Pathological Femoral Fracture Research Articles

A rare occurrence of enchondroma with pathological fracture of proximal femur in an adult female: A case report

Enchondroma occurrence in the proximal femur is a very uncommon condition. We report a 40-year-old female with a history of accidental slip and fall, sustained injury to her left lower limb, and was unable to bear weight on the injured leg since the fall. Anteroposterior radiograph of the pelvis with bilateral hips shows a well-defined lytic lesion in the neck of the femur with some calcified matrix and no periosteal reaction with the left femoral subtrochanteric fracture. Magnetic resonance imaging scan revealed hypointense signals on T1 and hyperintense signals on T2 sequence over the proximal femur as well as left subtrochanteric femur fracture. After preanesthetic evaluation, bone curettage with excision biopsy with open reduction and internal fixation with long proximal femoral nail and bolts and iliac crest bone graft was done. A biopsy sample sent for histopathological examination reveals enchondroma. Complete weight bearing was started after four months. No recurrence was noted on follow up.

Case Report: Pathological fracture in a Li-Fraumeni osteosarcoma patient: "Capasquelet'' femoral reconstruction and tumor vascular analysis with endomucin immunofluorescence multiplexing

We describe the case report of an Osteosarcoma patient, with a Li-Fraumeni Syndrome, presenting with a pathological femoral fracture. The patient was treated with a multidisciplinary approach associating neoadjuvant and adjuvant chemotherapy with excisional surgery. The femoral reconstruction consisted of a ``Capasquelet'' reconstruction combining an induced membrane and a vascularized fibula allograft allowing a good functional result with an early weight-bearing. We managed to complete our histological analysis in this patient, in order to evaluate the tumor vascularization. Indeed, using the syngeneic osteosarcoma MOS-J mouse model, we highlighted previously that CD31+/\ensuremath{\alpha}-SMA+ vessels may be indicators of vasculature normalization and therefore may be used as specific markers of a good therapeutic response. Thus, we search for its interest in this specific case as preliminary work. The aim was to assess the feasibility and technical validity of the vascularization analysis of a human osteosarcoma tumor specimen. Therefore, we propose an immunohistochemistry methodology with multiplexed immunofluorescence to assess the vascularization as a promising marker in human osteosarcoma tissue.

Van Nes rotationplasty. Case Report. Theme update

The objective of this work is to develop Van Nes rotationplasty as a therapeutic option in osteoarticular tumorsof the lower limbs surrounding the knee and to present the first case in which this technique was used inUruguay. Clinical case: this is an 8-year-old boy, who consulted for a pathological diaphyseal fracture of theright femur. He was diagnosed with undifferentiated osteosarcoma of the non-metastatic femur, whoseresponse to neoadjuvant chemotherapy was doubtful. Finally, it was decided to perform a Van Nes plasty aftera Winkelmann resection type AI. Conclusion: Van Nes plasty is a procedure that should be considered as avalid therapeutic option in tumors surrounding the knee, mainly in children. It is a unique biologicalreconstruction procedure with excellent functional results.

The Impact of Frailty and Gender Differences on Hospitalization and Complications in Proximal Femoral Pathological Fractures: A Cross-Sectional Study.

Frailty associated with aging increases the risk of falls, disability, and death. The aim of this study is to explore gender-related disparities in the survival outcomes of pathological femoral fractures in older frail patients, while analyzing potential specific prognostic factors. This study is a retrospective observational analysis conducted at a single medical center. It enrolled all patients aged 65 and above who were admitted to our emergency department between 2016 and 2020 with a diagnosis of pathological femur fracture requiring surgical intervention. The primary study endpoint was evaluating gender-related differences in survival outcomes. The secondary endpoint involves investigating gender-specific prognostic factors through the analysis of clinical and laboratory parameters. The average Charlson Comorbidity Index (CCI) was slightly lower in men, but the difference was not statistically significant (p = 0.53). The Clinical Frailty Scale (CFS) showed similar results, with men and women 5.23 (SD 1.46), also not significant (p = 0.83). An evaluation comparing patients aged 75 years or younger to those older than 75 years found significant differences in health metrics. The average CCI was higher in the over 75 group compared to the under 75 group, with a p-value of 0.001. Similarly, the CFS average was also greater in the over 75 group than in the under 75 group, with a p-value of 0.0001. Complications were more frequent in patients over 75 and those with lower educational qualifications. The evaluation analyzed cardiac patients compared to a control group, revealing that the average age of cardiac patients was 75.22 years, while the control group was younger at 73.98 years (p = 0.5119). The CCI for cardiac patients averaged 6.53, significantly higher than 4.43 for non-cardiac patients (p = 0.0003). Frailty assessment is therefore essential in patients with pathological fracture of the proximal femur and is an important predictor of both gender differences and hospital complications. Enhancing gender analysis in this field is crucial to gather more robust evidence and deeper comprehension of potential sex- and gender-based disparities.

Internal validation of modified Mirels’ scoring system for pathologic femur fractures

BackgroundThe proximal femur is a common site of bone metastasis. The Mirels’ score is a frequently utilized system to identify patients at risk for pathologic fracture and while it has consistently demonstrated strong sensitivity, specificity has been relatively poor. Our group previously developed a Modified Mirels’ scoring system which demonstrated improved ability to predict cases at risk of fracture in this patient population through modification of the Mirels’ location score. The purpose of the present study is to internally validate this newly developed scoring system on an independent patient series.MethodsRetrospective review was performed to identify patients who were evaluated for proximal femoral bone lesions. Patients were stratified into one of two groups: 1) those who went on to fracture within 4 months after initial evaluation (Fracture Group) and 2) those who did not fracture within 4 months of initial evaluation (No Fracture Group). Retrospective chart review was performed to assign an Original Mirels’ (OM) Score and Modified Mirels’ (MM) score to each patient at the time of initial evaluation. Descriptive statistics, logistic regression, receiver operating curve, and net benefit analyses were performed to determine the predictability of fractures when utilizing both scoring systems.ResultsThe use of the MM scoring improved fracture prediction over OM scoring for patients observed over a 4 month follow up based on logistic regression. Decision curve analysis showed that there was a net benefit using the MM score over the OM scoring for a full range of fracture threshold probabilities. Fracture prevalence was similar for current internal validation dataset when compared to the dataset of our index study with a comparable reduction in misclassification of fracture prediction when utilizing the modified scoring system versus the original.ConclusionsUse of MM scoring was found to improve fracture prediction over OM scoring when tested on an internal validation set of patients with disseminated metastatic lesions to the proximal femur. The improvement in fracture prediction demonstrated in the present study mirrored the results of our index study during which the MM system was developed.

Multiple Myeloma Diagnosis After Pathological Fracture of Femur

Multiple Myeloma Diagnosis After Pathological Fracture of Femur

Proximal femoral multiple myeloma pathological fractures, impending and actual fractures – a patient survival study

IntroductionThe femur is a common site for Multiple Myeloma (MM) involvement. This study explores the impact of preventive surgery for anticipated femoral pathological fractures (IFF), based on Mirels classification, versus treatment of pathological femur fracture (PFF) on MM patient mortality and morbidity.MethodsRetrospective cohort of 33 patients undergoing surgery due to femoral MM involvement (2004–2015), 18 patients with PFF, 15 patients with IFF, followed up until deceased or to July 2016. Demographic data, oncological, pathological, radiation, surgical reports, outpatient clinical records, and imaging studies were studied. Exclusion criteria included patients who had surgery at other medical centers.ResultsThe mean age was 70.4 ± 13.6 and 62.6 ± 12.2 years (p = 0.1) in the PFF and the IFF cohorts, respectively, primarily women (55.6% and 46.7%, respectively). The average Mirels' score was 10.4 ± 1.2. Post-operative complications were observed in 25% of patients, with no difference between IFF & PFF. We did not find a difference in mortality between IFF and PFF cohorts (p = 0.59).ConclusionThe femur is commonly involved in MM. This study found that actual fractures, compared to imminent fractures, do not affect MM morbidity or mortality. Our study shows that proximal femoral MM behaves differently from proximal femoral metastatic disease regarding the impact of surgery on life span. Due to the fracture healing potential of MM, an IFF can probably be treated initially conservatively unless it progresses to an actual fracture needing surgery. Future, more extensive studies are required before revolutionizing the proximal femoral Multiple Myeloma-related involvement treatment paradigm.

Rhabdomyosarcoma in a Rabbit

A geriatric Holland Lop rabbit presented for acute lameness. A pathologic fracture of the right distal femur associated with a pleomorphic rhabdomyosarcoma was diagnosed, and staging radiographs showed no overt metastasis upon initial presentation. The limb was amputated and submitted for microscopic examination. Immunohistochemical evaluation revealed the neoplastic cells were positive for desmin and MyoD1, and negative for cytokeratin AE1/AE3, CD204, IBA-1, and SMA. Gross, histologic, and immunohistochemical evaluation confirmed a diagnosis of pleomorphic rhabdomyosarcoma. The patient died 396 days after amputation, and a post-mortem examination showed metastatic sarcoma to multiple organs.

Primary extranodal lymphoma: a report of six cases in a private cancer centre in Nigeria

Primary extra-nodal lymphoma (PENL) refers to lymphomas which present with disease in any organ or tissue other than lymph nodes or spleen. Symptoms at initial presentation are mainly from extra nodal involvement and after routine staging procedures, the extra nodal involvement remains the clinically dominant site of disease with little or no nodal disease [1, 2]. About 25–40% of lymphomas arise at extra nodal sites and with clinical presentation similar to solid tumors [3, 4] creating ambiguity in diagnosis and delays in treatment especially in resource poor settings. We report six cases of PENL seen at a private cancer centre in Lagos, Nigeria between 2021 and 2022. The age range was 32–95 years with five females and one male. Two patients were HIV positive. Five patients had initial symptoms of vague abdominal pain with one patient investigated multiple times for peptic ulcer disease. One patient presented with pathological fracture of left femur. Another patient had previously been diagnosed with an inoperable cholangiocarcinoma. All patients had non-Hodgkin’s lymphoma, DLBCL being most common (83.37%). Four patients started chemotherapy. All treated patients showed good outcomes with complete or good partial response highlighting the importance of accurate diagnosis. Initial histological diagnosis in most of the cases did not suggest lymphoma until immunohistochemistry (IHC) results were received. Cancer care in Nigeria is fraught with difficulties obtaining accurate diagnosis due in part to the limited availability of IHC and molecular testing facilities required to characterize the malignant cells leading to delays in treatment and poorer prognosis [6–8].

Unusual soft tissue metastases in a patient with chondrosarcoma: a case report.

Chondrosarcoma (CS) is the second most frequent primary malignant bone tumour, characterized by production of non-osteoid cartilage matrix. Up to more than 30% of patients with CS present distant metastases, and the lungs represent the preferred site. Hence, CS soft tissue metastases and superficial cutaneous lesions are extremely rare. We report the case of a female who developed unusual multiple soft tissue CS metastases. This patient underwent left hindquarter amputation for recurrent grade 3 chondrosarcoma of the femoral neck with extension to the pelvis approximately 4years after internal fixation with an intramedullary nail for pathological fracture of left proximal femur and subsequent total proximal femoral endoprosthetic replacement for grade 1-2 chondrosarcoma. In the following years, she underwent metastasectomy for several grade 2 pulmonary metastatic chondrosarcomas. More than 14years after the amputation, she presented with multiple unusual superficial cutaneous lesions, and a whole-body magnetic resonance imaging demonstrated multiple soft tissue foci of metastatic disease. The histology of multiple soft tissue lesions excised confirmed metastatic chondrosarcoma. Then, she underwent marginal excision of further multifocal soft tissue metastatic high-grade chondrosarcoma. Unlike the poor survival from the onset of these metastases in the other cases reported in the literature, our patient is still alive 2years after the first multiple soft tissue excision of metastatic chondrosarcoma, and approximately 20years after the diagnosis of chondrosarcoma. Soft tissue CS metastases are a rare entity with few cases described in literature. This study aims to make the reader aware of this lesser-known CS manifestation.

THE USE OF A TRAINING 3D-MODEL IN THE TREATMENT OF A PATIENT WITH A PATHOLOGICAL FRACTURE OF THE PROXIMAL PART OF THE FEMUR (CASE FROM PRACTICE)

Prostate cancer is the second most common cause of malignancy in men, with bone metastases being a significant source of morbidity and mortality in advanced cases. Objective. To give a clinical example of a patient with a pathological transtrochanteric fracture of the right femur with displacement of fragments, the presence of metastasis at the fracture site, to emphasize the importance of 3D-training before surgery. Methods. A clinical example with a significant impairment of the function of the right lower extremity against the background of a significant pain syndrome is given. The diagnosis was established: pathological transtrochanteric fracture of the right femur with displacement of fragments, the presence of metastasis at the fracture site. Pre-surgical training was carried out using a 3D-model and total endoprosthetics of the right hip joint with a revision individual implant of the cement fixation type was carried out. The patient fully recovered the function of the right lower limb and hip joint, the pain syndrome was eliminated, and sleep normalized. The use of a 3D-model for preoperative training of surgeons made it possible to rationally limit traumatization of healthy tissues during tumor removal, prevent possible complications and optimize the time of surgical intervention and thus minimize blood loss. Conclusions. The use of a training 3D-model before surgery followed by prosthetics with a special oncological endoprosthesis provided satisfactory functional results and restoration of the patient's quality of life in the given clinical case. The use of a 3D-model is the key to careful preparation for surgical intervention, taking into account the individual anatomical features of the pathological process and adjacent tissues, which allows you to significantly optimize the terms of the operation and reduce blood loss, and also provides valuable experience for further surgical practice.

A clinical example of using a carbon-carbon composite to replace a femur diaphyseal defect

A separate direction in osteosynthesis is the study on the possibilities of bone union after tumor resection. In this regard, the issue of using implants made of metals, polymers, and carbon, which have a high bone binding affinity, is on the agenda for modern oncological orthopedics. Studying carbon composite materials has shown practical effectiveness of their medical use, in particular in orthopedics and traumatology, that can be applied to replace bone defects in oncological traumatology. Aim. To determine the possibility of using carbon composite materials in the femur defect replacement after tumor resection. Clinical case. A case of using an implant made of the carbon composite material for a patient with right femur osteosarcoma and a pathological femoral middle-third fracture is presented. The study was carried out in accordance with the principles of the Declaration of Helsinki. The patient signed the written informed consent form for the study. Conclusions. The results of using the implant made of the carbon composite material have shown its permeability to X-rays and potential use for bone defect replacement in oncological traumatology.

Detection and evaluation of signals for immune-related adverse events: a nationwide, population-based study.

Immune checkpoint inhibitors (ICIs) are one of the main pillars of cancer therapy. Since other studies such as clinical trial and retrospective study have limitations for detecting the immune-related adverse events (irAEs) characterized by unpredictable onset, nonspecific symptoms and wide clinical spectrum, we aimed to identify the incidence of irAEs and to detect and evaluate the signals using real-world data. Cancer patients treated with anticancer medications were analyzed using the nationwide health insurance claims database of South Korea from 2017 to 2019, and Clinical Data Warehouse (CDW) database of Asan Medical Center (AMC), a tertiary referral hospital, from 2012 to 2019. AEs of ICI users were compared with those of non-ICI anticancer medication users. PD-1 inhibitors (nivolumab and pembrolizumab) and PD-L1 inhibitors (atezolizumab) were evaluated. We defined an AE as a newly added diagnosis after the ICI prescription using an ICD-10 diagnostic code. A signal was defined as an AE that was detected by any one of the four indices of data mining: hazard ratio (HR), proportional claims ratio (PCR), claims odds ratio (COR), or information component (IC). All detected signals were reviewed and classified into well-known or potential irAEs. Signal verification was performed for targeted AEs using CDW of AMC using diagnostic codes and text mining. We identified 118 significant signals related to ICI use. We detected 31 well-known irAEs, most of which were endocrine diseases and skin diseases. We also detected 33 potential irAEs related to disorders in the nervous system, eye, circulatory system, digestive system, skin and subcutaneous tissues, and bones. Especially, portal vein thrombosis and bone disorders such as osteoporosis with pathological fracture and fracture of shoulder, upper arm, femur, and lower leg showed high HR in ICI users than in non-ICI users. The signals from hospital database were verified using diagnostic codes and text mining. This real-world data analysis demonstrated an efficient approach for signal detection and evaluation of ICI use. An effective real-world pharmacovigilance system of the nationwide claims database and the EMR could complement each other in detecting significant AE signals.

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

IntroductionThe 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. MethodsRetrospective 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. ResultsThe 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. ConclusionBreast 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.

An unusual presentation of Grave's disease with severe osteoporosis and pathological femoral fracture

An unusual presentation of Grave's disease with severe osteoporosis and pathological femoral fracture

Çocukta Patolojik Distal Femur Kırığı: Suçlu Kim?

Çocukta Patolojik Distal Femur Kırığı: Suçlu Kim?

Pathological Fracture of Distal Femur in a Child : What is the Culprit?

Pathological Fracture of Distal Femur in a Child : What is the Culprit?

Safety and Efficacy of a Single-Stage versus Two-Stage Intramedullary Nailing for Synchronous Impending or Pathologic Fractures of Bilateral Femur for Oncologic Indications: A Systematic Review.

Although intramedullary nail (IMN) fixation is the standard of care for most impending and/or complete pathologic fractures of the femur, the optimal timing/sequence of the IMN in cases of synchronous bilateral femoral disease in advanced cancer is not well established. Thus, we compared the outcomes of single-stage (SS) vs. two-stage (TS) IMN of the bilateral femur with a systematic review of the literature on this topic. Bilateral SS and TS IMN cases were identified from 14 studies extracted from four databases according to PRISMA guidelines. Safety (complications, reoperations, mortality, survival, blood loss, and transfusion) and efficacy (length of stay [LOS], time to start rehabilitation and adjuvant therapy, functional scores, and cost) were compared between the groups. A total of 156 IMNs in 78 patients (36 SS and 42 TS) were analyzed. There were one surgical (infection in TS requiring reoperation; p = 0.860) and fifteen medical complications (five in SS, ten in TS; p = 0.045), with SS being associated with lower rates of total and medical complications. Survival, intraoperative mortality, and postoperative same-admission mortality were similar. No cases of implant failure were reported. Data on LOS, rehabilitation, and adjuvant therapy were scarcely reported, although one study favored SS over TS. No study compared cost or functional scores. Our study is the largest and most comprehensive of its kind in supporting the safety and efficacy of a SS bilateral femur IMN approach in these select patients. Further investigations with higher levels of evidence are warranted to optimize treatment protocols for this clinical scenario.

A rare case of neglected long-term pathologic fracture of the distal femur due to a giant cell tumor of bone

Giant cell tumor of bone is a histologically benign bone neoplasia that clinically has an aggressive course. In rare cases, it can give "benign" lung metastases or undergo malignant transformation. The World Health Organization defines this neoplasia as an "aggressive, potentially malignant lesion".
 Herein, we present a rare case of a neglected long-term pathologic fracture of the distal femur in a 20-year-old female patient. After a biopsy, a giant cell tumor of bone was diagnosed. The patient was treated with intralesional curettage, osteoplasty and plate fixation of the fracture. Eight months postoperatively, no local recurrence or metastasis of the tumor was observed.

Intramedullary nailing versus plate compound osteosynthesis in subtrochanteric and diaphyseal pathologic femoral fractures: a retrospective cohort study

PurposePathologic fractures of the extremities due to carcinoma metastases require individual and patient prognosis-related stabilization procedures. Quick remobilization of the patient to restore the quality of life is of high importance, especially in the case of subtrochanteric and diaphyseal femoral fractures. In our retrospective cohort study, we evaluated intraoperative blood loss, length of operation, complication rate, and regain of lower extremity function in plate compound osteosynthesis (PCO) versus intramedullary nailing (IM) for subtrochanteric and diaphyseal pathologic fractures of the femur.MethodsBetween January 2010 and July 2021, we retrospectively reviewed 49 patients who were treated at our institution for pathologic fractures of the subtrochanteric and diaphyseal femurs for group differences in terms of blood loss, length of operation, implant survival, and Musculoskeletal Tumor Society (MSTS) score.ResultsWe included 49 stabilization procedures of the lower extremity due to pathologic fractures of the proximal or diaphyseal femur, with a mean follow-up of 17.7 months. IM (n = 29) had a significantly shorter operation time than PCO (n = 20) (112.4 ± 9.4 and 163.3 ± 15.96 min, respectively). We did not detect any significant differences in terms of blood loss, complication rate, implant survival, or MSTS score.ConclusionBased on our data, pathologic subtrochanteric and diaphyseal fractures of the femur can be stabilized with IM, which has a shorter operation time than PCO, but the complication rate, implant survival, and blood loss remain unaffected.