Fixation Of Pathologic Fractures Research Articles

Anaesthesia for Fixation of Pathological Fractures in a Patient with Multiple Myeloma with Comorbidities

Introduction: Patients with multiple myeloma (MM) have improved life expectancy and quality of life in the last decade with the introduction of new chemotherapeutic agents and improvement in treatment modalities. Due to this, patients are now being treated for surgical implications of the disease, which was not possible earlier. Case Report: We report a case of a 42-year male with MM with fractured femur bone posted for fixation of pathological fracture femur, discussing the perioperative considerations and management for anaesthesiologists. Conclusion: Proper anaesthetic management is crucial for the successful fixation of pathological fractures in patients with MM and comorbidities, considering the unique challenges posed by the disease and its associated complications.

Predicting Risk of 30-day Postoperative Morbidity Using the Pathologic Fracture Mortality Index.

The purpose of this study was to evaluate the ability of the Pathologic Fracture Mortality Index (PFMI) to predict the risk of 30-day morbidity after pathologic fracture fixation and compare its efficacy with those of the American Society of Anesthesiologists (ASA) physical status, modified Charlson Comorbidity Index (mCCI), and modified frailty index (mFI-5). Cohorts of 1,723 patients in the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2020 and 159 patients from a tertiary cancer referral center who underwent fixation for impending or completed pathologic fractures of long bones were retrospectively analyzed. National Surgical Quality Improvement Program morbidity variables were categorized into medical, surgical, utilization, and all-cause. PFMI, ASA, mCCI, and mFI-5 scores were calculated for each patient. Area under the curve (AUC) was used to compare efficacies. AUCs predicting all-cause morbidity were 0.62, 0.54, and 0.56 for the PFMI, ASA, and mFI-5, respectively. The PFMI outperformed the ASA and mFI-5 in predicting all-cause ( P < 0.01), medical ( P = 0.01), and utilization ( P < 0.01) morbidities. In the 2005 to 2012 subset, the PFMI outperformed the ASA, mFI-5, and mCCI in predicting all-cause ( P = 0.01), medical ( P = 0.03), and surgical ( P = 0.05) morbidities but performed similarly to utilization morbidity ( P = 0.19). In our institutional cohort, the AUC for the PFMI in morbidity stratification was 0.68. The PFMI was associated with all-cause (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.12 to 1.51; P < 0.001), medical (OR, 1.19; 95% CI, 1.03 to 1.40; P = 0.046), and utilization (OR, 1.32; 95% CI, 1.14 to 1.52; P < 0.001) morbidities but not significantly associated with surgical morbidity (OR, 1.21; 95% CI, 0.98 to 1.49; P = 0.08) in this cohort. The PFMI is an advancement in postoperative morbidity risk stratification of patients with pathologic fracture from metastatic disease. III.

Comparison of carbon fibre and titanium intramedullary nails in orthopaedic oncology.

AimsDue to their radiolucency and favourable mechanical properties, carbon fibre nails may be a preferable alternative to titanium nails for oncology patients. We aim to compare the surgical characteristics and short-term results of patients who underwent intramedullary fixation with either a titanium or carbon fibre nail for pathological long-bone fracture.MethodsThis single tertiary-institutional, retrospectively matched case-control study included 72 patients who underwent prophylactic or therapeutic fixation for pathological fracture of the humerus, femur, or tibia with either a titanium (control group, n = 36) or carbon fibre (case group, n = 36) intramedullary nail between 2016 to 2020. Patients were excluded if intramedullary fixation was combined with any other surgical procedure/fixation method. Outcomes included operating time, blood loss, fluoroscopic time, and complications. Fisher’s exact test and Mann-Whitney U test were used for categorical and continuous outcomes, respectively.ResultsPatients receiving carbon nails as compared to those receiving titanium nails had higher blood loss (median 150 ml (interquartile range (IQR) 100 to 250) vs 100 ml (IQR 50 to 150); p = 0.042) and longer fluoroscopic time (median 150 seconds (IQR 114 to 182) vs 94 seconds (IQR 58 to 124); p = 0.001). Implant complications occurred in seven patients (19%) in the titanium group versus one patient (3%) in the carbon fibre group (p = 0.055). There were no notable differences between groups with regard to operating time, surgical wound infection, or survival.ConclusionThis pilot study demonstrates a non-inferior surgical and short-term clinical profile supporting further consideration of carbon fibre nails for pathological fracture fixation in orthopaedic oncology patients. Given enhanced accommodation of imaging methods important for oncological surveillance and radiation therapy planning, as well as high tolerances to fatigue stress, carbon fibre implants possess important oncological advantages over titanium implants that merit further prospective investigation.Level of evidence: III, Retrospective studyCite this article: Bone Jt Open 2022;3(8):648–655.

CORR Insights®: Do Disparities in Wait Times to Operative Fixation for Pathologic Fractures of the Long Bones and 30-day Complications Exist Between Black and White Patients? A Study Using the NSQIP Database.

CORR Insights®: Do Disparities in Wait Times to Operative Fixation for Pathologic Fractures of the Long Bones and 30-day Complications Exist Between Black and White Patients? A Study Using the NSQIP Database.

Outcomes of Proximal Femoral Locking-plate Fixation for Pathological Fractures of the Proximal Femur

Objective: To study the treatment outcomes of proximal femoral locking-plate fixation of pathological fractures ofthe proximal femur relative to clinical results, implant failure, and surgical complications.Materials and Methods: From 2007 to 2018, 17 patients (18 femurs) with a diagnosis of impending or existingpathological fracture of the proximal femur were treated with proximal femoral locking-plate fixation. Data collectedincluded operative duration, estimated blood loss, ambulatory status, hardware failure events, and postoperativecomplications.Results: Of the 18 femurs that were included, 13 were existing pathological fractures and 5 were impending fractures.The mean age of patients was 53.7 years (range: 28-89), and 12 of them were female. The mean follow-up was 11.3months (range: 1-67). Ten of 17 patients (62.5%) had progressive lung disease from pulmonary metastasis or fromlung primary. No patient developed oxygen desaturation or cardiac arrest during the intraoperative or postoperativeperiod. Thirteen of 17 patients (76.5%) could walk with or without an assistive device at the time of final follow-up.Two patients required close postoperative monitoring in the intensive care unit due to poor preoperative status,and both of those patients died within one month after surgery from other medical problems. No hardware failureoccurred.Conclusion: For pathological fracture of the proximal femur, proximal femoral locking-plate fixation is a treatmentoption that results in fewer perioperative and postoperative cardiopulmonary events and surgical complications.Most patients can ambulate with or without an assistive device at the final follow-up.

The Pathologic Fracture Mortality Index: A Novel Externally Validated Tool for Predicting 30-day Postoperative Mortality

Current mortality predictive tools, in the setting of completed or impending pathologic fractures, are nonspecific. Clinical decision making and mortality prediction in research would benefit from creation of a high-fidelity scoring system for calculating the risk of 30-day postoperative mortality. The purpose of this study is to develop a validated research and clinical tool that is superior to existing methods in estimating postoperative mortality risk after fixation of pathologic fractures. One thousand two hundred nineteen patients who underwent fixation for either completed or impending pathologic fractures in the National Surgical Quality Improvement Program (2012 to 2018) database were analyzed. Multivariable logistic regression with diagnostics was used to develop a predictive model in a derivation cohort and then validated in a validation cohort. Area under the curve (AUC) from receiver operator curve analysis was used to assess accuracy. A score was derived and compared with the American Society of Anesthesiologists classification and modified five-component frailty index (mF-I5). The score was validated in an exclusive cohort of patients who underwent fixation for pathologic fractures at a tertiary care center. Of 1,219, a total of 177 (15%) patients did not survive beyond 30 days postoperatively. AUC for our predictive model was 0.76 in the derivation and 0.75 in the validation National Surgical Quality Improvement Program cohorts. The derived Pathologic Fracture Morbidity Index included seven data points: anemia, alkaline phosphatase > 150 U/L, albumin < 3.5 mg/dL, pulmonary disease, recent weight loss, functional dependence, and white blood cell count >12,000. The PFMI (AUC = 0.75) was more accurate than ASA (AUC = 0.60) or mF-5 (AUC = 0.58) (P < 0.01). The AUC for PFMI in predicting 30-day mortality in the exclusive cohort (N = 39) was 0.74. The PFMI is a validated tool that may be used for predicting postoperative 30-day mortality after fixation of pathologic fractures, with higher level of accuracy compared with ASA or mF-I5.

Utility of the Current Procedural Terminology Codes for Prophylactic Stabilization for Defining Metastatic Femur Disease.

Introduction:Cohorts from the electronic health record are often defined by the Current Procedural Terminology (CPT) codes. The error prevalence of CPT codes for patients receiving surgical treatment of metastatic disease of the femur has not been investigated, and the predictive value of coding ontologies to identify patients with metastatic disease of the femur has not been adequately discussed.Methods:All surgical cases at a single academic tertiary institution from 2010 through 2015 involving prophylactic stabilization of the femur or fixation of a pathologic fracture of the femur were identified using the CPT and International Classification of Disease (ICD) codes. A detailed chart review was conducted to determine the procedure performed as documented in the surgical note and the patient diagnosis as documented in the pathology report, surgical note, and/or office visit notes.Results:We identified 7 CPT code errors of 171 prophylactic operations (4.1%) and one error of 71 pathologic fracture fixation s(1.4%). Of the 164 prophylactic operations that were coded correctly, 87 (53.0%) had metastatic disease. Of the 70 pathologic operations that were coded correctly, 41 (58%) had metastatic disease.Discussion:The error prevalence was low in both prophylactic stabilization and pathologic fixation groups (4.1% and 1%, respectively). The structured data (CPT and ICD-9 codes) had a positive predictive value for patients having metastatic disease of 53% for patients in the prophylactic stabilization group and 58% for patients in the pathologic fixation group. The CPT codes and ICD codes assessed in this analysis do provide a useful tool for defining a population in which a moderate proportion of individuals have metastatic disease in the femur at an academic medical center. However, verification is necessary.

Osseous manifestations of non-Hodgkin's lymphoma in Human Immunodeficiency Virus (HIV) infection and Acquired Immunodeficiency Syndrome (AIDS)

BACKGROUND: Lymphoma is the second most common Acquired Human Immunodeficiency Syndrome (AIDS)-associated neoplasm, the commonest being Kaposi sarcoma. The diagnosis and treatment of bone lymphoma still remains a challenge in our environment. MATERIALS AND METHODS: This is a retrospective chart review of 105 patients who were diagnosed histopathologi-cally with lymphoma involving the bone over a period of 11 years in six local hospitals. RESULTS: Forty-five (42.9%) patients with bone lesions and who were positive for Human Immunodeficiency Virus (HIV) formed the cohort. Clinical manifestations varied from swelling and pain in all patients to pathological fractures (n = 5, 11.1%) and paraplegia (n = 11, 24.4%) due to cord compression. Common sites included the spine, pelvis, femur, humerus, ribs, tibia and mandible. Treatment included chemotherapy and radiation, splinting or surgical fixation of pathological fractures and decompression of the spine with or without fusion. CONCLUSION: Bone lymphoma should be considered in any HIV-positive patient presenting with unexplained swelling and pain. The radiological picture may mimic bone infections like chronic pyogenic osteomyelitis, tuberculosis and fungal infections, other systemic disorders like Paget's disease, blood-related tumours such as leukaemia and other primary and metastatic bone neoplasms.

Surgical Management of Metastatic Long Bone Fractures: Principles and Techniques

Management of metastatic long bone fractures requires identification of the lesion and the use of sound fracture fixation principles to relieve pain and restore function. The treating surgeon must understand the principles of pathologic fracture fixation before initiating treatment. Because these fractures occur in the context of a progressive systemic disease, management typically involves a multidisciplinary approach. When considering surgical stabilization of these fractures, the abnormal (or absent) healing environment associated with diseased bone and the overall condition of the patient must be taken into account. The goal of surgery is to obtain a rigid mechanical construct, which allows for early mobility and weight bearing. This can be achieved using internal fixation with polymethyl methacrylate cement or segmental resection and joint reconstruction. Prosthetic joint arthroplasty is a more reliable means of fracture management when insufficient bone is present for fixation. Prophylactic stabilization of impending pathologic fractures can reduce the morbidity associated with metastatic lesions.

Internal fixation of radiation-induced pathological fractures of the femur has a high rate of failure

We investigated the clinical outcome of internal fixation for pathological fracture of the femur after primary excision of a soft-tissue sarcoma that had been treated with adjuvant radiotherapy. A review of our database identified 22 radiation-induced fractures of the femur in 22 patients (seven men, 15 women). We noted the mechanism of injury, fracture pattern and any complications after internal fixation, including nonunion, hardware failure, secondary fracture or deep infection. The mean age of the patients at primary excision of the tumour was 58.3 years (39 to 86). The mean time from primary excision to fracture was 73.2 months (2 to 195). The mean follow-up after fracture fixation was 65.9 months (12 to 205). Complications occurred in 19 patients (86%). Nonunion developed in 18 patients (82%), of whom 11 had a radiological nonunion at 12 months, five a nonunion and hardware failure and two an infected nonunion. One patient developed a second radiation-associated fracture of the femur after internal fixation and union of the initial fracture. A total of 13 patients (59%) underwent 24 revision operations. Internal fixation of a pathological fracture of the femur after radiotherapy for a soft-tissue sarcoma has an extremely high rate of complication and requires specialist attention.

Plastic cylindrical cement mold in the treatment of long bone metastatic fractures

Presented here is a simple and practical surgical technique for creating a cement spacer in the cement-metal composite fixation of pathological fractures. This technique has been effectively used in several of our patients for fixation of pathological fractures due to metastatic disease of long bones.

Locking Compression Plate in Musculoskeletal Oncology 'a Friend in Need'

BackgroundWe are presenting our experience in the use of locking compression plate (LCP) after juxta-articular oncological resections in addition to its use in pathologic fracture.MethodsA retrospective audit of skeletal reconstruction using LCP in 25 cases of long bone tumors was performed from 2008 to 2010. Reconstruction following limb salvage surgery was done in 17 patients and internal fixation of pathological fracture was done in 8 patients. All patients were available for > 12 months of follow-up, and thus assessed for union at the resected ends.ResultsThere were 8 males and 17 females in the study. The average age at the time of surgery was 30 years (range, 9 to 66 years). The minimum follow-up was 12 months (range, 12 to 32 months). All patients except three went on to heal successfully. Complications occurred in those three patients: wound infection in one, nonunion in another, and periprosthetic fracture in the other patient. In the remaining patients, union was achieved at an average of 6.5 months after reconstruction in curative resection and 4.75 months after fixation of pathological fractures.ConclusionsJoint sparing limb salvage surgery was made successfully possible after sekeletal reconstruction with LCP. Its use was also quite effective in pathological fractures with poor bone quality. Use of locking plates for musculoskeletal oncological reconstruction resulted in a good and predictable rate of union.

Novel Venting Technique for Intramedullary Rod Fixation of Pathologic Fractures

This article introduces a novel technique to vent the femur and potentially decrease the embolic load created by reaming during intramedullary rod fixation of impending pathologic femur fractures. We used readily available operating room equipment to create a distal femoral vent hole without interfering with standard intramedullary instrumentation and with minimal increase in surgical time. This technique can be used for the prophylactic intramedullary stabilization of impending pathologic femur fractures from metabolic bone disease, metastatic cancer, and bisphosphonate use.

Surgical treatment of metastatic tumors of the femur

To evaluate the patients functional outcome and pain control after resection of metastatic femoral tumors. A prospective randomized clinical study was conducted, which included 26 cases of metastatic tumors of the femur with an associated pathologic fracture. These selected cases were randomly divided into two groups based upon the using of methylmethacrylate cement in fracture fixation. Group 1 (n=13) included all cases where the fractures were treated with bone cement augmentation. Group 2 (n=13) included all cases where the fractures were treated without bone cement augmentation. Functional outcome was evaluated according the American Musculoskeletal Tumor Society system. Good and excellent pain control was achieved in 61.5%, satisfactory in 38.5% of all cases in the Group 1 versus 15.5% (P=0.015) and 69% (chi(2)=2.4762; P=0.115) of all cases in the Group 2. Functional outcome after femoral metastasis resection and pathologic fracture fixation was significantly better in the Group 1. Total lower extremity function of full normal function was 67% in the Group 1 versus 49% in the Group 2 (P<0.05). We did not observe significant difference between patients' postoperative survival in the groups (P>0.05). The postoperative durability of stable pathologic fracture fixation was shorter in the Group 2 (273.9+/-51.7 vs. 358.9+/-116.8 days) comparing with Group 1 (P=0.03). The introduction of bone cement as the adjunct to the pathologic femoral fracture fixation significantly improved the clinical our study results: we achieved better functional outcome and better pain control.

Do locking plates have a role in orthopaedic oncological reconstruction

Role of locking plate in skeletal reconstruction after resection of bone tumours in Indian patients. Retrospective evaluation of skeletal reconstruction using locking plate in 20 cases of long bone tumours was done. Reconstruction was done in 12 patients following limb salvage surgery, internal fixation of pathological fracture in seven bone tumours and one angiomatous tumour. There were 12 females and 8 male patients. Average age at the time of surgery was 30.1 years (range 10-58). Minimum follow-up was 11 months (range 11-38). Average time for union in pathological fractures was 4 weeks and 120 days after limb salvage surgery. Vicryl mesh was used to contain the morcellized allograft and cancellous iliac crest in 17 cases. Eighteen reconstructions were intact at an average follow-up of 17 months. Two failed reconstructions included one plate breakage and one screw pull out. Use of locking plate does not ensure the bony union at the site of reconstruction but it expedite it and allow early mobilization of joints and weight bearing particularly in Indian patients with late presentations. Careful selection of patients and proper preoperative planning including length of resection are essential for optimal outcomes and to minimize complications. Reconstruction should be supported by cortico-cancellous autograft/allograft for stabilization and union at junction of host and autograft/allograft bone and should be given adequate protection. Vicryl mesh helps in containing the morcellized grafts along the long axis of reconstruction.

Surgical Treatment of Pathological Fractures of the Shaft of the Humerus

This report deals with the advantages and disadvantages associated with the most commonly used methods of stabilization after a pathologic fracture of the humerus shaft. A total of 39 patients with 41 metastatic lesions and pathologic fractures of the humerus, treated surgically between 1992 and 2007, were retrospectively analyzed. The rate of local complications was 14.6% (6 of 41). Radial nerve injury was the only local complication and was exclusively observed in patients who underwent open reduction and plate fixation. The overall rate of osteosynthesis failure was 12.2% (5 of 41). Two failures were observed in 21 patients with open reductions and plate fixations, compared with three failures in 20 procedures involving closed reductions and intramedullary stabilization. The 1- and 2-year survival rates were 0.35 and 0.2 in ORIF and 0.07 and 0 in patients with IM fixation retrospectively. Intramedullary stabilization is a reliable method for fixation of pathologic fractures of the humerus diaphysis for patients in the advanced stage of metastatic disease. ORIF are preferable to IM fixations for the treatment of metaphyseal fractures and for those patients with a solitary metastasis in the humerus or those with a better prognosis.

Early management of pathological fractures in children

The management of pathological fractures in children remains controversial. The indications for surgical treatment are unclear and the need for histological diagnosis before or after definitive treatment is not clearly defined. We reviewed retrospectively the records of all patients under the age of 16 years who presented over the past 7 years with a fracture as the first manifestation of bone pathology. There were 23 patients (16 boys and 7 girls) of an average age of 12 years and 2 months (range 4.1-15.8 years). There were nine cases of fracture through a simple bone cyst, five cases of fibrous dysplasia, two giant cell tumours, three aneurysmal bone cysts, one chondroblastoma, and three cases of Ewings sarcoma. After review of our cases we propose a simple algorithm for the safe early management and assessment of paediatric pathological fractures. We recommend that primary fixation of pathological fractures should be avoided until histological diagnosis is obtained. Most lesions should eventually be biopsied. However, if radiographic appearances are reassuringly benign, biopsy can be delayed until conservative fracture management is completed. Definitive treatment of benign lesions with protective intra medullary nailing or curettage and grafting can follow frozen section under the same anaesthetic.

Treatment of Pathologic Fractures of the Humerus With Seidel Nailing

A retrospective study is presented of 14 patients with pathologic fractures of the humerus (12 established, two impending) treated with Seidel nailing from 1988 through 1995 in the authors' institution. There were nine women and five men whose average age was 59.5 years. Breast, prostate, and kidney hypernephroma accounted for the majority of the primary lesions. All but one lesion were located in the middle shaft of the humerus. Ten lesions were considered large (> 5 cm long). In five cases an open curettage and allografting were done. Early pain relief was successful in 85% of the patients. The worst complication found was definite nerve palsy in two (14.28%) patients. Ten fractures healed and two failed to heal. Two thirds of the patients had good functional results. The average survival was 12 months. Intramedullary fixation of pathologic fractures improves the quality of life by controlling pain for most patients.

Paget's disease of bone: Orthopedic complications

Orthopedic complications of Paget's disease are among the most common indications for treatment of Paget's disease. These complications include severe bone pain, joint pain, skeletal deformity, pathological fracture, and rarely malignant degeneration. The use of effective pharmacological modalities has transformed the treatment of Paget's disease in the past four decades. Although few patients with Paget's disease ever require surgical therapy, successful surgical management of severe orthopedic complications has improved the quality of life for many sufferers. Selected modalities with promising results include total hip replacement for intractable pagetic arthritis of the hip, proximal tibial osteotomy for painful malalignment of the knees, total knee replacement for intractable arthritis of the knee, and internal fixation for pathological fracture. Common surgical complications of joint replacement include infection, hemorrhage, heterotopic ossification, and aseptic loosening. The medical, surgical, and rehabilitation modalities available in managing primary and secondary orthopedic complications of Paget's disease provide a wide array of options that must be carefully considered in each patient.

Intramedullary stabilization of neoplastic destructive disease involving the subtrochanteric region of the femur.

Neoplastic destructive disease involving the subtrochanteric region of the femur is a difficult condition to treat. This is a retrospective study of 11 femurs in 10 patients with subtrochanteric destructive lesions or pathologic fractures that were stabilized with the Zickel intramedullary device. The study investigated underlying disease process, ambulatory status, operative parameters, time to death, and associated metastasis. The average survival time of the patients who died was 4.7 months. All of the patients involved in this study could be mobilized, but only 3 out of 10 were ambulatory. This study concludes that the intramedullary fixation of pathologic fractures or lesions of the subtrochanteric region does not necessarily allow ambulation, but does allow mobilization of debilitated patients.