Atypical Femur Fracture in the Setting of Long-Term Bisphosphonate use for Osteogenesis Imperfecta: A Case Report

Bisphosphonate (BP) therapy for moderate to severe osteogenesis imperfecta (OI) has become a mainstay of treatment in the last three decades. Given the significant improvements in bone mineral density and theoretical reductions in fracture risk, many patients are treated with bisphosphonates for prolonged periods of time. There currently lacks consensus in the optimal duration of BP therapy for patients with OI, and patients are often treated on a case-by-case basis. Long-term BP therapy has been associated with atypical femur fractures in adult patients treated for osteoporosis. The American Society for Bone and Mineral Research concluded that the median duration of BP therapy in patients with atypical femur fractures was 7 years. The role of long-term BP therapy in OI patients with atypical femur fractures remains unclear. Here, a case report is presented of an adolescent patient with type V OI that sustained a subtrochanteric femur fracture with features of an atypical pattern following treatment with intravenous pamidronate for 10.5 years. At the time of injury, the contralateral femur was also found to have atypical features suggestive of an impending fracture. The completed fracture was treated with closed reduction and cephalomedullary nail fixation. The impending fracture was prophylactically stabilized using the same technique. Prior to the injury, limb-length radiographs obtained to evaluate lower extremity alignment demonstrated features of an impending fracture but went unnoticed. Further studies are needed to clarify the role of long-term BP therapy in patients with OI suffering from atypical femur fractures.

Detecting Criticality by Exploring the Acoustic Activity in Terms of the “Natural-Time” Concept

The acoustic activity developed in marble specimens under various loading schemes is explored in terms of the recently introduced F-function. The novelty of the study is that instead of describing the temporal evolution of the F-function in terms of conventional time, the Natural Time concept is employed. Although completely different geometries and loading schemes were considered, the evolution of the F-function in the Natural Time domain exhibits a self-consistent motive: its values increase progressively with fluctuations of varying intensity, however, while the fracture is approaching, a power law appears to systematically govern the response of the specimen/structure loaded. The exponent of this law, somehow corresponding to the intensity of the acoustic activity within the loaded complex, varies within broad limits. The onset of validity of the power law designates that the system has entered into its critical stage, namely that of impending fracture, providing a useful pre-failure signal.

Predicting Fracture Risk in Patients with Metastatic Bone Disease of the Femur: A Pictorial Review Using Three Different Techniques

One of the key roles of an orthopedic surgeon treating metastatic bone disease (MBD) is fracture risk prediction. Current widely used impending fracture risk tools such as Mirels scoring lack specificity. Two newer methods of fracture risk prediction, CT-based structural rigidity analysis (CTRA) and finite element analysis (FEA), have each been shown to be more accurate than Mirels. This case series illustrates comparative Mirels, CTRA, and FEA for 8 femurs in 7 subjects. These cases were selected from a much larger data set to portray examples of true positives, true negatives, false positives, and false negatives as defined by CTRA relative to the fracture outcome. Case illustrations demonstrate comparative Mirels and FEA. This series illustrates the use, efficacy, and limitations of these tools. As all current tools have limitations, further work is needed in refining and developing fracture risk prediction.

Proximal Femur Metastasis Treatment With Fixation or Hip Replacement. Results of 47 Patients

Objective: Purpose of the present study was to compare patients with proximal femur metastasis with actual or impending fractures who were treated by fixation or prosthetic hip replacement. Method: Twenty-seven patients underwent fixation treatment (IM nail, DHS), and 20 patients prosthetic (endoprosthesis or total hip arthroplasty) replacement. Data were analyzed regarding patient demographics, cancer type, localization and type of metastasis, actual or impending fracture, number of bone metastasis, presence of spinal or visceral metastasis and treatment data (ASA class, length of hospital stay or surgery or survival, cement usage, adjuvant treatment, postoperative walking status). Results: Fixation group (63 years) was younger than prosthesis group (70 years) (p: 0.03). Fixation was more preferred at subtrochanteric area (p˂0.001). Cementation of the lesion was more preferred and surgery time was longer at fixation group (p: 0.01). Greater number of complications (mostly medical) were more likely to be seen in the fixation group (6 ‘1 loosening’ vs 3 ‘1 dislocation’). Conclusion: It is not still clear whether one implant is clearly superior to other one, however it was revealed again that nailing was mostly preferred for the subtrochanteric area and tended to have more complications although mostly medical and unrelated to implant placement as previously reported

Possible Novel Treatment Modality for Non Ossifying Fibroma Neck of Femur

Nonossifying fibromas (NOFs) are benign bone tumors occurring in the second decade of life. Most of the NOFs are diagnosed incidentally on the basis of its presentation on plain radiographs where they typically appear as small, cortical osteolytic lesions with sclerotic margin. They are mostly asymptomatic but can result in pathologic fractures if the lesion involves more than 50% of bone diameter. They are mostly treated with curettage and bone grafting. But in challenging situations where the classical surgery has failed or there is impending fracture of the neck of femur, bone structural support is needed. We are discussing two cases diagnosed as NOFs of intracapsular femoral neck. Both cases underwent curettage of tumor followed by free vascularized fibular graft. Results in both the cases were very gratifying, with complete resolution of symptoms during 1 year of follow-up.

Practical Input on Bone Tumor Imaging: Pathological Fracture, Risk Features, and When to Contact Orthopaedics

Awareness of risk factors associated with impending fracture and its radiologic appearance allows early diagnosis, supports prophylactic surgical treatment, and prevents the multiple complications of a pathologic fracture. Because the femur is the most common long bone affected by metastatic bone lesions, we address this clinically relevant site in this review. The key to early detection of risky bone lesions is familiarity with the possible clinical presentation, biomechanical effects of the anatomical site (femoral head and neck, intertrochanteric zone, proximal diaphysis), and the lesion types (lytic, blastic, or mixed). Awareness of the possible treatment strategies depending on the characteristics just listed allows high-quality targeted reporting.

Percutaneous Fixation by Internal Cemented Screw for the Treatment of Unstable Osseous Disease in Cancer Patients

Interventional radiology expertise in image guidance has expanded the treatment options for cancer patients with unstable osseous disease. Percutaneous fixation by internal cemented screw (FICS) describes the technique by which the interventional radiologist stabilizes a fracture or impending fracture with the percutaneous placement of a cannulated screw that is locked in position by polymethyl methacrylate cement. The durable metallic screws provide added resistance to torque and tension stresses that complement the axial compression resistance of cement. Compared with cementoplasty alone, the procedure has been advanced as a more durable and precise technique for stabilization of osseous disease for certain disease presentations in cancer patients. The application of advanced image guidance techniques improves upon existing percutaneous surgical techniques to facilitate approaches that would otherwise prove quite challenging, particularly with stabilization of the pelvic flat bones. This article examines the applications of percutaneous FICS procedures for the treatment of unstable osseous disease in cancer patients. Indications, techniques, and follow-up care are reviewed. Case examples in which FICS can be performed in unstable pathology are detailed.