Pathological Femoral Fracture Research Articles

Chronic Lymphocytic Leukemia: A Rare Cause of Pathological Fracture of the Femur.

The incidence rate of chronic lymphocytic leukemia (CLL) in the United States is approximately 0.005%; men are at slightly higher risk than women. Bony involvement or pathological fracture rarely occurs in CLL, and it may be the initial presentation. An 85-year-old woman presented with acute respiratory failure secondary to pneumonia. Symptomatology included dyspnea. She was found to have pathological fracture of the femur caused by CLL. The diagnosis of CLL had been made 6 years previously, but the patient had refused therapy. On admission, the patient required endotracheal intubation, mechanical ventilation, and admission to the medical intensive care unit. Endotracheal intubation extubation was successful after 48 hours. The patient then complained of severe left knee pain. Bone radiograph and femoral computed tomography scan revealed acute pathological fracture of the left distal femur. There was no history of trauma. The fracture was stabilized with extension lock splint. Pathological fracture in patients with CLL is associated with hypercalcemia, Richter’s transformation, or multiple myeloma. This patient exemplifies the fact that pathological fracture can be caused by CLL in the absence of hypercalcemia, Richter’s transformation, or multiple myeloma and can be the initial presentation of CLL.

Application of three-dimensional printing technology in bone tumor surgery

To discuss the effect of three-dimensional (3D) printing individualized model and guide plate in bone tumor surgery. Between October 2015 and December 2016, 3D printing individualized model and guide plate for making preoperative surgical planning and intraoperative treatment were used in 5 patients of bone tumor. All the patients were male, with a median age of 32 years (range, 9-58 years). There were 1 case of cystic echinococcosis at left pelvis and pathological fracture of the proximal femur; 1 case of left iliac bone osteoblastoma associated with aneurysmal bone cyst; 1 case of fibrous dysplasia of the left femur (sheep horn deformity) with pathological fracture; 1 case of metastatic carcinoma of right calcaneus (tumor staging was T 2N 0M 0); and 1 case of Ewing sarcoma of left femur (tumor staging was T 2N 0M 0). The disease duration ranged from 1 month to 10 years (mean, 2.25 years). The operation was completed successfully. The operation time was 2.6-7.5 hours (mean, 4.9 hours). The intraoperative blood loss was 200-2 500 mL (mean, 1 380 mL). The intraoperative fluoroscopy times was 1-6 times (mean, 3.8 times). There was no infection after operation, and the blood supply and nerve function were good. All the patients were followed up 3-16 months (mean, 5.4 months). No loosening or breaking of the internal fixator occurred. According to Enneking scoring system, the limb function score was 15-26 (mean, 21); and the results were excellent in 2 cases, good in 2 cases, and fair in 1 case. 3D printing technology can make the implementation of the better preoperative planning and evaluation in bone tumor surgery, and it provides a new reference for individualized treatment in patients with bone tumor.

Poster 390: Pathologic Femoral and Lumbar Fractures During Rehabilitation for a Traumatic Spinal Cord Injury in Osteogenesis Imperfecta: A Case Report

Poster 390: Pathologic Femoral and Lumbar Fractures During Rehabilitation for a Traumatic Spinal Cord Injury in Osteogenesis Imperfecta: A Case Report

Augmented osteoplasty for proximal femur consolidation in cancer patients: Biomechanical considerations and techniques.

According to the literature, prophylactic consolidation of lytic metastasis located in the proximal femur is recommended when the Mirels' score is above 8. Osteoplasty alone provides inadequate consolidation but various devices have been used in association for better consolidation. The aim of this review is to detail the augmented osteoplasty techniques published in the literature and to report their safeties and their efficacies to prevent pathological fracture of the proximal femur. A Pubmed research found 5 studies that evaluated augmented osteoplasty of the proximal femur in cancer patients. All devices demonstrate adequate safety and low rate of secondary pathological fractures.

Management of pathological femoral fracture secondary to Ewing sarcoma in pregnancy: A case report

Ewing's sarcoma is an ultra-orphan disease (2/1,000,000/year) which requires a multimodal therapy approach in high-volume centers. Treatment consists of pre-operative therapy followed by surgery and post-operative combination of chemo-radiotherapy. Experience with diagnosis and therapy of Ewing's sarcoma in pregnancy is very limited. We herein report the case of an atypical Ewing's sarcoma detected in the second trimester of gestation. The present study reports a case of a 24-week primigravida presenting with presented with chief complains of sudden onset of pain in left proximal thigh and inability to stand from bed on 28 feb.2017 in early mornig. Consult local doctor where x ray advice & some analgesic given. X-ray done at periphery which shows pathological subtrochantric fracture. From there she refer to higher centre for further management. An internal fixator was placed in the left femur for definitive treatment of the fracture. Normal delivery was performed at 32 gestational weeks. Following delivery, staging of cancer was conducted. Subsequently, adjuvant treatment started. The rare nature of this condition underlines once more the need for a multidisciplinary team to improve the quality of care for this highly special patient collective.

Clinical case for the use of intramedullary osteosynthesis in the treatment of pathological fractures of the femur in 6-day newborn girls with a high partial intestinal obstruction

Abstract. Skeletal bone fractures in newborns present a problem of modern traumatology.
 Aim. The goal is to present the use of the method of intramedullary osteosynthesis in the treatment of a pathological fracture of the right femur in a newborn girl to a wide audience of pediatric orthopedic traumatologists.
 Material and methods. We have experience in the treatment of a 6-day-old girl, who was born with intrauterine growth retardation and bowel disease. On the second day of stay in the intensive care unit, she had a pathological fracture of the right femur. Diagnosis of the pathological fracture was established based upon the results of clinical examination and radiography of the injured limb segment.
 Results. Immediately after the diagnosis, the right lower limb of the child was fixed with a plaster bandage. On the control radiographs, the standing of the bone fragments were unsatisfactory, and a decision was made to use the intramedullary osteosynthesis method with a knitting needle on the 6th day after birth of the child. The need for surgical treatment of a fracture of the femur was due to a congenital abnormality of the intestine in the child, and a need to perform surgery on the abdominal organs.
 Discussion. Spontaneous fracture of the right femur occurred in the child in treatment in the intensive care unit. The cause of the fracture was osteopenic syndrome, which developed as a result of vitamin D deficiency. During the first 12 days of her life, the newborn had two laparoscopic operations to address the intestinal pathology.
 Four weeks after the operation using osteosynthesis, the metal from the bone marrow channel of the right femur was removed. After the removal of the needle, the correct axis of the operated segment was fixed to the same length of the lower extremities. The patient had absence of pathological mobility in the fracture region, and full amplitude of movements in the knee and hip joints.
 Conclusion. When receiving fractures of the femur, both traditionally used conservative methods of treatment, as well as surgical methods can be used on newborn children. This is especially true, when a newborn has an accompanying congenital pathology of the internal organs requiring immediate treatment.

Factors associated with the decision of operative procedure for proximal femoral bone metastasis: Questionnaire survey to institutions participating the Bone and Soft Tissue Tumor Study Group of the Japan Clinical Oncology Group.

Pathological fracture of the proximal femur is a main cause of cancer patients losing their ability to walk. Although both osteosynthetic devices (predominantly intramedullary nails) and prosthetic replacement have been widely performed for treatment, controversies exist regarding which procedure should be used for the various conditions. In order to decide the eligibility criteria of a planned randomized prospective study about the treatment of pathological fractures of the proximal femur, we assessed the factors affecting the selection of operative procedures using questionnaires sent to the members of the Bone and Soft Tissue Tumor Study Group (BSTTSG) of the Japan Clinical Oncology Group (JCOG). Questionnaire surveys to evaluate (1) the priority levels of the factors, (2) the equipoise range of each factor in situations where either procedure could be applied, (3) risk and benefit of each procedure, and (4) the degree of bone destruction affecting the selection of operative procedures, were sent to 26 institutions. Over 80% of the institutions answered. Orthopaedic surgeons of BSTTSG decided on the procedure according to the following factors in descending order: life expectancy, performance status before fracture, the degree of bone destruction, walking ability before fracture, general complications, the number of bone metastases in other sites, and the visceral metastasis status. With regard to bone destruction, (1) the involvement of the head, neck, calcar, and intertrochanteric region, (2) transverse destruction >1/2, and (3) soft-tissue tumor extension, were the factors that led to the choice of prosthesis treatment. Using these identified factors, the inclusion criteria for the prospective randomized study of the surgical treatment of metastatic bone tumors of the proximal femur were optimized. The evaluation system about the bone destruction of metastases needs to be refined through the following prospective randomized study.

Outcomes of Intercalary Prosthetic Reconstruction for Pathological Diaphyseal Femoral Fractures Secondary to Metastatic Tumors.

To evaluate the clinical outcomes and complications of segmental prosthetic reconstruction for pathological diaphyseal femoral fractures secondary to metastatic tumors. Between 2011 and 2015, we retrospectively evaluated 16 patients (6 men and 10 women; 64.5 ± 11.4 years old at diagnosis) who underwent prosthetic reconstruction after segmental resection of diaphyseal femoral fractures due to metastatic lesions. Visual analog scale (VAS), functional outcomes, implant-related complications, and Mean postoperative Musculoskeletal Tumor Society (MSTS) score for each patient were collected. The mean length of bone defect was 10.2 ± 2.6 cm (range, 8-16 cm); follow-up was 9 ± 6.8 months (range, 2-25 months) for all patients, and 24 months (23 and 25 months) for the 2 patients still alive. At final follow-up, 14 patients were dead, indicating a mean survival of 6.9 ± 3.6 months (range, 2-14 months). Mean preoperative VAS score was 8.5 ± 1.0, which decreased to 2.5 ± 1.3 at day 2 postoperatively, indicating significant pain relief (P < 0.05). The MSTS score for lower extremities was 84.6% (range, 73%-90%). The range of motion and function of adjacent joints was within the normal limits in all cases. Three patients (33%) developed complications, including aseptic loosening because of disease progression (1), infection (1), and peri-prosthesis fracture (1). These findings demonstrated that this approach greatly relieves pain, and yields satisfactory functional outcomes with fewer complications in patients with pathological femoral fractures secondary to metastatic tumors; however, survival was not significantly improved.

Development and clinical application of a new type of intramedullary nail tail cap

To develop a new type of tail cap for closing the tail of the central hole of the interlocking intramedullary nail so as to reduce difficulty in implantation of the tail cap into intramedullary nail, and ensure the accuracy of implantation, as well as reduce unnecessary operation time. In 2014, the new type of intramedullary nail tail cap ("new tail cap" for short) was successfully developed, and has been granted national utility model patent. A randomized controlled clinical trial was conducted in 34 patients with non pathological femoral shaft fractures treated between August 2014 and March 2016. The patients were randomly divided into groups A and B, 17 patients each group. There was no significant difference in gender, age, side, body mass index, cause of injury, injury to operation time, and fracture AO classification between groups ( P>0.05), with comparability. All patients underwent fixation with interlocking intramedullary nail, and the new tail cap and original tail cap were used in groups A and B respectively. The blood loss and operation time during tail cap implantation, fracture healing time, and complications were recorded and compared between 2 groups; the limb function was evaluated by Klemm function evaluation standard. The blood loss and operation time during tail cap implantation of group A [(3.5±0.8) mL and (10.57±3.15) s] were significantly less than those of group B [(5.5±1.7) mL and (21.99±6.90) s] ( t=-8.281, P=0.010; t=-10.743, P=0.009). All new tail caps were successfully implanted by one-time in group A, and the one-time success rate was 100%; the original tail cap exfoliation occurred in 3 cases of group B, and the one-time success rate was 82.4%. All the patients were followed up 6-16 months (mean, 9.7 months); there was no deep infection, loosening or breakage of internal fixation, and other serious complications. The time of fracture healing was (16.4±3.2) weeks in group A and (15.8±3.5) weeks in group B, showing no significant difference ( t=0.514, P=0.611). At last follow-up, according to the Klemm function evaluation standard, the results were excellent in 14 cases and good in 3 cases in group A, and were excellent in 11 cases and good in 6 cases in group B, showing no significant difference between 2 groups ( χ2=0.142, P=0.707). The new type of femoral intramedullary nail tail cap can simplify operation, shorten operation time, and reduce blood loss, and it has satisfactory effectiveness.

Draft Recommendations. Pharmacotherapy for the Prevention of Repeated Fractures in Patients with Osteoporosis after Surgical Treatment of Pathologic Proximal Femur Fracture

Treatment of pathologic proximal femur fractures complicating the course of systemic osteoporosis is most often limited by surgical intervention as until now trauma and orthopaedic surgeons have no concrete recommendations on pharmacologic correction of metabolism disorders typical to the pathology, that aggravate in the postoperative period due to operative trauma. Proposed draft recommendations are a part of National clinical recommendations “Treatment for pathologic fractures of skeleton bones complicating the course of osteoporosis”. This issue of recommendations is only applicable to pharmacotherapy directed to the correction of bone tissue remodeling with regard for the fracture localization and volume of surgical intervention. Present recommendations are intended for the improvement of patients’ life quality, reduction of present and future losses from pathologic fracture as well as the prevention of repeated fractures.

Draft Recommendations. Pharmacotherapy for the Prevention of Repeated Fractures in Patients with Osteoporosis after Surgical Treatment of Pathologic Proximal Femur Fracture

Treatment of pathologic proximal femur fractures complicating the course of systemic osteoporosis is most often limited by surgical intervention as until now trauma and orthopaedic surgeons have no concrete recommendations on pharmacologic correction of metabolism disorders typical to the pathology, that aggravate in the postoperative period due to operative trauma. Proposed draft recommendations are a part of National clinical recommendations “Treatment for pathologic fractures of skeleton bones complicating the course of osteoporosis”. This issue of recommendations is only applicable to pharmacotherapy directed to the correction of bone tissue remodeling with regard for the fracture localization and volume of surgical intervention. Present recommendations are intended for the improvement of patients’ life quality, reduction of present and future losses from pathologic fracture as well as the prevention of repeated fractures.

Percutaneous osteosynthesis and cementoplasty for stabilization of malignant pathologic fractures of the proximal femur.

To retrospectively evaluate the outcome of patients who underwent radiological percutaneous osteosynthesis and cementoplasty (RPOC) for stabilization of malignant pathological fracture of the proximal femur. The clinical files of 12 patients who underwent RPOC for stabilization of malignant pathological fracture of the proximal femur were reviewed. There were 9 men and 3 women with a mean age of 56 years±13 (SD) (range: 35-82 years). All patients had metastases of proximal femur and a high fracture risk (Mirels score≥8) and were not eligible for surgical stabilization. The primary endpoint was the occurrence of a fracture after RPOC. Secondary endpoints were the procedure time, early complications of RPOC, pain reduction as assessed using a visual analog scale (VAS) and duration of hospital stay. No patients treated with RPOC had a fracture during a mean follow-up time of 382 days±274 (SD) (range: 11-815 days). RPOC was performed under general (n=10) or locoregional (n=2) anesthesia. The average duration of the procedure was 95min±17 (SD) (range: 73-121min). The technical success rate was 100%. All patients were able to walk on the day following RPOC. The average duration of hospital stay was 4days±3 (SD) (range: 2-10 days). No major complication occurred. One patient complained of hypoesthesia in the lateral thigh. For symptomatic patients (n=7), VAS score decreased from 6.8±1.2 (SD) (range: 5-9) before treatment, to 2.3±1.1 (SD) (range: 1-4) one month later. Preventive RPOC for pathological fracture of the proximal femur is a reliable alternative for cancer patients who are not candidates for surgical stabilization. Studies involving more patients are needed to confirm our preliminary experience.

Malignant peripheral nerve sheath tumor presenting as pathological fracture of femur in neurofibromatosis patient

Malignant peripheral nerve sheath tumors (MPNSTs) are rare soft tissue sarcomas that arise from a peripheral nerve or cells associated with the nerve sheath, such as Schwann cells, perineural cells, or fibroblasts. MPNSTs account for 5%–10% of all soft tissue sarcomas. Neurofibromas in Neurofibromatosis-1 (NF-1) may undergo malignant transformation in 2%–5% of patients. We are reporting a very rare case in NF-1 patient who, presented with pathological intertrochanteric fracture of femur and liver metastasis. X-ray from left hip joint shows lytic lesion which on histopathology turned out to be MPNST. S-100 was positive confirming its neural origin. Elbow lesion which was excised later, also showed similar features with S-100 positivity. Ultrasonography abdomen showed target lesions in liver. Fine-needle aspiration cytology from liver showed scattered malignant spindle cells. A final diagnosis of metastatic MPNST was made. Although malignant transformation in neurofibromas is extremely rare when it occurs, it is associated with NF-1 in 75% of patients. This case highlights the possibility of fracture femur as the presenting complains, in patients of NF with malignant transformation. The case is unique with regard to its presentation and rarity of metastatic sites.

Chronic Localized Intravascular Coagulation in a Case of Sporadic Multifocal Venous Malformations with Phleboliths

ABSTRACT Aim The aim of this article is to report a case of chronic localized intravascular coagulation in widespread sporadic multifocal venous malformations (VMs) associated with phleboliths, presenting with pathological femur fracture with very high D-dimer level and deranged coagulation profile hampering the surgical management of the patient. Background Disseminated intravascular coagulation (DIC) is a well-known cause of raised D-dimer. It leads to derangement of coagulation profile with very poor management outcome and needs intensive care. A very high level of D-dimer present in localized intravascular coagulopathy (LIC) can be misleading to diagnosis of DIC. Localized intravascular coagulopathy is seen in few VMs and they show abnormally high D-dimer levels. Venous malformations are the most frequent slow-flow vascular malformations referred to specialized centers. Most of the VMs are sporadic, and unifocal, while 1% are multifocal VMs. Multifocal sporadic VMs are rare and associated with phleboliths. High D-dimer is associated with various types of VMs like cutaneomucosal VMs and capillarovenous malformations. We reported the case of a 22-year-old female with congenital multifocal VMs presenting with fracture shaft of left femur on trivial trauma with deranged coagulation profile as prolonged prothrombin time, activated partial thromboplastin time, thrombocytopenia, and persistently high D-dimer level along with the presence of multiple phleboliths. Review In the view of deranged coagulation profile with raised D-dimer level in presence of trauma, patient was initially managed as a case of DIC and her surgical procedure for fracture femur was delayed for the correction of her coagulation abnormality. She was transfused 16 units of fresh frozen plasma, 18 units of platelets, and 3 units of packed red blood cells, but her D-dimer level remained high. Persistently raised D-dimer level without any hemorrhagic manifestation along with the presence of multiple phleboliths in his X-rays clinched the diagnosis of LIC. Low molecular weight heparin was started and after stabilization of coagulation profile, the patient got shifted to orthopedics department for the management of fracture femur. Conclusion This case describes a unique presentation of sporadic multifocal VMs as coagulation abnormality mimicking DIC. It emphasizes prompt diagnosis and workup when multiple VMs are present to prevent morbidity during surgical excision secondary to intravascular coagulopathy. Clinical significance Multifocal VMs have been associated with an increased risk of spontaneous thrombosis and thrombolysis because of stasis of blood, a condition termed LIC. Severe LIC has potential to progress to DIC during surgical excision so this mandates preoperative evaluation. How to cite this article Chaurasia AK, Gupta P, Purwar N. Chronic Localized Intravascular Coagulation in a Case of Sporadic Multifocal Venous Malformations with Phleboliths. J Postgrad Med Edu Res 2017;51(3):144-149.

Pathological femoral neck fractures with impending shaft fractures treated by BHP: a report of three cases

Pathological femoral neck fractures with impending shaft fractures treated by BHP: a report of three cases

Prospective Role of Uniplanar Compressible External Fixation Devices in the Management of Pathological Diaphyseal Fractures Secondary to Osteomyelitis in Children

ABSTRACT Introduction Management of pathological diaphyseal fractures secondary to osteomyelitis in children still remains a nightmare for the treating orthopedic surgeon owing to the highly unpredictable clinical course and lack of certainty in achieving successful results. This study highlights the potential role of rail fixator in the management of pathological femur fracture secondary to osteomyelitis in children. Materials and methods A total of five children (8—13 years age group) with pathological diaphyseal fractures of femur (four cases) and tibia (one case), operated between January 2014 and December 2014, were included in the study. Chronic osteomyelitis was the underlying etiology in all the cases. The surgical management consisted of thorough debridement, lavage, freshening of fractured bone ends, opening of the bone ends, reduction and external stabilization using pediatric monorail fixator. All patients received postoperative antibiotics, based on intraoperative culture and sensitivity reports, for 6 weeks (intravenously for the initial 3 weeks, orally for the remaining 3 weeks). Weight bearing and knee range of motion were started in the early postoperative period as soon as the children were pain free. Results Staphylococcus aureus was the causative organism in all the cases. Out of five cases, four fractures united: Three femurs (between 9 and 12 weeks) and one tibia (11 weeks). There was one case of delayed union of femur (18 weeks). Septic pin tract loosening was seen in one case (femur) requiring prolonged antibiotic usage. Minimal limb length discrepancy (1—1.5 cm) was observed in all the cases. Conclusion Compression fixation achieved by monorail fixator can be considered as a viable option for the management of pediatric diaphyseal fractures secondary to active bony infection. It has the advantage of promoting bony union, aiding in early weight bearing, establishing successful joint mobilization, providing an option for future restoration of limb length, and improved patient comfort. How to cite this article Saibaba B, Gopinathan NR, Dhillon MS, Behera P, Santhanam SS. Prospective Role of Uniplanar Compressible External Fixation Devices in the Management of Pathological Diaphyseal Fractures Secondary to Osteomyelitis in Children. J Postgrad Med Edu Res 2017;51(1):17-21.

Polatuzumab Vedotin Combined with Rituximab, Cyclophosphamide, Doxorubicin, and Prednisone (R-CHP) for Patients with Previously Untreated Diffuse Large B-Cell Lymphoma (DLBCL): Updated Results of a Phase Ib/II Study

Introduction: Previously reported results from an ongoing study of polatuzumab vedotin (PoV), an antibody drug conjugate (ADC) containing the anti-mitotic MMAE targeting CD79b, in combination with rituximab, cyclophosphamide, doxorubicin, and prednisone (R-CHP) demonstrated an acceptable safety profile in patients (pts) with previously untreated DLBCL. The dose escalation (esc) phase established a recommended phase 2 dose of PoV at 1.8 mg/kg. We report updated safety and efficacy results for this multicenter, open-label Phase Ib/II study of PoV combined with R-CHP in previously untreated DLBCL pts (ClinicalTrials.gov NCT01992653).Methods: In the esc phase of this study, pts aged 60-80 years, with newly diagnosed or relapsed/refractory B-cell NHL were given PoV intravenously 1.0, 1.4, or 1.8 mg/kg with R-CHP every 21 days for a total of 6 or 8 cycles. In the dose expansion (exp) phase, pts were restricted to those with previously untreated DLBCL and aged 18-80 years. Investigator assessments for anti-tumor activity by Cheson 2007 were performed following 4 cycles of study treatment (tx) and at the end of study tx (EOT).Patients: DLBCL patient characteristics as of February 5, 2016 are included in Table 1. The majority of the subjects were IPI 4-5.Results: Of the 36 safety evaluable pts, the most common adverse events (AEs) in > 20% of pts were fatigue (36%) and diarrhea (30%), nausea (31%), and neutropenia (25%). 44% had at least one Gr 3/4 AE including neutropenia (22%), febrile neutropenia (14%), hypertension (8%), thrombocytopenia (4%), leukopenia (4%), oral fungal infection (4%), dysphagia (4%), vomiting (4%), asthenia (4%), fatigue (4), decreased appetite (4%), hyponatremia (4%), malnutrition (4%), chylothorax (4%), back pain (4%), motor dysfunction (4%), and confusional state (4%).Serious AEs were reported in 33% of pts, with 17 different events. These included 4 episodes of febrile neutropenia, 2 of neutropenia, 2 of pneumonia, and 1 each of E. coli UTI, oral fungal infection, hyponatremia, malnutrition, chylothorax, pulmonary embolism, pyrexia, pathologic femur fracture, and worsening of rheumatoid arthritis. 33% of pts experienced peripheral neuropathy (PN). The reported terms included PN, paresthesia, muscular weakness, neuralgia, and motor dysfunction. All neurologic AEs attributed to PoV were Gr 1 except one PN that was Gr 2 and improved to Gr 1 after PoV dose reduction. There were 2 pts that discontinued study treatment due to AEs (one with a Gr 2 tremor who is still in CR, and the other with Gr 2 UTI who ultimately progressed) while 5 (14%) had PoV dose reductions (2 PN, 2 neutropenia, 1 weight decrease and asthenia). No Gr 5 AEs were reported among the exp cohort.At the time of this report, response assessments were available in 26 pts. All pts in the esc phase have completed study tx and 8 in exp cohort have completed study tx. Interim and EOT PET response is summarized in Table 2. Among the 2 pts that developed progressive disease in the exp phase, one pt had a new axillary lesion and subsequently died despite salvage tx; the other patient had a CR at interim evaluation, but stopped all tx after 5 cycles due to E. coli UTI and subsequently developed recurrent disease.Conclusions: Early results show that PoV plus R-CHP has an acceptable safety profile in pts with previously untreated DLBCL. Although the protocol-specified MTD was not formally reached, the recommended phase 2 dose of PoV was established at 1.8 mg/kg based on the overall safety and tolerability profile at that dose. The pts treated at the phase 2 dosing were strongly weighted in the high risk category by IPI and in that context, efficacy is promising and will be updated at the time of presentation. [Display omitted] [Display omitted] DisclosuresMorschhauser:Janssen: Honoraria; Roche: Consultancy, Honoraria; Celgene: Consultancy, Honoraria; Gilead Sciences: Consultancy, Honoraria; Servier: Consultancy, Honoraria. Bartlett:Gilead: Consultancy. Sharman:Gilead: Research Funding; Seattle Genetics: Research Funding; Celgene: Research Funding; Pharmacyclics: Research Funding; Acerta: Research Funding; TG Therapeutics: Research Funding. Haioun:Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Gilead: Honoraria, Membership on an entity's Board of Directors or advisory committees; Sandoz: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees. Kolibaba:Celgene: Research Funding; Acerta: Research Funding; Janssen: Research Funding; Amgen: Research Funding; Cell Therapeutics: Research Funding; GSK: Research Funding; Novartis: Research Funding; Gilead: Consultancy, Research Funding; Genentech: Research Funding; Pharmcyclics: Research Funding; Seattle Genetics: Research Funding; TG Therapeutics: Honoraria, Research Funding. Chen:Seattle Genetics: Consultancy. Jones:Genentech, Inc.: Employment. Penuel:Genentech/Roche: Employment. Lee:Genentech, Inc.: Employment. Salles:Gilead: Honoraria, Research Funding; Celgene: Consultancy, Honoraria; Janssen: Consultancy, Honoraria; Mundipharma: Honoraria; Novartis: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Roche/Genentech: Consultancy, Honoraria, Research Funding.

Patients With Multiple Myeloma Have More Complications After Surgical Treatment of Hip Fracture.

Objectives:Bone lesions from multiple myeloma may lead to pathological fracture of the proximal femur, requiring either fixation or arthroplasty. Little is known about the impact of multiple myeloma on hip fracture care. We investigated whether the patients with multiple myeloma undergoing surgical treatment of hip fractures would be at increased risk for adverse outcomes versus patients who sustain a hip fracture without multiple myeloma.Methods:Using discharge records from the Nationwide Inpatient Sample (2002-2011), we identified 2 440 513 patients older than 50 years of age with surgically treated hip fractures. Of which, 4011 (0.2%) were found to have multiple myeloma. We compared perioperative outcomes between the patients with multiple myeloma and the nonmultiple myeloma patients using multivariable logistic regression modeling.Results:Patients with multiple myeloma were more likely to have several postoperative complications, such as in-hospital pneumonia (odds ratio [OR]: 1.31, 95% confidence interval [CI]: 1.14-1.51), sepsis (OR: 1.72, 95% CI: 1.32-2.25), surgical site infection (OR: 1.66, 95% CI: 1.38-2.00), and acute renal failure (OR: 1.28, 95% CI: 1.14-1.43). We found that myeloma was not associated with increased inpatient mortality, myocardial infarction, respiratory failure, thromboembolic events, or pulmonary embolism.Conclusion:Patients with multiple myeloma are at increased risk for immediate postoperative complications following surgical treatment of hip fractures including in-hospital pneumonia, surgical site infection, and acute renal failure but not hospital mortality, when compared to hip fracture patients without multiple myeloma. Perioperative management of hip fractures in patients with myeloma may be optimized by increased awareness of these risks in this subset of patients.

CT-Guided Percutaneous Femoroplasty for the Treatment of Proximal Femoral Metastases

Background: The spine, pelvis, skull, and femur are the most common sites of bone metastases, and pain is the main symptom of metastatic tumors. Percutaneous femoroplasty (PFP) is becoming increasingly popular for treating proximal femoral metastases. Objectives: To assess the clinical value and feasibility of PFP performed under the guidance of computed tomography (CT). Study Design: A retrospective clinical review comparing pain intensity and the ability to perform activities of daily living before and after treatment with PFP. Setting: Single academic medical center. Methods: Sixteen patients with proximal femoral metastasis were treated with PFP under CT guidance and followed up for 6 – 12 months. Pain intensity was evaluated using the visual analog scale (VAS) and patients’ quality of life was evaluated using the Barthel Index of Activities of Daily Living (BIADL) preoperatively and at both 7 days and 6 months after PFP. Results: The mean VAS score decreased from 7.44 ± 0.81 preoperatively to 2.69 ± 0.79 at 7 days postoperatively and 1.25 ± 0.93 at 6 months postoperatively. The BIADL score increased from 44.06 ± 9.53 preoperatively to 69.06 ± 8.61 at 7 days postoperatively and 83.13 ± 6.55 at 6 months postoperatively. No patients suffered from pulmonary embolism or complications such as pathologic fracture of the proximal femur. The median overall survival was 12 months. One patient experienced cement leakage into the hip, and the injection was immediately stopped. Then dexamethasone was injected intravenously to prevent potential pulmonary fat embolism caused by localized high pressure. Limitations: The study evaluated a single group of patients before and after CT-guided PFP and did not include a comparison with conventional fluoroscopic approaches in a large patient sample. Conclusion: Use of CT-guided PFP was associated with a low risk of complications and improvement in patients’ quality of life. CT guidance made the operation easy and safe, and thus, this approach represents a potential treatment option for proximal femoral metastases if indications are observed closely. Key words: CT guidance, percutaneous femoroplasty, proximal femoral metastasis, pain relief, cementoplasty

Novel Nonsurgical Approach to Stabilization of Bilateral Pathologic Femoral Fractures in an Egg-laying Maroon-bellied Conure (Pyrrhura frontalis).

A 2-year-old, egg-laying maroon-bellied conure (Pyrrhura frontalis) was referred for treatment of bilateral femoral fractures believed to be secondary to recent egg laying and nutritional and husbandry deficiencies. On radiographs, all skeletal components were diffusely osteopenic, precluding surgical fixation. A novel device to stabilize the bilateral femoral fractures was manufactured with polyvinyl chloride piping, which braced the bird's feet at the level of the perch and supported its upper body weight via a breast plate, thus maintaining the bird in a physiologically appropriate perching position. The conure was ambulatory and returned to normal function after 3 weeks of external coaptation with this device. After 6 weeks, callus formation was palpable over both fracture sites even though minimal bone remodeling was visible radiographically. This body splint device may present a viable alternative to euthanasia in select cases of bilateral femoral fractures in companion birds.