and bone tissue samples sent for culture and histopathologic examination were positive for tuberculosis suggesting tuberculous spondylitis in both cases., Results: In both patients, tuberculous spondylodiscitis at the proximal adjacent level was diagnosed <1 year after the initial spinal surgery. Neither patient had a previous history of pulmonary or extrapulmonary tuberculosis. They were successfully treated with antituberculous therapy and proximal extension of the construct with anterior reconstruction., Conclusions: Adjacent segment spondylodiscitis should be suspected and intraoperative biopsy must be considered for histopathologic and microbiologic examination to rule out subclinical infection in immunosuppressed patients with multiple comorbidities. Management should be individualized, considering the context of infection, causative organism, extent of bone destruction, and neurologic involvement., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: To evaluate electromagnetic navigation system (ENS) for percutaneous fixation by internal cemented screw (FICS) under CT guidance., Background: FICS is a recently developed modality that consists in inserting screws, under imaging guidance, into bone through a minimal skin incision. FICS recently showed good efficacy for the palliation or prevention of pathologic fractures of the pelvic ring and femoral neck., Materials and Methods: In this single-center retrospective study, we reviewed all consecutive cancer patients treated with percutaneous FICS under ENS-assisted CT guidance for the prevention or palliation of pelvic or femoral neck fractures. The primary endpoint was technical success. Secondary endpoints were screw placement accuracy (defined by proximal deviation p, distal deviation d, and angle deviation θ), radiation dose exposure, number of CT acquisitions, duration of procedures, and complications., Results: Mean duration of FICS procedures was 111 ± 51 min. Mean post-procedure hospitalization length was 2.1 days. Technical success was achieved in 48 cases (96%) with a total of 76 screws inserted. Mean distance p, mean distance d, and mean angle θ were respectively 8.0 ± 4.5 mm, 7.5 ± 4.4 mm, and 5.4 ± 2°. Angle θ accuracy was higher for screws with a craniocaudal angulation of less than 20° (4.4° vs 6.4°, p = 0.02). The mean number of CT acquisitions during procedures was 6.4 ± 3.0. The mean dose length product was 1524 ± 953 mGy cm and the mean dose area product was 12 ± 8 Gy cm 2 . Five complications occurred in 4 patients., Conclusion: CT guidance assisted by ENS is an effective approach for percutaneous FICS., Key Points: • ENS-assisted CT enables screw insertion in the pelvic ring and femoral neck, with a wide range of trajectories, even when a significant craniocaudal angulation is required. • ENS-assisted CT can be used as an alternative to CBCT guidance for percutaneous fixation by internal cemented screw. • ENS-assisted CT provides high technical success rate with excellent placement accuracy.

Background: Treatment goals for pathologic fractures about the knee include pain relief and unrestricted weight bearing. In cases of condylar destruction, these fractures may not be amenable to internal fixation, and arthroplasty may be considered. The purpose of this study was to analyze the outcomes of knee arthroplasty for primary treatment of impending or pathologic fractures of the distal femur or proximal tibia., Methods: Fifteen (8 males and 7 females) patients, mean age 62 ± nine years, undergoing arthroplasty for management of a pathologic peri-articular distal femur (n = 11) or proximal tibia (n = 4) fracture between 2001 and 2017 were reviewed. Implants included tumour endoprostheses (n = 11) and rotating hinged total knees (n = 4). Pathology included metastatic disease (n = 14) and lymphoma (n = 1). Eight (53%) patients presented with a fracture while the remainder had large impending lesions., Results: Mean follow-up was 19 months. At final follow-up, 11 patients had died with overall five year survival of 33%. Two (13%) patients required re-operation; including wound irrigation and debridement (n = 1) and above knee amputation for local recurrence (n = 1). An additional two (13%) patients developed post-operative VTE. MSTS, KSS, and KSS-F scores improved from a mean 12 ± 16%, 30 ± 11, and 14 ± 24 pre-operatively to 69 ± 26%, 75 ± 16, and 67 ± 25 at final follow-up, respectively (P < 0.001). Thirteen (87%) patients had severe pain prior to surgery with no patients (0%, P < 0.001) reporting severe pain at last follow-up., Conclusion: Knee arthroplasty provided improved function and full weight-bearing making it an effective treatment for pathologic periarticular fractures of the distal femur and proximal tibia.

Objectives: To describe patient-specific characteristics associated with non-operative failure leading to surgery., Patients and Methods: We conducted a retrospective review of patients treated for spinal metastases from 2005 to 2017. We deemed patients as failures if they were treated non-operatively and then received a surgical intervention within one year of starting a non-operative regimen. We used multivariable Poisson regression to identify factors associated with non-operative failure. We conducted internal validation using bootstrapping with 1000 replications., Results: We identified 1205 patients with spinal metastases, of whom 834 were initially treated non-operatively and constituted the analytic sample. Of these 77 (9%) went on to have surgery within 1-year of presentation and were deemed non-operative treatment failures. We identified vertebral body collapse and/or pathologic fracture (adjusted Risk Ratio [RR] 1.75; 95% Confidence Interval [CI] 1.11, 2.76) and neurologic signs or symptoms at presentation (RR 1.90; 95% CI 1.19, 3.03) as factors independently associated with an increased risk of non-operative failure. Platelet-lymphocyte ratio >155, a marker for inflammatory state, was also associated with an increased risk of failure (RR 2.32; 95% CI 1.15, 4.69). Failure rates among those with 0, 1, 2 or all three of these risk factors were 5%, 7%, 12% and 20%, respectively (p = 0.004)., Conclusion: We found that 9% of patients with spinal metastases initially treated non-operatively received surgery within 1-year of commencing care. The likelihood of surgery increased with the number of risk factors. These results can be used in counseling and shared decision making at the time of initial presentation., (Copyright © 2019 Elsevier B.V. All rights reserved.)

The purpose of this retrospective study was to evaluate the short and midterm radiological outcome with regards to bone healing, correlated with humeral shaft fractures treated with anterograde intramedullary nailing, when interfragmentary gap was significant. Here, we critically review our experience of short and midterm term results in over 65 year-old patients. Inclusion criteria in the study were: (1) patients over 65 years old (2) patients with displaced humeral mid shaft fractures (AO/OTA 12 A B C type fractures); (3) patients treated with closed reduction and internal fixation with intramedullary nail (Trigen Humeral Nail® Smith and Nephew) with at least two screws for proximal locking and one screw for distal locking; (4) residual interfragmentary gap, being considered significant any gap >6 mm (being 7 mm the minimum nail diameter available in our facility). Various factors were considered in our analysis: the size of the interfragmentary gap in both projections (also the mean of the measured gaps was calculated), the relationship between the greater and the mean interfragmentary gap and the second diameter measurement of the nail in the half distal part, the number of the screws in distal locking procedure, the use of a reaming procedure or not, the AO classification, the actual age at the time of surgery, the operating time, the nail second diameter as described before and its ratio with the measured residual gap. At 3 months follow-up, 4 patients showed radiographic healing (26,67%), 9 patients showed a visible callus (60%), with a total of 13 patients (86,67%) showing signs of normal recovery, the remaining 2 patient had insufficient callus formation (13,3%). At 6 months follow-up, 1 patient was missing (6,67%), although radiographic healing was already evident during the previous follow-up check, another one showed incomplete callus formation, the remaining 13 patients showed radiographic healing (86,67%), with a total of 14 patient considered healed at 6 months follow-up (93,33%). In conclusion, osteosynthesis with anterograde nail in geriatric patients appears to be a quite safe approach despite a great interfragmentary gap. After 6 months of treatment, callus formation and the overall clinical outcome were proven to be above satisfaction. (www.actabiomedica.it).

Background: Chondroblastoma is a rare primary bone tumor of young people that generally occurs in the epiphyseal plate of long bones. To date, only 13 cases of patella with pathological fracture in chondroblastoma have been previously published., Case Presentation: A 15-year-old male patient presented with acute pain in the left knee after an injury occurred while playing basketball. Plain radiographs and computed tomography showed a pathological fracture of the left patella with an osteolytic lesion (1.5 × 2 × 3 cm). Magnetic resonance imaging revealed an expansile lesion within the patella with a slightly high signal on the T1-weighted image, a high signal on the T2-weighted image and soft tissue swelling in front of the patella. A m99 Tc bone scintigraphy revealed moderate uptake. The preoperative diagnosis was chondroblastoma. This patient underwent intralesional meticulous extended curettage, adjuvant high-speed burr, 95% alcohol and electrotome treatment, autogenous iliac crest bone grafting, and internal fixation. A postoperative pathological diagnosis was chondroblastoma. The patient's function was satisfactory, and there was no sign of tumor recurrence. The internal fixator was good, with no loosening or migration observed at the last follow-up at 20 months after surgery., Conclusions: Rarely, chondroblastoma of the patella can present with acute pain due to pathological fracture. We present the 14th such case in the literature to associate patellar chondroblastoma with pathological fracture. The patient was treated with curettage, inactivation, autogenous bone grafting, and internal fixation. A satisfactory therapeutic effect was obtained. This case may be beneficial to the diagnosis and treatment of chondroblastoma patella.

The number of fragility fractures is rising, and treatment is a challenge for orthopaedic trauma surgeons. Various augmentation options have been developed to prevent mechanical failure. Different composites can be used based on the fracture type, patient needs, and biomechanical needs. Indications for augmentation are not limited to osteoporotic fractures but can also be performed as a salvage procedure or in pathologic fractures. Biomechanical studies have shown advantages for augmented implants in the spine, proximal femur, and humerus. Clinical studies are preliminary but promising, showing good clinical results after augmentation with reduced mechanical failure and minimal complications.

Case: Case 1 is a 6-month-old female who presented for evaluation of asymptomatic vertebral anomalies in the setting of jaundice and cardiac murmur; she was diagnosed with Alagille syndrome (AGS). Her spine has been monitored clinically. Case 2 is a 10-year-old female who sustained a pathologic femur fracture in the setting of known AGS, requiring operative stabilization and optimization of her bone mineral density., Conclusions: Pediatric orthopaedists care for children with AGS both in management of congenital musculoskeletal anomalies and in treatment of pathologic fractures. Familiarity with the current AGS literature is necessary for provision of optimal multidisciplinary care.

Background: Limb salvage is important in pediatric patients with bone sarcomas. The vascularized fibula flap is a versatile option, combined or not with a bone allograft. The authors evaluated the functional long-term outcomes, complications, and survival of using this technique in pediatric patients., Methods: A retrospective review of 27 pediatric patients reconstructed between 2011 and 2018 with the fibula flap after bone sarcoma resection was conducted. Long-term functional outcomes, complications, and survival were assessed. Variables analyzed were age, sex, Capanna technique, follow-up, complications, additional surgeries, time to weight bearing, length discrepancy, and sport practice., Results: Twenty-seven patients with a mean age of 9.3 years were included. The mean follow-up was 44.33 months. The Capanna technique was performed in 15 patients. All extremities but one were salvaged. The overall complication rate was 74.07%. Fibula fracture and nonunion rates were 34.04% and 11.11%, respectively. Partial weight bearing was resumed at a mean of 9.07 months. About 79.17% of patients with a 12-month follow-up achieved full weight bearing. An age below 8 years was significantly associated with a lower major complication rate and a shorter time to weight bearing and full weight bearing. Major complications and additional surgeries were significantly associated with longer periods until weight bearing and full weight bearing., Conclusions: The fibula flap allows the majority of extremities to be reconstructed. However, a high rate of complications and additional surgeries should be anticipated. Full weight bearing is usually achieved within the first year, with modest functional increase afterward. Less complications and a faster functional recovery are expected in patients below the age of 8 years., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: As oncology patients have increasing life expectancies, total hip arthroplasty (THA) may become an important treatment option for pathologic proximal femur fractures (PPFFs). Although THA and hemiarthroplasty (HA) have been compared for native hip fracture treatment, no data on short-term morbidity and mortality are available in the pathologic setting. The purpose of this study is to compare short-term morbidity and mortality of HA vs THA for PPFFs., Methods: The National Surgical Quality Improvement Program database was queried from 2007 to 2017 for patients with PPFFs treated with HA or THA. Propensity-adjusted logistic regressions were implemented to compare 30-day morbidity and mortality between procedures. Backwards stepwise regression was then used to determine independent predictors of treatment with HA compared to THA., Results: In adjusted analysis, THA was associated with longer operative times (120.3 ± 5.6 vs 98.7 ± 4.9 minutes, P < .001); however, there were no differences between THA and HA with regard to 30-day rates of major complications (P = .3), minor complications (P = .77), reoperations (P = .99), readmissions (P = .35), or deaths (P = .63). Older age (P < .001), dependent functional status (P = .02), and the presence of disseminated cancer (P = .049) were predictive of undergoing HA compared to THA., Conclusion: As patients with metastatic cancer continue to live longer with their disease, the durability of surgical reconstruction to treat PPFFs is becoming increasingly important. This study demonstrated no significant differences in 30-day complications between PPFF patients treated with THA or HA after controlling for underlying confounders. These results suggest that THA can be utilized to treat certain patients with PPFFs, and future work is warranted to examine long-term functional outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background and Objectives: Neurosurgeons and other specialists are increasingly having to treat patients with osteoporosis who require spinal fusion surgery. Although there are effective pharmacological treatments and innovations in surgical techniques that can benefit these patients, low rates of diagnosis and preoperative treatment of osteoporosis have been reported, in addition to the limited participation of spine surgeons in this area. The objective of this study was to evaluate trends in diagnosis and treatment of osteoporosis with regard to spine surgeons of the neurosurgical community., Material and Methods: An electronic survey with 10 multiple-choice questions was issued to Spanish Neurosurgery Society (SENEC) members. The following were evaluated: 1) the surgeon's role regarding osteoporosis in spinal arthrodesis, 2) the influence of osteoporosis in pseudarthrosis, and 3) treatment trends in relation to osteoporotic vertebral fractures., Results: A total of 77 completed questionnaires were obtained. In patients with suspected osteoporosis, 32.5% of respondents did not consider any measure to diagnose it before spinal arthrodesis. In osteoporosis without treatment, 37.7% would proceed with surgery without treatment or would do so after surgery. A total of 48% of respondents would choose to modify their surgical strategy in patients with osteoporosis. The preferred surgical technique was the placement of augmentation screws (70%). In pseudarthrosis, 46.1% did not consider an osteoporosis diagnosis to be necessary for a reoperation. In osteoporotic vertebral fractures, 80.5% of surgeons considered some measure that would facilitate the treatment of osteoporosis., Conclusions: Greater participation of the spine surgeon could improve the diagnosis and preoperative treatment of osteoporosis in spinal arthrodesis surgery and pseudarthrosis. In vertebral fractures, there is greater awareness of the optimisation of treatment and monitoring of osteoporosis., (Copyright © 2019 Sociedad Española de Neurocirugía. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: To evaluate the prevalence of biological abnormalities leading to secondary osteoporosis in recently fractured patients., Methods: Adults older than 50, hospitalized for a non-vertebral fracture from July 2015 to October 2016, were assessed for bone fragility contributors in the orthopedics department. Bone mineral density (BMD) measurements and vertebral fracture assessment (VFA) were performed within 3 months. We assessed the prevalence of biological abnormalities in all the patients with recent fracture and in subgroups., Results: Among 439 hospitalized patients for non-vertebral low trauma fracture, 372 had biological tests (285 women, mean age 77.5 ± 13 years) and 353 (94.6%) had at least ≥ 1 biological abnormality, most frequently vitamin D insufficiency (< 75 nmol/L) (80%). Hypercalcemia was found in 22 (7.7%) patients, explained by possible primary hyperparathyroidism in 6 cases, and by the other causes of hypercalcemia including postoperative low albumin. A high PTH level was observed in 64 (20.8%) patients. We found 3 monoclonal bands. Results were similar in patients with and without vertebral fracture or osteoporosis. Finally, many biological abnormalities can be explained by the postoperative context (low TSH, hypogammaglobulinemia, low albumin, low alkaline phosphatase) and need a control., Conclusion: This study performed in patient with recent low trauma non-vertebral fractures showed that 94.6% of patients had at least one contributor to bone fragility, which was the vitamin D insufficiency in most of cases. We found a high proportion of biological abnormalities which require additional explorations but most of them can be explained by the postoperative context., (Copyright © 2019. Published by Elsevier Masson SAS.)

Background: Intramedullary nailing is the procedure of choice for pathologic fractures in humeral shaft because it allows early pain relief and mobilization. The aim of this study was to analyze the prognostic factors affecting survival of patients with pathologic humeral shaft fractures treated with intramedullary nailing without tumor removal., Methods: We performed a retrospective study by evaluating the records of patients treated in our clinic between 2003 and 2018 for pathologic humerus shaft fractures with a minimum follow-up of one year. Kaplan-Meier methods were applied to estimate overall survival. A multivariate Cox algorithm was applied to recognize factors independently associated with survival., Results: 52 patients (56 humeral fractures) were operated. The average age at the time of surgery was 58.9 years. There were 28 women and 24 men. In our series, multiple myeloma accounted for 52% of the cases. At the time of this study, 34 (65.3%) patients had deceased. Survival rates at first month, 6 months and 1 year after surgery were 96.2%, 67.4% and 59.6%, respectively. The median survival after surgery was 7.5 (6 days-84 months) months for deceased patients and 18 (34.7%) surviving patients with a median survival of 68.6 months. Rapid growth tumor, presence of pathological fracture in other extremities and, Eastern Cooperative Oncology Group performance status (ECOG-PS) were independently associated with a worse overall survival., Conclusion: More than 50% of patients with pathological humerus shaft fractures were diagnosed with multiple myeloma. Rapid growth tumors such as lung cancer and renal cell cancer increased mortality by a factor of 1 while presence of operative metastases in other extremities increased mortality by a factor of 3.1 and ECOG-PS increased mortality by a factor 6.8. Rapid growth tumors, ECOG-PS and presence of pathological fracture in other extremities were important prognostic factors influencing overall survival., (Copyright © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background and Importance: Dual iliac-screw and dual-rod fixation provides additional stability to lumbopelvic constructs and can be employed in management of neoplastic disease with extensive osseous involvement. Optimal iliac-screw positioning is vital to achieve the desired dual iliac-screw and dual-rod linkage., Clinical Presentation: In this report, we describe our technique with particular focus on subcrestal iliac-screw entry point position using a 4-quadrant teardrop radiological view concept in a case of minimally invasive L3-iliac spinopelvic fixation using dual iliac-screw and dual-rod for a patient with pathological sacral fracture. At the last follow-up 20 mo postsurgery there was minimal axial and radicular pain and no evidence of screw prominence. Radiographs showed no evidence of construct failure., Conclusion: The 4-quadrant teardrop concept provides a good visual reference for optimal subcrestal screw placement when employing a dual iliac-screw and dual-construct., (Copyright © 2019 by the Congress of Neurological Surgeons.)

Background: Simultaneous bilateral femoral neck fracture is a very rare condition, even in osteoporotic elderly individuals. We report an atypical case of a young male adult who developed simultaneous bilateral femoral neck fractures without previous trauma or overuse., Case Presentation: A 33-year-old man presented with discomfort in the bilateral groin, which had started 2 weeks previously. Bilateral femoral neck fractures were observed on a radiograph, and in addition, a fracture line was seen at the right subchondral region of the acetabulum using magnetic resonance imaging (MRI). Although the patient had no obvious risk factors associated with bone fragility, his bone mineral density measured using dual X-ray absorptiometry indicated severe osteoporosis (lumber spine: T score - 3.4 standard deviation [SD]; femoral neck: T score - 2.8 SD). Serum 25-hydroxyvitamin D level was deficient (19 ng/mL), which was considered to be partly due to non-sunlight exposure for 3 years owing to social withdrawal. Bilateral osteosynthesis was performed, considering his young age, although more than 2 weeks had passed since the onset of the fracture. Bone union and non-occurrence of osteonecrosis of the femoral head were confirmed via radiography and MRI 8 months after the surgery., Conclusions: Our case suggests that simultaneous non-traumatic bilateral femoral neck fractures can occur in healthy young men.

Intraosseous hemangioma (IH) in the maxillofacial area is a very uncommon neoplasm. Here, the authors show an exceptional case not previously reported in the literature of a 65-year-old man who presented with a pathological mandibular fracture following a facial trauma that was the first sign of an occult cavernous IH. Complete excision of the tumor in the mandibular ramus reduced the risk of severe bleeding and prevented long-term recurrence, whereas immobilization of the fracture obtained an excellent functional result. This clinical report highlights the possibility that a previously unknown primary IH may debut as a pathological fracture and the importance of differential diagnosis in this location.

Objectives: Surgical site infection (SSI) is a devastating complication of proximal femoral fracture surgery, related with an increased morbidity and mortality. As warfarin treatment has been described as a risk factor for SSI, we aimed to compare patient and SSI characteristics in warfarin and nonanticoagulated patients., Design: Retrospective cohort study., Setting: Level-1 trauma center., Patients: Individuals 65 years of age and older with fragility hip fractures., Intervention: Patients were divided into 2 cohorts: warfarin treated (n = 85) or nonanticoagulated (n = 771). Demographics, in-hospital characteristics, laboratory data, prior hospitalizations, recent antibiotic use, and 1-year incidence of SSIs and their characteristics were gathered., Main Outcome Measures: Postoperative SSIs., Results: Twelve patients (14.1%) from the warfarin group and 21 patients (2.7%) from the noncoagulated group had SSI (P < 0.001). Both groups were comparable in terms of demographics and Charlson comorbidity score. Warfarin-treated patients had reduced white blood and neutrophils counts (10.1 ± 3.2 vs. 11.6 ± 4.0 cells/mm and 8.1 ± 3.2 vs. 9.6 ± 3.9 cells/mm for both comparisons respectively; P < 0.001 for both). They were more likely to be admitted to a geriatric ward than to orthopedics ward and were delayed to theater (58.5 ± 44.5 vs. 30.6 ± 27.4 hours; P < 0.001). Following surgery, there was no difference in blood transfusions required, in-hospital complications, or time to infection. Rates of prior hospitalizations, antibiotic use, or type of bacteria did not differ., Conclusions: Warfarin treatment in fragility hip fracture surgery is correlated with an increased risk for SSI, regardless of in-hospital complications, and hospitalizations before surgery or to the infection itself., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.