Rotationplasty after failed limb salvage: an alternative to amputation.

PURPOSE: Limb salvage procedures for musculoskeletal tumors have inherent complications. Though most complications can be managed with retention of the reconstructions, occasionally salvaging these reconstructions is not possible. We evaluated the outcomes of patients undergoing rotationplasty after multiple failed revisions of limb salvage surgery and document the success rate of this "salvage" technique and the subsequent functional outcome of these patients. METHOD: Between January 1, 1999, and December 31, 2018, 14 patients (12 male and 2 female) with a median age of 24 years (11-51 years) underwent rotationplasty after multiple failed revisions of limb salvage surgery. Indication for rotationplasty was infection (10 patients), failed megaprosthesis (2 patients), unstable biological reconstruction (1 patient) and local recurrence (1 patient). The mean number of surgeries done before the patient underwent rotationplasty was 5 (range 2-7). RESULTS: One patient developed a vascular complication (venous congestion) immediately after rotationplasty and underwent an early amputation. The remaining 13 patients had no surgical complications. Mean Musculo Skeletal Tumor Society score in 13 evaluable patients was 26 (23-30). CONCLUSION: Our study demonstrates the utility of rotationplasty as a "salvage" procedure after multiple failed lower limb salvage surgeries. It offers good success rates, low rates of complications and good functional outcomes in carefully selected cases.

Functional and Oncological Outcomes of Multidisciplinary Management of Ewing's Sarcoma of Clavicle: A Single-Center Experience.

Objectives Ewing's sarcoma is best treated using a multidisciplinary approach. We discuss the functional and oncological outcomes of clavicular Ewing's sarcoma which has been sparsely reported in literature. Materials and Methods We retrospectively evaluated patients who underwent resections for Ewing's sarcoma of clavicle from January 2002 to December 2017. The study end points were locoregional recurrence free survival (LRFS), disease-free survival (DFS), and overall survival (OS) at 3 and 5 years, and functional outcomes measured by Musculoskeletal Tumor Society (MSTS) scores. Statistical Analysis The LRFS, DFS, and OS were calculated and analyzed using the Kaplan-Meier method and log-rank test. Results Data of 21 patients (male: 12, female: 9) was analyzed with a mean age [range] of 15.3 [6-40] years. Total clavicle excision was done in 62% (13 of 21) while 38% ( n = 8) had partial resections. Radiotherapy was administered in 15 patients (71.5%). At a median follow-up of 42 months (range: 7-198), data of 20 patients was available for follow-up. Ten patients died (due to disease: nine, other reasons: One), eight are disease free and alive, one had metastasectomy on recurrence and is disease free and, one patient is alive with disease and on palliative chemotherapy. The LRFS, DFS, and OS were 95, 59, 65% and 95, 47, 59% at 3 and 5 years, respectively. The functional evaluation done for nine patients who are free of disease showed a mean MSTS score of 29 (range: 27-30; total clavicle excision: 28.5, partial clavicle excision: 29.5). Conclusion Patients with Ewing's sarcoma of the clavicle who underwent resection without reconstruction have acceptable local control rates and excellent functional outcomes.

Implant cement spacer-a cost-effective solution for reconstruction of proximal humerus defects after tumor resection.

The proximal humerus is a common location for both primary benign and malignant bone tumors and may require sacrificing deltoid muscles, axillary nerve and/or rotator cuff along with proximal humerus resection. Thus, post operatively shoulder movements are restricted. The main goals of reconstruction are to maintain a stable shoulder so that the function of elbow and hand can be optimized. Various reconstruction options are available after proximal humerus resection. We present our experience in using implant-cement spacers as a primary reconstruction option for limb salvage in the primary tumors of proximal humerus. All cases were retrieved from our prospectively maintained surgical database. 142 patients (96 males and 46 females) with a median age of 17.5 years (3-70 years) were operated with implant cement spacer between January 2006 and April 2019. Median follow up was 34 months (1-174 months). Functional outcome of the surgery was assessed in survivors by Musculoskeletal Tumor Society score (MSTS). Implant survival was assessed by Kaplan Meier analysis and competing risk analysis. On last follow up, out of 142 cases, 81 patients had died, 54 are alive and seven were lost to follow up. 18(13%) patients underwent revision surgery for symptomatic proximal migration, implant failure or infection. Four (2.8%) patients underwent forequarter amputation for local recurrence. The five years implant survival (IS) by Kaplan Meier analysis was 79.6% and as per competing risk analysis, the chances of implant revision are 12% and 18% at five and ten years respectively. Mean MSTS score in survivors was 71% (60-80%). Implant cement spacer is a cost-effective alternative for reconstruction of proximal humerus with revision rates and function comparable to other reconstructions in cases where deltoid, axillary nerve and/or rotator cuff are excised.

The effect of COVID-19: Adopted changes and their impact on management of musculoskeletal oncology care at a tertiary referral centre.

BACKGROUND: COVID-19 pandemic has disrupted access to healthcare. Delay in diagnosis and onset of care increases cancer related mortality. We aim to analyse its impact on patient profile, hospital visits, morbidity in surgically treated patients and process outcomes. METHODS: We analysed an ambi-directional cohort from 16th March to June 30, 2020 (Pandemic cohort, PC) as compared to 2019 (Pre-pandemic cohort, PPC). We measured, new patient registrations, proportion of 'within state' patients vs 'rest of India', median time to treatment decision, proportion of patients seeking 'second opinions', modality of initial treatment (surgery/radiotherapy/chemotherapy), 30-day post-operative morbidity/mortality and conversion of inpatient-to 'teleconsult' in the PC. RESULTS: Between the 2 cohorts, new registrations declined from 235 to 69 (70% reduction). The percentage of 'within state' patients increased from 41.7% to 53.6% (11.9% increase). There was a decline in second opinion consults from 25% to 16%. The median time to decision-making decreased to 16 days in PC vs 20 days in PPC (20% reduction). Surgery was the first line of treatment in 40% as compared to 34% in the PPC with a mean time to surgery of 24 days in PC compared to 36 days in PPC (33% reduction). 66 surgeries were performed in the PC compared to 132 in the PPC. Thirty day post operative morbidity needing readmission remained similar (18% PC, vs 17% PPC). Perioperative intensive care remained similar in both cohorts. Teleconsultation was deemed medically safe in 92.8% (439/473 patients). CONCLUSIONS: The COVID 19 pandemic has substantially reduced access and onset to cancer care. Post operative morbidity and mortality did not seem to worsen with triage. Teleconsultation is an effective tool in optimizing follow up strategy.

Elbow reconstruction after excision of proximal ulna tumors: Challenges and solutions.

Most malignant bone tumors are treated with surgical excision, adhering to oncologic principles, followed by reconstruction to preserve form and function whenever feasible. Primary bone tumors around the elbow are rare accounting for <1% of all skeletal tumors. They pose a reconstructive challenge, due to the complex interplay between the osseous & capsulo-ligamentous structures which is essential for elbow stability and function. Tumors affecting the proximal ulna are rare and reconstruction of the defects following these tumors is extremely challenging. Various reconstruction options like arthrodesis, autogenous bone grafts, allografts, re-implantation of sterilized tumor bone, pseudoarthrosis, and endoprosthesis have been tried with variable success. However, due to lack of standardization and the rarity of the site, surgeons are often in a dilemma to choose the correct option. This can lead to suboptimal functional outcomes and long-term failures. In this article, we reviewed the published literature on proximal ulnar tumors and noted the pros and cons of various reconstructive procedures. We have also attempted to formulate reconstruction recommendations based on the level of resection of proximal ulna.

Importance of Skeletal Staging in Chondrosarcoma of Bone: Results of Survey on Current Practices Among Musculoskeletal Oncologists.

PURPOSE: There are no clear guidelines for staging of conventional chondrosarcoma. We conducted an online survey to determine the current practices for skeletal staging for conventional chondrosarcoma among practicing oncologists and to assess any discrepancy in practices and with the published literature. METHODOLOGY: A simple ten-question online survey (e-mails and WhatsApp) was conducted among practicing oncologists over a period of 3 weeks using online portal (surveymonkey.com). It was followed by analysis based on each question to find current practices. RESULTS: 139 members participated in the survey (84% surgeons, 9% radiologists, 3% medical and 3% radiation oncologists and 1% nuclear medicine). 65% have been treating chondrosarcoma for more than 5 years. 88% opined that biopsy is mandatory even if the radiology is suggestive of a chondrosarcoma. 66% said that solitary skeletal metastasis is seen in less than 2% of the cases but 84% of participants were in favour of performing an investigation (bone scan/PET scan) for skeletal survey. While 43% opined skeletal metastasis is more common in recurrent chondrosarcoma, 26% said that performing a bone scan was likely to impact management, 28% said it will not impact management and 46% were unsure. Of the group who thought that a bone scan would impact management or were unsure, the majority (56%) opined that this was relevant only in grade 2 and grade 3 chondrosarcoma. CONCLUSION: There was lack of consensus regarding staging for chondrosarcoma. Only 26% of respondents were convinced that performing a bone scan was likely to impact management of chondrosarcoma. There is a need to analyze large data sets (retrospective/prospective) to arrive at an evidence-based staging algorithm for chondrosarcoma.

Operative technique of distal radius resection and wrist fusion with iliac crest bone graft.

Malignant lesions of distal radius and appropriately selected cases of benign aggressive lesions (giant cell tumor) of distal radius require resection for limb salvage. Post resection, reconstruction of that defect can be accomplished by either arthrodesis or arthroplasty both having their own pros and cons. In cases undergoing arthrodesis as modality of reconstruction, small defects (≤6 cm) can be reconstructed using autologous iliac crest bone graft which results in good cosmetic appearance and functional outcome. We have described in detail, the preoperative planning, surgical steps and rehabilitation of wrist fusion with iliac crest bone grafting post distal radius resection.

'Umbrella construct' - an innovative technique for reconstruction of the proximal humerus after curettage in locally aggressive benign bone tumours.

AIM: Reconstructing locally aggressive benign bone tumours of the proximal humerus after intralesional curettage is a challenge. We present a novel reconstruction technique 'Umbrella construct' where a femoral head and a strut allograft are combined to reconstruct the cavity. Complications, graft incorporation time, functional (Musculoskeletal Tumor Society score [MSTS]) and oncological outcomes were evaluated. METHODS: Between January 2006 and June 2017, 11 cases (10 giant cell tumours, 1 chondroblastoma) underwent curettage followed by reconstruction with Umbrella construct. There were six females and five males with a mean age of 23 years (range 14-36 years). The maximum longitudinal extent of disease was 9 cm (range 5-9 cm). RESULTS: The median follow-up was 54 months (range 34-122 months). The mean allograft incorporation time was 7 months (5-8 months). One patient had a graft fracture which was managed conservatively. Two cases developed local recurrence and the construct was revised to a prosthesis in both. The mean MSTS score for the nine cases with retained graft was 27 (23-29). CONCLUSIONS: Umbrella construct is an effective reconstruction modality which helps to maintain joint congruity and limb length. It has acceptable oncological outcomes with good function.

Giant cell tumors of the sacrum: is non-operative treatment effective?

PURPOSE: Giant cell tumors of sacrum in which surgery could endanger important neural components were treated with short term denosumab, angioembolisation and radiotherapy in different combinations to provide a non-operative function preserving treatment option. METHODS: Between April 2013 and April 2017, 13 sacral GCTs [proximal extent of disease-S1 (10), S2 (2) and S3 (1)] were treated. Age ranged from 20 to 50 years. One patient had loss of bladder control at presentation. Treatment protocol included short term denosumab, angioembolisation and radiotherapy in different combinations. Patients were evaluated every 10-12 weeks. If disease ceased to progress no further treatment was advised. In case of progress, patient was advised additional denosumab and/or angioembolisation and/or radiotherapy till disease stopped progressing. RESULTS: 10 patients have non-progressive disease and are asymptomatic, 2 have non-progressive disease with occasional pain, 1 patient died. Follow-up duration (since final non-progression of disease) ranged from 15 to 54 months (mean 31 months). Total number of angio embolisation sessions ranged from 0 to 12 (mean = 4), total number of denosumab doses ranged from 5 to 16 (mean = 9). Five patients did not receive any radiotherapy, 5 received 50.4 Gy and one patient each received 50.4 + 30 + 12 Gy, 50.4 + 30 Gy and 50.4 + 12 Gy. The patient with loss of bladder control at presentation recovered. There were no other long-term complications. CONCLUSION: This study offers a non-surgical management option that provides good mid-term local control while preserving neurological function in these complex lesions.

Proximal femur sarcomas with intra-articular disease-Do intra-articular resections provide adequate local control?

BACKGROUND AND OBJECTIVES: Hip preserving (intra-articular) resections for proximal femur sarcoma have better function compared to peri-acetabular (extra-articular) resections, which are more complex and morbid. But, do intra-articular resections in selected cases with intra-articular disease provide adequate local control? METHOD: Extra-articular resection or intra-articular resection in cases without pathologic fracture or away from joint/capsule was classified as a planned safe margin (SM). Circumferential removal of labrum without acetabular resection in cases without gross joint contamination was classified as planned close margins (CM). We analyzed local recurrence-free survival (LRFS) (death as a competing event) for 86 proximal femur resections (SM = 55, CM = 31). RESULTS: The 5 years LRFS was 84% (n = 6/55, 10%) in the SM group and 67% (n = 4/31, 12%) in the CM group. There was no worsening of local recurrence (LR) in the CM group (subdistribution hazard [sH] = 0.69; 95% confidence interval [CI], 0.21-2.29; P = .56). Poor chemotherapy-induced necrosis predicted worse LR (sH = 0.1; 95% CI, 0.01-0.8; P = .03). Overall survival was 16% (SE 8%) at 5 years with LR vs 64% (SE 7%) without LR (P = .0076). CONCLUSION: In proximal femur sarcomas with potential for involvement of the hip joint, a CM in selected cases did not worsen LR; providing an option for avoiding additional morbidity with extra-articular resections.

Sarcoma Care Practice in India During COVID Pandemic: A Nationwide Survey.

BACKGROUND: Amidst the COVID-19 pandemic, management of cancer has been one of the most intensely debated topics across the globe. We conducted an online survey to determine the consistency/or the lack of it, in the management of sarcoma patients between centres and the changes in policies. METHODS: A twenty-five question online survey was conducted among practicing physicians over a period of 10 days using online portal (surveymonkey.com). It was followed by a critical analysis based on responses to each question. RESULTS: Of 194 medical professionals who participated, 80% were surgeons and 53% were working in government institutes. Most respondents (81%) continued their practice with some modifications. In OP majority (67%) relied only on symptom, contact enquiry and temperature recording for screening. COVID-19 testing was done more (43%) in IP patients. Most of institutes (83%) followed rotational policy to reduce the number of staff at risk while 57% offered an alternate accommodation. 52.3% continued chemotherapy for all patients while radiotherapy for all was offered by 45%. In metastatic cases, majority preferred either no treatment or non-surgical intervention (71%).84.5% believed in adapting changes (42%-avoid supra major surgeries, 27%-Operating only emergency cases and 15.5%-High grade sarcomas with curative intent) in surgical management of sarcomas. For benign bone tumors, majority (71%) agreed on adapting changes while 25% agreed on deferring all cases. 69% preferred teleconsultations for follow-up. Complete PPE were being used for all aerosol generating procedures by 44%. Only two thirds agreed with their institutes policy of PPE usage and COVID-19 testing. CONCLUSION: This survey has highlighted disparity on COVID-19 screening and management in various institutes across the country. This will act as a reference point for tracking future trends in bone and soft tissue tumor management guidelines, as the COVID-19 scenario unfolds globally and particularly in India.

Is Skeletal Imaging Essential in the Staging Workup for Conventional Chondrosarcoma?

BACKGROUND: Staging of a bone sarcoma before initiating treatment helps orthopaedic oncologists determine the intent of treatment and predicting the prognosis. As per National Comprehensive Cancer Network (NCCN) and European Society for Medical Oncology (ESMO) guidelines, there are no exclusive recommendations for chondrosarcoma staging. They are staged similar to other bone sarcomas even though skeletal metastases are extremely rare in chondrosarcomas. QUESTIONS/PURPOSES: We asked: (1) What proportion of patients with a chondrosarcoma present with detectable only skeletal metastasis? (2) What proportion of patients with chondrosarcoma present with skeletal metastasis with or without concurrent pulmonary metastases? METHODS: Between January 2006 to December 2017, 480 patients with histology-proven chondrosarcomas of the extremity, including clavicle, scapula, spine, and pelvis, presented to our institute. Fifty-three patients were excluded due to incomplete details about their staging. The remaining 427 were retrospectively analyzed and included in this study. Their clinical, radiological, and histopathological details were retrieved from patient files and electronic medical records. Of the 427 patients included, 53 had Grade 1 chondrosarcoma, 330 had Grade 2 chondrosarcoma, and 41 had Grade 3 chondrosarcoma. Grade was not available in three patients. All patients were staged with a thoracic CT scan and bone scan or a whole body fluorodeoxyglucose positron-emission tomography/CT (FDG PET/CT). Patients with a suspected or documented metastasis were reviewed again by an experienced radiologist and a nuclear medicine expert for the purpose of this study. A total of 8% (35 of 427) of patients with chondrosarcoma had isolated lung metastases at the time of initial staging. These included 9% (31 of 330) of patients with Grade 2 chondrosarcomas and 10% (4 of 41) of patients with Grade 3 chondrosarcomas. No patient with a Grade 1 chondrosarcoma had detectable lung metastases. The primary study endpoint was the number of patients who had a diagnosis of skeletal or skeletal and lung metastases as identified by the staging modalities. RESULTS: Three patients with Grade 2 chondrosarcoma had only skeletal metastasis. No patients with Grade 1 or Grade 3 chondrosarcoma had detectable bone metastases. Combined lung and bone metastases were seen in only two patients with Grade 2 chondrosarcoma. CONCLUSIONS: Our study found that the incidence of bony metastasis in conventional chondrosarcomas is extremely low. Considering the present results, we believe skeletal scanning may be overused in current staging algorithms. We do not have survival outcomes to know if detecting these few patients with skeletal lesions at initial presentation would be important in the absence of symptoms, but our data suggest that omitting skeletal imaging from the staging work-up of conventional chondrosarcomas should be considered. It may be reserved for patients with documented pulmonary metastases. LEVEL OF EVIDENCE: Level IV, diagnostic study.

Principles of Management of Spine Metastasis.

BACKGROUND: With evolution of medicine, radiation therapy and surgical methods, cancer care has improved the quality of life for patients with improved survival and functional status in patients with skeletal metastasis. The most common site of skeletal metastases from other primary malignant neoplasms is the spine, hence, understanding the epidemiology of metastatic spine disease and its presentation is essential for developing a diagnostic and treatment strategy which eventually results in optimum care to reduce disease-related morbidity. PURPOSE: With this review article we intend to describe an evidence-based review on the presentation, diagnosis and treatment of metastatic spinal disease. METHODS: We reviewed the current available literature on management of spinal metastasis and have described a step wise evaluation and management strategy of metastatic spine disease. CONCLUSION: The present review article addresses various aspects and related controversies related to evaluation, staging and treatment options in the management of spinal metastasis.

Comparison of MRI and Histopathology with regard to Intramedullary Extent of Disease in Bone Sarcomas.

In today's era, limb salvage surgery is the procedure of choice and current standard of care in appropriately selected patients of bone sarcomas. For adequate oncologic clearance, preoperative evaluation of the extent of tumor is mandatory. The present study was done to compare measurements of bone sarcomas (osteosarcoma, Ewing's sarcoma, and chondrosarcoma) as determined by magnetic resonance imaging (MRI) with the histopathological extent seen on resected specimens. We prospectively evaluated 100 consecutive patients with a diagnosis of bone sarcoma who underwent limb salvage surgery between May 2014 and December 2014. The maximum longitudinal (cranio-caudal) dimension of tumor on the noncontrast T1-WI sequence of MRI (irrespective of whether it was pre/postchemotherapy) was compared with the gross dimensions of the tumor on histopathology. The arithmetic mean difference, Wilcoxon signed-rank test, and Spearman's correlation analysis were used to test the differences and correlation between groups. Mean tumor size on MRI based on the largest extent on MRI was 12.1 ± 4.85 cm (mean ± standard deviation), while it was 10.77 ± 4.6 cm (mean ± standard deviation) on histopathology. In 79 cases, MRI overestimated the extent of disease; the mean was 1.79 cm with a standard deviation of 1.56 cm. When the disease extent was underestimated on MRI (13 cases), the mean was 0.58 cm with a standard deviation of 0.43 cm. In 8 cases (osteosarcoma (7), Ewing's sarcoma (1)), MRI measurement was equal to histopathology. The Spearman correlation analysis showed a high correlation of tumor length on histopathology with the MRI for all patients (R = 0.948, P < 0.0001). We thus conclude that MRI is accurate in delineating the extent of bone sarcomas. A margin of 2 cm from the maximum tumor extent is adequate to ensure appropriate surgical resection.

Principles of Management of Extremity Skeletal Metastasis.

Understanding the epidemiology of extremity skeletal metastasis and the factors deciding the treatment decision-making are essential in developing a diagnostic and treatment strategy. This leads to optimum care and reduces disease-related burden. With the evolution of medical, radiation therapy, and surgical methods, cancer care has improved the quality of life for patients with improved survival and functional status in patients with skeletal metastasis. Based on the currently available literature, we have described a step-wise evaluation and management strategy of metastatic extremity bone disease. The present review article addresses various aspects and related controversies related to evaluation, staging, and treatment options in the management of extremity bone metastasis. This article also highlights the role of multidisciplinary involvement in management of extremity skeletal metastasis.

Definitive Management of Open Tibia Fractures Using Limb Reconstruction System.

INTRODUCTION: Open fractures are treated as surgical emergency and early administration of intravenous antibiotic coupled with early irrigation and debridement decreases the infection rate dramatically. Limb Reconstruction System (LRS) is a unilateral rail system which consists of Shanz pins, rail rods and sliding clamps. It is specifically designed to enable the surgeon to perform simple and effective surgery as it offers rigid fixation of fracture fragments, allowing early weight bearing and reduces economic burden. AIM: To determine the efficacy of Limb Reconstruction System for treatment of compound tibia fractures. MATERIALS AND METHODS: A prospective study was carried out where in 54 cases out of 412 compound tibia fractures having Modified Gustilo Anderson Type IIIA and IIIB with a mean age of 42±5 years were treated using LRS over a period of 26 months. Limb reconstruction system was used in acute docking mode or with corticotomy and bone transport was done depending upon the bone loss. The soft tissue condition was assessed and split thickness skin grafting and flap repairs were done as per the need. Clinical and radiological assessment was done at every follow-up. Bony and functional assessment was done by Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria. RESULTS: Among 54 patients, bony results as per ASAMI score were excellent in 36, good in 14, fair in 2 and poor in 2 patients. Functional results were excellent in 43, good in 7, fair in 4 patients. The average fracture union time was 8 months. Post-surgery patient satisfaction was excellent since fixation allowed weight bearing immediately. Average hospital stay was 7 days and financial burden was reduced by 40% as compared to multi staged surgery. The average time of return to work was 20 days. CONCLUSION: LRS is an easy, simple and definitive surgical procedure that allows immediate full weight bearing walking. It reduces hospital stay, is cost effective with excellent patient compliance and can also be used for bone lengthening/transportation.

A Case Report of Bisphosphonate-induced Bilateral Osteoporotic Subtrochanteric Fracture Femurii: Review of Literature.

INTRODUCTION: Osteoporosis is a significant health-care problem characterized by excessive skeletal fragility, susceptibility to low-trauma fractures in men as well as women. Any abnormality of the bone that reduces the strength of the bone predisposes it to mechanical failure during normal activity or with minimum trauma. The mechanical failure manifests itself as a fracture, and this fracture must be recognized as a pathological fracture if the patient is to be treated properly. Osteoporosis is one of the leading causes of such pathological fractures and accounts for 1.5 million fractures annually. In the following case report, we present a 56-year-old postmenopausal female patient with bilateral pathological subtrochanteric fracture femurii due to intake of bisphosponates for 4 years for osteoporosis. Bilateral pathological subtrochanteric femurii fractures are extremely uncommon injuries which occur in adults who sustain injuries due to trivial trauma. A variety of management modalities has been tried to treat this complex fracture pattern. Standard fixation treatment is intramedullary nailing. CASE REPORT: A postmenopausal female of rheumatoid arthritis aged 56 years, presented to our emergency department with a history of trivial fall at home. Following the fall, she was unable to bear weight on bilateral feet and complained of deformity. History revealed consumption of bisphosphonates (tablet alendronate 10 mg) for the last 4 years and glucocorticoids for rheumatiod arthritis. Radiographs were taken, which revealed bilateral pathological subtrochanteric fracture femurii. After obtaining necessary fitness, the patient was taken up for surgery. Closed reduction and Internal fixation with long proximal femoral nail were done. Bisphosphonate intake was stopped and teriparatide 20 µg/day subcutaneously given for 3 months. Fracture healed after 3 months and patient resumed her daily activities. CONCLUSION: In people taking long-term bisphoshponate therapy, symptomatic cortical stress reactions accompanied by evidence of a stress line across the cortical thickening suggest an increased risk of a complete stress fracture. The patients should be informed about the prodromal symptoms like pain and swelling, following this bisphosphonates should be stopped and teriparatide has to be started for osteoporosis.