What Is the Prosthetic Survival After Resection and Intercalary Endoprosthetic Reconstruction for Diaphyseal Bone Metastases of the Humerus and Femur?

BACKGROUND: Large metastatic lesions of the diaphysis can cause considerable pain and result in difficult surgical challenges. Resection and cemented intercalary endoprosthetic reconstruction offer one solution to the problem, but it is an extensive operation that might not be tolerated well by a debilitated patient. The risk of aseptic loosening and revision after intercalary endoprosthetic replacement has varied in previous reports, which have not examined the risk of revision in the context of patient survival. QUESTIONS/PURPOSES: (1) In a small case series from one institution, what is the survivorship of patients after cemented intercalary endoprosthetic replacement for diaphyseal metastasis, and what is the cumulative incidence of revision for any reason? (2) What are the complications associated with cemented intercalary reconstruction? (3) What is the functional outcome after the procedure as assessed by the MSTS93 score? METHODS: We retrospectively studied 19 patients with diaphyseal long bone metastases who were treated with resection and cemented intercalary endoprosthetic reconstruction by five participating surgeons at one referral center from 2006 to 2017. There were 11 men and eight women with a median age of 59 years (range 46 to 80 years). The minimum follow-up required for this series was 12 months; however, patients who reached an endpoint (death, radiographic loosening, or implant revision) before that time were included. One of these 19 patients was lost to follow-up but was not known to have died. The median follow-up was 24 months (range 0 to 116 months). Eight of the 19 patients presented with pathologic fractures. Ten of 19 lesions involved the femur, and nine of 19 were in the humerus. The most common pathologic finding was renal cell carcinoma (in 10 of 19). Survival estimates of the patients were calculated using the Kaplan-Meier method. A competing risks estimator was used to evaluate implant survival, using death of the patient as the competing risk. We also estimated the cumulative incidence of aseptic loosening in a competing risk analysis. Radiographs were analyzed for radiolucency at the bone-cement-implant interfaces, fracture, integrity of the cement mantle, and component position stability. Complications were assessed using record review that was performed by an individual who was not involved in the initial care of the patients. Functional outcomes were assessed using the MSTS93 scoring system. RESULTS: Patient survivorship was 68% (95% CI 50% to 93%) at 1 year, 53% (95% CI 34% to 81%) at 2 years, and 14% (95% CI 4% to 49%) at 5 years; the median patient survival time after reconstruction was 25 months (range 0 to 116 months). In the competing risk analysis, using death as the competing risk, the cumulative incidence of implant revision was 11% (95% CI 2% to 29%) at 1 year and 16% (95% CI 4% to 36%) at 5 years after surgery; however, the cumulative incidence of aseptic loosening (with death as a competing risk) was 22% (95% CI 6% to 43%) at 1 year and 33% (95% CI 13% to 55%) at 5 years after surgery. Other complications included one patient who died postoperatively of cardiac arrest, one patient with delayed wound healing, two patients with bone recurrence, and one patient who experienced local soft tissue recurrence that was excised without implant revision. Total MSTS93 scores improved from a mean of 12.6 ± 8.1 (42% ± 27%) preoperatively to 21.5 ± 5.0 (72% ± 17%) at 3 months postoperatively (p < 0.001) and 21.6 ± 8.5 (72% ± 28%) at 2 years postoperatively (p = 0.98; 3 months versus 2 years). CONCLUSION: Resection of diaphyseal metastases with intercalary reconstruction can provide stability and short-term improvement in function for patients with advanced metastatic disease and extensive cortical destruction. Aseptic loosening is a concern, particularly in the humerus; however, the competing risk analysis suggests the procedure is adequate for most patients, because many in this series died of disease without undergoing revision. LEVEL OF EVIDENCE: Level IV, therapeutic study .

Periosteal reaction-like lesions at the cranial aspect of the humeral diaphysis have a high prevalence in older, large breed dogs and may represent entheses of the superficial pectoral muscles.

Authors have commonly observed lamellar periosteal new bone formation at the cranial aspect of the humeral diaphysis in mediolateral radiographs of the humerus for large breed dogs with no evidence of pain or lameness. The aim of this retrospective, analytical study was to investigate the appearance and prevalence of "humeral periosteal reaction-like lesions" (HPRLL) in dogs and identify any predispositions. Mediolateral radiographs of humeri were evaluated and the presence and extent of "humeral periosteal reaction-like lesions" at the cranial aspect of the humerus were recorded. Macroscopic and histological examination of the humeri were performed for one dog with HPRLL. A total of 2877 mediolateral radiographs of 1727 dogs were included and focal or extended periosteal reaction-like lesions were found in 643 humeri of 387 dogs. Body weight ≥ 30 kg and age ≥ 7 years had a statistically significant, positive effect (P < 0.001) on the presence of HPRLL. German Shepherd dogs and Rottweilers were overrepresented in the group with HPRLL (P < 0.01). At the level of the HPRLL, the enthesis of the superficial pectoral muscles (M. pectoralis descendens and M. pectoralis transversus) to the Crista tuberculi majoris and Crista humeri were macroscopically and histologically identified. The authors propose that higher mechanical loads to the enthesis in large breed dogs may lead to physiological, age-related remodeling processes of the muscular attachment. The finding should not be confused with a pathological condition such as bone neoplasia.

Differences in subtrochanteric and diaphyseal atypical femoral fractures in a super-aging prefectural area: YamaCAFe Study.

INTRODUCTION: Atypical femoral fractures (AFFs) have been correlated with long-term use of bisphosphonates (BPs), glucocorticoids (GCs), and femoral geometry. We investigated the incidence and characteristics of subtrochanteric (ST) and diaphyseal (DP) AFFs in all institutes in a super-aging prefectural area. MATERIALS AND METHODS: We performed a blinded analysis of radiographic data in 87 patients with 98 AFFs in all institutes in Yamagata prefectural area from 2009 to 2014. Among the 98 AFFs, 57 AFFs comprising 11 ST fractures in 9 patients and 46 DP fractures in 41 patients with adequate medical records and X-rays were surveyed for time to bone healing and geometry. RESULTS: Of the 87 patients, 67 received BPs/denosumab (77%) and 10 received GCs (11%). Surgery was performed in 94 AFFs. Among 4 AFFs with conservative therapy, 3 required additional surgery. In univariate regression analyses for ST group versus DP group, male-to-female ratio was 2/7 versus 1/40, mean age at fracture was 58.2 (37-75) versus 78 (60-89) years, rheumatic diseases affected 55.5% (5/9) versus 4.9% (2/41), femoral lateral bowing angle was 1.7 (0-6) versus 11.8 (0.8-24)°, GC usage was 67% (6/9) versus 4.9% (2/41), and bone healing time was 12.1 (6-20) versus 8.1 (3-38) months (p < 0.05). In multivariate analyses, higher male-to-female ratio, younger age, greater proportion affected by rheumatic diseases, and higher GC usage remained significant (p < 0.05). CONCLUSIONS: The incidence of AFFs in our prefectural area was 1.43 cases/100,000 persons/year. This study suggests that the onset of ST AFFs have greater correlation with the worse bone quality, vice versa, the onset of DP AFFs correlated with the bone geometry. The developmental mechanisms of AFFs may differ significantly between ST and DP fractures.

Changes in the intra- and peri-cellular sclerostin distribution in lacuno-canalicular system induced by mechanical unloading.

INTRODUCTION: Mechanical stimuli regulate Sclerostin (Scl), a negative regulator of bone formation, expression in osteocytes. However, the detailed Scl distribution in osteocytes in response to mechanical unloading remains unclear. MATERIALS AND METHODS: Twelve-week-old male rats were used. The sciatic and femoral nerves on the right side were excised as mechanical unloading treatment. A sham operation was performed on the left side. One week after neurotrauma, the bone density of the femora was evaluated by peripheral quantitative computed tomography, and immunofluorescence was performed in coronal sections of the femoral diaphysis. The mean fluorescence intensity and fluorescent profile of Scl from the marrow to the periosteal side were analyzed to estimate the Scl expression and determine to which side (marrow or periosteal) the Scl prefers to distribute in response to mechanical unloading. The most sensitive region indicated by the immunofluorescence results was further investigated by transmission electron microscopy (TEM) with immunogold staining to show the Scl expression changes in different subcellular structures. RESULTS: In femur distal metaphysis, neurotrauma-induced mechanical unloading significantly decreased the bone density, made the distribution of Scl closer to the marrow on the anterior and medial side, and increased the Scl expression only on the lateral side. TEM findings showed that only the expression of Scl in canaliculi was increased by mechanical unloading. CONCLUSIONS: Our results showed that even short-term mechanical unloading is enough to decrease bone density, and mechanical unloading not only regulated the Scl expression but also changed the Scl distribution in both the osteocyte network and subcellular structures.

Animal models for studying metaphyseal bone fracture healing.

An estimated 2 million osteoporotic fractures occur annually in the US, resulting in a dramatic reduction in quality of life for affected patients and a high economic burden for society. Osteoporotic fractures are frequently located in metaphyseal bone regions. They are often associated with healing complications, because of the reduced healing capacity of the diseased bone tissue, the poor primary stability of the fracture fixation in the fragile bone, and the high frequency of comorbidities in these patients. Therefore, osteoporotic fractures require optimised treatment strategies to ensure proper bone healing. Preclinical animal models can help understanding of the underlying mechanisms and development of new therapies. However, whereas diaphyseal fracture models are widely available, appropriate animal models for metaphyseal fracture healing are scarce, although essential for translational research. This review covers large and small animal models for metaphyseal fracture healing. General requirements for suitable animal models are presented, as well as advantages and disadvantages of the current models. Furthermore, differences and similarities between metaphyseal and diaphyseal bone fracture healing are discussed. Both large- and small-animal models are available for studying metaphyseal fracture healing, which mainly differ in fracture location and geometry as well as stabilisation techniques. Most common used fracture sites are distal femur and proximal tibia. Each model found in the literature has certain advantages and disadvantages; however, many lack standardisation resulting in a high variability or poor mimicking of the clinical situation. Therefore, further refinement ofanimal models is needed especially to study osteoporotic metaphyseal fracture healing.

Effects of FK506 on the healing of diaphyseal, critical size defects in the rat femur.

There is much interest in understanding the influence of the immune system on bone healing, including a number of reports suggesting a beneficial effect of FK506 (tacrolimus) in this regard. The influence of FK506 in a rat, femoral, critical size defect was examined using locally implanted, recombinant, human (rh) BMP-2 and adenovirally-transduced, autologous, adipose-derived mesenchymal stromal cells (AD-MSCs) expressing BMP-2. FK506 was delivered systemically using an implanted osmotic pump. Empty defects and those implanted with unmodified AD-MSCs did not heal in the presence or absence of FK506. Defects treated with rhBMP-2 healed with a large callus containing thin cortices and wispy trabeculae; this, too, was unaffected by FK506. A third of defects implanted with adenovirally-transduced AD-MSCs healed, but this improved to 100 % in the presence of FK506. New bone formed in response to BMP-2 synthesised endogenously by the genetically modified cells had a slimmer callus than those healed by rhBMP-2, with improved cortication and advanced reconstitution of marrow. These results suggest that FK506 may have had little effect on the intrinsic biology of bone healing, but improved healing in response to adenovirally-transduced cells by inhibiting immune responses to the first-generation adenovirus used here. Because the genetically modified cells produced bone of higher quality at far lower doses of BMP-2, this approach should be explored in subsequent research.

Locking plate femur fracture repair in a juvenile Western chimpanzee (Pan troglodytes verus) in Sierra Leone.

This case reports the successful management of a traumatic diaphyseal femoral fracture in an infant Western chimpanzee (Pan troglodytes verus) from a rescue centre in Sierra Leone using a 2.4-mm intramedullary pin and two 2.7-mm String of Pearls™ locking plates. Locking plate use has not been previously described in chimpanzees.

Morphological profile of atypical femoral fractures: age-related changes to the cross-sectional geometry of the diaphysis.

The use of bisphosphonates for osteoporosis patients has markedly decreased the incidence of femoral neck or trochanteric fractures. However, anti-osteoporosis drugs have been reported to increase the incidence of atypical femoral fractures, which involve stress fractures in the subtrochanteric region or the proximal diaphysis. In this study, the morphological characteristics of the cortical bone in human femoral diaphysis samples were analyzed from individuals who lived before bisphosphonate drugs were available in Japan. A total of 90 right femoral bones were arbitrarily selected (46 males and 44 females) from modern Japanese skeletal specimens. Full-length images of these femurs were acquired using a computed tomography scanner. An image processing method for binarization was used to calculate the threshold values of individual bones for determining their contours. The range between the lower end of the lesser trochanter and the adductor tubercle of each femur was divided at regular intervals to obtain 10 planes. The mean value of cortical bone thickness, periosteal border length, and the cortical cross-sectional area was evaluated for all planes. Moreover, the ratio of the area of the cortical bone to the total area of cross-section at the mid-diaphysis was calculated. A comparison between males and females demonstrated that most females had lower cortical bone area ratios at the mid-diaphysis. The femoral outer shape did not differ markedly according to age or sex; however, substantial individual differences were observed in the shape of the inner surface of the cortical bone. The cortical bone thickness and the cross-sectional area decreased with age in the femoral diaphysis; furthermore, in females, the decrease was higher for the former than for the latter. This may be due to a compensatory increase in the circumference of the femoral diaphysis. In addition, in about half of the subjects there was a discrepancy between the region with maximal value of the cortical bone thickness and that of the total cross-sectional area. Biological responses to mechanical stresses to the femoral diaphysis are thought not to be uniform. Bisphosphonates inhibit bone resorption and may promote non-physiological bone remodeling. Thus, a nonhomogeneous decrease in cortical thickness may be related to the fracture occurrence in the femoral diaphysis in some cases. Thus, long-term administration of bisphosphonates in patients with morphological vulnerability in the femoral cortical bones may increase the occurrence of atypical femoral fractures.

Outcome of segmental prosthesis reconstruction for diaphyseal bone tumors: a multi-center retrospective study.

BACKGROUND: The optimal reconstructive method after diaphyseal malignant bone tumor resection remains controversial. This multicenter clinical study was designed to investigate the clinical value and complications of segmental prosthesis in the repair of diaphyseal defects. METHODS: We present 49 patients from three clinical centers treated with wide resection for primary or metastatic bone tumors involving the diaphysis of the femur, tibia, humerus, or ulna, followed by reconstruction using a modular intramedullary segmental prosthesis. RESULTS: Enrolled patients included 23 men and 26 women with a mean age of 63.3 years. Of these, seven patients had primary bone tumors and 42 patients had metastatic lesions. At the mean follow-up of 13.7 months, 17 patients were alive, 31 patients were deceased due to tumor progression, and one patient was dead of another reason. There were eight nononcologic complications (two with radial nerve injury, three with delayed incision healing, two with aseptic loosening in the proximal humerus prosthetic stem and one with structural failure) and three oncologic complications (three with primary tumor recurrence) among all patients. The incidence of complications in primary tumor patients (4/7, 57.1%) was higher than that in patients with metastatic tumors (7/42, 16.7%) (p = 0.036). Aseptic loosening and mechanical complications were not common for patients with primary tumors, although the reconstruction length difference was statistically significant (p = 0.023). No statistically significant differences were observed in limb function, while the mean musculoskeletal tumor society score was 21.2 in femora, 19.6 in humeri, and 17.8 in tibiae (p = 0.134). CONCLUSIONS: Segmental prostheses represent an optional method for the reconstruction of diaphyseal defects in patients with limited life expectancy. Segmental prostheses in the humerus experienced more complications than those used to treat lesions in the femur.

Impact of Diaphyseal Cortical Thickness on Functional Outcomes After Arthroscopic Rotator Cuff Repair.

PURPOSE: To study the influence of combined cortical thickness (CCT) of the proximal humerus on arthroscopic rotator cuff tear repair outcomes. METHODS: The study included 210 patients who underwent arthroscopic repair of full-thickness supraspinatus tears. An independent reviewer measured CCT on preoperative radiographs, and patients were evaluated postoperatively at 3, 6, 12, and 24 months. Functional outcome was assessed with the Constant shoulder score (CSS), Oxford shoulder score (OSS), and University of California at Los Angeles Shoulder rating scale (UCLASS). The patients were divided based on CCT: ≥4 mm (higher CCT) and <4 mm (lower CCT). Univariate analysis and multivariate linear regressions were applied to study the effect of higher CCT on functional scores. RESULTS: At 6 months' follow-up, CSS and UCLASS were higher in the patients with higher CCT (mean ± standard deviation, 59 ± 17 vs 54 ± 14, P = .020; and 30 ± 5 vs 28 ± 5, P = .020, respectively). At 12 months' follow-up, CSS, UCLASS, and OSS were higher in the patients with higher CCT (71 ± 13 vs 65 ± 14, P = .002; 30 ± 5 vs 28 ± 5, P = .009; and 15 ± 6 vs 18 ± 7, P = .001, respectively). At 24 months' follow-up, CSS and OSS were higher in the patients with higher CCT (74 ± 11 vs 69 ± 13, P = .006; and 14 ± 4 vs 16 ± 8, P = .041, respectively). CONCLUSION: We conclude that although a higher CCT is not associated with clinically significant differences in functional outcomes, further studies examining postoperative imaging as well as perioperative optimization of bone mineral density may yield valuable results regarding the impact of CCT on cuff healing and functional outcomes. LEVEL OF EVIDENCE: III (retrospective comparative therapeutic trial).

Effect of the humeral neck-shaft angle and glenosphere lateralization on stability of reverse shoulder arthroplasty: a cadaveric study.

BACKGROUND: Lateralizing the glenosphere and decreasing the humeral neck-shaft angles are implant design parameters that reduce the risk of scapular impingement. The effects of these parameters on joint stability remain unclear. This study evaluated the effect of glenosphere lateralization and humeral neck-shaft angle on joint stability by quantifying the anterior dislocation force in different arm positions. METHODS: Reverse shoulder arthroplasty was performed on 19 human shoulder specimens. Anterior dislocation force and maximum external rotation were evaluated using a robot-based shoulder simulator. By varying the neck-shaft angle and magnitudes of glenosphere lateralization, 12 configurations were analyzed with the glenohumeral joint in 30° and 60° of abduction, in neutral, and in 30° of external rotation. RESULTS: At 30° of abduction, measurements showed significantly higher dislocation forces for the 9-mm and 6-mm lateralized glenosphere than for the 0-mm (P < .0001, P = .007) nonlateralized glenosphere. At 60° of abduction, measurements showed significantly higher dislocation forces for the 9-mm and 6-mm lateralized glenosphere than for the 0-mm (P < .0001, P = .0007) and 3-mm (P = .0003, P = .04) glenosphere. Configurations with a neck-shaft angle of 135° showed significantly higher dislocation forces than configurations with a neck-shaft angle of 145° (P = .02) or 155° (P = .02) at 30° of abduction in 30° of external rotation. Neck-shaft angle and glenosphere lateralization had no influence on maximum external rotation capability. CONCLUSION: Glenosphere lateralization significantly increased anterior stability of the glenohumeral joint without influencing the range of passive external rotation. The humeral neck-shaft angle only had a minor effect on anterior stability.

An Anatomic Study on Whether Femoral Version Originates in the Neck or the Shaft.

BACKGROUND: Femoral anteversion is generally asymptomatic but can result in lower extremity issues like patellofemoral instability and pain. Surgical correction of anteversion can be performed proximal, mid shaft or distal. A better understanding of the specific location of the rotational deformity can help guide the optimal location of the osteotomy. In this study we examine the contribution of the femoral neck and shaft to total femoral version. METHODS: We studied 590 pairs of well-preserved cadaveric femurs. Total femoral version was defined as the axial plane angle between the femoral neck and posterior femoral condyles. Femoral shaft torsion was defined as the axial plane angle between the lesser trochanter and posterior femoral condyles. Neck version was the mathematical difference between total femoral version and shaft version. RESULTS: Neck version (right femur R=0.582; left femur R=0.632) contributed slightly more than shaft version (right femur R=0.505; left femur R=0.480) to overall femoral version, but both were substantial and neither completely predicted overall femoral version. Age was not found to contribute to femoral version, and sex and race had statistically significant but small contributions. CONCLUSIONS: Our data show that both the femoral neck and femoral shaft substantially contribute to femoral version, and to our knowledge is the first to statistically demonstrate that neither level can be used to predict total femoral version. This suggests that one cannot generalize a single optimal site for correction or prediction of femoral version from an osteological perspective, and that individualized assessment may be beneficial. CLINICAL RELEVANCE: This study suggests that methodologies for determining the level of femoral version might be important as the level in any given patient can vary.

Experimental Evaluation of the Properties of 3D Porous Bone Substitute Based on Calcium Phosphate on the Model of Monocortical Diaphysial Femur Defect in Rats.

A new alloplastic high-permeable material based on tricalcium phosphate with Kelvin architectonics created by stereolithographic 3D-printing was studied in vivo. A monocortical defect of the femur was modeled in rats and the material was implanted into the defect area. In 24 weeks, the animals were euthanized and histological examination of the defect area was performed. One femur fracture with fixator migration was recorded after implantation of the studied material and the reference chronOS synthetic material. The studied material demonstrated better osteoconductive properties then traditional osteoplastic material, which was seen from greater number of bone trabeculae and their area in the defect area.

Reconstructing diaphyseal tumors using radiated (50 Gy) autogenous tumor bone graft.

AIMS: Establish oncologic safety using 50 Gy to sterilize tumor bearing bone before reimplantation in primary diaphyseal high grade extremity tumors, determine extracorporeal radiotherapy (ECRT) graft survival, and analyze factors that affect union at osteotomy sites. MATERIALS AND METHODS: Seventy non metastatic patients underwent reconstruction with intercalary ECRT grafts sterilized with 50 Gy. Diagnosis included osteosarcoma (38) and Ewing's sarcoma (32). At last follow-up-49 patients were alive, 19 had died and 2 were lost to follow up. Survivors had minimum follow up of 3 years (range 39-127 months). RESULTS: Ninty one percent metaphyseal osteotomies united without additional intervention compared to 71% diaphyseal osteotomies. Additional small plate at diaphyseal osteotomy apparently reduced incidence of non-union (17% vs 31%) (P = 0.49). Addition of morsellised allograft did not help union. There were seven (10%) local recurrences, all in soft tissue. Seventeen of 69 patients (25%) needed removal of ECRT graft. Five year survival for ECRT graft (removal for all causes) was 79% and 84% (excluding removal for local recurrence). CONCLUSIONS: Reimplanting sterilized tumor bone using 50 Gy for tumor ablation is an easily applicable, oncologically safe, biological reconstruction option for primary diaphyseal extremity tumors.

Endochondral growth disruption during vitamin D deficiency rickets in a mid-19th century series from Bethnal Green, London, UK.

OBJECTIVES: Vitamin D affects many aspects of cartilage and skeletal development. Inconsistent findings currently exist regarding the impact of vitamin D deficiency on childhood growth. This study aims to evaluate the impact of vitamin D deficiency on childhood skeletal development by exploring long bone growth in children with healed and active rickets. MATERIALS AND METHODS: Forty-four known-age children (2 months to 12 years) with rickets and 99 without rickets were compared with modern reference data from North America. Diaphyseal lengths of children with active rickets (34.1%, 15/44), healed rickets (65.9%, 29/44), and without rickets (99/143, 69.2%) were expressed as a percentage of expected length and an average percentage value was calculated across all available long bones. RESULTS: Combined data for all six long bones revealed that children with active rickets had achieved only 75.3% of their expected size whereas, on average, children with healed rickets had achieved 81.6% of their expected size. On average, children without skeletal evidence of rickets had achieved 83.7% of their expected size. Children with severe skeletal manifestations of active rickets had a lower average percentage of expected size (70.4%) than the remainder of children affected by the condition. DISCUSSION: Pronounced growth faltering existed in children with active rickets and affected the upper and lower limb, indicating systemic growth failures during the deficiency. Poor maternal health, early weaning and inadequate infant feeding, and lack of sunlight exposure likely contributed to the development of rickets. Complex interactions between pathological conditions, nutritional deficiencies and vitamin D deficiency may have exacerbated growth impacts.

What Is the Adverse Event Profile After Prophylactic Treatment of Femoral Shaft or Distal Femur Metastases?

BACKGROUND: Prophylactic surgical treatment of the femur is commonly offered to patients with metastatic disease who have a high risk of impending pathologic fracture. Prophylactic fixation is associated with improved functional outcomes in appropriate patients selected based on established criteria, but the perioperative complication profile has received little attention. Given the substantial comorbidity in this population, it is important to characterize surgical risks for surgeons and patients to improve treatment decisions. QUESTIONS/PURPOSES: (1) What is the incidence of postoperative adverse events after prophylactic surgical stabilization of metastatic lesions of the femoral shaft or distal femur? (2) How does this complication profile compare with stabilization of pathologic fractures adjusted for differences in patient demographics and comorbidity? METHODS: We performed a retrospective study using the National Surgical Quality Improvement Program (NSQIP) database. We identified patients undergoing prophylactic treatment of the femoral shaft or distal femur by Current Procedural Terminology (CPT) codes. Patients undergoing treatment of a pathologic fracture were identified by CPT code for femur fracture fixation as well as an International Classification of Diseases code indicating neoplasm or pathologic fracture. We tracked adverse events, operative time, blood transfusion, hospital length of stay, and discharge to a facility within 30 days postoperatively. There were 332 patients included in the prophylactic treatment group and 288 patients in the pathologic fracture group. Patients in the prophylactic treatment group presented with greater body mass index (BMI), whereas the pathologic fracture group presented with a greater incidence of disseminated cancer. The odds of experiencing adverse events were initially compared between the two groups using bivariate logistic regression and then using multivariate regression controlling for age, sex, BMI, and American Society of Anesthesiologists (ASA) class and disseminated cancer causing marked physiological compromise per NSQIP guidelines. RESULTS: With multivariate analysis controlling for age, sex, BMI, and ASA class, patients with pathologic fracture were more likely to experience any adverse event (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.03-2.29; p = 0.036), major adverse events (OR, 1.61; 95% CI, 1.01-2.55; p = 0.043), death (OR, 1.90; 95% CI, 1.07-3.38; p = 0.030), blood transfusion (OR, 1.57; 95% CI, 1.08-2.27; p = 0.017), and hospital stay ≥ 9 days (OR, 1.51; 95% CI, 1.05-2.19; p = 0.028) compared with patients undergoing prophylactic treatment. However, when additionally controlling for disseminated cancer, the only difference was that patients with pathologic fractures were more likely to receive a blood transfusion than were patients undergoing prophylactic fixation (OR, 1.61; 95% CI, 1.12-2.36; p = 0.011). CONCLUSIONS: After controlling for differences in patient characteristics, prophylactic treatment of femoral metastases was associated with a decreased likelihood of blood transfusion and no differences in terms of the frequency of other adverse events. In the context of prior studies supporting the mechanical and functional outcomes of prophylactic treatment, the findings of this cohort suggest that the current guidelines have achieved a reasonable balance of morbidity in patients with femoral lesions and further support the current role of prophylactic treatment of impending femur fractures in appropriately selected patients. LEVEL OF EVIDENCE: Level III, therapeutic study.

Painful transient edema in the tibial diaphysis: the challenges and the essence of biopsy in treatment.

BACKGROUND: Some patients experience a non-traumatic pain in the tibial diaphysis similar to that in the clinical and radiological findings of a tumor, an infection or a stress fracture and cannot be definitively diagnosed even after biopsy. In this study, our aim was to exhibit the challenges in the diagnosis of this patient group and to evaluate this type of patients with a limited population in the literature. METHODS: Eighteen extremities of 16 patients, whose complaints of non-traumatic pain in the tibial diaphysis were evaluated by our tumor council and T2-weighted MR scans of the medullary bone had shown hyperintense signal changes or tumor-like appearances, were evaluated with histological, radiological, and clinical results. RESULTS: Lesions were detected in 18 extremities of the 16 patients (seven males, nine females; mean age 23 [range 7 to 51] years). Four of the lesions were in the right tibial diaphysis, ten were in the left, and two were bilateral. Laboratory findings of the patients were normal. Based on the decision of the tumor council, biopsy was performed on 12 patients. All patients' complaints were gone and MRI findings decreased during the follow-up period. The complaints of the three patients who did not have a biopsy decreased after a mean period of three months. CONCLUSIONS: Medullary stress syndrome has been reported in the literature in various forms and in a limited number of cases, including longitudinal stress fracture and transient medullary edema of the bone. In light of our findings, we deduced that biopsy of the diaphyseal lesions in this patient group is essential and that the complaints of this patient group declined in the earlier term in comparison to the patients who were not performed biopsy.

Bone Formation Parameters of the Biopsied Ilium Differ between Subtrochanteric and Diaphyseal Atypical Femoral Fractures in Bisphosphonate-Treated Patients.

Atypical femoral fractures (AFFs) are defined as atraumatic or low-trauma fractures located in the subtrochanteric or diaphyseal sites. Long-term bisphosphonates (BPs) are administered to prevent fragility fractures in patients with primary osteoporosis or collagen diseases who are already taking glucocorticoids (GCs). Long-term BP use is one of the most important risk factors for AFFs. Its pathogenesis is characterized by severely suppressed bone turnover (SSBT), but whether the characteristics of patients are different regarding to location of fracture site remains unknown. In this study, we compared the characteristics and bone histomorphometric findings between subtrochanteric and diaphyseal sites in patients with BP-associated AFFs. Nine women with BP-associated AFFs were recruited, including 3 with systemic lupus erythematosus, 2 with rheumatoid arthritis, 2 with primary osteoporosis, 1 with polymyalgia rheumatica, and 1 with sarcoidosis. Patients were divided into the subtrochanteric group (n = 5; average age, 52 years; BP treatment, 5.9 years) and the diaphyseal group (n = 4; average age, 77 years; BP treatment, 2.6 years). Compared with the diaphyseal group, the subtrochanteric group had significantly higher daily GC doses (average, 10.9 vs. 2.3 mg/day) and significantly lower serum 25-hydroxyvitamin-D levels (17.8 vs. 25.6 ng/mL). Bone histomorphometry of the biopsied iliac bone showed SSBT in 3 cases (subtrochanteric, n = 1; diaphyseal, n = 2). Osteoid volume and trabecular thickness were significantly lower in the subtrochanteric group than in the diaphyseal group. Bone formation was inhibited more severely in subtrochanteric than in the diaphyseal group due to the higher GC doses used.

Beaming in Charcot Arthropathy-Intramedullary Fixation for Complicated Reconstructions: A Cadaveric Study.

In the modern treatment of Charcot neuroarthropathy, beam screw fixation is an alternative to plate and screw fixation. Exposure is minimized for implantation, and this technique supports the longitudinal columns of the foot as a rigid load-sharing construct. A published data review identified a paucity of data regarding metatarsal intramedullary canal morphology relevant to beam screw fixation. The purpose of the present study was to describe metatarsal diaphyseal morphology qualitatively and quantitatively in an effort to provide data that can be used by surgeons when selecting axially based intramedullary fixation. Twenty fresh-frozen cadaveric below-the-knee specimens were obtained. The metatarsals were exposed, cleaned of soft tissue, and axially transected at the point of the narrowest external diameter. Next, a digital caliper was used to measure the size and shape of the diaphysis of the first through fourth metatarsals. The diaphyseal canal shape was categorized as round, oval, triangular, or pear. The widest distance between the endosteal cortical surfaces was measured. Triangular endosteal canals were only found in the first metatarsal, and the remainder of the metatarsal canals were largely round or oval. These data help to approximate the size of fixation needed to achieve maximal screw-endosteal purchase.

Multiple diaphyseal sclerosis (Ribbing disease): what about neridronate?

Sclerosing bone disorders are uncommon diseases and represent a diagnostic challenge. Osteocondensation is a bone alteration, involving both acquired and hereditary conditions. Multiple diaphyseal sclerosis (Ribbing disease) is an inherited condition. It is characterized by excessive proliferation of endosteal and periosteal osseous tissue at the diaphyses of long bones, especially of tibias and femurs. The conventional radiology depicts cortical thickening of diaphyses of long bones while bone scintigraphy shows characteristically an abnormal tracer concentration in the involved diaphyses. The magnetic resonance imaging (MRI) examination confirms the presence of sclerosis and reveals bone marrow edema in the diaphyses of the afflicted bones. Due to the lack of knowledge of the pathophysiology, the treatment is empirical with glucocorticoids or bisphosphonates. Concerning bisphosphonates, the literature reports are conflicting. We report the case of a patient that showed lack of response to intravenous neridronate within 1 year of treatment, both in terms of pain and persistence of bone marrow edema at MRI.