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Background Prophylactic intervention for impending pathological fractures (IF) is associated with improved survival in patients with long-bone metastasis. However, information regarding whether the tumor burden and/or physical status are associated with survival benefits of intervention for IF is lacking. Methods This multicenter retrospective study investigated 121 patients who underwent surgery for 63 impending and 58 complete metastatic fractures of the proximal femur between 2008 and 2023. After matching for age, sex, body mass index, and Katagiri-New score, 42 patients with IF were compared with 42 patients with complete pathological fractures. The 1-year mortality rate was considered the primary outcome, and was compared and stratified by risk based on the Katagiri-New score. The 1-year mortality rate was evaluated according to the surgical method in the subgroup analysis of patients with IF. Results The 1-year mortality rate was significantly lower in patients with IF with intermediate-to-high risk( p  = 0.04), whereas no difference was observed in patients with low-to-high risk. IF was associated with a significantly higher rate of home discharge ( p  < 0.01) and improved post-operative ambulatory function ( p  = 0.07). The subgroup analysis of patients with IF revealed no difference in the survival rate between nailing and hemiarthroplasty. Conclusion Patients with intermediate-to-high risk IF based on the Katagiri-New score had a lower mortality rate than those who underwent surgery for pathological fractures. A higher rate of home discharge was observed in patients with IF. Based on the Katagiri-New score, survival benefits can be obtained from prophylactic intervention for IF of the proximal femur in patients with intermediate-to high-risk.

Background Traditional treatments for pathological fractures of the proximal femur resulting from metastatic bone disease include fixation with intramedullary nailing supplemented with polymethylmethacrylate, osteosynthesis with a plate-screw construct and polymethylmethacrylate, or endoprosthetic reconstruction. Despite the frequent practice of these treatments, treatment outcomes have not been rigorously compared. In addition, very few studies examine specific approaches to endoprosthetic reconstruction such as long stem hemiarthroplasty. Questions/purposes This study examines survival, functional outcomes, and complications associated with long stem hemiarthroplasty in a small group of patients treated for impending and actual pathologic fractures of the proximal femur resulting from metastatic bone disease. Methods Between 2012 and 2015, 21 patients were treated with long stem cemented hemiarthroplasty in 22 limbs. During that time, indications for this approach included lesions from metastases, myeloma, or lymphoma involving the proximal femur that resulted in an impending or actual pathological fracture. An impending fracture was classified as a painful lesion with at least 50% cortical erosion. During the study period, six patients with proximal femoral metastases not deemed to meet these indications were treated with other surgical approaches such as intramedullary nailing supplemented with polymethylmethacrylate and osteosynthesis with a plate-screw construct and polymethylmethacrylate. Mortality was tracked through medical records and phone calls to the patients and their families. Followup for the entire group of patients (n = 22) ranged from 1 to 27 months with a mean duration of 11 months. For patients with at least 1 year of followup (n = 11), the mean duration was 18 months (range, 12–27 months) and for patients with less than 1 year of followup (n = 11), the mean duration was 3 months (range, 1–11 months). Functional outcomes were evaluated according to the Musculoskeletal Tumor Society (MSTS) scoring system for lower extremities, the Eastern Cooperative Oncology Group (ECOG) Scale of Performance Status, and the Karnofsky Performance Scale (KPS) Index. Scores and complications were determined by direct patient examination, retrospective chart review, review of a longitudinally maintained institutional database, and followup phone calls. Results Ten patients died of disease within the followup period. Before surgery, the median total MSTS score for the entire group of patients (n = 22) was 4.5 (range, 0–23), the median ECOG score was 3.5 (range, 1–4), and the median KPS score was 40 (range, 30–70). Postoperatively, the median total MSTS score (measured at most recent followup) for the entire group of patients was 21 (range, 5–30), the median ECOG score was 2 (range, 0–3, 68% ≤ 2), and the median KPS score was 60 (range, 40–100). For the 11 patients with at least 1 year of followup, the median total MSTS score (measured at most recent followup) was 27 (range, 21–30), the median ECOG score was 1 (range, 0–2, 100% ≤ 2), and the median KPS score was 80 (range, 60–100). For the remaining 11 patients with less than 1 year of followup, the median total MSTS score (measured at most recent followup) was 11 (range, 5–25), the median ECOG score was 3 (range, 1–3, 36% ≤ 2), and the median KPS score was 40 (range, 40–80). Complications included one periprosthetic fracture resulting from a fall, three cases of radiation-induced edema, and two cases of sciatica that developed unrelated to the procedure. Conclusions Long stem cemented hemiarthroplasty results in fair levels of function in a complex population of patients whose prognosis is sometimes measured only in months and who otherwise might be disabled by their metastatic lesions. Comparative trials applying consistent indications and inclusion criteria should be performed between this approach and fixation with intramedullary nailing supplemented with polymethylmethacrylate as well as osteosynthesis with a plate-screw construct and polymethylmethacrylate. Level of Evidence Level IV, therapeutic study.

PurposeBenign lesions of the proximal femur region, such as simple bone cysts, aneurysmal bone cysts, and fibrous dysplasia, are common in children. Benign lesions may cause pathologic fractures, limb length inequities, and growth disturbances. Differential diagnoses, e.g., malignant bone tumors and osteomyelitis, are sometimes difficult to rule out.ObjectiveWe aimed to evaluate outcomes in children with benign lesions of the proximal femur treated with curettage, bone grafting, and plate fixation.MethodsIn this retrospective study, we included 30 children (median age 10.5 years; range 1.1–17.8 years) suffering from bone cysts and tumor-like lesions of the proximal femur region treated between 2002 and 2018. We analyzed plain X-ray images and CT scans in all children and obtained MRI scans in a selected group of children (63.3%). We examined histopathologic biopsy results for all bone lesions before initiating treatment. Surgical management comprised tumor curettage with adjuvant high-speed drilling and allogenic bone grafting supplemented by bone graft substitutes before plate fixation. Median follow-up interval was 87 months (range 24–156 months). We evaluated the healing of lesions according to Capanna’s classification and rated functional outcomes according to Merle d’Aubigné and Postel score.ResultsOverall, 25 of 30 (83.3%) patients were admitted to hospital because of a pathologic fracture. We diagnosed simple bone cysts in 15 (50.0%) patients, aneurysmal bone cysts in 7 (23.5%) patients, and fibrous dysplasia in 8 (26.5%) patients. Bone consolidation was achieved in 22 of 30 (73.3%) patients after a mean of 5 months (range 3–7 months). The main complication was recurrence of the lesion in 4 of 30 (13.3%) patients. With respect to the Merle d’Aubigné and Postel scores, 17 of 30 (56.7%) patients obtained an excellent result (18 points), while 12 (40.0%) patients had a good result (15–17 points) and only 1 (3.3%) patient had a fair result (14 points).ConclusionSurgical treatment of bone cysts and tumor-like lesions of the proximal femur by local resection or destruction of the lesion, followed by filling the defect with bone graft material and internal stabilization represents a safe and effective treatment option in children.Level of evidenceTherapeutic, retrospective comparative study—Level III

The increasing prevalence of fragility fractures of the sacrum (FFS) occurring predominantly in osteoporotic individuals poses a diagnostic and therapeutic challenge. The clinical presentation varies from longstanding low back pain without the patient remembering a traumatic event to immobilized patients after suffering a low-energy trauma. FFS are often combined with a fracture of the anterior pelvic ring; hence they are classified as a part of fragility fractures of the pelvis (FFP). If not displaced, the patients are treated with weight bearing as tolerated and analgesics; however, we advocate to treat displaced fractures surgically according to the fracture personality and the patient’s comorbidities. Surgical options include minimal invasive sacro-iliac screws, trans-sacral bar osteosynthesis, open reduction and internal fixation, or spinopelvic stabilization. In the light of the high complication rate associated with immobilized patients, an operative approach often is indicated to accelerate the patient’s mobility.

Elastic stable intramedullary nailing (ESIN) internal fixation is used clinically to treat pathological fractures of bone cysts in children. However, one of the most important complications was removal difficulty. In this study, we aim to analyse the factors which can influence ESIN removal in healed bone cysts in children. From April 2014 to November 2020, the clinical data of 49 children who underwent elastic stable intramedullary nail removal for pathological fractures of the bone cysts in our hospital were retrospectively analysed. The following data, including age, sex, pathological fracture site, with bone graft, number of ESINs, ESIN indwelling time, and extraosseous length of ESIN were collected, and univariate analysis and logistic regression analysis was performed. The frequency of difficulty in ESIN extraction was 44.90% (22/49). The univariate logistic regression analysis showed that age,ESIN indwelling time,with bone garft and extraosseous length of ESIN may be correlated with the difficulty in removing ESIN ( P  < 0.05), while sex, pathological fracture site, number of ESIN may not be correlated with the difficulty in removing ESIN ( P  > 0.05).The multivariate logistic regression analysis showed that the ESIN indwelling time was the independent influencing factor for difficulty in removing ESIN ( P  < 0.05). The factors influencing the ESIN removal in healed bone cysts in children include over 11.79 years old, the long indwelling time of the ESIN(over 10.5 months),with bone graft and short extraosseous length of ESIN(≤ 0.405 cm). These factors influencing ESIN removal in healed bone cysts in children should be considered.

Purpose The management of pathologic fractures (PF) following osteomyelitis (especially the acute subtype) has not been widely investigated. Therefore, this study aims to assess a stepwise treatment plan for the acute incidence of PF in long bones following pediatric acute Hematogenous osteomyelitis (AHO). Methods This case series was conducted between 2011 and 2023 in a tertiary pediatric center. Patients with fracture incidence within the first 10 days after AHO diagnosis were included. Patients’ characteristics were retrospectively reviewed. Our stepwise treatment plan was as follows: Intravenous antibiotics until ESR<20, then oral to ESR<5 Debridement surgery was performed if abscesses were detected. Fracture type determined initial fixation: external fixation or casting. If the union was not obtained, internal fixation (with or without bone graft) was applied Circular external fixation was applied if the union was not obtained or the leg length discrepancy occurred. Results Eight patients (6 boys) with a mean age of 32.1 ± 26.7 months and a follow-up time of 8.64 ± 1.95 years were included. The etiology in all patients was hematological Methicillin-resistant Staphylococcus aureus. Except for one patient who died of septic shock, all other patients (87.5%) reached complete recovery (average length of hospital stay of 19.9 days) and obtained union with an average union time of 14.6 months. A mean of 1.25 surgical procedures, ranging from 0 to 4, were required to obtain union. Conclusion The outcome of the stepwise plan in this study suggests that acute PF following AHO in pediatrics can be managed effectively with favorable clinical and functional outcomes in the mid- and long-term.

Background Treatment of impending pathologic fractures and insufficiency fractures of the sacrum due to metastatic disease and radiation is challenging. The use of traditional hardware is limited by poor bone quality and presence of non-contained defects. The role of minimally invasive photodynamic nails (PDN) for treatment of these fractures remains poorly understood. Methods Patients with symptomatic impending pathologic fractures of the sacrum due to metastatic bone disease, multiple myeloma, or insufficiency fractures from radiation osteitis who underwent PDN stabilization were identified. Primary outcomes included post-operative complications, pain relief, opioid consumption, and function. Pain was assessed using Visual Analog Scale (VAS), and function was measured using the Combined Pain and Ambulatory Function (CPAF) score. Outcomes were assessed preoperatively at 6 weeks, 3 months, 6 months, 1 year and 2 years. Results Fourteen patients (median age 70, 50% female) underwent sacral PDN stabilization between 2020 and 2023, with a median 1.4-year follow-up. Overall complication rate was 7% (1/14 patients), with one case of venous thromboembolism. Median pain VAS decreased from 7 preoperatively to 6 at 6 weeks ( p  = 0.02), and to 4 at 2 years ( p  = 0.002). Median CPAF score improved from 6 preoperatively to 7 at 3 months and remained at this level through the 2-year follow-up. Chronic opioid use decreased from 85.7% preoperatively to 60% at 2 years. Conclusion PDN stabilization sacral insufficiency fractures in oncologic patients is a safe surgical technique that effectively restores patient ambulatory function and provides rapid pain relief. Further research with larger cohorts is warranted to confirm these promising results. Level of evidence III. Clinical trial number Not applicable.

Background Metastatic bone disease (MBD) and its complications have a significant impact on patients’ quality of life. Pathological fractures are a particular problem as they affect patient mobility and pose a high risk of non-union. The pelvis is frequently affected by MBD and its fixation is challenging. We present a case series of three pathological sacral fractures treated with a new minimally invasive bilateral fixed angle locking system. Case presentation Case 1 and 2 suffered a pathological transforaminal sacral fracture without adequate trauma in stage 4 carcinomas (gastric cancer and breast cancer). Both were initially treated with non-surgical treatment, which had only a limited effect and led to imminent immobility. Both were operated on with fluoroscopic navigation and underwent transsacral SACRONAIL ® stabilisation according to CT morphology (S1 + S2 and S1 respectively). Immediately after the operation, pain decreased and mobilisation improved. Case 3 had a pathological transalar sacral fracture during the 2nd cycle of chemotherapy due to non-Hodgkin’s lymphoma. He soon became immobile and could only move in a wheelchair. The operation was performed with CT navigation due to the very small corridors and an implant was inserted in S1 and S2. The patient reported immediate pain relief and his ability to walk improved over the following months. Despite continued chemotherapy, no wound complications occurred. Conclusions The cases show the advantages of the minimally invasive bilateral fixed angle locking system SACRONAIL ® in the treatment of patients with pathological sacral fractures. It allows immediate full weight bearing and the risk of secondary surgical complications is low. All cases showed an improvement in pain scores and mobility.

Background The proximal femur is the most common site of surgery for bone metastases, and stabilization may be achieved through intramedullary fixation (IMN) or endoprosthetic reconstruction (EPR). Intramedullary devices are less expensive, less invasive, and may yield improved function over endoprostheses. However, it is unclear which, if either, has any advantages. Questions/purposes We determined whether function, complications, and survivorship differed between the two approaches. Methods We retrospectively reviewed 158 patients with 159 proximal femur metastatic lesions treated with surgical stabilization. Forty-six were stabilized with IMN and 113 were treated with EPR. The minimum followup was 0.25 months (mean, 16 months; median, 17 months; range, 0.25–86 months). Results The mean Musculoskeletal Tumor Society score was 24 of 30 (80%) after IMN and 21 of 30 (70%) after EPR. There were 12 complications (26%) in the IMN group, including 10 nonunions, six of which went on to mechanical failure. There were complications in 20 of 113 (18%) of the EPR group, which consisted of 10 dislocations (9%) and 10 infections (9%). There were no mechanical failures with EPR. Both implants remained functional for the limited lifespan of these patients in each group at all time intervals. EPRs were associated with increased implant longevity compared with IMNs (100% versus 85% 5-year survival, respectively) and a decreased rate of mechanical failure (0% versus 11%, respectively) when compared with the intramedullary devices. Conclusions Patients with metastatic disease to the proximal femur may live for long periods of time, and these patients may undergo stabilization with either IMN or EPR with comparable functional scores and the implant survivorship exceeding patient survivorship at all time intervals. Endoprostheses demonstrate a lower mechanical failure rate and a higher rate of implant survivorship without mechanical failure than IMN devices. Level of Evidence Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background Pathologic proximal femur fractures result in substantial morbidity for patients with skeletal metastases. Surgical treatment is widely regarded as effective; however, failure rates associated with the most commonly used operative treatments are not well defined. Questions/purposes We therefore compared surgical treatment failure rates among intramedullary nailing, endoprosthetic reconstruction, and open reduction-internal fixation when applied to impending or displaced pathologic proximal femur fractures. Patients and Methods We retrospectively compared the clinical course of 298 patients who underwent intramedullary nailing (n = 82), endoprosthetic reconstruction (n = 197), or open reduction-internal fixation (n = 19) from 1993 to 2008. Primary outcome was treatment failure, which was defined as reoperation for any reason. Treatment groups were compared for differences in demographic and clinical parameters. Results The number of treatment failures in the endoprosthetic reconstruction group (3.1%) was significantly lower than in the intramedullary nailing (6.1%) and open reduction-internal fixation (42.1%) groups. The number of revisions requiring implant exchange also was significantly lower for endoprosthetic reconstruction (0.5%), compared with intramedullary nailing (6.1%) and open reduction-internal fixation (42.1%). Conclusions Endoprosthetic reconstruction is associated with fewer treatment failures and greater implant durability. Prospective studies are needed to determine the impact of operative strategy on function and quality of life. Level of Evidence Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.