Pathological Femoral Neck Fracture Research Articles

Aloarthroplasty of the Hip After Pathological Fracture of the Right Femoral Neck and Right Femoral Dyaphysis and Osteosynthesis after Fracture of the Left Femoral Dyaphysis in 41-Year-Old Female Patient with Polyostotic Fibrous Dysplasia? Case Report

A 41-year- old female patient with pathological basicervical right femoral neck fracture and fractures of both femoral bones 15-20 cm distally from the small trochanter is presented. Skeletal scintigraphy was performed and multiple pathological accumulations of radioactive substances were found in almost the entire locomotor system. First, we implanted a partial biarticular hip prosthesis with long stem in right femur, and one year later osteosynthesis of the left femoral diaphysis was done. Pathohistological examination did not find tumor cells and polyostotic fibrous dysplasia also was not clear. Our patient had not problems with bones earlier and she was never treated for this disease, except surgery of femoral fractures. Today, 11 years later the patient is in good general state, she has no pain in her legs and fractures of femur bones healed completely. We did not find a case in literature that a two fractures of proximal right femur bone (femoral neck and proximal diaphysis) and fracture of the left femoral diaphysis were solved with long stem prosthesis, and osteosynthesis of another femoral bone in patient who, we believe, has fibrous dysplasia and was never treated for this disease.

No Difference Between Hemiarthroplasty and Total Hip Arthroplasty in the Treatment of Pathologic Femoral Neck Fractures

BackgroundHemiarthroplasty (HA) and total hip arthroplasty (THA) have been widely discussed as treatment options for displaced osteoporotic femoral neck fractures. Pathologic femoral neck fractures from primary or metastatic tumors are comparatively rare and poorly investigated. The purpose of this study was to compare outcomes, complications, and perioperative survival for HA and THA in the treatment of pathologic femoral neck fractures of neoplastic etiology. MethodsA multicenter retrospective cohort study identified patients with pathologic femoral neck fractures treated with HA or THA from 2005 to 2018. Demographics, American Society of Anesthesiologists classification, Charlson comorbidity index, Dorr classification, histopathologic diagnosis, and surgical data were compared. The primary outcome was reoperation. Secondary outcomes included 90-day mortality, estimated blood loss, length of stay, periprosthetic fracture, periprosthetic joint infection, and Eastern Cooperative Oncology Group performance status. ResultsThere were 116 patients with HA and 48 patients with THA, with no differences between groups with regard to American Society of Anesthesiologists classification, Charlson comorbidity index, or Dorr classification. There were no differences between HA and THA in the primary outcome of reoperation (5.2% vs 4.2%, P = 1.00) or secondary outcomes of perioperative 90-day overall mortality (30.2% vs 25.0%, P = .51), estimated blood loss, transfusion rates, length of stay, discharge location, periprosthetic joint infection, periprosthetic fracture, or preoperative or postoperative Eastern Cooperative Oncology Group performance status. ConclusionsBoth HA and THA are viable options for the treatment of patients with pathologic femoral neck fractures and demonstrated no differences in reoperations, complications, perioperative 90-day mortality, or functional outcome scores. Level of EvidenceLevel III.

Calciphylaxis in Association With Hungry Bone Syndrome. A Possible Risk Factor?

Background: Calciphylaxis (calcific uremic arteriolopathy) is a rare complication seen in, although not limited to, patients with end-stage renal disease (ESRD). The abnormal regulation of calcium (Ca) and phosphorus (P) homeostasis in this patient group results in intravascular Ca deposition. These patients often develop secondary/tertiary hyperparathyroidism, presenting unique treatment challenges. When patients do not respond to medical therapy, parathyroidectomy is an option that may be complicated by hungry bone syndrome (HBS). We present a case of a patient with calciphylaxis with HBS post-parathyroidectomy.Case Report: The patient is a 41 y.o. male with ESRD on hemodialysis who presented with lower extremity ulcers complicated by calciphylaxis. On admission, the PTH was elevated at 2200 U with a normal corrected Ca 8.7 and P 8.5. He was found to have a non-displaced pathologic fracture of the right femoral neck. CT scan of the neck revealed nodular parathyroid hyperplasia affecting all four glands. His hyperparathyroidism was managed medically with cinacalcet, phosphate binder, and sodium thiosulfate to optimize his condition before surgery.He underwent a subtotal parathyroidectomy, with post-op course complicated by HBS. Repeat labs showed PTH 444, P 6.1, corrected Ca 7.4, and ionized Ca <4. Despite frequent repletion with IV Ca and addition of calcitriol, he remained persistently hypocalcemic with symptoms (paresthesia, perioral numbness) and prolonged QTc (560 ms) on 12-lead EKG. After weighing the more imminent risk of unstable arrhythmia versus exacerbation of HBS by targeting too high of a Ca level post-op, ICU admission was decided where Ca levels could be more closely monitored and titrated. The patient eventually demonstrated an improvement in his Ca level and symptoms.Discussion: This patient with ESRD complicated by hyperparathyroidism presented with ulcers and calciphylaxis refractory to medical therapy, requiring parathyroidectomy. HBS was a concern in this particular patient given his risk factors.Hypocalcemia is an expected electrolyte imbalance that usually resolves within 2–4 days after parathyroidectomy. Severe and persistent hypocalcemia on day 4 after the procedure should raise concern for HBS. It has been shown that the risk is higher in patients who have secondary hyperparathyroidism, prolonged duration of elevated PTH, age >60, and radiologic evidence of bone disease.ConclusionCalciphylaxis is an uncommon but potentially fatal illness seen in ESRD patients associated with Ca and P abnormalities. Whether this may increase the risk of HBS status-post parathyroidectomy is unknown; however, HBS requiring ICU management to treat refractory hypocalcemia has been reported in this group1. It is arguable that calciphylaxis may serve to identify such patients.(1) Hassanein M, et al. BMJ Case Rep 2018;11:e226696. doi:10.1136/bcr-2018–226696

Metastatic Squamous Cell Carcinoma with an Impending Femoral Neck Fracture

Case: A 57-year-old man presented with a soft-tissue neck mass that has been present for 3 weeks. The patient is a former smoker. A biopsy of the mass confirmed squamous cell carcinoma (SCC). A positron emission tomography scan indicated metastatic disease in the patient’s left femur. An impending pathologic fracture of the left femoral neck was evident. Discussion: The global incidence of oral SCC is increasing. Metastatic disease occurs rapidly with SCC. It is important for those practicing in orthopaedics to understand the aspects of this disease. This case review discusses the importance of understanding the rapid progression of metastatic SCC.

Image-guided Percutaneous Fixation with Internal Cemented Screws of Impending Femoral Neck Pathologic Fractures in Patients with Metastatic Cancer: Safety, Efficacy, and Durability.

Background Prophylactic image-guided procedures performed by interventional radiologists for impending pathologic fractures are becoming more pertinent, as patients with metastatic cancer have extended overall survival because of advanced therapies. Purpose To evaluate the efficacy, safety, and palliative durability of collimated-beam CT-guided percutaneous fixation with internal cemented screws (FICS) for impending pathologic fractures of the femoral neck. Materials and Methods This single-institute retrospective study examined all patients with metastatic cancer treated between February 2010 and October 2019 with collimated-beam CT-guided percutaneous FICS procedures for preventive consolidation of impending femoral neck pathologic fractures. The short-term palliative efficacy was assessed through comparison of visual analog scale (VAS) scores before and 1 month after FICS. A review of cross-section imaging and clinic reports identified any procedural complications. Long-term consolidation efficacy was defined as the absence of any screw dislodgement or development of a pathologic fracture at completion of the study. The Wilcoxon test was used for the mean comparison of paired nonparametric variables. Results Sixty-one consecutive patients (mean age, 59 years ± 11 [standard deviation]; 35 women) underwent preventive FICS for consolidation of impending pathologic femoral neck fracture with a mean follow-up of 533 days ± 689. Two patients died of cancer within the first month. Complications were limited to three self-resolving hematomas. The mean VAS score decreased 1 month after FICS from 4.2 ± 3.2 to 1.8 ± 2.0 (P < .001). The long-term consolidation efficacy was 92% (54 of 59 patients), with three of 59 patients (5%) subsequently developing fractures despite FICS and an additional two of 59 patients (3%) with durable FICS undergoing definitive total hip arthroplasty surgery because of local tumor progression. Conclusion Percutaneous fixation with internal cemented screws as performed by the interventional radiologist is a safe nonsurgical treatment that provides an effective palliative result and durable prevention for impending pathologic fractures of the femoral neck. © RSNA, 2020 Online supplemental material is available for this article.

Wagner Technique of Transphyseal Proximal Femoral Fixation

Proximal femoral fractures and deformities in children are often difficult to treat because of high complication rates and risk of physeal closure resulting from the treatment fixation. The Wagner technique of smooth pin fixation through the femoral neck and across the proximal femoral physis provides stable fixation of the femoral neck and reduces the risk of avascular necrosis and growth disturbance. Eighteen consecutive cases in which the Wagner technique was used were reviewed. Diagnoses included fixation after proximal femur osteotomy, slipped capital femoral epiphysis reduction with associated valgus-producing osteotomy secondary to pre-existing coxa vara, traumatic femoral neck fractures, and pathologic femoral neck fractures secondary to aneurysmal bone cyst, unicameral bone cyst, fibrous dysplasia, or osteomyelitis in which bone defects were bone grafted before fixation. Outcomes included proximal femoral physeal closure, avascular necrosis (AVN), maintenance of alignment, and need for revision or implant removal surgery. There was no AVN, unintended proximal femoral physeal closure, or loss of fracture alignment requiring revision surgery. One patient required revision to an antegrade femoral nail for correction of progressive varus deformity. Four required implant removal: 2 because of continued growth and need for prophylaxis, 1 because of patient preference, and 1 for infection. Revision curettage and fixation was required for 1 of 10 patients with cyst recurrence after fixation for a pathologic femoral neck fracture. The Wagner technique is a versatile, safe, and effective method of transphyseal fixation for pediatric femoral neck fractures or proximal femoral deformity correction. In this series, there were no cases of AVN, premature unexpected proximal femoral physeal closure, or fracture malalignment requiring revision.

Pathological Fracture of Femoral Neck Associated to Femoral Head Osteonecrosis: Case Report

Introduction: The osteonecrosis of femoral head is a progressive and devastating condition for the prognosis of the coxofemoral joint, with an increase in its prevalence and an etiology of multifactorial nature, and with compromise specially in young or middle age (20 to 40 years of age) patients [1-3]. The fractures associated to femoral head osteonecrosis are very rare, being the subchondral portion the site with a higher compromise, and the junction between the necrotic bone and the bone under remodeling process another site of potential fracture [4-7]. The management of this condition can vary from a conservative management to a surgical management with total hip arthroplasty, depending on patient’s clinic and the extension of his necrotic lesion. Discussion: This patient presents a sub-capital fracture of his femoral neck, associated to osteonecrosis of the femoral head. This patient was managed with decompression of the osteonecrosis nucleus plus bone graft and osteosynthesis with cannulate screws, in order to decrease bone hypertension and avoid femoral collapse. Conclusion: Although femoral neck fractures, as a complication from femoral head osteonecrosis are rare, in our patient such association can be found due to the worsening of his painful clinical features and the absence of a previous traumatic event, which allows discarding femoral osteonecrosis as a fracture complication.

Pathological femoral neck fracture secondary to Ectopic Parathyroid adenoma located in the Mediastinal Aoroto-Pulmonary window : A Rare Case

Vol 34 | Issue 3 | Sep - Dec 2019 | page: 41-45 | Pulak Sharma, Niraj Ranjan Authors: Pulak Sharma [1], Niraj Ranjan [1] [1] Department of Orthopaedics, APEX TRAUMA CENTER, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UttarPradesh, India.. Address of Correspondence: Dr. Niraj Ranjan, Department of Orthopaedics, APEX TRAUMA CENTER, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UttarPradesh, India. E-mail: niraj.ranjan333gmail.com Abstract Primary Hyperparathyroidism (PHPT) has a diverse clinical spectrum which varies from asymptomatic hypercalcaemia to severe metabolic bone disease, pathological fractures and renal stones. Biochemical parameters including serum calcium, phosphorus, alkaline phosphatase (ALP) and PTH assay help in diagnosing PHPT. Ectopic parathyroid adenoma is a rare cause of PHPT. High index of clinical suspicion and a systematic approach is required for its diagnosis and management .Pathological fractures due to ectopic parathyroid adenoma is even rare .We present a case of pathological femoral neck fracture as a result of PHPT due to ectopic parathyroid adenoma situated adjacent to the Aoroto pulmonary window . Stabilization of the fracture once the PTH hormone levels have settled following treatment of hyperparathyroidism are the mainstay in the treatment of this rare clinical entity. Keywords: Femoral Neck , Hyperparathyroidism, Ectopic parathyroid

Does the Use of Magnetic Resonance Imaging Scan in Occult and Suspected Metastatic Pathological Neck of Femur Fractures Affect the Choice of Surgical Intervention?

Background:Magnetic resonance imaging (MRI) is often employed as the diagnostic modality of choice in occult and suspected pathological femoral neck fractures. We evaluated the clinical utility of MRI scan in this patient population.Method:Retrospective observational analysis of cases with a radiologically occult or suspected metastatic pathological neck of femur fracture.Results:From a total of 894 femoral neck fractures treated in our institution, 100 patients had and MRI scan pre-operatively for either occult fracture or suspected fracture secondary metastatic disease. Magnetic resonance imaging confirmed the presence of 13 simple fractures. A total of 14 patients had pathological features suggestive of metastasis, of which 12 were clearly visible on plain radiographs. Surgical plan did not change after MRI for any of these pathological fractures.Conclusion:Results of this study demonstrate that an MRI scan had an impact on treatment selection only when a simple but radiographically occult fracture is suspected and but not in the context of suspected metastatic pathological fractures.

Radiologic Findings in Polyarticular Amyloid Arthropathy and Myopathy in Multiple Myeloma: A Case Report

Patient: Male, 56Final Diagnosis: Amyloid arthropathy and myopathySymptoms: PolyarthralgiaMedication: —Clinical Procedure: —Specialty: RadiologyObjective:Rare diseaseBackground:Amyloid arthropathy and myopathy are complications of amyloidosis that can be associated with non-specific imaging findings, which may be challenging to interpret. The report is of a case of polyarticular amyloid arthropathy and myopathy in a 56-year-old man with multiple myeloma and includes a description of the radiographic, computed tomography (CT), and magnetic resonance imaging (MRI) findings.Case Report:A 56-year-old man with multiple myeloma presented with chronic polyarticular pain and swelling. Soft tissue thickening of the wrist and knee were found on MRI to be of intermediate T1 weighted imaging (T1WI) and low to intermediate T2 weighted imaging (T2WI) signal intensity. Denervation muscle edema seen in the thenar muscles on the MRI of the right wrist were associated with carpal tunnel syndrome secondary to amyloid deposition. Soft tissue lesions in the periarticular regions of both hip joints were contiguous with subchondral bone lesions. Diffusely scattered myeloma lesions were shown as hyperintense on short tau inversion recovery (STIR) MRI imaging throughout the appendicular and axial skeleton, with vertebral compression fractures. Bilateral iliopsoas involvement with hypertrophy and abnormal surrounding fat reticulated signal intensity was consistent with amyloid myopathy. The patient had a pathological fracture of the right femoral neck and underwent surgical fixation. Histology of the right femoral head confirmed amyloid deposits.Conclusions:Because the clinical presentation and imaging findings of musculoskeletal amyloidosis can be nonspecific, they can result in delay in diagnosis and treatment. Early radiologic identification of polyarticular amyloid arthropathy and myopathy should prompt confirmatory biopsy to confirm the diagnosis.

Denosumab Treatment in a Rare, Neglected Giant Cell Tumor (GCT) of the Femoral Neck: Case Report and Literature Review

Abstract Introduction. GCT resembles an aggressive benign tumor of bone and its evolution based on the histological features is unpredictable. About 50% of the cases are located around the knee (proximal femur and distal tibia), with the proximal humerus and distal radius representing the third and fourth most common sites. Femoral neck location is unusual. We report a case of GCT located at the femoral neck level, in a 19-year-old female. Case presentation. Onset was hidden by pathologic femoral neck fracture and, due to insidious symptoms, proper diagnosis and treatment were neglected for almost six months. After 6 months, the case was referred to our clinic and re-evaluated with complete examination and biopsy. Wide resection and tumoral arthroplasty of the hip was performed. Postoperative complete recovery was achieved and the patient returned to previous activities. After 2 years of normal clinical evolution, a neurological severe issue appeared; at this time, a cerebral metastasis was diagnosed. Once the positive diagnosis was achieved, 120 mg Denosumab treatment was initiated monthly. At 16 months follow-up, the patient was symptom free and continued Denosumab treatment. Discussion. Denosumab is a human monoclonal IGG2 antibody inhibiting osteoclast differentiation, activation, and survival with applicable suppression of bone turnover in patients with multiple myeloma, osteolytic bone disease, and bone metastases from breast and prostate cancer. It is also a useful drug for managing the GCT of bone and one excellent option in metastatic GCT. The long time safety and complications, especially in young female patients, are to be proven. Conclusions. Early diagnosis and accurate management of GCT are mandatory in order to achieve good long-term clinical results. Denosumab treatment may be necessary in order to avoid secondary metastasis or local recurrence.

A Case of Precursor B-cell Acute Lymphoblastic Leukemia Occurre d with Rapid Hip Bone Destruction and Femoral Neck Fracture

Background: Precursor B-cell lymphoblastic lymphoma is a rare subtype of acute lymphoblastic lymphoma and sometimes presents as lytic bone lesions. Diagnosis and treatment of lytic bone lesions are always challenging. This is a rare case of delayed leukemic change of precursor B-cell acute lymphoblastic lymphoma presented with a rapid hip bone destruction.Case presentation: A 12-year-old Japanese girl presented with progressive left hip pain, and bone destruction of her left hip two months after the onset of symptoms. She had no past medical or family history of malignancy and had no genetic abnormality. Radiograph and MRI examination showed bone destruction and osteolytic lesions in her left femoral neck and pelvis. Blast cells were not found in our initial examination of the peripheral blood and aspirated bone marrow cells. The case was finally diagnosed as Precursor B-cell lymphoblastic lymphoma as the results of bone biopsy, and blast cells were then detected after preforming multiple bone marrow aspirations. She also had pathological femoral neck fracture, but after treatment regimen by chemotherapy, her osteolytic lesions cured with obtainment of femoral neck fusion. She could walk at the final period.Conclusion: This case highlights the importance of early diagnosis of this disease for greater curing rates. Diagnosis of Precursor B-cell lymphoblastic lymphoma was finally made based on the results of biopsy of tissues because of the delayed appearance of leukemic changes. Orthopaedic surgeons should be aware of Precursor B-cell lymphoblastic lymphoma, when making diagnosis of patients exhibiting a rapid hip bone destruction.

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

Femoral neck fractures in children and the role of early hip decompression in final outcome.

Femoral neck fractures in children are very rare and account for about 1% of all paediatric fractures. The aim of this retrospective study was to analyse the clinical and radiographic outcome in paediatric femoral neck fracture and to review the role of early decompression of the hip in the final outcome. The study was performed at the Department of Paediatric Orthopaedics and Traumatology, University Children's Hospital in Belgrade, Serbia from January 1996 to January 2010. The study included 28 patients, 12 female and 16 male, aged 4-14 years. Patients who were aged over 14 years or who had pathological femoral neck fractures or metabolic disturbances were excluded from the study. The type of neck fracture was determined according to the Delbet and Colonna classification. The patients were treated using different surgical procedures: closed reduction and cast immobilisation, closed reduction and percutaneous fixation with Kirschner wires (K-wires), closed reduction and fixation with cannulated screws and open reduction with Wagner plate stabilisation. The final outcome was evaluated using the clinical outcome (based on the Howorth-Ferguson scale), radiographic outcome and occurrence of complications. The median age of patients included in the study was 10.75 years and the average follow up was 9 years. According to the Delbet classification, there was one patient with type I, eight patients with type II, 16 patients with type III and three patients with type IV femoral neck fracture. Based on the Colonna classification, there were 23 displaced and five non-displaced femoral neck fractures. Decompression of the hip was performed in 21 patients. Avascular necrosis (AVN) developed as the main complication in 11 patients. The final outcome was excellent in 14 patients, good in four patients and poor in 14 patients. Our study unequivocally confirms the positive effect of urgent treatment on the incidence of AVN as well as on the outcome. We have established a 12-hour interval after injury as an optimal time limit for commencing treatment. Unambiguously positive effects of hip decompression on the incidence of AVN were also noted. We found similar efficiency for open and needle hip decompression.

Une fracture pathologique de la hanche chez un adulte révélant une ostéomalacie hypophosphorémique oncogénique secondaire à une dysplasie fibreuse des os.

Oncogenic hypophosphatemic osteomalacia is a rare acquired condition (about 160 reported cases). The initial abnormality is the unregulated secretion of FGF-23 by small growth mesenchymal tumors. Fibrous dysplasia is a well-known cause of oncogenic osteomalacia, with the polyostotic form complicated in 50% of cases with severe hypophosphatemia. We report here the case of a 43 years-old man, admitted for diffuses bone pain and muscular proximal weakness, evolving for 2 years, complicated with a pathological femoral neck fracture. Lab studies found severe hypophosphatemia and an elevation of alkaline phosphatases with normal levels of serum calcium, 25OH-vit D3 and PTH. X-Rays revealed a diffuse bone demineralization with multiple vertebral fractures and a fracture of the femoral neck associated with multiple lytic lesions of the femoral diaphysis. Histological examination has concluded fibrous dysplasia. Main etiologies, such as iatrogenic causes and Fanconi syndrome, have not been considered. Treatment with phosphorus associated with 1,25OH-Vit D3 has been installed, associated with intravenous infusions of bisphosphonates.

Surgical management of metastatic disease of the proximal part of the femur.

➤ Pathologic fracture of the proximal part of the femur resulting from metastatic disease causes severe pain and an inability to walk. Surgical stabilization can be challenging because of bone loss resulting from the underlying metastatic lesions, the potential for major blood loss, and the poor health of the patient.➤ The goal of surgical treatment is the creation of a stable construct to allow early weight-bearing.➤ Pathologic femoral neck fractures secondary to metastases are best managed with arthroplasty.➤ The treatment of intertrochanteric or subtrochanteric fractures is more controversial. Surgical stabilization may be performed with cephalomedullary nailing or arthroplasty. The choice of implant and operative technique is dependent on careful consideration of multiple factors, including the patient's life span, the type of tumor, the perceived response to other therapies, the need for adjuvant radiation therapy and chemotherapy, the location and number of metastatic lesions, and the degree of bone involvement.➤ While the potential for complications is high, surgical stabilization of the proximal part of the femur decreases pain and improves function.

What can we learn from a patient on dialysis for 42 years?

We performed autopsy on a 60-year-old Japanese man who had received dialysis for 42 years. He started on intermittent peritoneal dialysis in 1968, which was combined with hemodialysis in 1969. His serum calcium-phosphate balance and his blood pressure had been controlled well. Carpal tunnel syndrome occurred in 1984. Then lumbar spinal canal stenosis (SCS) occurred in 1997, followed by cervical SCS in 2000, destructive lumbar spondyloarthropathy (DSA) in 2002, and pathological fracture of the right femoral neck due to an enlarging bone cyst in 2006. All of his surgical specimens showed dialysis-related deposition of beta2MG amyloid (dialysis-related amyloidosis: DRA). Thereafter, lumbar and cervical spinal palsy progressed. In 2009, he developed severe paralytic ileus with dilatation of the sigmoid colon, and subsequently died of peritonitis due to necrotizing cholecystitis. Autopsy showed massive DRA deposits in his intestinal blood vessels and thickened spinal dura, resulting in the above-mentioned intestinal and spinal complications. However, his arterial tree, including the aorta and coronary arteries, showed very little atheroma. Strict control of the Ca-P balance and blood pressure may have prevented cardiovascular disease, while progress in dialysis technology delayed fatal complications of DRA and allowed this patient to survive on dialysis for 42 years.

Inflammatory Bowel Disease, High-Dose Steroids, Osteoporosis, or an Oncological Etiology for a Pathological Femoral Neck Fracture in a Young Adult: A Case Report

Femoral neck fractures occur in approximately 6,000 of young adults annually (ages 18-49) (1). Of these, a high-energy traumatic event is the typical cause. Although medications and chronic diseases have been implicated as confounding causes of hip fractures, clinicians should have a high index of suspicion for an oncologic etiology of hip fractures occurring in young patients without an inciting traumatic event.Study Design: A case report and literature search in the English language.

Biomechanical analysis of impending femoral neck fractures: The role of percutaneous cement augmentation for osteolytic lesions

BackgroundManagement of impending pathologic femoral neck fractures includes internal fixation, arthroplasty and megaprostheses. The study aim was to determine the augmentative effect of cement injection for minimally invasive treatment of femoral neck lesions. MethodsTwenty-seven cadaveric femora received a simulated osteolytic lesion previously shown to decrease the femur's failure load by 50%. Specimens were allocated to three groups of nine and loaded to failure in simulated single-leg stance: (1) percutaneous cementation + internal fixation (PCIF); (2) percutaneous cementation (PC); and (3) internal fixation (IF). Lesion-only and augmented finite element models were virtually loaded and stresses were queried adjacent to the lesion. FindingsPCIF resulted in the largest failure load though the increase was not significantly greater than the PC or IF groups. Inspection of the PC and PCIF specimens indicated that the generation of a cement column that spanned the superior and inferior cortices of the femoral neck increased failure loads significantly. Finite element analysis indicated that IF and PCIF constructs decreased the stress adjacent to the lesion to intact femur levels. Cementation without superior-to-inferior femoral neck cortical contact did not restore proximal femoral stress toward the intact condition. InterpretationInternal fixation alone and internal fixation with or without cementation produce similar levels of mechanical augmentation in femora containing a high-risk lesion of impending fracture. A cement injection technique that produces a cement column contacting the superior and inferior femoral neck cortices confers the highest degree of biomechanical stability, should percutaneous cementation alone be performed.

Lumbar paravertebral blockade as intractable pain management method in palliative care

Optimal symptoms control in advanced cancer disease, with refractory to conventional pain treatment, needs an interventional procedure. This paper presents coadministration of local anesthetic (LA) via paravertebral blockade (PVB) as the alternative to an unsuccessful subcutaneous fentanyl pain control in a 71-year old cancer patient with pathological fracture of femoral neck, bone metastases, and contraindications to morphine. Bupivacaine in continuous infusion (0.25%, 5 mL · hour−1) or in boluses (10 mL of 0.125%–0.5% solution), used for lumbar PVB, resulted in pain relief, decreased demand for opioids, and led to better social interactions. The factors contributing to an increased risk of systemic toxicity from LA in the patient were: renal impairment; heart failure; hypoalbuminemia; hypocalcemia; and a complex therapy with possible drug-drug interactions. These factors were taken into consideration during treatment. Bupivacaine’s side effects were absent. Coadministered drugs could mask LA’s toxicity. Elevated plasma α1-acid glycoprotein levels were a protective factor. To evaluate the benefit-risk ratio of the PVB treatment in boluses and in constant infusion, bupivacaine serum levels were determined and the drug plasma half-lives were calculated. Bupivacaine’s elimination was slower when administered in constant infusion than in boluses (t½ = 7.80 hours versus 2.64 hours). Total drug serum concentrations remained within the safe ranges during the whole treatment course (22.9–927.4 ng mL−1). In the case presented, lumbar PVB with bupivacaine in boluses (≤ 137.5 mg · 24 hours−1) was an easy to perform, safe, effective method for pain control. Bupivacaine in continuous infusion (≤150 mg · 12 hours−1) had an acceptable risk-benefits ratio, but was ineffective.