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У статті наведені дані світової літератури про частоту і особливості проведення симультанних операцій у пацієнтів з поєднаною первинною одномоментною онкопатологією. Наведений клінічний випадок, проаналізовані показання, переваги, можливі ризики та ускладнення таких оперативних втручань, а також причини, що стають іноді наріжним каменем спотикання для більш широкого впровадження подібних операцій в лікарську практику., В статье приведены данные мировой литературы о частоте и особенностях проведения симультанных операций у пациентов с сочетанной первичной одномоментной онкопатологией. Приведен собственный клинический случай, проанализированы показания, преимущества, возможные риски и осложнения таких оперативных вмешательств, а также причины, которые становятся иногда краеугольным камнем преткновения для более широкого внедрения подобных операций во врачебную практику., The article provides a review of the world literature on the incidence and characteristics of conducting simultaneous operations in patients with concomitant primary oncopathology. Сlinical case is given, the authors analyzed the indications, advantages, potential risks and complications of surgical interventions, as well as the causes that often impede wider implementation of similar operations in the medical practice.

Sacral fracture with spino-pelvic dissociation is a rare and unstable injury caused by high-energy trauma, often with serious haemodynamic and neurological implications. Diagnosis is easily delayed or missed as it is often masked by severe associated injuries. Here, we present an unusual case of spino-pelvic dissociation sustained during a seizure episode in a young epileptic patient on long-term anticonvulsant therapy with previous thoracolumbar spinal arthrodesis. This unique case brings to light the need for clinicians to consider sacral fractures in patients presenting with low back pain with no preceding trauma who otherwise may have risk factors for pathological fractures.

Bone metastases of the long bones often lead to pain and pathological fractures. Local treatment consists of radiotherapy or surgery. Treatment strategies are strongly based on the risk of the fracture and expected survival. Diagnostic work-up consists of CT and biopsy for diagnosis of the primary tumour, bone scan or PET-CT for dissemination status, patient history and blood test for evaluation of general health, and biplanar radiograph or CT for evaluation of the involved bone. A bone lesion with an axial cortical involvement of >30 mm has a high risk of fracturing and should be stabilised surgically. Expected survival should be based on primary tumour type, performance score, and presence of visceral and cerebral metastases. Radiotherapy is the primary treatment for symptomatic lesions without risk of fracturing. The role of post-operative radiotherapy remains unclear. Main surgical treatment options consist of plate fixation, intramedullary nails and (endo) prosthesis. The choice of modality depends on the localisation, extent of involved bone, and expected survival. Adjuvant cement should be considered in large lesions for better stabilisation.Cite this article: Willeumier JJ, van der Linden YM, van de Sande MAJ, Dijkstra PDS. Treatment of pathological fractures of the long bones. EFORT Open Rev 2016;1:136–145. DOI: 10.1302/2058-5241.1.000008.

Aims This study aims to assess first, whether mutations in the epidermal growth factor receptor (EGFR) and Kirsten rat sarcoma (kRAS) genes are associated with overall survival (OS) in patients who present with symptomatic bone metastases from non-small cell lung cancer (NSCLC) and secondly, whether mutation status should be incorporated into prognostic models that are used when deciding on the appropriate palliative treatment for symptomatic bone metastases. Patients and Methods We studied 139 patients with NSCLC treated between 2007 and 2014 for symptomatic bone metastases and whose mutation status was known. The association between mutation status and overall survival was analysed and the results applied to a recently published prognostic model to determine whether including the mutation status would improve its discriminatory power. Results The median OS was 3.9 months (95% confidence interval (CI) 2.1 to 5.7). Patients with EGFR (15%) or kRAS mutations (34%) had a median OS of 17.3 months (95% CI 12.7 to 22.0) and 1.8 months (95% CI 1.0 to 2.7), respectively. Compared with EGFR-positive patients, EGFR-negative patients had a 2.5 times higher risk of death (95% CI 1.5 to 4.2). Incorporating EGFR mutation status in the prognostic model improved its discriminatory power. Conclusion Survival prediction models for patients with symptomatic bone metastases are used to determine the most appropriate (surgical) treatment for painful or fractured lesions. This study shows that NSCLC should not be regarded as a single entity in such models. Cite this article: Bone Joint J 2017;99-B:516–21.

Endoprosthetic replacement (EPR) and intramedullary nailing (IMN) are the two most commonly applied surgical methods used to treat proximal metastatic lesions; however, indication of the above procedures remains controversial. The aim of the present study was to evaluate the clinical, functional and oncological outcomes of patients who underwent EPR compared to IMN for the treatment of proximal femur metastases to investigate the surgical indication for patients. The records of patients (n=88) with pathological fractures secondary to metastatic tumors of the proximal femur admitted between January 2005 and December 2014 to West China Hospital, Sichuan University (Chengdu, China) were retrospectively studied. A total of 57 patients were treated with EPR (34 males and 23 females; mean age, 62.5 years) and 31 patients were stabilized with IMN (19 males and 12 females; mean age, 60.2 years). Patients were analyzed regarding surgery time, blood loss, hospital stay, Musculoskeletal Tumor Society (MSTS) score, survival, recurrence and complications. The median follow-up period was 12.9 (range, 3-98) months. The median survival time in EPR was 10.0 months and 7.5 months in IMN. The surgery time was 142.6±22.7 min in the EPR group and 98.7±19.5 min in the IMN group (P=0.001). Significantly less blood loss was observed in the IMN group (345.2±66.4 ml) than in the EPR group (631.5±103.6 ml; P=0.001). The median hospital stay in the EPR group was 8 (quartile range, 7-9) days and 5 (quartile range, 5-6) days in the IMN group (P=0.001). Local recurrence rate was 10.5% (6/57) in the EPR group and 25.8% (8/31) in the IMN group (P=0.074). The complication rates were 10.5% (6/57) in the EPR group and 29.0% (9/31) in the IMN group (P=0.038). MSTS-93 score was higher in IMN compared with EPR at 6 weeks postoperatively (P=0.001), while the EPR group demonstrated a higher score at 6 months postoperatively (P=0.001). EPR has the advantage of better functional outcomes and higher life quality in the long term, with lower complication rates in treating metastatic lesions of the proximal femur with pathological fractures. EPR is recommended for patients with relatively good general condition and prognosis. IMN is best indicated when the patient's life expectancy is extremely limited.

Enchondroma, reportedly the most common primary tumor of the long bones of the hand, usually develops during the first till fourth decades of life. However, there has no consensus been reached regarding the surgical intervention timing for these patients. We aim to evaluate the optimal surgical intervention timing for the patients with fractures due to enchondromas, investigate the impact of pathological fractures on the treatment and outcomes in these patients. Medical records and X-rays of patients treated for enchondroma of the hand from 2005 to 2015 were retrospectively reviewed. We collected 148 cases in total and 92 of them had complete information including X-rays, medical records, and files of follow up. There were no significant differences in terms of consolidation time after surgery, recurrence rate, and DASH scores between the groups with and without fractures; the treatment costs were higher in the group with fractures than those without fractures; however, patients without fractures were able to resume work earlier than those with fractures. The pathological fractures associated with enchondromas have no significant impact on the treatment outcomes compared to those with simple nonfractured enchondromas. Although the cost was more expensive for patients treated primarily with pathological fractures due to enchondromas, these patients could resume their work normally much earlier than those treated by delayed surgery. Early surgical intervention is recommended for better results and no increased risks for patients with pathological fractures caused by enchondromas.

Background: The purpose of this study was to investigate whether pathological fractures (PF) influence the prognosis of patients with osteosarcoma (OS) or Ewing tumor (ET) regarding 5-year survival, occurrence of metastases, and local recurrence. Methods: We retrospectively analyzed 205 patients with metastatic and nonmetastatic OS or ET. Survival analysis was performed for all patients and differentiated for patients with OS (n = 127) and ET (n = 78) as well as for adults (n = 101) and children (n = 104). Results: Patients with PF showed survival rates of 64% compared to 83% for those without PF (p = 0.023). Local recurrence occurred in 7% of the patients without and in 24% of those with PF (p = 0.023). In patients with ET and in children, survival analysis showed no significant difference between patients with and without PF in survival and local recurrence rates. In patients with OS, survival rate decreased from 83 to 59% (p = 0.024) and local recurrence rate increased from 13 to 30% (p = 0.042). In adults, survival rate decreased from 78 to 51% (p = 0.004) and local recurrence rate increased from 13 to 42% (p < 0.001). In multivariate analysis, age and PF were associated with inferior survival. Conclusion: This study suggests that the occurrence of PF has a negative impact on survival and implicates an increased risk of local recurrence. In children and in patients with ET, PF did not have a prognostic impact.

Introduction There is no consensus on when and how to treat unicameral bone cysts (UBCs), partly because of a lack of knowledge of the aetiology. Purpose To review the different treatment techniques for UBCs and to describe our results with a single injection of autogenous bone marrow (BM) mixed with demineralised bone matrix (DBM) in very young children. Patients and methods We reviewed five patients under the age of 8 years with UBCs treated by percutaneous aspiration and a single injection of BM associated with DBM. The cyst was located in the proximal humerus in four patients and in the proximal femur in one patient. Assessment of the need for surgery was based on the clinical and radiographic suspicion of new pathological fractures. The administration of a second injection, when necessary, was based on the surgeon's judgement regarding the risk of fracture. The mean follow-up after first injection was 41 months. Results There were no complications related to the procedure, except a non-displaced fracture, which healed without problems. All patients were pain free and progressively resumed their activities without restriction until a new fracture occurred in two cases. According to Capanna's classification, only one case healed completely (grade 1), one lesion was classified as grade 2, and there were three recurrences at 11, 12 and 27 months after initial treatment (grade 3). The final outcome was treatment failure for three out of the five patients. Two patients were treated with a second injection and one patient is waiting for surgery. Conclusion A single injection of aspirated autogenous BM mixed with DBM in very young children with active UBCs at risk of fracture is very simple, comfortable and safe. Nevertheless, the results seem to be unpredictable and are probably more dependent on the natural evolution of the cyst than on the treatment. Further comparative studies with larger sample numbers are needed.

Background Pathological fractures are a significant and often devastating event in the progression of metastatic bone disease. They are frequently a marker of end-stage cancer and the end of functional independence. Although several studies look into prognosis following the development of metastatic lesions, few look into the prognosis after the fracture itself. This study investigates the variables affecting prognosis in patients suffering pathological fractures. Method Retrospective clinical audit of 72 patients from the Orthopaedic Unit at Fremantle Hospital in Western Australia. The variables of interest include primary cancer, fracture site, method of fixation, use of cement augmentation, appendicular metastatic load, spinal metastatic load, presence of visceral metastases, patient co-morbidities and functional scoring before and after the fracture has occurred. Results The median time between diagnosis of cancer to pathological fracture was 8.3 months, while the median survival post-fracture was 3.3 months. There is a statistically significant correlation between patient survival and primary cancer type, spinal metastatic burden and functional performance score. Conclusion Overall, the prognosis following pathological fracture is extremely poor. We propose that these variables are scrutinized by the treating orthopaedic team preoperatively to help guide management and provide patients and their families with a realistic expectation of functional outcome and survival time.

Presented the clinical observation of patients with multiple metastatic and myeloma lesions of the spine with the presence of pathological fractures of vertebral bodies and severe pain. The authors recommend multilevel vertebroplasty, as it allows to reduce pain, to prevent pathological fracture of the spine, and activate patients in a short time.

182 Background: Prostate cancer commonly metastasizes to the bone, resulting in pathological fractures and poor prognosis. CCN3/NOV (Nephroblastoma overexpressed) has been implicated in promoting the formation of osteolytic prostate cancer (PC) bone metastases. The C-terminal domain of CCN3 binds growth factors, heparin sulfate proteoglycans, activates Notch signaling and promotes dimerization of CCN family members. We hypothesize that the CCN3 CT domain is required to promote osteolytic PC bone metastasis and that CCN3 represents a prognostic biomarker in primary PC tumors to predict recurrence to bone. Methods: CCN3WT and CCN3∆CT were overexpressed in LNCaP C4-2 cells. The role of CCN3 was assessed with in vitro proliferation, migration and invasion assays, and in vivo through intracardiac injection in male Nude mice (Nu/Nu). Ex vivo µCT scans were performed on bone specimens. CCN3 expression was assessed in two unique tissue microarrays (TMA) comprising over 1,500 primary prostate tumor using different anti-CCN3 antibodies with immunohistochemistry and immunohistofluorescnece, respectively. Results: While CCN3WT and CCN3∆CT had little effect in vitro on cell proliferation, migration or invasion, intracardiac injection of CCN3WT resulted in increased incidence of bone metastasis compared to empty vector control and CCN3∆CT. Ex vivo µCT revealed decreased bone mineral density in bones from mice injected with CCN3WT cells compared to control and CCN3∆CT expressing cells. In both TMAs studied, high CCN3 expression in tumor epithelium correlated with increased risk of biochemical relapse and bone metastasis at 5 years and 15 years post-resection, respectively. Conclusions: CCN3 requires its C-terminal domain for its bone metastatic function, and CCN3 is correlated with aggressive disease biology in prostate cancer. These findings point to CCN3 as a biomarker that can be useful to predict prostate cancer aggressiveness, while providing clarity on its role as a functional mediator of prostate cancer bone metastasis.

Objectives: The management of giant cell tumor (GCT) lesions around the knee is challenging. This study aimed to investigate the long-term outcome of treating GCTs around the knee with associated pathological fractures by curettage and adjuvant cementation with the use of high-speed burr. Methods: Fifty patients with a mean age of 28.3 years were included in the study. The tumor was located in the distal femur (40 patients) and proximal tibia (10 patients). Eighteen patients were Grade II Campanacci, whereas 32 patients were Grade III. The mean follow-up period was 65 months. Twenty-nine patients (58%) underwent extended curettage and bone cement. Twenty-one patients (42%) underwent extended curettage, bone cement, and internal fixation. High-speed burr was used in 45 patients (90%). Bone graft was used in 8 patients (16%). Functional evaluation was done using the Musculoskeletal Tumor Society (MSTS) scoring system for the lower extremity. Results: The overall MSTS score was excellent in 42 patients (84%), good in 5 patients (10%), fair in 2 patients (4%), and poor in 1 patient (2%). The overall local recurrence rate was 12% (6 cases) and a 10% complication rate. There were no cases of fracture nonunion or distant metastasis. Conclusions: GCTs around the knee with associated pathological fractures at diagnosis can be treated with extended curettage using high-speed burr and adjuvant cementation with favorable functional long-term outcome.

espanolPresentamos el caso de una mujer de 60 anos de edad que acudio a nuestro hospital por dolor precordial pleuromecanico y fue diagnosticada de fracturas oseas multiples. La biopsia de medula osea dio el diagnostico de mieloma multiple y no se detecto pico monoclonal, ni tampoco cadenas ligeras en sangre ni orina. El diagnostico final fue de mieloma multiple no secretor y fracturas espontaneas secundarias. El mieloma multiple no secretor representa solo el 3% del total de mielomas multiples y tiene caracteristicas peculiares que hacen necesaria su distinction del resto de mielomas. EnglishWe present the clinical case of a 60 year-old woman who was admitted to our hospital referring a precordial pleuromechanic pain and was diagnosed with multiple bone fractures. A bone marrow biopsy gave the diagnosis of multiple myeloma and no monoclonal peak was detected, neither light chains in blood nor urine. The final diagnosis was non-secretory multiple myeloma and secondary spontaneous fractures. Non-secretory multiple myeloma represents only 3% of all multiple myelomas and has several characteristics that make it important to distinguish from other myelomas

Giant cell tumors of distal radius are locally aggressive tumors with a high rate of recurrence. Though surgery remains the mainstay of treatment, reconstruction remains a challenge in cases of recurrence. Recurrences of GCT in autogenous fibular grafts have been rarely reported and pathological fractures through such grafts are even rarer. Ulnocarpal arthrodesis has never been described as a limb preservation procedure in such a recurrent lesion in distal radius with pathological fracture through a well incorporated fibular graft. A case of pathological fracture in a well incorporated autogenous non-vascularized fibular bone graft in recurrent GCT of distal radius and its successful management with ulnocarpal arthrodesis is reported. In such a scenario where other reconstructive options like allograft or prosthetic reconstructions are not likely to succeed, ulnocarpal arthrodesis may be considered as a salvage procedure.

Fractures of the distal humerus account for 5% of osteoporotic fractures in patients over 60 years. The osteoporotic field, comorbidities, and joint comminutions make it difficult to support. The objective of our work is to show the interest of the total e...

Fractures include pathological and traumatic fractures; and a certain line of thinking should be followed when coding. The pathological fractures caused by osteoporosis should be coded to M80.-. The pathological fractures not caused by osteoporosis, if occurring in the spine, should be coded to M49.5*; those not occurring in the spine, if they are caused by a tumor, should be coded to M90.7*, while those not caused by a tumor should be coded to M84.4. In traumatic fractures, fatigue fractures of spine should be coded to M48.4, while those not of the spine should be coded to M84.3; fractures due to birth injury should be coded to P11.5 or P13.-; in general traumatic fractures, if the region of fractures is unspecified, the fractures should be coded to T08-T14, the fractures of multiple regions (cross-categories) should be coded to T02, multiple fractures of single region (cross-subcategories) should be coded to S-2.7, and single fractures should be coded to relevant subcategories in S-2 except for ...

Despite promising advances in antibiotic and surgical therapy osteomyelitis remians a severe disease with a high morbidity. Nowadays it occurs mainly after traumata. Typical clinical manifestations are signs of local infection, non-healing wounds, pathological fractures or loosening of orthopedic implants. Besides the clinical judgement the diagnosis is consolidated by imaging procedures, histopathological and microbiological examinations. Ideally, the treatment plan is based on an interdisciplinary approach. Besides the radical surgical debridement a test appropriate antibiotic therapy is essential. Defect reconstruction after surgical debridement and optimization of local microcirculation is essential to preserve limbs and to obtain a good functional result. Microsurgical free tissue transfer is often necessary to achieve healing. An optimal therapeutic management with stable long-term clinical results can be achieved by the interaction of different surgical and medical disciplines.

Case report Two dark-coloured alpaca crias aged 5 and 5.5 months, respectively, born in September in the Pacific Northwest, USA, were presented for evaluation of acute recumbency. Both crias had cervical spine fractures and one had additional fractures in other locations within the spine. Both crias had valgus deformities of the forelimbs and one had similar deformities of the hindlimbs. Both crias showed characteristic radiological signs of rickets syndrome, including wide, irregular physes, cupping of the metaphyses, bowing of long bones, pathological fractures and enlarged costochondral junctions. One cria responded clinically to treatment with parenteral administration of vitamin D. The other cria was euthanased because of the multiple spinal fractures and postmortem examination supported the diagnosis of rickets syndrome. Conclusions Hypovitaminosis D is associated with abnormal bone formation in young growing animals. The clinical and laboratory findings of rickets syndrome in camelids in the Pacific Northwest, and other regions with low annual sunlight exposure, have been described, although there are only few reports of the radiological signs associated with this condition in camelids and other animals. Additionally, vertebral fractures have not been previously reported in animals with rickets syndrome. Because vertebral fractures were identified in both crias in this report, it suggests that this is a common and clinically important manifestation of the disease in alpaca crias. Hence, in geographic regions with low sunlight exposure, rickets syndrome should be considered as a differential diagnosis in crias presenting with clinical signs consistent with vertebral fracture.

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

The possibility of the spinal stabilization in patients with a history of somatic diseases and contraindications to general anesthesia is discussed. As an example, the authors have given the histories of two patients with vertebral pathological fractures against a background of the osteoporosis and metastatic gastric cancer who underwent transpedicular fixation of the spine under local anesthesia. In both cases good results of treatment were received.

McCune Albright syndrome is a rare genetic disorder which is characterized by cafe au lait skin pigmentation, precocious puberty and polyostotic fibrous dysplasia. Treating recurring pathological fractures due to Albright syndrome is a very challenging endeavor, and more so when it is accompanied by poor bone quality and deformity. We hereby present the case of a 23-year-old male patient who is treated several times for recurrent pathological fractures of the femur at our center. We analyze the difficulties associated with treating a patient with poor bone quality over several years, discuss our treatment options, review the literature for similar cases and look at what we could have done differently. We weigh in on the difficulties in treating a severely deformed shepherd’s crook, the ways of achieving proper internal fixation and the dangers of using plating instead of an IM nail as suggested in the literature. Our main goal in reporting this case is to bring forth the unusual challenges encountered when treating patients with Albright syndrome and discussing the options of the orthopedic surgeons when treating these types of patients.

Although there have been many reports of small bone and vertebral involvement in sarcoidosis, long bone pathology is rare. We report a case of almost identical bilateral fractures of the proximal femoral diaphysis during separated in time through a low-energy mode of injury, and explore the difficulties encountered when seeking radiological and tissue diagnosis.

Neuroblastoma is the most common extracranial solid tumor of childhood which should be considered in the differential diagnosis of bone metastases and resultant pathological fractures, especially in children under 5 years old. We present an 11-month-old girl who presented with a pathological femur fracture and was diagnosed with metastatic neuroblastoma., Nöroblastom çocukluk çağının en sık rastlanan ekstrakraniyal solid tümörü olmakla birlikte özellikle 5 yaş altı çocuklarda kemik metastazları ve buna bağlı patolojik kırıkların ayırıcı tanısında akılda bulundurulmalıdır. Çalışmamızda, patolojik femur kırığıyla başvuran ve metastatik nöroblastom tanısı konulan 11 aylık bir kız olgu sunuyoruz.

Simple bone cyst is a common benign lesion of bone. Although it is considered to be benign (non cancerous), it can cause fractures, deformities and psychosocial problems. Several treatments have been advocated with variable success, and the search for better treatments is ongoing. In this chapter, we have summarised the evidence that underpin current treatments.

WE would like to bring to the attention of your readers and the general veterinary community an increasing number of Bengal kittens (seven within the past year) that have presented with pathological fractures, particularly vertebral fractures, as a result of secondary nutritional hyperparathyroidism. Clients of affected cats report they have been …

A middle aged patient with multiple myeloma resulting in numerous pathological fractures underwent an L2, L3, and L5 vertebral cement augmentation for pain relief. After injection, the trocar at L2, the final level, could not be withdrawn despite several attempts of needle rotation, a second needle inserted to distract on, and rocking the needle on the pedicle. After a neurosurgical consultation, the patient was transferred to the operating room for open removal. As the needle protruded approximately 3 inches from the patient's back, the patient could not be positioned supine, and was anesthetized and intubated in the right semi-prone position prior to being placed prone on the operating room table. The needle was surgically exposed, cut off at the pedicular bone edge, and its free component was removed.

Polyostotic fibrous dysplasia (PFD) is a sporadic benign skeletal condition that typically presents with bone pain, deformities and pathological fractures. It preferentially affects long bones. Sarcomatous transformation, most commonly osteosarcoma, occurs in 7% of patients with PFD.1 Diagnostic challenges exist as radiographic appearances range from cystic foci to pagetoid or sclerotic lesions. Differential diagnoses include juvenile bone cysts, aneurysmal bone cysts and giant cell tumours.2 We describe a case of a 27-year-old woman who had been diagnosed with PFD at the age of 12 years, and who had an extensive history of pathological …

У статті поданий сучасний підхід до тактики лікування хворих на ортопедичну патологію при недосконалому остеогенезі, описаний перспективний напрямок медикаментозної корекції стану кісткової тканини та хірургічного лікування патологічних переломів і осьових деформацій довгих кісток. Авторами проведений аналіз результатів лікування 22 пацієнтів із недосконалим остеогенезом із використанням нової тактики, що включала застосування патогенетично обґрунтованої антиостеопоротичної терапії та «ростучих» телескопічних інтрамедулярних конструкцій; чітко встановлена та об’єктивно доведена ефективність та перспективність описаної методики як із лікувальних, так і з профілактичних позицій.

Pathological fractures of the long bones occur in 10–29% of patients with bone metastases. The occurrence of these fractures may alter management and prognosis, decrease quality of life and jeopardize survival [1–4]. The fracture hematoma may contaminate the adjacent soft tissue, nerves, vessels and joint, and damage to the microcirculation may favor distant hematogenous dissemination of the tumor [5].

The aim of this study was to evaluate the accuracy of pedicle screw placement after computed tomography (CT)-assisted positioning of guide wires and subsequent insertion of transpedicular screws in particularly narrow pedicles in the thoracic spine. Transpedicular pedicle screw placement has been commonly used for a number of decades. However, a significant number of malpositioned screws still occur, especially in the thoracic spine, potentially correlating with relevant complications, e.g., neurological deterioration. A retrospective analysis was performed after CT-assisted and -controlled implantation of guide wires into the pedicle. A total of 39 patients underwent dorsal spondylodesis using two different internal fixation systems, i.e., with a cannulated or a solid screw design. The postoperative screw position was evaluated with CT scans in three planes in a total of 254 screws. The number of the screws inserted at each level were as follows (total n = 326): T1, n = 8; T2, n = 26; T3, n = 26; T4, n = 36; T5, n = 50; T6, n = 37; T7, n = 38; T8, n = 32; T9, n = 24; T10, n = 18; T11, n = 10; T12, n = 6. Indications for the operative treatment were fractures, tumors, and infectious diseases. A total of 254 screws inserted were evaluated by CT scan in order to determine the screw position inside the pedicle and potential perforation of the pedicle wall. The overall rate of pedicle wall perforation was 7.5%, including 1.2% perforations of the medial wall. A significant correlation between the perforation rate and the type of fixation system in favor of the cannulated system was found (P = 0.033). During the study, no revision surgery due to screw misplacement was necessary. None of the treated patients showed neurological deterioration after screw implantation during the presented study. The CT-assisted pedicle screw implantation procedure using guide wires implanted prior to surgery is an accurate, reliable, and safe method for dorsal spondylodesis in the treatment of a variety of spinal instabilities, including fractures, tumors, and infections.

Pathological lesions of long bones increase the morbidity of many common cancers. The orthopedic management of metastatic skeletal lesions can be challenging. The ultimate aim is to provide patients with a painless, functional limb. We present a report of two cases were a novel minimally invasive long bone nailing technique has been utilized to achieve skeletal stability and alleviation of symptoms.

Clinical Question Among patients with multiple myeloma, is bisphosphonate therapy associated with lower rates of mortality, vertebral fractures, nonvertebral fractures, and skeletal-related events compared with placebo or no treatment? Bottom Line Among patients with myeloma, bisphosphonates were associated with lower rates of pathological fractures and skeletal-related events compared with placebo or no treatment. Direct meta-analysis showed no association between bisphosphonates and mortality. In network meta-analysis, zoledronate was associated with lower risk of mortality compared with placebo or no treatment.

Maffucci’s syndrome comprises of multiple venous malformations in combination with dyschondroplasia and a variety of cutaneous, vascular, chondro-osseous and other benign and malignant mesodermal growths. This report describes the case of a 20 -year-male patient with a clinical diagnosis of Maffucci syndrome with multiple lobulated sof tissue swelling with phleboliths in left upper and lower limbs. Significant findings were presence of multiple haemangiomas, enchondromas and pathological fractures- those were evaluated by X-ray, skeletal scintigraphy and ultrasound. Skeletal scintigraphy play an important role to see the extent of the disease.Early detection and surgical management of these tumors form the basis of its treatment and desirable outcome.Bangladesh J. Nuclear Med. 20(1): 67-69, January 2017

Beim multiplen Myelom – mit nicht selten uber 10-jahrigem Verlauf – sollte bei der operativen Versorgung ossarer Lasionen eine dauerhafte Rekonstruktion angestrebt werden. Sowohl bei der Wahl der Operationsmethode als auch des -zeitpunkts mussen der Allgemeinzustand und die Langzeitprognose des Patienten berucksichtigt werden. Eine weite oder gar radikale Resektion ist beim multiplen Myelom aus onkologischen Grunden nicht erforderlich. Das funktionelle Ergebnis hangt stark von der gewahlten Rekonstruktion ab. Die operative Versorgung pathologischer Frakturen der Extremitaten ist hinsichtlich Schmerzreduktion, funktionellem Ergebnis und Gehfahigkeit allen konservativen, strahlentherapeutischen und medikamentosen Therapieansatzen uberlegen. Nach marginalen oder intralasionalen Resektionen muss eine ausreichend hoch dosierte Radiatio des gesamten Operationsgebiets einschlieslich des Zugangswegs angeschlossen werden. Das solitare Plasmozytom des Knochens bietet in Kenntnis der genauen Ausdehnung und Dignitat des Tumors die Moglichkeit einer kurativen lokalen Therapie durch adaquate Resektion und ausreichend hoch dosierte Strahlentherapie, insbesondere bei Lasionen peripherer Skelettabschnitte. Die weitere Verbesserung der serologischen und bildgebenden Diagnostik, hier insbesondere durch den vermehrten Einsatz der MRT, wird die therapeutisch wichtige Einteilung in solitare und systemische Plasmozytome erleichtern, um eine Ubertherapie durch ausgedehnte Resektion und Rekonstruktion bei bereits systemischen Plasmozytomen zu vermeiden.

245 Background: Skeletal metastasis (SM) in advanced PDAC is an infrequent occurrence and has been previously reported to be < 2.5%. However; pathological fractures in these patients can result in intractable pain, immobilization and a significant deterioration in quality of life. Methods: A retrospective analysis was conducted of patients (pts) with advanced PDAC receiving palliative chemotherapy. Data collection included age, gender, ECOG, sites of disease, and overall survival (OS). Statistical analysis included Kaplan Meier survival analysis. Results: The 135 pts included had a median age of 65.8 years (range: 53.7–91.3); 5 (31.2%) were women and 11 (68.7%) had an ECOG performance status of 0 or 1. A majority of patients received combination therapy that was either gemcitabine or 5-flurouracil based. Sixteen pts (11.8%) had skeletal metastasis with the primary tumor located in the pancreatic body/tail (11 pts - 68.7%).The sites of SM included thoracic vertebrae (8), lumbar vertebrae (5), pelvis (5), ribs (4), sacrum (4), scapula (3), acetabulum (2), cervical vertebrae (2), femoral head (2), sternum (1) and humerus head (1). A majority of the lesions were osteolytic (62.5%) with a median time of diagnosis of SM from initial diagnosis being 1.25 months (range 0-33). Bone pain was observed as the initial symptom in 5 pts (32%), 1 pt (6.2%) had a pathological fracture. The mOS for patients with SM was 6.5 months (range 0-38) when compared to 8 months (range 0-147) without SM.The mOS for pts treated with gemcitabine based regimen was 5.75 months (range 2.5-14), and patients who received multiple lines of therapy including gemcitabine and 5-FU based regimens was 15 months (range 5-38). Survival from onset of skeletal metastases ranged from 0-14 months (mOS: 4 months). Conclusions: More effective systemic therapies which improve mOS are likely to result in increased incidence of SM. The most common sites observed were the thoracic and lumbar vertebrae and pathological fractures in these sites can be catastrophic. Therefore careful evaluation of skeletal signs and symptoms, early detection and intervention will be important to prevent morbidity and mortality from pathological fractures.

AIM Children with severe cerebral palsy (CP) are at risk for developing low bone mineral density (BMD) and low-impact fractures. The aim of this study was to provide a systematic literature review of the epidemiology of fractures and low BMD in children with severe CP, with an emphasis on risk factors. Gross Motor Function Classification System (GMFCS) levels IV and V were criteria for severe cerebral palsy.METHOD The literature (PubMed) was searched and eligible studies were given a level of evidence score using the Scottish Intercollegiate Guidelines Network criteria.RESULTS Seven studies were found concerning epidemiology of fractures, 11 studies described epidemiology of low BMD, and 14 studies concerned risk factors. The methodological quality of most of these studies was poor. Five studies were considered well-conducted with low risk of confounding and bias. In these studies, the incidence of fractures in children with moderate to severe CP approached 4% per year, whereas the prevalence of low BMD in the femur was 77%. Limited ambulation, feeding difficulties, previous fractures, anticonvulsant use, and lower body fat mass were associated with low BMDz-scores.INTERPRETATION There is only a limited amount of high-quality evidence on low BMD and fractures in children with severe CP.