Incidence Of Pathological Fractures Research Articles

The low and disproportionate utilization of antiresorptive therapy in patients with osseous metastasis

IntroductionAntiresorptive therapies are commonly utilized to mitigate and prevent skeletal-related-events in patients with metastatic osseous disease. However, limited data exists on the incidence or factors associated with prescription of antiresorptives or their effects on the incidence of pathologic fractures in patients with osseous metastatic disease. The aims of this study were to determine 1) the proportion of patients with osseous metastasis who receive antiresorptive therapy and sustain a pathologic fracture within 2-years of a new diagnosis, 2) factors associated with sustaining a pathologic fracture, and 3) factors are associated with the likelihood of receiving antiresorptive therapy. MethodsBetween January 2010 and October 2021, 1,492,301 patients with a new diagnosis of osseous metastasis were captured in the Mariner dataset of the PearlDiver database. Patients were identified using International Classification of Disease (ICD) 10 codes for osseous metastasis. We excluded patients with a prior diagnosis of osseous metastasis and if they had less than two-years of follow-up. There were 696,459 patients (46.7 %) included for analysis. Of these patients, 63 % (N = 437,716) were over the age of 65, 46 % were women, and 5.6 % had Medicaid insurance. We identified patients who were prescribed antiresorptive therapy within 2-years of a new diagnosis of osseous metastasis. Cox proportional hazard ratio models were created to predict factors associated with 1) pathologic fracture and 2) receiving antiresorptive therapy within 2-years of a new diagnosis of osseous metastasis, respectively. ResultsThe incidence of antiresorptive therapy prescription was 7.7 % in our cohort. The incidence of pathologic fracture within 2-years of a new diagnosis was 7.3 %. The risk of sustaining a pathologic fracture was higher for patients aged 35–44 (HR 1.27 [95 % CI 1.08–1.51]; p = 0.004), those with primary kidney cancer (HR 1.78 [95 % CI 1.71–1.85]; p < 0.001), p = 0.005), multiple myeloma (HR 2.49 [95 % CI 2.39–2.59]; p < 0.001), and Medicaid insurance (HR 1.17 [95 % CI 1.13–1.21]; p < 0.001). The risk of sustaining a pathologic fracture was lower for patients on antiresorptive therapy (HR 0.71 [95 % CI 0.66–0.83]; p < 0.001). Increasing age was an independent predictor for antiresorptive therapy prescription (HR 1.77–16.38, all p < 0.05). Male sex as well as diagnosis of primary prostate, lung, or kidney cancer and Medicaid insurance were negative predictors for antiresorptive prescription (HR 0.15–0.87, all p < 0.001). ConclusionsThe utilization of antiresorptive therapy in patients with osseous metastases remains unacceptably low, with only 7.7% patients being prescribed these therapies, despite shown efficacy in reduction of pathologic fractures incidences. This study identified younger patients, males, and those diagnosed with primary prostate, kidney, and lung cancers to be at increased risk of not being prescribed antiresorptive therapy, suggesting possible bias in prescription patterns. Greater efforts are needed by providers who care for this vulnerable population to increase the utilization and reduce disparities of prescribing antiresorptive therapy.

Predictors of pathologic fracture and local recurrence following stereotactic body radiation therapy to 505 non-spine bone metastases

PurposeStereotactic Body Radiation Therapy (SBRT) is increasingly applied to treat non-spine bone metastases (NSBM) though data remains limited on this approach. In this retrospective study, we report outcomes and predictors of local failure (LF) and pathological fracture (PF) post-SBRT for NSBM using a mature single-institution database. MethodsPatients with NSBM treated with SBRT between 2011 and 2021 were identified. The primary objective was to assess the rates of radiographic LF. Secondary objectives were to assess the rates of in-field PF, overall survival (OS), and late grade ≥ 3 toxicity. Competing risks analysis was used to assess rates of LF and PF. Univariable regression and multivariable regression (MVR) were performed to investigate predictors of LF and PF. ResultsA total of 373 patients with 505 NSBM were included in this study. Median follow-up was 26.5 months. The cumulative incidence of LF at 6, 12, and 24 months were 5.7%, 7.9%, and 12.6%, respectively. The cumulative incidence of PF at 6, 12, and 24 months were 3.8%, 6.1%, and 10.9%, respectively. Lytic NSBM (HR = 2.18; p < 0.01), a lower biologically effective dose (HR = 1.11 per 5 Gy10 decrease; p = 0.04), and a PTV ≥ 54 cc (HR = 4.32; p < 0.01) predicted for a higher risk of LF on MVR. Lytic NSBM (HR = 3.43; p < 0.01), mixed (lytic/sclerotic) lesions (HR = 2.70; p = 0.04), and rib metastases (HR = 2.68; p < 0.01) predicted for a higher risk of PF on MVR. ConclusionSBRT is an effective modality to treat NSBM with high rates of radiographic local control with an acceptable rate of PF. We identify predictors of both LF and PF that can serve to inform practice and trial design.

Stereotactic Body Radiation Therapy for Non-Spine Bone Metastases: Local Control and Fracture Risk

<h3>Purpose/Objective(s)</h3> Stereotactic Body Radiation Therapy (SBRT) is increasingly being utilized to treat non-spine bone metastases (NSBM) with both palliative and radical intent. There remains limited data on the long-term outcomes and toxicities and, therefore, we report mature results from our institutional database. <h3>Materials/Methods</h3> Patients with NSBM who were treated with SBRT were identified from 2011 to 2021. The primary endpoint was radiographic local failure (LF). Secondary endpoints included rate of in-field pathologic fracture (PF), overall survival (OS), and late (>3 months post-SBRT) grade ≥3 toxicity (Common Terminology Criteria for Adverse Events, version 5.0). Competing risks analysis was used to assess rates of LF and PF. OS was estimated using the Kaplan-Meier method. Univariable regression (UVR) and multivariable regression (MVR) were performed to investigate predictive factors for LF and PF. <h3>Results</h3> A total of 373 patients with 505 NSBM were included in this study. Primary indications for SBRT included oligometastatic disease (52.6%), pain relief (23.8%), and oligoprogression (19.7%). Median follow-up was 26.5 months (range: 3.0-128.3 months). The most common primary histologies included prostate (33.7%), RCC (20.7%), breast (16.9%), and lung (14.8%). The two most common NSBM sites were pelvic (42.3%) and rib (30.5%). Of all NSBM, 217 (42.7%) were lytic and 230 (45.3%) were symptomatic. The most common dose prescriptions were 35 Gy in 5 fractions (33.3%) and 24 Gy in 2 fractions (25.2%). The cumulative incidence of LF at 6, 12, and 24 months were 5.7%, 7.9%, and 12.6%, respectively. The cumulative incidence of PF at 6, 12, and 24 months were 3.8%, 6.1%, and 10.9%, respectively. There were 3 instances of late grade ≥3 toxicity: 1 grade 3 osteonecrosis, 1 grade 3 peripheral neuropathy, and 1 grade 5 bowel fistula. Median OS was 53.9 months (95% confidence interval: 45.3-63.2 months). Lytic NSBM (HR=2.20; p<0.01), symptomatic NSBM (HR=2.15; p<0.01), and those with a larger PTV (HR=1.01; p=0.04) were at higher risk of LF on MVR. Lytic lesions (HR=3.43; p<0.01), mixed (lytic/sclerotic) lesions (HR=2.70; p=0.04), and rib metastases (HR=2.68; p<0.01) were at a higher risk of PF on MVR. <h3>Conclusion</h3> SBRT is an effective modality to treat NSBM with high rates of radiographic local control with an acceptable rate of fracture. We identify predictors of both LF and PF that can serve to inform practice.

MON-381 Endocrinological Evaluation of Adult Thalassemia Patients

Background: Endocrine disorders are among the most common complications in thalassemia patients. Although cardiac complications are the main cause of mortality, endocrinological disturbances have a significant impact on morbidity and quality of life. Methods: Sixty-eight patients (35 F, 33 M; 60 thalassemia major, 8 thalassemia intermedia) admitted to our outpatient clinic between August 2015 - December 2017 were included in the study. Patients were evaluated for short stature, hypogonadism, glycemic abnormalities, hypoparathyroidism, hypothyroidism and osteoporosis. Results: The average height of thalassemia major patients was 165.67±8.8 cm in men and 155.6±6.6 cm in women. Nine patients had short stature (4 F, 5 E), but 91.5% (54/59) of the whole group had low IGF-1 levels. There were 23 thalassemia major patients (11 F, 12 M) who had a history of hormonal induction therapy for delayed puberty. Overall, 60% (n = 36) of the patients were currently receiving hormone replacement therapy for central hypogonadism (19 F, 17 M). The median age at diagnosis of central hypogonadism was 22.5 years in men (IQR: 16.5-27.5) and 18 years in women (IQR: 16-25). There were five diabetic thalassemia major patients in study group whose median age at diagnosis was 20 (16-36). Of the 47 patients who underwent OGTT, 13 thalassemia major patients had prediabetes (27.7%). None of the thalassemia intermedia patients had glycemic abnormalities. Subclinical hypothyroidism was present in 19.7% (13/66) of the whole group, hypoparathyroidism was found in 8.5% (9/59) of thalassemia major patients, and vitamin D deficiency (25OH D < 20 ng/ml) was found in 70.8% (46/65) of all patients. Of 64 patients who underwent BMD, 25 had osteoporosis (39.1%) while 23 hadosteopenia (35.9%). The incidence of pathological fractures in thalassemia major patients was 20% (11/55). Conclusions: The incidence of endocrine disorders may increase in thalassemia patients due to prolonged duration of lifespan. Regular screening for newly emerging endocrinopathies during adulthood has great value. In our study, the most common endocrine disorders were vitamin D deficiency, hypogonadism, osteoporosis and glycemic abnormalities; respectively. Early diagnosis and treatment would prevent patients from having related morbidities and therefore increase quality of life.

Measurement of morphological parameters of giant cell tumor of bone in the knee.

The aim of the present study was to characterize the morphological parameters of giant cell tumor of bone (GCTB) in the knee. The imaging data of 250 patients with GCTB in the knee were retrospectively reviewed, and the morphological parameters were analyzed. The study included 137 cases with GCTB in the distal femur and 113 cases with GCTB in the proximal tibia. The maximal longitudinal diameter of the tumor was 6.616±2.322 cm in the femur group and 5.738±2.278 cm in the tibia group (P=0.003). The maximal transverse diameter in the two groups was 4.865±1.525 and 4.313±1.309 cm, respectively (P=0.003). The shortest distance from the articular surface (SDAS) in the two groups was 0.381±0.404 and 0.280±0.328 cm, respectively (P=0.035), whereas the longest distance from the articular surface in the two groups was 6.924±2.135 and 5.878±1.825 cm, respectively (P=0.001). There were statistically significant differences between the two groups in terms of the range of SDAS (P=0.043). Additionally, the incidence of pathological fractures in the femur was higher compared with that in the tibia (P=0.001), and the incidence of pathological fractures in the two groups gradually increased with the increase in lesion diameter. GCTB in the distal femur was larger compared with that in the proximal tibia, whereas GCTB in the tibia was closer to the articular surface compared with that in the femur. Furthermore, the incidence of pathological fractures in the femur was higher compared with that in the tibia.

Influence of proton pump inhibitors and histamine H2 receptor antagonists on serum phosphorus level control by calcium carbonate in patients undergoing hemodialysis: a retrospective medical chart review.

BackgroundHyperphosphatemia is one of the common complications in patients undergoing hemodialysis. Although calcium carbonate (CaC) is often used to control serum inorganic phosphorus level in dialysis patients, co-administration of gastric acid reducers (ARs) may interfere with the phosphate binding effect of CaC. We performed a retrospective medical chart review to study whether ARs attenuate the hypophosphatemic effect of CaC in patients undergoing hemodialysis.MethodsOne hundred and eight chronic hemodialysis patients receiving either CaC alone or CaC concomitant with one of the ARs (proton pump inhibitors and histamine H2-receptor antagonists) were retrieved from the medical charts in Juntendo University Nerima Hospital. The patients were subdivided according to the interval between hemodialysis sessions (interdialysis interval of 48 or 72 h). A multivariate analysis was performed to identify clinical covariates associated with the variability of serum inorganic phosphorus levels. The study protocol was approved by the Institutional Review Board before the study was begun.ResultsAmong patients on hemodialysis with a 72-h interdialysis interval, the magnitude of increase in serum inorganic phosphorus concentration in patients receiving CaC and AR was significantly greater than in those receiving CaC alone. While a similar trend was observed among patients with a 48-h interdialysis interval, the difference did not reach a significant level. A multivariate regression analysis revealed that concomitant administration of ARs with CaC and a longer interdialysis interval (72 h) were significantly and independently associated with the magnitude of increase in serum phosphorus concentration between dialysis sessions. No significant differences in albumin-corrected serum calcium concentrations and incidence of pathological fractures were observed between patients receiving CaC alone and those receiving CaC with ARs.ConclusionsConcomitant use of ARs with CaC may attenuate the hypophosphatemic effect of CaC in patients undergoing chronic hemodialysis. When hemodialysis patients require prescription of ARs for the prevention of upper gastrointestinal mucosal diseases (such as peptic ulcer), it may be prudent to choose a phosphate binder other than CaC.

EL-7 - Palliative Radiotherapy for Painful Bone Metastases

Radiotherapy is a highly successful modality to palliate pain due to bone metastases, with mild adverse effects and short treatment durations. According to previous meta-analyses, response rates and complete response rates were 59-73 and 23-34%, respectively. The median period until pain relief is 3-4 weeks, while the median period until a pain increase is 5-6 months. For uncomplicated painful bone metastases, which are defined as the presence of painful bone metastases that are not associated with impending or existing pathological fracture or existing spinal cord or cauda equine compressions, multiple randomized trials have shown that a single 8-Gy fraction regimen is equally effective as multiple fraction regimens, such as 20 Gy in 5 fractions or 30 Gy in 10 fractions. A single fraction regimen is equally effective not only in terms of response rates of pain relief but also in the period until a pain increase, incidence of spinal cord compression, incidence of pathological fracture, quality of life, as well as acute and late adverse effects. Therefore, a single fraction regimen is applicable not only for patients with a poor prognosis but also for those with a good prognosis. For patients with complicated bone metastases, multiple fraction regimens are recommended. Multiple fraction regimens are also recommended for patients with neuropathic pain. For patients who have recurrent or persistent pain after radiotherapy, reirradiation of the same sites is also effective. The response to the first irradiation is not a predictive factor of the response to reirradiation. Radiopharmaceuticals such as Strontium-89 are an important option for multifocal painful bone metastases, of which the number of anatomical sites is too high to reasonably be treated with external beam radiotherapy. Stereotactic body radiotherapy (SBRT) for spinal metastases should be used only within clinical trials.

Management of skeletal metastases: An orthopaedic surgeon's guide.

Skeletal metastasis is a common cause of severe morbidity, reduction in quality of life (QOL) and often early mortality. Its prevalence is rising due to a higher rate of diagnosis, better systemic treatment, longer lives with the disease and higher disease burden rate. As people with cancer live longer and with rising sensitivity of body imaging and surveillance, the incidence of pathological fracture, metastatic epidural cord compression is rising and constitutes a challenge for the orthopedic surgeon to maintain their QOL. Metastatic disease is no longer a death sentence condemning patients to “terminal care.” In the era of multidisciplinary care and effective systemic targeted and nontargeted therapy, patient expectations of QOL, even during palliative end of care period is high. We lay emphasis on proving the diagnosis of metastasis by biopsy and histopathology and discuss imaging modalities to help estimate fracture risk and map disease extent. This article discusses at length the evidence and decision-making process of various modalities to treat skeletal metastasis. The modalities range from radiation including image-guided, stereotactic and whole body radiation, systemic targeted or hormonal therapy, spinal decompression with or without stabilization, extended curettage with stabilization, resection in select cases with megaprosthetic or biological reconstruction, percutaneous procedures using radio frequency ablation, cementoplasties and discusses the role of emerging modalities like high frequency ultrasound-guided ablation, cryotherapy and whole body radionuclide therapy. The focus lies on the role of multidisciplinary care, which considers complex decisions on patient centric prognosis, comorbidities, cost, feasibility and expectations in order to maximize outcomes on QOL issues.

Radiological features about pathological fracture of giant cell tumor around the knee joint

Objective To compare the radiological differences of giant cell tumor (GCT) around the knee between those with pathological fracture and those without pathologic fracture and explore the radiological features of pathological fracture.Methods From March 2000 to December 2013,91 patients with GCT around the knee from domestic five bone tumor centers were involved,including 40 males and 51 females,with an average age of 36.81 years (range,17-78).All patients were divided into non pathological fracture group (53 cases) or pathological fracture group (38 cases).The radiological differences such as tumor volume,the distance between tumor and subchondral bone,Campanacci classification,soft tissue invasion and bone displacement were analyzed.Results GCT most frequently occurred in young adults between 20 and 40 years of age (58.2％,53/91),pathological fracture group with 78.9％.The proportion of tumors on the distal femur of pathological fracture group was higher than the non pathological fracture group,which showed statistical significance (x2=10.40,P=0.001).The tumor volume of pathological fracture group [(98.46±53.35) cm3] was greater than the no pathological fracture group [(63.19±34.92) cm3],there was statistical difference between the two groups (t=3.57,P=0.001).The distance between tumor and subchondral bone of pathological fracture group [median (M)=0.145 cm,range (R)=0.46 cm] was lower than that non pathological fracture group (M,0.170 cm; R,1.90 cm),and the difference was statistically significant (u=2.853,P=0.004).There were also significant differences in the incidence of pathologic fracture between the degree of soft tissue invasion (x2=l 1.08,P=0.004).Conclusion Tumor volume,distance between tumor and subchondral bone and the degree of soft tissue invasion are closely related to pathological fracture of GCT around the knee. Key words: Knee joint; Giant cell tumor of bone; Fractures, spontaneous; Radiography

Monitoring of osteoporosis among geriatric population in the primary care service

Introduction. Osteoporosis is a chronic, progressive bone disease which leads to a reduction in bone mineral density and disruption of bone micro-architecture. Patients with osteoporosis have an increased risk of fractures caused by ?small trauma? - stresses which would not normally cause fracture in a non-osteoporotic individual. This study was aimed at determining the incidence of osteoporosis in geriatric population, crucial demographic parameters (gender and age structure) in patients, presence of comorbidities, and the most common drug choice in treatment of osteoporosis. Material and Methods. A retrospective study was conducted in the period from August 1st, 2012 to May 12th, 2014 and it included 526 patients over 65 years of age who were diagnosed to have osteoporosis based on clinical findings (presence/absence of pathological fractures), laboratory tests and osteodensitometry. Data were analyzed by using standard statistical methods and statistical significance was assessed by x2 and t - test. Results. The most affected patients were women (91%). The incidence of pathological fractures was 31.80%. The presence of two or more fractures caused by a ?small trauma? was determined in 13.6%. Cardiovascular comorbidities dominated in 72.70% of cases. The most common therapeutic choice was the bisphosphonates, being administered in 77% along with the simultaneous use of vitamin D analogs - alfacalciferol (13.6%), cholecalciferol (40.9%), calcium carbonate + cholecalciferol (22.7%). Conclusion. Osteoporosis shows predominance in females aged 65-70 years. Comorbidities do not increase the risk of disease but significantly reduce the quality of life in patients. Bisphosphonates are the most common drug choice with the simultaneous use of calcium and vitamin D analogs.

Patterns of Practice in Palliative Radiotherapy for Painful Bone Metastases: A Survey in Japan

To determine the current patterns of practice in Japan and to investigate factors that may make clinicians reluctant to use single-fraction radiotherapy (SF-RT). Members of the Japanese Radiation Oncology Study Group (JROSG) completed an Internet-based survey and described the radiotherapy dose fractionation they would recommend for four hypothetical cases describing patients with painful bone metastasis (BM). Case 1 described a patient with an uncomplicated painful BM in a non-weight-bearing site from non-small-cell lung cancer. Case 2 investigated whether management for a case of uncomplicated spinal BM would be different from that in Case 1. Case 3 was identical with Case 2 except for the presence of neuropathic pain. Case 4 investigated the prescription for an uncomplicated painful BM secondary to oligometastatic breast cancer. Radiation oncologists who recommended multifraction radiotherapy (MF-RT) for Case 2 were asked to explain why they considered MF-RT superior to SF-RT. A total of 52 radiation oncologists from 50 institutions (36% of JROSG institutions) responded. In all four cases, the most commonly prescribed regimen was 30 Gy in 10 fractions. SF-RT was recommended by 13% of respondents for Case 1, 6% for Case 2, 0% for Case 3, and 2% for Case 4. For Case 4, 29% of respondents prescribed a high-dose MF-RT regimen (e.g.,50Gy in 25 fractions). The following factors were most often cited as reasons for preferring MF-RT: "time until first increase in pain" (85%), "incidence of spinal cord compression" (50%), and "incidence of pathologic fractures" (29%). Japanese radiation oncologists prefer a schedule of 30 Gy in 10 fractions and are less likely to recommend SF-RT. Most Japanese radiation oncologists regard MF-RT as superior to SF-RT, based primarily on the time until first increase in pain.

Treatment incidence of and medical utilization for hospitalized subjects with pathologic fractures in Taiwan-Survey of the 2008 National Health Insurance data

BackgroundAlmost all studies of pathologic fractures have been conducted based on patients with tumours and hospital-based data; however, in the present study, a nationwide epidemiological survey of pathologic fractures in Taiwan was performed and the medical utilization was calculated.MethodsAll claimants of Taiwan's National Health Insurance (NHI) Program in 2008 were included in the target population of this descriptive cross-sectional study. The registration and inpatient expenditure claims data by admission of all hospitalized subjects of the target population were examined and the concomitant International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes were evaluated and classified into seven major categories of fracture.ResultsA total of 5,244 incident cases of pathologic fracture were identified from the 2008 hospitalized patient claims data. The incidence of pathologic fracture of the humerus, distal radius/ulna, vertebrae, femoral neck, other part of the femur, and tibia/fibula was 0.67, 0.08, 10.58, 1.11, 0.56, and 0.11 per 100,000 people, respectively, and patients with those fractures were hospitalized for 43.9 ± 42.9, 31.1 ± 32.9, 29. 4 ± 34.4, 43.3 ± 41.2, 42.4 ± 38.1, and 42.0 ± 32.8 days, respectively, incurring an average medical cost of US$11,049 ± 12,730, US$9,181 ± 12,115, US$6,250 ± 8,021, US$9,619 ± 8,906, US$10,646 ± 11,024, and US$9,403 ± 9,882, respectively. The percentage of patients undergoing bone surgery for pathologic fracture of the humerus, radius/ulna, vertebrae, femoral neck, other part of the femur, and tibia/fibula was 31.2%, 44.4%, 11.3%, 46.5%, 48.4%, and 52.5% respectively.ConclusionsComparing Taiwan to other countries, this study observed for Taiwan higher medical utilization and less-aggressive surgical intervention for patients hospitalized with pathologic fractures.

Unusual presentation of altered bone metabolism with long-term antiepileptic therapy: pathological fracture of neck of femur due to brown tumor at calcer

The antiepileptic drugs are known to alter the bone metabolism and result in various range of pathological conditions (osteoporosis, osteomalacia, vitamin D deficiency, secondary hyperparathyroidism). These clinical conditions developed either due to direct effect of these therapeutic agents on bone or due to alteration in the homeostasis of other regulators of bone metabolism like serum calcium, vitamin D, and parathyroid hormone. Long-term therapy with antiepileptic agents results in higher incidence of pathological fracture, which is a consequence of either osteoporotic or osteomalasic (secondary to vitamin D deficiency) changes in bone produced by these drugs. Secondary hyperparathyroidism due to vitamin D deficiency following long-term polytherapy of antiepileptic drug ultimately leading to development of brown tumor and pathological fracture is very unusual.

Encounter of cancer cells with bone. Therapy for bone metastasis from lung cancer

Bone metastasis from lung cancer requires a thorough examination of bones, including axial bones (e.g., spine, pelvis, and proximal femur) . Most patients have multiple bone metastases by the time they are initially diagnosed. In such patients, radiation therapy is often the first choice of treatment. Surgical treatment is indicated for pathological fracture and impending fracture associated with cortical bone invasion in long bone metastasis. Spinal metastasis requires accurate imaging to evaluate the extent of bone metastasis ; surgical treatment is indicated when the spinal cord is compressed. Given reports that bisphosphonates decrease the incidence of pathological fractures, prescribing bisphosphonates at an early stage is likely to be an effective therapeutic strategy for bone metastasis.

Bone mineral density, pathological fractures and bisphosphonate therapy in prostate cancer patients on androgen deprivation therapy

The aim of the study is to evaluate the changes of bone mineral density (BMD), incidence of pathological fractures and to asses the effect of bisphosphonate therapy in prostate cancer patients (PCa) on androgen deprivation therapy (ADT) with the use of LHRH. In this prospective study bone mass density (BMD) was assessed by dual x-ray absorptiometry (DXA) in 97 PCa patients and 89 patients of compared group. DXA was examined at baseline and patients in the study group were subjected to ADT. PCa patients with osteoporosis were treated by calcium, vitamin D, and bisphosphonate and the subsequent DXA was made after 10 months. All other PCa patients (non-osteoporotic) had DXA examined every 12-14 months. Patients of the study group had significantly lower baseline L1-L4 and total hip BMD (p=0.028, p=0.022). BMD was significantly lower in L1-L4 and total hip (p=0.004, p<0.001, resp.) after 10-14 months and in L1-L4, femoral neck, and total hip (p=0.001, p=0.037, p< 0.001, resp.) after 20-26 months of ADT. After the treatment for osteoporosis with bisphosphonate a significant increase of BMD (p=0.04) was found in a total of 23 patients. Overall, the incidence of fractures after 20-26 months of ADT was 8.5 %. Osteopenia is very common in hormone naive PCa patients. There was a significant loss of BMD after 12 months of ADT which was progressive while the patients were on ADT. Bisphosphonate therapy was effective after 20 months of treatment. The incidence of pathological fractures was 7-fold higher in the study group.

Results of Operative Treatment for a Bone Cyst in the Proximal Femur

� Purpose: We retrospectively evaluated performing curettage and bone grafting for the treatment of simple bone cyst in 21 patients with cysts in the proximal femur. The purpose of this study was to review the results with a minimum follow up of 24 months. Materials and Methods: We treated 21 cases of simple bone cysts with curettage and a bone graft from June 1995 to July 2008. 4 male and 17 female patients (age range: 14~62 years (mean age: 39.8 years) volunteered for this study. The range of the follow-up period was from 24 months to 6 years (mean follow-up: 63.7 months). We evaluated the effect of treatment by examining the simple follow-up radiographs according to Oppenheim's classification. We retrospectively reviewed the site of the cysts, the patients' ages at the time of the diagnosis, the incidence of pathologic fracture, the association with femoro-acetabular impingement (FAI) and the type of bone graft. Results: The investigation revealed that 20 out of 21 patients had better than improved results. 14 patients of the 15 patients who were treated with an autogenous bone graft had better than improved results and all 6 patients who received an autogenous and allergenic bone graft had better than improved results. Two patients had associated FAI. These cases were managed with arthroscopic labral trimming and curettage. There were no specific complications related to the bone cyst and the operative procedure. Conclusion: We believe curettage and bone grafting and stabilization with compression hip screws is a reasonable treatment for simple bone cysts in the proximal femur. The bone cyst in the femoral head neck junction in patients older than 50 years old is related with femoroacetabular impingement.

Palliative Orthopaedic Surgery for Skeletal Metastases

Advances in oncological therapies have resulted in improved survival in patients with skeletal metastases. The resultant effect is that the skeletal metastases result in an increased incidence of pathological fracture and bone pain. This article focuses on the options available to the orthopaedic surgeon in the treatment of patients with skeletal metastases. It covers the controversial area of prophylactic fixation and the roles of conventional internal fixation, cement, arthroplasty and endoprosthetic replacement. The role of radiotherapy in the management of patients with surgically treated skeletal metastases is highlighted. Treatment for these patients is always individualised and should always be subject to a multidisciplinary approach. Despite the prognosis, satisfying results can be obtained that achieve the aims of palliative surgery, namely pain relief and maintenance of or improvement in function.

Treatment results of pathological fractures of the long bones: a retrospective analysis of 88 patients.

Due to the advances in oncological therapy, the life expectancy of patients with malignant tumours and the incidence of pathological fractures have increased over the last decades. Pathological fractures of the long bones are common complications of metastatic disease; however, the outcome of different surgical techniques for the treatment of these fractures has not been clearly defined. The aim of this study was to evaluate differences in patient's survival and postoperative complications after the treatment of pathological fractures of the long bones. Eighty-eight patients with 96 pathological fractures of the long bones were analysed retrospectively. Seventy-five patients with 83 fractures received surgical treatment. The operative treatments used were intramedullary fixation, gliding screws, plate osteosynthesis or arthroplasty. Five patients were still alive at the end of data collection at a median time of 42.5 months, and 16.2% survived 1 year, 7% 2 years and 4% more than 3 years postoperatively. All surgically treated patients had a reduction of local pain and were able to walk after the operation. The overall rate of complications was 8%. Early palliative treatment of pathological fractures of the long bones is indicated in most patients in the advanced stage of metastatic disease. The low complication rate, reduction of local pain and early mobilisation justify the surgical stabilisation of fractures in this cohort of patients.

Paraplegia-related alterations of bone density in forearm and hip in Greek patients after spinal cord injury

Purpose : Paraplegia due to spinal cord injury is related with sublesional bone demineralization with an increased incidence of pathologic fractures in lower extremities. This study was carried out in order to evaluate bone density alterations in forearm and hip in Greek paraplegic patients after spinal cord injury and to correlate the findings with the level of injury, the neurological status, the time interval from injury and the performing of physiotherapy and therapeutic standing. Method : Fifty-seven paraplegic patients (33 men and 24 women, with injuries sustained from 6 months to 27 years) and 36 able-bodied age-matched controls (25 men, 16 women) participated in the study. Bone mineral density (BMD) was measured by dual X-ray absorptiometry (DXA) in the proximal and distal forearm, the femoral neck, the greater trochanter and Ward's triangle. Results : The measurements revealed a significant reduction of BMD of femoral neck ( p <0.001 in male, p <0.001 in female paraplegics), greater trochanter ( p <0.001 and p =0.001, respectively) and Ward's triangle ( p =0.001 and p =0.005, respectively). Proximal forearm depicted non-significantly decreased BMD values and distal forearm depicted a slight increase in BMD values. The degree of demineralization was independent of factors such as complete or incomplete spinal cord injury, level of the lesion, physiotherapy and performing of standing. In addition to that, BMD values in both hip and forearm showed no statistically significant correlation with time after injury. Conclusions : BMD measurements in Greek paraplegic patients reveal bone loss, which most dramatically occurs in the region of hip with a consequent increase of fracture risk. Forearm measurements depict a non-homogeneous response with limited proximal bone loss and slight distal increase of BMD, the latter being possibly attributed to daily activities.

Radiotherapy for palliation of symptoms in incurable cancer

Approximately one half of prescribed radiotherapy is given for palliation of symptoms due to incurable cancer. Distressing symptoms including pain, bleeding, and obstruction can often be relieved with minimal toxic effects. Painful osseous metastasis is common in oncologic practice. Ninety percent of patients with symptomatic bone metastases obtain some pain relief with a lowdose, brief course of palliative radiotherapy. One half of the responding patients may experience complete pain relief. A single dose of 800 cGy in the setting of painful bone metastasis may provide pain control comparable to more protracted treatment at a higher dose of radiation. Patients with lytic disease in weight-bearing bones, particularly in the presence of cortical destruction, should be considered for prophylactic surgical stabilization of their condition. Routinely a brief, fractionated course of radiotherapy is given postoperatively. Pain due to multiple bone metastases uncontrolled by analgesics can be managed with single doses of halfbody irradiation. Doses of 600 cGy delivered to the upper half-body (above the umbilicus) and 800 cGy to the lower half-body (from the umbilicus to the middle of the femur) will provide some pain relief in 73% of patients. Half-body techniques have been investigated as prophylactic treatment, as a complement to local-field irradiation, and as fractionated rather than singledose therapy. Although intravenous administration of strontium 89 has been associated with myelosuppression, this treatment has been shown (a) to relieve pain due to bone metastasis and (b) to delay development of new painful sites. Recent data from phase III trials demonstrated that bisphosphonates have a role in reducing skeletal morbidity due to bone metastasis. Bone pain was reduced, and the incidence of pathologic fracture and the need for future radiotherapy was decreased. Radiotherapy relieves clinical symptoms in 70% to 90% of patients with brain metastases. Brief treatment schedules (e.g., 2000 cGy in five fractions over 1 week) are as effective as more prolonged therapy. Patients with solitary brain metastasis and no extracranial disease or controlled extracranial disease should be considered for surgical resection, because phase III data indicate enhanced survival with such an approach. Whole-brain radiotherapy is routinely administered postoperatively. A phase III study is examining the impact of accelerated fractionated doses of radiotherapy (two treatments per day) on survival of patients with brain metastases. Stereotaxic radiosurgical treatment is becoming increasingly available and permits delivery of radiation to metastatic intracranial tumor with minimal exposure of normal surrounding brain This treatment is most commonly used at the time of a solitary recurrence of disease in patients who previously received whole-brain radiotherapy. A role for this modality in newly diagnosed brain metastases remains to be defined. Chest symptoms are common in patients with locally advanced lung cancer and are effectively palliated with one 1000 cGy or two 850 cGy one fraction doses of radiation to the thoracic inlet and mediastinum. Chest pain and hemoptysis are more effectively palliated than cough and dyspnea. In patients with stage III cancer there is no compelling evidence that radiotherapy confers a survival advantage, and it may be reasonable to administer thoracic radiotherapy only when the patient has significant symptoms and the goal is to achieve control of these symptoms. Approximately 75% of the cases of superior vena cava syndrome are due to lung cancer, and small-cell lung cancer is the most common histologic type. A histologic diagnosis should be obtained before treatment is started, because detection of lymphoma or small-cell carcinoma would necessitate systemic therapy. Eighty percent of the patients with vena cava syndrome due to malignant disease achieve symptom relief with a brief, fractionated, palliative course of rad