Percutaneous Fixation of Impending Fracture of the Hip.

According to the literature, prophylactic consolidation of proximal femur lytic metastasis the is recommended when the Mirels' score is above 8. Osteoplasty (cementoplasty of proximal femur) alone provides inadequate consolidation. Various mini-invasive technics, augmented osteoplasties, have been proposed for better long-term consolidation. The aim of this review is to detail the augmented osteoplasty techniques described in the literature and to report their safeties and efficacies to prevent pathological fracture of the proximal femur. A PubMed research found 8 studies that evaluated augmented osteoplasty of the proximal femur in cancer patients. All devices demonstrate adequate safety and low rate of secondary pathological fractures.

Prevention and Treatment of Pathologic Femur Fractures: Evidence as of 2019.

This chapter is largely drawn from the recently published (2019) clinical practice guideline on the treatment of metastatic carcinoma and myeloma of the femur jointly produced by the Musculoskeletal Tumor Society, American Society for Radiation Oncology, and American Society of Clinical Oncology. Previous clinical practice guidelines on this topic broadly addressed the potential benefits of bone-targeted agents (eg, diphosphonates) on skeletal-related events, a broad term that encompasses pathologic fractures of any bone, need for surgery or radiation, and hypercalcemia. Guidelines on the use of palliative radiation therapy primarily focused on short-term pain control and long-term radiation-induced adverse effects. The starting goals of this guideline were twofold-focus on the femur, as fractures of the femur almost always require surgery and, when about the hip, dramatically alter patients' quality of life and, potentially, survival; and to address this topic in a multidisciplinary fashion that includes the insights of orthopaedic surgeons, along with radiation oncologists and medical oncologists. For many important clinical topics, there is a dearth of evidence, which will hopefully prompt researchers and funding agencies to help fill these evidentiary gaps.

The Sensitivity of Orthopaedic Surgeons to the Secondary Prevention of Fragility Fractures.

BACKGROUND: Orthopaedic surgeons must play an important role in the secondary prevention of fragility fractures; however, some surgeons are more aware than others of their responsibility regarding fracture prevention. The purpose of the present study was to identify which factors can lead to a higher sensitivity for fracture prevention. METHODS: A cross-sectional survey was distributed to orthopaedic surgeons via online invitation or at academic conferences in China from July through October 2015. A total of 452 surgeons responded. As the primary outcome measure, we created a sensitivity scoring system for fracture prevention based on the respondents' answers to 5 questions regarding behavior in the following areas: risk-factor evaluation, pharmacologic therapy, nonpharmacologic therapy, patient education, and follow-up. Multivariable linear regression and multivariable logistic regression analyses were used to identify factors related to surgeon sensitivity to fracture prevention. RESULTS: Very few surgeons reported having received adequate training regarding fracture prevention or reading guidelines or other fracture prevention literature (22% and 30%, respectively). Most respondents initiated pharmacologic or nonpharmacologic therapy (82% and 75%, respectively) for the treatment of confirmed osteoporosis among patients with fragility fractures, but only half performed a risk-factor evaluation, patient education, or timely patient follow-up (51%, 52%, and 48%, respectively). In the multivariable linear regression model, the orthopaedic surgeon's age (ß = 0.09, p = 0.003), self-rated knowledge level regarding osteoporosis or related issues (ß = 0.16, p < 0.001), self-perceived effectiveness in using preventive measures for patients with a fragility fracture (ß = 0.62, p < 0.001), and use of clinical pathways for fragility fractures in his or her workplace (ß = 1.24, p < 0.001) were independently associated with sensitivity scores for fracture prevention. Similar results were obtained from a multivariable logistic regression model. CONCLUSIONS: In China, the sensitivity of orthopaedic surgeons to the secondary prevention of fragility fractures is relatively low. Implementation of a comprehensive prevention approach and targeted continuing medical education are required to encourage surgeons to take greater responsibility for screening, treating, educating, and following their patients with fragility fractures.

Early Improvement in Pain and Functional Outcome but Not Quality of Life After Surgery for Metastatic Long Bone Disease.

BACKGROUND: Bone metastases represent the most frequent cause of cancer-related pain, affecting health-related quality of life and creating a substantial burden on the healthcare system. Although most bony metastatic lesions can be managed nonoperatively, surgical management can help patients reduce severe pain, avoid impending fracture, and stabilize pathologic fractures. Studies have demonstrated functional improvement postoperatively as early as 6 weeks, but little data exist on the temporal progress of these improvements or on the changes in quality of life over time as a result of surgical intervention. QUESTIONS/PURPOSES: (1) Do patients' functional outcomes, pain, and quality of life improve after surgery for long bone metastases? (2) What is the temporal progress of these changes to 1 year after surgery or death? (3) What is the overall and 30-day rate of complications after surgery for long bone metastases? (4) What are the oncologic outcomes including overall survival and local disease recurrence for this patient population? METHODS: A multicenter, prospective study from three orthopaedic oncology centers in Quebec, Canada, was conducted between 2008 and 2016 to examine the improvement in function and quality of life after surgery for patients with long bone metastases. During this time, 184 patients out of a total of 210 patients evaluated during this period were enrolled; of those, 141 (77%) had complete followup at a minimum of 2 weeks (mean, 23 weeks; range, 2-52 weeks) or until death, whereas another 35 (19%) were lost to followup but were not known to have died before the minimum followup interval was achieved. Pathologic fracture was present in 34% (48 of 141) of patients. The median Mirel's score for those who underwent prophylactic surgery was 10 (interquartile range, 10-11). Surgical procedures included intramedullary nailing (55), endoprosthetic replacement (49), plate osteosynthesis (31), extended intralesional curettage (four), and allograft reconstruction (two). Seventy-seven percent (108 of 141) of patients received radiotherapy. The Musculoskeletal Tumor Society (MSTS), Toronto Extremity Salvage Score (TESS), Brief Pain Inventory (BPI) form, and Quality Of Life During Serious Illness (QOLLTI-P) form were administered pre- and postoperatively at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year. Analysis of variance followed by post hoc analysis was conducted to test for significance between pre- and postoperative scores. The Kaplan-Meier estimate was used to calculate overall survivorship and local recurrence-free survival. A p value of < 0.05 was considered statistically significant. RESULTS: MSTS and BPI pain scores improved at 2 weeks when compared with preoperative scores (MSTS: 39% ± 24% pre- versus 62% ± 19% postoperative, mean difference [MD] 23, 95% confidence interval [CI], 16-32, p < 0.001; BPI: 52% ± 21% pre- versus 30% ± 21% postoperative, MD 22, 95% CI, 16-32, p < 0.001). Continuous and incremental improvement in TESS, MSTS, and BPI scores was observed temporally at 6 weeks, 3 months, 6 months, and 1 year; for example, the TESS score improved from 44% ± 24% to 73% ± 21% (MD 29, p < 0.001, 95% CI, 19-38) at 6 months. We did not detect a difference in quality of life as measured by the QOLLTI-P score (6 ± 1 pre- versus 7 ± 4 postoperative, MD 1, 95% CI, -0.4 to 3, p = 0.2). The overall and 30-day rates of systemic complications were 35% (49 of 141) and 14% (20 of 141), respectively. The Kaplan-Meier estimates for overall survival were 70% (95% CI, 62.4-78) at 6 months and 41% (95% CI, 33-49) at 1 year. Local recurrence-free survival was 17 weeks (95% CI, 11-24). CONCLUSIONS: Surgical management of metastatic long bone disease substantially improves patients' functional outcome and pain as early as 2 weeks postoperatively and should be considered for impending or pathologic fracture in patients whose survival is expected to be longer than 2 weeks provided that there are no immediate contraindications. Quality of life in this patient population did not improve, which may be a function of patient selection, concomitant chemoradiotherapy regimens, disease progression, or terminal illness, and this merits further investigation. LEVEL OF EVIDENCE: Level II, therapeutic study.

Infective complications in tumour endoprostheses implanted after pathological fracture of the limbs.

INTRODUCTION: Pathological fractures represent an adverse prognostic factor in primary and metastatic bone tumours. The purpose of this study was to evaluate the results of tumour silver-coated prosthesis implanted after pathological fractures. MATERIALS AND METHODS: A retrospective analysis was conducted on 30 patients with pathological limb fracture after primary or metastatic bone tumours treated by the same surgeon with wide margin resection and tumour prosthesis implant between 2005 and 2015. Silver-coated prostheses were implanted in 17 patients and uncoated prostheses were implanted in 13 patients. The primary outcome of the study was to evaluate the infective risk, the secondary outcomes were survival and functional level (visual analogue scale [VAS], 36-Item Short Form Health Survey [SF 36], and Musculoskeletal Tumour Society [MSTS] score) obtained at the longest follow-up available. A multivariate analysis was performed considering age, sex, tumour histology, grading and location, resection size, concomitant radiotherapy/chemotherapy, use of mesh for soft tissue reconstruction and local complications (dislocation, relapse, implant breakage). Scanning electron microscopy (SEM) analysis of explanted prosthesis was performed to study the residual silver-coating. RESULTS: The average age of patients in the study was 56.2 years (range 12-78 years). Silver-coated prostheses were implanted in 56.7% of patients, and uncoated tumour prostheses were used in the remaining 43.3%. The mean follow-up was 40.7 months. A total of 26.7% of patients died at a median time of 28.6 months after surgery. The overall rate of complications was 30%, with 16.7% due to infection. A total of 11.8% of the patients treated with silver-coated implants developed infection compared with 23.1% of the patients treated with uncoated tumour prostheses. There were no cases of early infection in the silver-coated prosthesis group, whereas early infection occurred in 66.7% of patients in the uncoated prosthesis group. All the functional outcomes were significantly improved after surgery. None of the other parameters analysed can be considered a significant negative prognostic factor for infection. The SEM analyses showed severe silver-coating degradation 2 years after first implant. No case of silver toxicity was demonstrated. DISCUSSION: There are few papers in the literature about infective complications in tumour prosthesis after pathological fracture. Silver-coated implants showed a protective action against early infection. Late infection rate was similar between the groups, thereby indicating a reduction of antimicrobial activity for the silver-coating over time. CONCLUSIONS: Silver-coated prostheses are a protective factor against early infections in limb salvage surgery after pathological fractures, so may represent the first-choice of implants in this type of surgery.

Osteomalacia with low alkaline phosphatase: a not so rare condition with important consequences.

Hypophosphatasia is a genetic disorder, characterised by a dysfunctional tissue-non-specific isoenzyme of alkaline phosphatase that impacts bone metabolism and predisposes to osteomalacia or rickets. The clinical presentation is very diverse, depending on the age of onset and the severity of the disease. Several forms of hypophosphatasia are recognised. We present a case of a 50-year-old woman with low impact fractures and loss of teeth at a young age. She also had a low alkaline phosphatase and was diagnosed with adult hypophosphatasia. Although the severe forms of hypophosphatasia are rather rare, the adult form is thought to occur quite frequently. As this condition is not well known by healthcare professionals, the time to diagnosis and initiation of adequate treatment is often postponed. When encountering a patient with low alkaline phosphatase, low bone density or a history of bone fractures, the possibility of hypophosphatasia should be considered.

Burden of skeletal-related events in prostate cancer: unmet need in pain improvement.

PURPOSE: Up to 75% of patients with prostate cancer experience metastatic bone disease, which leads to an increased risk for skeletal-related events (SREs) including pathological bone fracture, spinal cord compression, and hypercalcemia of malignancy. Our objective was to systematically review the literature on the impact of SREs on quality of life (QOL), morbidity, and survival with a primary focus on the impact of SREs on pain in prostate cancer patients. METHODS: We searched PubMed, limiting to peer-reviewed English-language human studies published in 2000-2010. The search was based on the US Food and Drug Administration and European Medicines Agency definition of an SRE, which includes pathologic fracture, spinal cord compression (SCC), hypercalcemia of malignancy, and radiotherapy or surgery to bone resulting from severe bone pain. RESULTS: A total of 209 articles were screened, of which 173 were excluded, and 36 were included in this review. Patients with SREs had more pain and worse survival compared with no SREs. Pathologic bone fractures worsened QOL and were associated with shorter survival. Radiation therapy of SCC alleviated pain and improved morbidity. SCC was associated with decreases in patient survival. Radiation therapy and surgery to bone improved pain. CONCLUSIONS: Specific SREs are associated with worse outcomes, including increased pain, poorer QOL, morbidity, and survival. Treatment of SREs is associated with improved pain, although there remains a need for more effective treatment of SREs in prostate cancer patients.

Impending fracture: A difficult diagnosis.

INTRODUCTION: The concept of impending fracture has been developed to help address this difficult skeletal-related problem. There is no consensus on the subject in the literature and a specific definition of impending fracture has not been outlined. DISCUSSION: There is disagreement in the literature on the best criteria for the diagnosis of impending fracture. A method of discrimination for patients who need preventative treatment for a metastatic lesion has not yet been established. CONCLUSIONS: Current score systems consider variables like size, location and treatment response and are easy to remember. However, these score systems have never been evaluated prospectively and rigorously, their sensitivity is low and they do not take into account potentially relevant factors that can influence patient prognosis. A consistent tool to evaluate impending fractures would be of great value to guide the treatment of metastatic bone disease.

Addressing secondary prevention of osteoporosis in fracture care: follow-up to "own the bone".

The majority of the 1.8 million individuals who sustain a fracture annually in the United States have osteopenia or osteoporosis, yet <15% of these patients subsequently receive treatment for osteoporosis. A prospective cohort study was conducted to assess the effect of two different interventions on the rate of osteoporosis treatment in patients with a fragility fracture. Patients who were fifty years of age or older and were hospitalized for the treatment of a fragility fracture at either of two academic institutions were eligible for inclusion in the study. The intervention at one hospital involved immediate care for osteoporosis, including initiation of pharmacologic therapy during hospitalization. The intervention at the other hospital involved delayed care, including recommendations for osteoporosis counseling, bone-mineral density testing, and potential treatment for osteoporosis that were communicated to the primary care physician after the patient was discharged from the hospital. Patients were surveyed by telephone six months after the fracture, and their medical and pharmacy records were reviewed to verify the osteoporosis treatment that they had received. The mean age was 73 ± 10 years in the immediate-care group and 74 ± 12 years in the delayed-care group. Eighty percent of the patients were women. Sixty-five percent of the patients in each group completed the telephone interview six months after the fracture, and most had seen their primary care physician and undergone bone-mineral density testing. The rate of bone-mineral density testing was 92% in the immediate-care group compared with 76% in the delayed-care group. Both immediate and delayed care for osteoporosis resulted in a significant increase in the treatment rate compared with the baseline rate of 0% (p < 0.001). However, the primary care physician had initiated osteoporosis therapy by six months after the fracture in only 30% of the patients in the delayed-care group compared with a treatment rate of 67% in the immediate-care group (p < 0.001). Limitations of the study include the possibility that the findings resulted from a difference between the two study centers rather than between the two strategies. In addition, because of the academic and integrated nature of the medical systems at which the study was conducted, the findings cannot necessarily be extrapolated to other types of institutions. In summary, a recommendation for osteoporosis treatment made by an orthopaedic surgeon to the patient's primary care physician resulted in an increase in the rate of bone-mineral density testing and in the rate of therapy compared with baseline. However, immediate initiation of osteoporosis care during hospitalization for the fragility fracture resulted in a higher rate of treatment--with two-thirds of the patients receiving therapy six months after the fracture--compared with delayed initiation.

Preventing osteoporotic fractures in older people.

While fractures at the spine, wrist and hip are regarded as classical osteoporotic fractures, all fragility fractures in the elderly should be considered as osteoporotic once pathological fracture (e.g. metastatic disease) has been excluded. The assessment of fracture risk should take account of specific risk factors in addition to bone mineral density (BMD). The WHO has produced FRAX, a well validated tool that estimates the probability of a major osteoporotic fracture in the next 10 years. The algorithm is specifically designed for primary care. After age and prior fragility fracture, BMD is the next major determinant of fracture risk. Rather than scanning all individuals with a risk factor, measurements should be targeted to those whose probability of fracture lies close to the intervention threshold where knowledge of BMD will influence management. Individuals with a low trauma vertebral fracture or low BMD for age should be investigated for underlying causes of osteoporosis. Secondary causes account for up to 40% of cases of osteoporosis in women and 60% in men. The goal of osteoporosis management is to reduce the future risk of fracture. Lifestyle modification includes measures to reduce falls risk and bone loss such as exercise, adequate dietary calcium and avoidance of smoking and excessive alcohol consumption. All patients with an osteoporotic fracture and those at high risk should be assessed for falls risk. Combined therapy, with calcium and vitamin D, has been shown to reduce hip fracture risk in the frail elderly and should be considered in all older patients who are housebound or in residential care. Alendronate and risedronate are available as once-weekly preparations with evidence for significant reductions in vertebral and non-vertebral fractures. Denosumab is approved for osteoporosis in postmenopausal women at increased risk of fractures. Strontium ranelate has been shown to reduce fracture risk significantly in postmenopausal women.

[Estrogens for treatment of osteoporoses].

It has been noted that estrogens have strong effects for suppression of bone absorption and prevention of fracture. Although WHI reports emphasized on adverse events of hormone replacement therapy (HRT) too much to avoid this therapy for osteoporosis, recently there are several statements for HRT with positive assessment. Those mentioned that considering risk factor of HRT and age factor, it is possible to use estrogens safely. There is the evidence that estrogens prevent bone fractures in not only osteoporotic women but also healthy women. It is a unique effect that only estrogen has among antiosteoporotic drugs. Taking these characters into consideration, it seems that estrogen therapy is useful for prevention of fractures in perimenopausal women irrespective of bone condition.

[Evidence for the selective estrogen receptor modulator raloxifene--its pharmacological characteristics, efficacy and safety profiles].

With the endpoint of osteoporosis treatment thus clarified, currently, the selective estrogen receptor modulator (SERM) raloxifene represents the mainstay of therapy for osteoporosis, together with the antiresorptive agents bisphosphonates. Thus, this review has drawn mainly on the results of the MORE study to explore the efficacy of raloxifene in inhibiting bone metabolism, increasing bone mineral density effects, and preventing bone fractures. Notably, the available evidence for raloxifene suggests that the efficacy of raloxifene in preventing bone fractures has not only to do with bone mineral density but also to do with bone quality.

[Bone lesion in multiple myeloma].

Bone destruction is a hallmark of multiple myeloma(MM). Almost all MM patients develop osteolytic bone lesions that can cause pathologic fractures and severe bone pain. Osteolytic lesions result from increased bone resorption due to osteoclast stimulation and decreased bone formation due to osteoblast inhibition. Plain radiography, CT, and MRI are established imaging techniques in MM. FDG-PET imaging is promising newer scanning technique under current evaluation. The aggressive features of MM bone lesions have significantly contributed to poor prognosis. Therefore, a systemic approach to analgesia, which includes radiotherapy and orthopedic intervention, must be applied as a part of the comprehensive care plan of MM patient. Bisphosphonates have been shown to reduce vertebral fractures and bone pain.

[Drug therapy for prevention of falls and fractures]. / Medikamentöse Sturz- und Frakturprävention.

The primary goal in the practical management of osteoporosis is to prevent first or subsequent fractures and thereby to avoid acute or chronic pain and progressive skeletal deformity. Therapeutic strategies should always take the complex pathogenetic mechanisms of fractures into account, especially the fact that mechanical impacts and falls play an important role in the majority of fracture events. Accordingly, recommendations to patients and the selection of drugs should aim at both, falls and fractures. In this context there is an increasing interest in the dual effects of vitamin D on bone and muscle. Controlled studies proved that adequate vitamin D supplementation is able to improve muscle strength, coordination and body sway and thereby reduce the risk of falls and fractures. Alendronate has been studied extensively by large trials of high quality and its efficacy to reduce the risk of vertebral and nonvertebral fractures is in line with the criteria of evidence-based medicine. The innovative combination of 70 mg alendronate with 2,800 IU vitamin D in a once-weekly tablet guarantees a basic supply with this important prohormone for bone and muscle. Due to a regular combined intake an improved compliance can be anticipated which will be followed by better therapeutic results in osteoporosis patients with increased fracture risk.

[Epidemiology of osteoporosis]. / Epidemiologija osteoporoze.

Osteoporosis represents a major and increasing public health problem with the aging of population. Major clinical consequences and economic burden of the disease are fractures. Many risk factors are associated with the fractures including low bone mass, hormonal disorders, personal and family history of fractures, low body weight, use of certain drugs (e.g. glucocorticoids), cigarette smoking, elevated intake of alchohol, low physical activity, insufficient level of vitamin D and low intake of calcium. This epidemiological review describes frequency, importance of risk factors and impact of osteoporosis and osteoporotic fractures. Objective measures of bone mineral density along with clinical assessment of risk factors can help identify patients who will benefit from prevention and intervention efforts and eventually reduce the morbidity and mortality associated with osteoporosis-related fractures.

Should low bone mass be treated?

More postemenopausal women with osteopenia fracture than those who have osteoporosis. Algorithms are being developed to enhance risk stratification to facilitate decisions when to treat in the osteopenic population. Evidence exists that osteoporosis agents can reduce fracture risk in the osteopenic population.

The role of menopausal hormone therapy in preventing osteoporotic fractures: a critical review of the clinical evidence.

Osteoporosis is a common disease resulting in millions of potentially preventable fractures each year. Women are disproportionately affected by osteoporosis compared to men, with loss of gonadal functioning and aging being the 2 most important contributing factors to osteoporosis. For many decades, menopausal hormone therapy (HT) has been the mainstay for the prevention and treatment of osteoporosis among menopausal women. While recent randomized trial data have confirmed findings from observational studies concerning HT's protective effect on osteoporosis, they showed that HT increases the risks of breast cancer, venous thromboses, stroke, and coronary heart disease. With a strong body of evidence showing the benefit of HT in preventing osteoporotic fractures, the challenge facing clinicians is not whether HT helps to prevent osteoporotic fractures, but whether HT's fracture-prevention benefits outweigh its risks. With several medications now available having efficacy comparable to HT in preventing fractures, decisions about therapy for osteoporosis or osteopenia should take into consideration bone mineral density, other risk factors for osteoporotic fracture, and a careful examination of the benefits and risks of each treatment option. After a brief discussion of the epidemiology and pathophysiology of osteoporosis, we review the evidence from observational studies and randomized studies examining the impact of menopausal hormone therapy on osteoporosis. We focus on whether there are specific subgroups of women that accrue greater or smaller benefit from HT in terms of osteoporotic fracture reduction. We then expand our perspective to include clinical endpoints other than osteoporosis, presenting a framework for factoring in the many risks and benefits of HT. We conclude that all women should be informed of all alternative treatment options and allowed to make an informed treatment decision according to their personal risks, preferences, values, and willingness to tolerate the risks of treatment.

Origin and treatment of fractures in spina bifida.

Children with spina bifida cystica have a high risk of fracturing their paraplegic legs. During the last fifteen years we observed 261 fractures and epiphyseal injuries in 173 children out of 1,400 (12.2%) patients with spina bifida. The increased risk of fracture seems to be due to reduced muscle activity in the paralysed limb with insufficient axial loading of the legs. A large proportion of fractures occurs after orthopedic interventions. Fractures are less common after urologic or neurosurgical procedures. Breaks are extremely frequent after operations in association with cast immobilization. Early standing and short immobilization times are the best defence mechanisms against fractures. If plasters are needed postoperatively one should preferably use the "Max and Moritz" standing cast. Fractures in spina bifida children heal quickly as compared to those in non-paralyzed children. In 30% excessive callus is seen. Immobilization for fracture care can be done in a standing cast even in the very early phase of treatment. In spite of the swelling and elevated temperature axial loading in the standing cast should continue. Splints and braces can be used instead of the plaster cast. By any means, the vicious circle of Fracture-Plaster-Fracture-Plaster should be avoided. Repeated stress on the growth plate causes a mechanism of loosening. The most common site is the distal tibia and femur, less often loosenings occur in the proximal tibia and proximal femur. Epiphyseal loosening is a nosological entity seen in spina bifida and also in congenital absence of sensation. Distal tibial epiphyseal loosening is frequently seen in adolescents who have learned to walk only after muscle balancing procedures in the hips.(ABSTRACT TRUNCATED AT 250 WORDS)