Lumbar vertebral bone density is decreased in horses with pituitary pars intermedia dysfunction

BACKGROUND

Pathological fractures have been reported in equids with pituitary pars intermedia dysfunction (PPID) but their prevalence and pathogenesis is unknown.

OBJECTIVES

To compare: (1) bone mineral density (BMD) in weight bearing and nonweight bearing bones in PPID+ equids and aged and young PPID- controls; and (2) biomechanical properties of the fourth lumbar vertebral body in PPID+ equids and aged PPID- equids.

STUDY DESIGN

Case-control study: five PPID+ equids and six aged and four young PPID- control horses.

METHODS

PPID status was based on clinical signs and necropsy examination of the pituitary gland (PG). The lumbar vertebral column, right front third metacarpus (MC3), left hind third metatarsus (MT3), and PG were removed after euthanasia. BMD was determined by quantitative computed tomography of regions of interest (ROI) in each bone and biomechanical testing was performed on the fourth lumbar vertebral body. Serum concentrations of parathormone (PTH), ionised Ca++ , 25-hydroxyvitamin D, and osteocalcin (OC) were also measured. Data were analysed using one-way ANOVA and correlation analyses.

RESULTS

BMD of trabecular and cortical regions of interest (ROI) of the third, fourth (L4), and fifth lumbar vertebrae were significantly lower in PPID+ equids as compared with aged (p < 0. 001) and young (p < 0.01) PPID- controls. In contrast, no differences were found in BMD of trabecular or cortical ROIs of MC3 and MT3 between groups. No differences were detected in force at fracture, displacement at fracture, Young's modulus or strain of L4 between PPID+ and aged PPID- horses. No differences were found in serum PTH, ionised Ca++ , 25-hydroxyvitamin D, or OC concentrations between groups.

MAIN LIMITATIONS

Limited number of equids studied and variation in test results.

CONCLUSIONS

BMD of nonweight bearing bones can be decreased with PPID and could increase risk of developing pathological fractures.

Massive bone destruction in a human proximal femur from ancient Nubia

Massive bone destruction in a human right proximal femur is described and differentially discussed in this case study. The individual was an older adult female buried at the ancient Nubian site of Tombos (modern-day Sudan) dating to the early Napatan/Third Intermediate Period (c. 1069-750 BCE). The right femur displayed a pathologic fracture with extensive lytic destruction and resorption of the entire femoral neck, most of the femoral head, and trochanters. Macroscopic and radiographic analyses revealed cortical thinning of the proximal diaphysis with new bone formation enclosing the medullary cavity. The lesion is eccentrically located involving the anterior aspect of the neck. Numerous vascular channels are apparent in the underlying bone. Sclerotic bone marks the limit of the lesion, and osseous lucency is visible in the radiograph. The individual displayed no other lytic lesions; vertebral osteophytic growth, compression fractures, and Schmorl's nodes were observed along with dental disease typical for older individuals. A traumatic etiology is eliminated due to the extensive osteolysis. Vascular, congenital, and developmental conditions are also not consistent with the observed changes. Expansive osteolytic lesions may have been caused by a cyst. Neoplastic tumors resulting in lytic lesions with a high risk of pathologic fracture are also consistent. There have been few reports of such extensive lytic lesions of the proximal femur in the paleopathological and clinical literature; this case adds an example of this underreported condition.

Long-Term Outcomes of Decompression and Grafting in Acute Pathological Proximal Femur Fractures in Children with Unicameral Bone Cysts: A Retrospective Study Utilizing a 120° Fixed-Angle Low-Contact Locking Pediatric Hip Plate

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

Femoral metastatic pathological fractures, impending and actual fractures - A patient survival study

INTRODUCTION

The skeleton is a common site for metastases. Prostate, breast, lung, renal and thyroid carcinomas account for 80 % of the original cancers, with the femur being the most affected long bone. With improved oncological treatments, prolonged patient survival leads to an increased prevalence of osseous metastases. This study examines the impact of preventive surgery for impending femoral pathological fracture (IFF), versus treatment of pathological femur fracture (PFF) on patient mortality and morbidity.

METHODS

Retrospective cohort of 174 patients undergoing surgery due to femoral metastases (2004-2015). Eighty-two patients were with PFF, and 92 were with IFF based on the Mirels' score. The followed-up period was until 2016. Demographic data, oncological, pathological, radiation, surgical reports, outpatient clinical records, and imaging studies were examined. Exclusion criteria included primary tumours and Multiple Myeloma.

RESULTS

The mean age was 64.8 ± 13.3 and 60.2 ± 11.9 years (p = 0.02) in the PFF and the IFF cohorts, with 62.1 % women and 57 % men. The breast was the most common source of femoral metastases. The average Mirels' score was 10 ± 1.2. There was an association between tumour origin and survival. Carcinoma of the lung had the worst survival, while the prostate had the most prolonged survival. Survival rates differed between IFF and PFF (p = 0.03). Postoperative complications occurred in 26 % of the patient, with no difference between IFF & PFF.

CONCLUSION

Breast and lung are the most common tumours to metastasize the femur. Our study revalidates that pathological femoral fractures impede patient survival compared to impending fractures and should undergo preventive surgery. Postoperative complications do not differ between IFF and PFF but remain relatively high. Overall, patients with proximal femoral metastatic disease survive longer than previously published, probably due to improved treatment modalities.

Two pathological fractures due to mandibular metastasis, rare in colon cancer; a case report presentation

We reported on 65 years old patient who has colon cancer and referred to our palliative care center with pain due to enlarging metastatic mass on the dorsal of the right hand. She had swelling and numbness on her jaw. Computed tomography (CT) scan was performed for mandible imaging and two pathologic fractures were detected on the right corpus and right condyle of the mandible. Clinicians should consider possible metastases for terminal stage cancer patients.

Risk assessment of femoral pathological fracture in prostate cancer patients by computed tomography analysis

INTRODUCTION

Prostate cancer often forms osteoblastic lesions that appear as a high-dense shadow upon X-ray. Although the lesions may seem to increase bone strength, pathological fracture occurs in one in four patients with prostate cancer. The aim of this study is to elucidate the factors that may increase the risk of pathological fracture in patients with prostate cancer metastases in the proximal femur by analyzing computed tomography data.

MATERIALS AND METHODS

Computed tomography data of the femur of 62 prostate cancer patients were retrospectively analyzed. The patients were divided into three groups based on the presence or absence of femoral metastatic lesions and pathological fracture. Surgical specimens of the proximal femur collected from patients who had a pathological fracture were histologically analyzed.

RESULTS

Bone density in the marrow area was increased in all cases with metastases compared with those with no metastases. Contrarily, the cortical bone density at the medial trochanter region was significantly lower in patients who had pathological fractures in the proximal femur than those who did not. Accordingly, histological analysis of the surgical specimens revealed that the affected cortical bone was osteopenic without any apparent new bone formation.

CONCLUSION

These results indicate that prostate cancer is less effective in inducing bone formation in the cortex than in the marrow and that the decrease in the cortical bone density at the medial trochanter region leads to an increased risk of pathological fracture. Therefore, a previously undocumented risk factor for pathological fracture in prostate cancer patients is presented.

[Intramedullary Nailing in Managing Diaphyseal Metastases of Long Bones: Retrospective Study Comparing the Expected Survival and the Actual Survival of Patients]

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

An unusual case of metaphyseal osteonecrosis of humerus in a post covid patient: a case report

Osteonecrosis of the metaphysis is often rare as it is a highly vascular region. Here we report an unusual case of non-traumatic osteonecrosis of the humerus predominantly involving the metaphysis in a post covid elderly female. The patient had a pathological fracture of humerus during the post-operative period of intertrochanteric femur fracture surgery. She was evaluated for the causes of pathological fracture and the fracture was managed with hemi replacement of the shoulder because of the extensive bone loss. The pathology here could only be explained as some sequelae of hyper inflammatory state associated with COVID-19 infection. The possible differentials are also discussed here. This case report will help clinicians to consider COVID-19 infection as a cause for non-traumatic osteonecrosis among other reported causes of osteonecrosis.

Bone Evaluation by High-Resolution Peripheral Quantitative Computed Tomography in Patients With Adrenal Incidentaloma

CONTEXT

Data regarding high-resolution peripheral quantitative computed tomography (HR-pQCT) in patients with adrenal incidentaloma (AI) are unknown.

PURPOSE

To evaluate the areal bone mineral density (aBMD), microstructure, and fractures in patients with nonfunctioning AI (NFAI) and autonomous cortisol secretion (ACS).

METHODS

We evaluated 45 patients with NFAI (1 mg dexamethasone suppression test [DST] ≤1.8 µg/dL) and 30 patients with ACS (1 mg DST 1.9-5.0 µg/dL). aBMD was measured using dual-energy X-ray absorptiometry; vertebral fracture by spine X-ray; and bone geometry, volumetric bone mineral density (vBMD), and microstructure by HR-pQCT.

RESULTS

Patients with ACS showed lower aBMD values at the spine, femoral neck, and radius 33% than those with NFAI. Osteoporosis was frequent in both groups: NFAI (64.9%) and ACS (75%). Parameters at the distal radius by HR-pQCT were decreased in patients with ACS compared to those with NFAI: trabecular vBMD (Tb.vBMD, P = 0.03), inner zone of the trabecular region (Inn.Tb.vBMD, P = 0.01), the bone volume/tissue volume ratio (BV/TV, P = 0.03) and trabecular thickness (P = 0.04). As consequence, a higher ratio of the outer zone of the trabecular region/inner zone vBMD (Meta/Inn.vBMD, P = 0.003) was observed. A correlation between the cortisol levels after 1 mg DST and Meta/Inn.vBMD ratio was found (r = 0.29; P = 0.01). The fracture frequency was 73.7% in patients with ACS vs 55.6% in patients with NFAI (P = 0.24).

CONCLUSION

Our findings point to an association between trabecular bone microarchitectural derangement at the distal radius and ACS. Our data suggest that AI have a negative impact on bone when assessed by HR-pQCT, probably associated to subclinical hypercortisolism.

Bone Metastases in Medullary Thyroid Carcinoma: High Morbidity and Poor Prognosis Associated With Osteolytic Morphology

CONTEXT

The clinical relevance of bone metastases (BM) in advanced medullary thyroid carcinoma (MTC) is poorly described.

OBJECTIVE

The objectives of this work are to describe the prevalence of BM, frequency of skeletal related events (SREs), and impact of BM morphology and SREs on prognosis, and to assess the role of antiresorptive treatment (ART).

DESIGN

A retrospective cohort study was conducted.

SETTING

This study was conducted at 4 German referral centers.

PATIENTS

A total of 1060 MTC patients were included.

MAIN OUTCOME MEASURE

Main outcome measures include descriptive statistics, overall survival (OS) by the Kaplan-Meier method, and risk factors by Cox proportional hazards modeling.

RESULTS

A total of 120 of 416 patients (29%) with metastatic MTC had BM, of which 97% had concurrent nonosseous metastases. BM occurred 2.1 years (median, range -0.1 to 20.6 years) after initial diagnosis, were multifocal in 79%, and were located preferentially in the spine (86%) and pelvis (60%). BM morphology was osteolytic in 32%, osteoblastic in 25%, and mixed in 22% of cases (unknown: 21%). Within a median observation period of 26.6 months (range, 0-188 months) after BM diagnosis, 47% of patients experienced one or more SREs (bone radiation 50%, pathological fractures 32%), of which 42% occurred in osteolytic and 17% in osteoblastic BM (P = .047). Presence of osteolytic metastases (hazard ratio 3.85, 95% CI 1.52-9.77, P = .005) but not occurrence of SREs was associated with impaired OS. Among the 36 patients who received ART (no ART: n = 71), SREs were significantly less frequent than in untreated patients (P = .04).

CONCLUSION

BM are common in metastatic MTC and most often with an osteolytic morphology and an unfavorable prognosis. The majority of SREs occur in osteolytic metastases and may be prevented by ART.

Diffuse, fracturing systemic skeletal histiocytosis of unknown type: a novel metabolic bone disease

We describe a novel disease of diffuse skeletal histiocytosis associated with multiple fragility fractures and high osteoclast activity. Clinical, radiographic, biochemical, genetic, and histopathological investigations were performed to characterize the diagnosis of an Asian man who presented with hip fracture and diffuse skeletal lytic lesions. After excluding malignancy and other common metabolic bone diseases, open bone biopsy yielded several pathological samples all showing extensive skeletal histiocytosis likely to explain the diffuse axial and appendicular lytic lesions. Rare disorders such as Langerhans histiocytosis, Erdheim-Chester disease, and diffuse cystic skeletal angiomatosis were excluded through careful pathological examination and lack of CD1a and S-100 staining. Whole exome sequencing did not yield diagnostic findings to explain this likely acquired disease. High markers of osteoclast activity suggested excessive focal bone resorption but normalized after zoledronic acid treatment. A novel disease of skeletal histiocytosis with high bone turnover is differentiated from other histiocytic and lytic skeletal diseases.

Effects of combined menaquinone-4 and PTH1-34 treatment on osetogenesis and angiogenesis in calvarial defect in osteopenic rats

PURPOSE

The aim of this study was to evaluate the effect of combining human parathyroid hormone (1-34) (PTH_1-34; PTH) and menaquinone-4 (MK-4) on calvarial bone defect repair in osteopenic rats.

METHODS

Fourteen week olds were subject to craniotomy for the establishment of osteopenic animal models fed through a chronically low-protein diet. After that, critical calvarial defect model was established and all rats were randomly divided into four groups: sham, MK-4, PTH, and PTH + MK-4. The animals received MK-4 (30 mg/kg/day), PTH_1-34 (60 μg/kg, three times a week), or PTH_1-34 (60 μg/kg, three times a week) plus MK-4 (30 mg/kg/day) for 8 weeks, respectively. Serum γ-carboxylated osteocalcin (Gla-OC) levels, histological and immunofluorescent labeling were employed to evaluate the bone formation and mineralization in calvarial bone defect. In addition, Microfil perfusion, immunohistochemical, and micro-CT suggested enhanced angiogenesis and bone formation in calvarial bone healing.

RESULTS

In this study, treatment with either PTH_1-34 or MK-4 promoted bone formation and vascular formation in calvarial bone defects compared with the sham group. In addition, combined treatment of PTH_1-34 plus MK-4 increased serum level of Gla-OC, improved vascular number and vascular density, and enhanced bone formation in calvarial bone defect in osteopenic conditions as compared with monotherapy.

CONCLUSIONS

In summary, this study indicated that PTH_1-34 plus MK-4 combination therapy accelerated bone formation and angiogenesis in calvarial bone defects in presence of osteopenia.

Treatment of pathologic fractures of the proximal femur

BACKGROUND

Metastatic lesions to the proximal femur occur frequently and require special consideration due to the high risk of pathologic fractures. Type of surgery might influence patient survival considering the growing concept of oligometastases. In fact, the use of modular tumor megaprosthesis is increasing in the last decades compared to intramedullary nailing. Aim of this study was to evaluate oncological and functional results of treatment in patients with pathologic or impending fracture of the proximal femur, with patient survival being the primary, complications the secondary, and functional results the tertiary endpoint.

METHODS

Between 2016 and 2017, 40 patients with pathologic fracture (29 cases) or impending fracture according to the Mirels score (11 cases) of the proximal femur, were treated in our Institute and prospectively collected. There were 29 females (72.5%) and 11 males (27.5%), with a mean age at diagnosis of the metastasis of 63.6 years (range 35 to 92 years). Patients were treated due to bone metastases (commonly develop from breast cancer) or hematologic malignancies. Considering number of lesions, 17 patients had less than three bone metastases. Surgical procedures included intramedullary nailing (7 patients), conventional endoprosthesis (4 patients) and modular endoprosthetic replacement (29 patients). Adjuvant treatments included chemotherapy (13 cases), radiation therapy (8 cases) or both (15 cases), and selective arterial embolization (6 pre-op). Oncological results were evaluated considering the survival of patients. Functional results were assessed as pain intensity in VAS score and MSTS score.

RESULTS

The mean follow-up of patients was 10.2 months (range 6-26.3 years). At the latest evaluation, 23 patients were alive with disease, 3 patients were alive without evidence of disease and 14 patients were dead with disease. There was a significant better survival in patients treated with PFR compared to IMN and EPR groups (p = 0.0080). No differences in term of survival were found comparing impending vs actual pathological fracture and oligo vs multiple metastases. After surgery, all patients experienced improvement in quality of life resulting from reduction in pain. Mean MSTS score was 22.4. The overall complications rate was 22.5%. The most frequent complication was dislocation followed by wound dehiscence and deep infections.

CONCLUSION

Modular tumour prosthesis for proximal femur replacement provides good functional outcome, relative low incidence of complications and higher life quality in the medium term. Oncologic results were influenced by type of surgery, biased by the correct indications for resection and nailing. Preoperative general health condition, life expectancy and ambulatory capacity may influence treatment strategy. With the numbers available, the patients with actual pathologic or impending fracture of the proximal femur treated with resection had a significantly higher survival, especially those with metastases from renal carcinoma or multiple myeloma.

Retrospective analysis of the effect of treatment of osteosarcoma complicated by pathological fracture by neoadjuvant chemotherapy combined with limb salvage surgery

PURPOSE

To explore the efficacy of neoadjuvant chemotherapy combined with limb salvage surgery for the treatment of osteosarcoma complicated by pathological fracture.

METHODS

215 osteosarcoma patients who were admitted in our hospital from 2001 and 2012 were followed up for 5 years and were retrospectively analyzed among them. The patients were divided into 4 groups based on their condition and treatment method to observe the 5-year overall survival and tumor-free survival (TFS) in each group. Adverse reactions caused by chemotherapy were recorded and analyzed. In addition, the quality of life was compared in these 4 groups.

RESULTS

No significant differences were observed in postoperative overall survival and TFS between patients who were subjected to limb salvage surgery (Group A) and amputation (Group B). Similarly, there was no difference between patients who underwent surgery for pathological fracture and those without fracture (Group D). However, the survival of non-preoperative chemotherapy group (group C) was significantly different from that of preoperative chemotherapy group (group C vs group A/B/D, p=0.008, p=0.042, p=0.010, respectively). Besides, the TFS of non-preoperative chemotherapy group was significantly lower than that of preoperative chemotherapy group (group C vs. group A/B/D, p=0.012, p=0.002, p=0.008, respectively). Vomiting was the main adverse effect in our research. In the comparison of quality of life, social function and physical limitations in the limb-salvage group were superior to the amputation group.

CONCLUSIONS

Neoadjuvant chemotherapy combined with limb salvage surgery is effective for the patients with osteosarcoma complicated by pathological fractures.

What Factors Are Associated With Implant Breakage and Revision After Intramedullary Nailing for Femoral Metastases?

BACKGROUND

Actual and impending pathologic fractures of the femur are commonly treated with intramedullary nails because they provide immediate stabilization with a minimally invasive procedure and enable direct weightbearing. However, complications and revision surgery are prevalent, and despite common use, there is limited evidence identifying those factors that are associated with complications.

QUESTIONS/PURPOSES

Among patients treated with intramedullary nailing for femoral metastases, we asked the following questions: (1) What is the cumulative incidence of local complications? (2) What is the cumulative incidence of implant breakage and what factors are associated with implant breakage? (3) What is the cumulative incidence of revision surgery and what factors are associated with revision surgery?

METHODS

Between January 2000 and December 2015, 245 patients in five centers were treated with intramedullary nails for actual and impending pathologic fractures of the femur caused by bone metastases. During that period, the general indications for intramedullary nailing of femoral metastases were impending fractures of the trochanter region and shaft and actual fractures of the trochanter region if sufficient bone stock remained; nails were used for lesions of the femoral shaft if they were large or if multiple lesions were present. Of those treated with intramedullary nails, 51% (117) were actual fractures and 49% (111) were impending fractures. A total of 60% (128) of this group were women; the mean age was 65 years (range, 29-93 years). After radiologic followup (at 4-8 weeks) with the orthopaedic surgeon, because of the palliative nature of these treatments, subsequent in-person followup was performed by the primary care provider on an as-needed basis (that is, as desired by the patient, without any scheduled visits with the orthopaedic surgeon) throughout each patient's remaining lifetime. However, there was close collaboration between the primary care providers and the orthopaedic team such that orthopaedic complications would be reported. A total of 67% (142 of 212) of the patients died before 1 year, and followup ranged from 0.1 to 175 months (mean, 14.4 months). Competing risk models were used to estimate the cumulative incidence of local complications (including persisting pain, tumor progression, and implant breakage), implant breakage separately, and revision surgery (defined as any reoperation involving the implant other than débridement with implant retention for infection). A cause-specific multivariate Cox regression model was used to estimate the association of factors (fracture type/preoperative radiotherapy and fracture type/use of cement) with implant breakage and revision, respectively.

RESULTS

Local complications occurred in 12% (28 of 228) of the patients and 6-month cumulative incidence was 8% (95% confidence interval [CI], 4.7-11.9). Implant breakage occurred in 8% (18 of 228) of the patients and 6-month cumulative incidence was 4% (95% CI, 1.4-6.5). Independent factors associated with increased risk of implant breakage were an actual (as opposed to impending) fracture (cause-specific hazard ratio [HR_cs], 3.61; 95% CI, 1.23-10.53, p = 0.019) and previous radiotherapy (HR_cs, 2.97; 95% CI, 1.13-7.82, p = 0.027). Revisions occurred in 5% (12 of 228) of the patients and 6-month cumulative incidence was 2.2% (95% CI, 0.3-4.1). The presence of an actual fracture was independently associated with a higher risk of revision (HR_cs, 4.17; 95% CI, 0.08-0.82, p = 0.022), and use of cement was independently associated with a lower risk of revision (HR_cs, 0.25; 95% CI, 1.20-14.53, p = 0.025).

CONCLUSIONS

The cumulative incidence of local complications, implant breakage, and revisions is low, mostly as a result of the short survival of patients. Based on these results, surgeons should consider use of cement in patients with intramedullary nails with actual fractures and closer followup of patients after actual fractures and preoperative radiotherapy. Future, prospective studies should further analyze the effects of adjuvant therapies and surgery-related factors on the risk of implant breakage and revisions.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Leiomyosarcoma of the Wing in a Vieilott's Fireback Pheasant (Lophura rufa)

A 15-year-old, female Vieilott's fireback pheasant (Lophura rufa) presented with a 2-day history of a drooping right wing. Examination revealed severe soft tissue swelling in the area extending from the right shoulder to the humeral-radio-ulnar joint with associated bruising and feather loss. Results of a complete blood cell count revealed marked heterophilia and lymphocytosis, and results of serum biochemical analysis showed severe increases in creatine kinase and aspartate aminotransferase activities, hypoproteinemia, and hypoalbuminemia. Radiographs revealed osteolytic lesions of the right humerus with pathologic fractures and circumferential soft tissue swelling. Although surgical wing amputation was successful, the bird died the next day while being treated. The mass was diagnosed histologically and immunohistochemically as a leiomyosarcoma. This is the first neoplasia of any kind reported in this species, to our knowledge, and one of the very few reports of smooth muscle neoplasms affecting the limb of a bird.

Pathologic Tuft Fracture in a Thumb: A Rare Presentation of Metastatic Endometrioid Ovarian Carcinoma: A Case Report and Review of the Literature

CASE

A 51-year-old woman with a medical history noteworthy for endometrioid ovarian carcinoma presented with progressive left thumb swelling in the absence of trauma or injury. Radiographs revealed a lytic lesion in the distal phalanx. Inflammatory markers and white blood-cell count were mildly elevated. The thumb was amputated at the interphalangeal joint, and pathologic examination identified the lesion as an adenocarcinoma, consistent with the known endometrioid ovarian carcinoma.

CONCLUSION

The similar presentation of tumor and infection can present a diagnostic challenge. Despite the rare incidence of osseous metastases to the hand, orthopaedic surgeons must consider metastatic bone lesions in patients presenting with swollen or painful fingers.

Pathologic fracture in childhood and adolescent osteosarcoma: A single-institution experience

PURPOSE

Pathologic fractures occur in 5-10% of pediatric osteosarcoma (OS) cases and have historically been considered a contraindication to limb salvage. Our purpose was to describe the radiographic features of pathologic fracture and examine its impact on local recurrence rates, functional outcomes, and overall survival.

METHODS

We retrospectively analyzed patients at our institution from 1990 to 2015 with pathologic fracture at diagnosis or during neoadjuvant chemotherapy. We selected a control group of 50 OS patients of similar age and gender without pathologic fracture from 1990 to 2015. Functional outcomes were scored using Musculoskeletal Tumor Society criteria. Chi-square test was used for comparative analysis of groups.

RESULTS

Thirty-six patients with 37 pathologic fractures form the study cohort. Of patients who received surgery, 18 of 34 patients with fracture underwent amputation compared to 8 of 48 patients in the nonfracture group (P = 0.007). Indications for amputation in fracture patients were tumor size (n = 7), neurovascular involvement (n = 6), and tumor progression during neoadjuvant chemotherapy (n = 5). Only one patient (2.9%) in the fracture group who underwent limb salvage suffered local recurrence. Of patients who received neoadjuvant chemotherapy, 25 of 34 fracture patients showed poor histological response compared to 24 of 47 nonfracture patients (P = 0.044). There was no statistically significant difference in overall survival (P = 0.96). Functional outcomes were significantly lower in fracture patients (median = 17.5) than nonfracture patients (median = 24) (P = 0.023).

CONCLUSIONS

Radiographic features of pathologic fractures were highly variable in this population. Limb salvage surgery can be performed without increased risk of local recurrence. Patients with pathologic fracture suffer worse functional outcomes but no decrease in overall survival.

Severe Rebound-Associated Vertebral Fractures After Denosumab Discontinuation: 9 Clinical Cases Report

CONTEXT

Denosumab inhibits bone resorption, increases bone mineral density, and reduces fracture risk. Denosumab was approved for the treatment of osteoporosis and the prevention of bone loss in some oncological situations. Denosumab discontinuation is associated with a severe bone turnover rebound (BTR) and a rapid loss of bone mineral density. The clinical consequences of the BTR observed after denosumab discontinuation are not known.

CASES DESCRIPTION

We report 9 women who presented 50 rebound-associated vertebral fractures (RAVFs) after denosumab discontinuation. A broad biological and radiological assessment excluded other causes than osteoporosis. These 9 cases are unusual and disturbing for several reasons. First, all vertebral fractures (VFs) were spontaneous, and most patients had a high number of VFs (mean = 5.5) in a short period of time. Second, the fracture risk was low for most of these women. Third, their VFs occurred rapidly after last denosumab injection (9-16 months). Fourth, vertebroplasty was associated with a high number of new VFs. All the observed VFs seem to be related to denosumab discontinuation and unlikely to the underlying osteoporosis or osteopenia. We hypothesize that the severe BTR is involved in microdamage accumulation in trabecular bone and thus promotes VFs.

CONCLUSION

Studies are urgently needed to determine 1) the pathophysiological processes involved, 2) the clinical profile of patients at risk for RAVFs, and 3) the management and/or treatment regimens after denosumab discontinuation. Health authorities, physicians, and patients must be aware of this RAVF risk. Denosumab injections must be scrupulously done every 6 months but not indefinitely.

Characterization and Surgical Management of Metastatic Disease of the Tibia

Osseous metastases are common in advanced cancer stages. The tibia is the appendicular skeleton bone affected third most often. However, tibial metastases are not well described. We conducted a retrospective descriptive single-institution study of patients with evidence of tibial metastatic disease in order to better characterize tibial metastases in their anatomical distribution and histology, and to describe their clinical presentation and surgical management. Using proprietary research software, we searched pathology and radiology reports and cross-referenced results with Current Procedural Terminology procedure codes to identify patients with metastatic lesions of the tibia. We then reviewed these patients' medical records and reviewed and verified all available imaging. We reviewed the medical records of 36 patients (20 females, 16 males) with 43 affected tibiae. Mean age was 63.5 years. Of 12 different primary neoplasms, the most common were prostate, breast, and lung cancers. The proximal tibia was the region most commonly affected, followed by the diaphysis. Of 6 impending fractures, 3 were treated with intramedullary nail, 2 with total knee megaprosthesis, and 1 with total knee arthroplasty. Of 2 pathologic fractures, 1 was treated with intramedullary nail and 1 with periarticular locking plate. Almost all identified patients (88.9%) had other metastatic lesions. Almost half (47.2%) of patients presented with symptomatic tibia lesions. Mean time from diagnosis of malignancy to tibial metastasis was 1282 days (range, 0-3708 days). Metastases to the tibia are uncommon but often require surgical intervention. Fixation technique should be selected on a case-by-case basis, and patients should be treated by a multidisciplinary team. Patients with known malignancy and tibial pain should undergo a work-up for tibia lesions.

[Imploding antrum syndrome: three cases with different management approaches]

BACKGROUND

Silent sinus or imploding antrum syndrome is a very rare condition, consisting of a usually asymptomatic spontaneous collapse of the sinus walls and floor of the orbit. It is associated with negative pressures, and when this occurs, it presents with manifestations such as enophthalmos, hypoglobus, and tilt flow orbital floor. As its incidence is very low, it is frequently missed as a diagnosis, and in fact there are currently fewer than 150 cases reported in the literature.

CLINICAL CASES

Three patients have been identified in our practice over a period of two years, with different symptoms that influenced the decision of the treatment modality, which were: watch and wait, endoscopic sinus surgery, or endoscopic sinus surgery plus orbitoplasty.

CONCLUSIONS

Despite being a rare entity, it stills catches the attention of the ENT, OMF surgery and Ophthalmologist. The diagnosis is mainly radiological, due to the late clinical manifestations and symptomatology. The treatment should be individualised and based on the symptoms and the individual decision of each patient, firstly by Functional Endoscopic sinus surgery, and once sinus permeability is restored, it may require augmentation surgery of the orbital floor, either with autologous bone implant, titanium or other material. It is important to be aware of this pathology, to know and to suspect it, avoiding misdiagnosis.

Factors associated with pathological fractures in dogs with appendicular primary bone neoplasia: 84 cases (2007-2013)

OBJECTIVE

To determine the incidence of pathological fractures associated with appendicular primary bone tumors in dogs managed medically and to identify potential risk factors at the time of radiographic diagnosis that may be associated with eventual pathological fracture.

DESIGN

Retrospective case series.

ANIMALS

84 dogs with primary long bone neoplasia treated medically.

PROCEDURES

Medical records for dogs with a diagnosis of primary long bone neoplasia based on results of radiography that was confirmed subsequently at necropsy were reviewed. Owners elected medical treatment at a pain clinic. Data regarding clinical signs, diagnostic testing, pathological findings, and outcome were evaluated.

RESULTS

84 dogs met study inclusion criteria with 85 limbs affected. Osteosarcoma was the most common tumor and was identified in 78 of 85 (91.8%) limbs. The median time from diagnosis to euthanasia was 111 days (range, 28 to 447 days). Pathological fractures were identified in 33 of 85 limbs (38%), with the femur most commonly affected, (8/14 [57.1%]), followed by the tibia (9/17 [52.9%]), humerus (10/27 [37%]), radius (5/25 [20%]), and ulna (1/2 [50%]). Logistic regression analysis indicated that tumors arising from long bones other than the radius had odds of eventual fracture 5.05 as great as the odds for tumors of the radius, and lytic tumors had odds of eventual fracture 3.22 as great as the odds for tumors that appeared blastic or mixed lytic-blastic.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that radial primary bone tumors were less likely and lytic tumors were more likely to fracture. The overall incidence of pathological fractures secondary to appendicular primary bone neoplasia in this study with patients treated by means of intensive management for bone pain was higher than previously reported.

Risk Factors for Developing Skeletal-Related Events in Breast Cancer Patients With Bone Metastases Undergoing Treatment With Bone-Modifying Agents

BACKGROUND

Bone-modifying agents (BMAs) reduce the incidence of skeletal-related events (SREs) and are thus recommended for breast cancer patients with bone metastases. However, the risk factors for SREs during BMA treatment are not well-understood. This study evaluated the number and timing of SREs from case studies to identify these factors.

METHODS

The medical records of 534 women with breast cancer who developed bone metastases between 1999 and 2011 were reviewed. SREs were defined as a pathologic fracture, spinal cord compression, or the need for bone irradiation or surgery. Multiple variables were assessed and were analyzed by using the Cox proportional hazard analyses and the Andersen and Gill method.

RESULTS

Multivariate analyses for both the time to the first SRE and the primary and subsequent SRE frequency demonstrated that significant baseline risk factors included luminal B type disease, a history of palliative radiation therapy, BMA treatment within 2 years, and elevated serum calcium levels at the time of the initial BMA dose. Additionally, for the time to the first SRE and for the primary and subsequent SRE frequency, the presence of extraskeletal metastases and BMA administration initiation ≥6 months after the detection of bone metastases were also significant risk factors, respectively.

CONCLUSION

In breast cancer patients with bone metastases, more vigilant observation should be considered for patients with the identified risk factors. To reduce the risk for SRE, BMAs should be administered within 6 months of bone metastases diagnosis and before palliative radiation therapy.

IMPLICATIONS FOR PRACTICE

Retrospectively, risk factors were identified for skeletal-related events (SREs) in breast cancer patients with bone metastasis who were treated with bone-modifying agents (BMAs). For the time to the first SRE and for the SRE frequency, presence of extraskeletal metastases and BMA initiation ≥6 months after the detection of bone metastases were risk factors, respectively. Luminal B type disease, a history of palliative radiation therapy, BMA treatment within 2 years, and elevated serum calcium levels at initial BMA dose were risk factors for both first SRE and SRE frequency. More vigilant observation should be considered for patients with these risk factors.

Identification of a novel mutation of the PRKAR1A gene in a patient with Carney complex with significant osteoporosis and recurrent fractures

OBJECTIVE

Carney complex (CNC) is a rare autosomal dominant multiple neoplasia syndrome characterized by the presence of endocrine and non-endocrine tumors. More than 125 different germline mutations of the protein Kinase A type 1-α regulatory subunit (PRKAR1A) gene have been reported. We present a novel PRKAR1A gene germline mutation in a patient with severe osteoporosis and recurrent vertebral fractures.

DESIGN

Clinical case report.

CASE REPORT

A 53-year-old male with a medical history of surgically removed recurrent cardiac myxomas was evaluated for repeated low-pressure vertebral fractures and severe osteoporosis. Physical examination revealed spotty skin pigmentation of the lower extremities and papules in the nuchal and thoracic region. The presence of hypercortisolism due to micronodular adrenal disease and the history of cardiac myxomas suggested the diagnosis of CNC; the patient underwent detailed imaging investigation and genetic testing.

METHODS

Standard imaging and clinical testing; DNA was sequenced by the Sanger method.

RESULTS

Sequence analysis from peripheral lymphocytes DNA revealed a novel heterozygous point mutation at codon 172 of exon 2 (c.172G>T) of the PRKAR1A gene, resulting in early termination of the PRKAR1A transcript [p.Glu58Ter (E58X)].

CONCLUSION

We report a novel point mutation of the PRKAR1A gene in a patient with CNC who presented with significant osteoporosis and fractures. Low bone mineral density along with recurrent myxomas should point to the diagnosis of CNC.

INTRAOSSEOUS PROLIFERATIVE SPARGANOSIS PRESENTING AS A PATHOLOGICAL FRACTURE: A CASE REPORT AND REVIEW OF THE LITERATURE

We report a case of 63-year-old male, who presented with pathological fracture of left distal humerus 3 weeks previously. The radiographic findings showed an ill-defined permeative osteolytic lesion of the left distal humerus. Incisional biopsy and debridement was done; pathological examination revealed a folded cestode larva with calcareous corpuscles in the bone and soft tissue, and increased eosinophils. IgG antibody tests for sparganosis were positive. The patient refused to have surgery for internal fixation and placement of an endoprosthesis.

Surgical treatment of pathological fractures occurring at the proximal femur

PURPOSE

To analyze the results of surgical treatment for pathological fractures at the proximal femur.

MATERIALS AND METHODS

Nineteen patients with a pathological fracture were included. The mean age was 65.7 years old. The patients comprised 8 males and 11 females. Primary tumors, types of pathological fractures, surgical procedures, and postoperative complications were recorded. Musculoskeletal Tumor Society (MSTS) functional score was used for functional evaluation. A Kaplan-Meier survival analysis was used to determine survival rate.

RESULTS

The primary malignancies were 6 cases of breast cancer, 3 cases of lung cancer, 3 cases of renal cell carcinoma, 2 cases of cholangiocarcinoma, 2 cases of hepatocellular carcinoma, 1 case of esophageal cancer, 1 case of colon cancer, and 1 case of ovarian cancer. Pathological fractures included 8 cases of pertrochanteric fractures and 11 cases of subtrochanteric fractures. Intramedullary nailing was performed in 10 cases, and joint replacement surgery was performed in 9 cases. Postoperative complications included local recurrence in 1 case, infection in 1 case, and nail breakage in 1 case. The mean postoperative MSTS score was 21. The mean survival period was 10.6 months. Patient survival rates were 42.1% after 6 months, 26.3% after 12 months, and 10.5% after 24 months.

CONCLUSION

Surgical treatment of pathological fractures at the proximal femur provided early ambulation, and excellent pain relief. The surgery was well tolerated emotionally. Surgery is necessary for improving the quality of life in such patients; however, more cases of pathological fractures in these regions should be subjected to detailed analysis.

Congenital indifference to pain: an illustrated case report and literature review

Congenital indifference to pain is a rare and debilitating congenital disease. Individuals with the disorder may have one or a combination of sensory or autonomic deficits, which can range from lack of mechanical nociception, diminished ability to detect heat and cool stimulation, to the devastating and fatal form which includes autonomic dysfunction. It is important for radiologists to be able to recognize the radiographic presentations of this rare disorder, as delay in diagnosis can lead to extensive and sometimes unnecessary workup. We present a case of congenital indifference to pain initially interpreted as a mass of the distal femur.

[Justification criteria for vertebral fractures ; year 2012 revision]

Justification Criteria for Vertebral Fractures 2012 version was made based on new clinical findings. Major differences in this version compared to the 1996 version are 1) inclusion of the semi quantitative method (SQ) , 2) statements to improve considerations during radiographic analysis, and 3) the need for more detailed evaluation by MRI. New Justification Criteria aims that the treatment of vertebral fracture in both fracture and osteoporosis is properly performed in daily clinical practice.

Prospective study on the incidence of bone metastasis (BM) and skeletal-related events (SREs) in patients (pts) with stage IIIB and IV lung cancer-CSP-HOR 13

BACKGROUND

Bone metastasis (BM) is a frequent complication in patients with advanced lung cancer and it causes skeletal-related events (SREs). Our study aim is to prospectively investigate the incidence of BM, incidence and types of SRE, and predictive factors of BM and SREs.

METHODS

Newly diagnosed, advanced non-small-cell lung cancer (NSCLC) or small-cell lung cancer (SCLC) patients were enrolled into the study. Patients were followed up every 4 weeks to monitor the development of SREs. Treatment for lung cancer was performed at the discretion of the investigator.

RESULTS

Two hundred seventy-four patients were enrolled in this study between April 2007 and December 2009 from 12 institutions. Patients included 77 cases of SCLC and 197 of NSCLC (stage IIIB/IV = 73/124). Median follow-up time was 13.8 months. The incidence of BM at initial diagnosis was 48% in stage IV NSCLC and 40% in extensive stage (ED)-SCLC. Forty-five percent of patients who developed BM had SREs consisting of pathologic fracture (4.7%), radiation to bone (15.3%), spinal cord compression (1.1%), and hypercalcemia (2.2%). Multivariate analysis revealed that factors predicting BM are stage IV, performance status 1 or greater and higher bone alkaline phosphatase in NSCLC patients, higher lactate dehydrogenase, and lower parathyroid hormone-related peptide in SCLC patients. Factors predicting SREs were stage IV, age 64 or younger, and lower albumin in NSCLC patients. Multivariate analysis of SRE was not performed for SCLC because of the small number of events.

CONCLUSION

Predictive factors should be taken into consideration in future randomized studies evaluating BM and SREs.

Surgical management and outcome of skeletal metastatic disease of the humerus

PURPOSE OF THE STUDY Evaluation of outcome after surgical treatment of humerus metastases with a focus on tumour and patient derived factors, timing and strategy of intervention, surgical outcome and complications. MATERIAL AND METHODS Sixty-fie patients with a mean age of 64.3 years (range 25-89) with 66 metastases of the humerus were surgically treated in a 7-year time-period and retrospectively reviewed. RESULTS Renal cell carcinoma and breast cancer were the most abundant types of primary tumour. The mean time from diagnosis of primary tumour to fist metastasis was 14.5 months (range 0-173). The mean time from diagnosis of metastasis to surgery was 21.4 months (range 0-173). 38/28 intramedullary nails/locking plates were used for 58/8 manifest/impending pathological fractures. Mean cumulative survival was 16.3 months and implant failure rate was 6.1% with a mean time from initial surgery to revision of 22.2-20.6 months. CONCLUSIONS Our data indicate that treatment with intramedullary fiation or cement augmented plate osteosynthesis is successful for the vast majority of patients, but thorough clinical evaluation and precise decision making adapted to the patient's estimated life expectancy must be applied to avoid overtreatment or risk of implant failure. Key words: bone metastases, skeletal metastatic disease, humerus metastasis, pathologic fracture, impending fracture.

Natural history of skeletal-related events in patients with breast, lung, or prostate cancer and metastases to bone: a 15-year study in two large US health systems

PURPOSE

To document the risk of skeletal complications in patients with bone metastases from breast cancer (BC), lung cancer (LC), or prostate cancer (PC) in routine clinical practice.

METHODS

We used data from two large US health systems to identify patients aged ≥18 years with primary BC, LC, or PC and newly diagnosed bone metastases between January 1, 1995 and December 31, 2009. Beginning with the date of diagnosis of bone metastasis, we estimated the cumulative incidence of skeletal-related events (SREs) (spinal cord compression, pathologic fracture, radiation to bone, bone surgery), based on review of medical records, accounting for death as a competing risk.

RESULTS

We identified a total of 621 BC, 477 LC, and 721 PC patients with newly diagnosed bone metastases. SREs were present at diagnosis of bone metastasis in 22.4, 22.4, and 10.0 % of BC, LC, and PC patients, respectively. Relatively few LC or PC patients received intravenous bisphosphonates (14.8 and 20.2 %, respectively); use was higher in patients with BC, however (55.8 %). In BC, cumulative incidence of SREs during follow-up was 38.7 % at 6 months, 45.4 % at 12 months, and 54.2 % at 24 months; in LC, it was 41.0, 45.4, and 47.7 %; and in PC, it was 21.5, 30.4, and 41.9 %. More than one half of patients with bone metastases had evidence of SREs (BC: 62.6 %; LC: 58.7 %; PC: 51.7 %), either at diagnosis of bone metastases or subsequently.

CONCLUSIONS

SREs are a frequent complication in patients with solid tumors and bone metastases, and are much more common than previously recognized in women with BC.

[Complex treatment of mandibular malignant tumors using a fixing device for prophylaxis of pathological fracture, the early postoperative prosthesis and rehabilitation]

Even in modern conditions of achievements in the head and neck oncosurgery the restoration of the volume defects of the bone tissue in a jaw-facial region is impossible to do without the orthopedic methods application because of present severe psychoemotional and general state of the patients. The problem of prophylaxis of mandibular pathological fractures in its malignant affection constitute a peculiar place, taking into account a complexity and numerousness of the unsolved issues. There was elaborated and constructed apparatus for the pathological fracture prophylaxis or for fixing of fragments in the angle of a toothless mandibula. After the apparatus being applied in place the patient's quality of life improves: they better tolerate radiation therapy; the conditions for surgical treatment are improving; the acts of chewing and deglutition are not disordered, what improves the patients state significantly; the general image of the face is not disturbed. The methods may be introduced into specialized clinics.

[Forensic medical implications of histomorphological changes in the bone and cartilage tissues under effect of radiation]

The objective of the present work was to study roentgenological, microscopic, and histomorphological changes in the bone and cartilage tissues under effect of different doses of gamma-ray radiation from Gammatron-2 (GUT Co 400) and betatron bremsstrahlung radiation (25 MeV). The total radiation dose varied from 9.6 Gy to 120 Gy per unit area during 5-8 weeks. The study included 210 patients at the age from 7 to 82 years (97 men and 113 women). Histomorphological studies were carried out using samples of bone and cartilage tissues taken from different body regions immediately after irradiation and throughout the follow-up period of up to 4 years 6 months. Control samples were the unexposed bone and cartilage tissues from the same subjects (n = 14). The tissues were stained either with eosin and hematoxylin or by Van Gieson's and Mallory's methods. Gomori's nonspecific staining was used to detect acid and alkaline phosphatase activities. Moreover, argyrophilic substance was identified in the cartilaginous tissue. Best's carmine was used for glycogen staining and Weigert's stain for elastic fibers. Metachromasia was revealed by toluidine blue staining and fat by the sudan III staining technique. In addition, the ultrastructure of cartilaginous tissue was investigated. Taken together, these methods made it possible to identify the signs of radiation-induced damage to the bone and cartilage tissues in conjunction with complications that are likely to develop at different periods after irradiation including such ones as spontaneous fractures, deforming arthrosis and radiation-induced tumours.

Spontaneous capital femoral physeal fracture in a cat

A young neutered male cat was presented with a 1-week history of left hind limb lameness. Pain and crepitus were identified on manipulation of the left coxofemoral joint. Radiographic evaluation led to the diagnosis of physeal dysplasia with slipped capital femoral epiphysis of the left femur, which did not respond to conservative management.

Pathological fractures as an initial presentation of Wilson's disease

Wilson's disease (WD) has varied phenotypic presentations. Here we report the case of a 16-year-old boy who presented with a history of multiple pathological fractures, severe joint deformities, hepatic dysfunction, cognitive decline and limb dystonia. On examination, the patient had pinched out facies, pallor and leukonychia totalis. Bilateral Kayser Fleischer (KF) ring was present. Musculoskeletal examination revealed pectus carinatum, bilateral genu valgus and gun-stock deformity of the left elbow joint. Splenomegaly and moderate ascites were present. Neurological examination revealed mild rigidity and intermittent episodes of dystonic posturing of all four limbs. On this basis a diagnosis of WD with dystonia with cirrhosis of liver with portal hypertension with renal tubular acidosis with renal rickets was thought likely. Investigations confirmed the diagnosis. The patient was started on treatment but he did not improve. He suffered aspiration pneumonia during his hospital stay and succumbed to the illness.

[Sternal tuberculosis causing spontaneous fracture of the sternum]

Sternal tuberculosis is an uncommon condition. Few cases have been reported. We report the case of a 74-year-old man, presented with a swelling and pain of the anterior chest wall associated to worsening of general state. All routine investigations were normal. Chest radiograph in lateral view showed sternal and chest wall hypertrophy with spontaneous fracture of the sternum. Computed tomography (CT) scan demonstrated ring-enhancing hypodense soft tissue mass surrounding the sternum with sternal fracture. Tuberculosis diagnosis was confirmed by histological study of the mass biopsy. We noted clinical and radiological recovery with medical tuberculosis treatment.

Monitoring and risk of progression of osteolysis after total hip arthroplasty

Osteolysis after total hip arthroplasty (THA) develops in response to particulate wear debris and may not be associated with clinical symptoms. Osteolysis is associated with greater wear volume. Wear increases with the increased use and activity of the joint, so longer in vivo use of a THA implant increases the risk of osteolysis. Patients with non-cross-linked, ultra-high-molecular weight polyethylene implants and younger more active patients are at greater risk for the development of osteolysis. Routine monitoring for osteolysis 5 years after THA, with radiographic imaging every 2 to 3 years thereafter, is recommended. Patients at greater risk for osteolysis should be monitored more closely. If a lesion is seen radiographically, serial radiographs are helpful to determine the relative rate of progression of the lesion. CT with metal artifact reduction can be used to effectively quantitate the lesion size and location. MRI is useful in visualizing osteolytic areas and soft-tissue pathology. Both MRI and CT with metal artifact reduction protocols have been developed to effectively visualize osteolytic lesions in proximity to THA implants and provide supplemental information to plain radiography.

Pathological fracture of femur secondary to infected synovial sarcoma

Pathological fracture is not uncommon in musculoskeletal oncological surgical practice. When complicated by infection, it is both limb- threatening and life-threatening problem. Pathological fractures require urgent investigation, not urgent treatment. We present the case of a 75-year-old man who presented with an infected sarcoma causing a pathological fracture of his right femur.

Strontium ranelate decreases the incidence of new caudal vertebral fractures in a growing mouse model with spontaneous fractures by improving bone microarchitecture

Young mice over-expressing Runx2 fail to gain bone relative to wild type mice with growth and present spontaneous fractures. It allows, for the first time in rodents, direct assessment of anti-fracture efficacy of strontium ranelate which was able to decrease caudal vertebrae fracture incidence through an improvement of trabecular and cortical architecture.

INTRODUCTION

The aim was to investigate whether strontium ranelate was able to decrease fracture incidence in mice over-expressing Runx2, model of severe developmental osteopenia associated with spontaneous vertebral fractures.

METHODS

Transgenic mice and their wild type littermates were treated by oral route with strontium ranelate or vehicle for 9 weeks. Caudal fracture incidence was assessed by repeated X-rays, resistance to compressive loading by biochemical tests, and bone microarchitecture by histomorphometry.

RESULTS

Transgenic mice receiving strontium ranelate had significantly fewer new fractures occurring during the 9 weeks of the study (-60%, p < 0.05). In lumbar vertebrae, strontium ranelate improves resistance to compressive loading (higher ultimate force to failure, +120%, p < 0.05) and trabecular microarchitecture (higher bone volume and trabecular number, lower trabecular separation, +60%, +50%, -39%, p < 0.05) as well as cortical thickness (+17%, p < 0.05). In tibiae, marrow cavity cross-section area and equivalent diameter were lower (-39%, -21%, p < 0.05). The strontium level in plasma and bone was in the same range as the values measured in treated postmenopausal women.

CONCLUSIONS

This model allows, for the first time, direct assessment of anti-fracture efficacy of strontium ranelate treatment in rodents. In these transgenic mice, strontium ranelate was able to decrease caudal vertebral fracture incidence through an improvement of trabecular and cortical architecture.

Vertebral fracture

Vertebral fractures are usually the first to occur in osteoporosis, provide indisputable evidence of reduced bone strength, and are frequently a harbinger of further vertebral and nonvertebral fracture. Radiologists are best placed to draw attention to the presence of vertebral fractures, most of which are clinically silent. Magnetic resonance imaging supplemented if necessary by computed tomography is usually sufficient to enable distinction between osteoporotic and non-osteoporotic vertebral fracture, without a need for percutaneous biopsy.

[Bone fracture and the healing mechanisms. Fragility fracture and bone quality]

Fracture occurs in bone having less than normal elastic resistance without any violence. Numerous terms have been used to classify various types of fractures from low trauma events; "fragility fracture", "stress fracture", "insufficiency fracture", "fatigue fracture", "pathologic fracture", etc. The definitions of these terms and clinical characteristics of these fractures are discussed. Also state-of-the-art bone quality assessments; Finite element analysis of clinical CT scans, assessments of the Microdamage, and the Cross-links of Collagen are introduced in this review.

A rare emergency condition in neurosurgery: foot drop due to Paget's disease

Paget's disease is a chronic, focal skeletal disorder that usually affects the pelvis and spine. Spinal cases are generally asymptomatic; in the symptomatic cases, the neurological dysfunctions are related to non-compressive vascular defects, hemorrhage, sarcomatoid degeneration, spinal stenosis, or pathological fractures, primarily in the lumbar region. The Neurosurgeon should have a fundamental understanding of the complications of Paget's disease and should be familiar with the indications for treatment, as well as available medical and surgical therapies. In the present paper, we report a case of Paget's disease that presented with an isolated foot drop due to a pathological fracture of L5 vertebra, and then discuss the therapeutic strategies presented in the literature.

[Indications for usage of oncological prostheses in the treatment of proximal femur methastases]

In this paper we present indications for usage of oncological prosthesis in the treatment of metastases in proximal femur. According to our experience, based on clinical material of 78 patients treated between year 1997 and 2007 in Spine Surgery, Onclological Orthopaedics and Taumatology Clinic, University of Medical Sciences in Poznan, the indications are: massive bone loss, second surgery in the same place, damage of articular surface, small possibility of stable union, threatening patological fracture. At the appropriately selected group of patients application of onclological prosthesis lets for restoring the function of the limb, reducing or bearing pain complaints or removing the entire methastasis.