The Clinical Outcome of Dedifferentiated Chondrosarcoma / 대한정형외과학회잡지

PURPOSE: A dedifferentiated chondrosarcoma is a rare lethal tumor characterized by a low grade chondrosarcoma juxtaposed with a high grade dedifferentiated sarcoma, such as osteosarcoma, fibrosarcoma. The aim of our study was to document the clinical manifestation and oncologic outcomes of a dedifferentiated chondrosarcoma. MATERIALS AND METHODS: This study identified 11 patients who were diagnosed and treated for dedifferentiated chondrosarcoma between January 2007 and December 2016. The identified cohort was then reviewed regarding age, sex, symptom onset, tumor location, magnetic resonance imagings (MRIs), surgical margin, and pathologic diagnosis. The time to local recurrence and/or metastasis, follow-up duration, and the patients' final status were analyzed. RESULTS: The patients were comprised of 7 males and 4 females with a mean age of 54 years (range, 33–80 years). The location of the tumor was in the femur in 6 cases, pelvis in 4 cases, and metatarsal in 1 case. The average tumor diameter was 12.7 cm (range, 6.0–26.1 cm). At the time of diagnosis, 2 patients showed pathologic fracture; 1 patient was Enecking stage IIA, 9 patients were stage IIB, and 1 patient was stage III. Eight patients were classified as a primary dedifferentiated chondrosarcoma and 3 patients were secondary. One of the primary lesions was misinterpreted initially as a low grade chondroid lesion by MRI and underwent curettage. Local recurrence occurred in 8 cases and distant metastasis occurred in 10 cases with a mean duration of 8 months (range, 2–23 months) and 7 months (range, 1–32 months), respectively. The three-year overall survival of patients with dedifferentiated chondrosarcoma was 18%, and 10 patients died due to disease progression. CONCLUSION: Dedifferentiated chondrosarcoma developed lung metastases in the early period of the clinical courses and the prognosis was dismal.

Preliminary study of anesthetic risk factors in surgery for pathologic fractures secondary to metastatic tumors

BACKGROUND: Despite advances in the treatment of primary cancer, metastatic pathologic fractures still affect the survival of cancer patients. The goals of surgery, such as those with terminal cancer, are to maintain a maximum level of independence and improve the quality of life. A patient may be a poor surgical candidate because of a short life expectancy or illness that is too severe to benefit from surgical fixation. Moreover, this surgery is an operation accompanied with significant morbidity and mortality. This retrospective study investigated the characteristics of these patients and assessed the influence of anesthetic risk factors on the outcome. METHODS: The records of 45 patients with pathologic fractures who underwent surgical stabilization for metastatic factors from 1 January 1995 to 31 December 2013 at our hospital were reviewed. Demographic data, various severity scores, anesthetic factors, and survival were reviewed. RESULTS: The most common sites of primary tumors were lung, liver and stomach. The predominant sites of pathologic fractures were the femur (71.1%); six lesions were in the humerus and four in the spine. Univariate and multivariate analyses identified several prognostic factors with a significantly worse influence on survival, including lung tumor and Acute Physiology and Chronic Health Evaluation (APACHE) II score. CONCLUSIONS: Although the number of patients was too small to result in a satisfactory appraisal, the most important step is to select candidates to gain the benefits of palliative surgery. We suggest the possibility of APACHE II scoring and the recognition of lung cancer in making the clinical decision of performing the palliative osteosyntheses for patients with pathologic fractures.

Incidencia de fracturas patológicas por metástasis en el fémur proximal en un hospital de concentración / Incidence of proximal femur pathologic fractures secondary to metastasis in a national reference orthopedic hospital

Resumen: Objetivo: Reportar la incidencia de fracturas en terreno patológico secundarias a metástasis que se presentaron en un hospital de referencia nacional en un período de cinco años. Métodos: Se registraron los ingresos totales a nuestro centro, así como los pacientes que satisficieran la condición de presentar una fractura de fémur proximal en terreno patológico. Con base en información oficial, se calculó el tamaño de población derechohabiente potencial de acuerdo al área de influencia. Con base en los datos se hizo el cálculo de la incidencia anual y de la densidad de incidencia. Resultados: Se identificaron 98 fracturas en 95 individuos. El cálculo de la densidad de incidencia fue de 0.70/100,000 personas durante el período de observación. Se incluyeron 54 sujetos femeninos y 41 masculinos con un promedio de edad de 65.3 años, aunque el rango fue muy variable (de 18 a 90 años). La mayor parte de las personas presentó metástasis por tumores sólidos. De los casos, 29% fue tratado de manera conservadora y el resto requirió tratamiento quirúrgico que incluyó desde osteosíntesis hasta artroplastía protésica. El promedio de estancia hospitalaria fue ligeramente mayor a una semana. Conclusiones: La incidencia reportada es relativamente baja. Encontramos una gran variedad de orígenes y localizaciones anatómicas. No se puede, al momento, generalizar tratamientos o predecir supervivencia.

Abstract: Objective: To report the incidence of pathological fractures secondary to metastasis at a national referral hospital during a 5-year period. Methods: Total admissions to our center were recorded, together with the patients who met the requirement of having a proximal femur fracture in a pathological area. The potential number of beneficiaries was estimated based on official figures and the hospital's area of influence. The annual incidence rate and the incidence density were calculated using the latter data. Results: 98 fractures were identified in 95 patients. The calculated incidence density was 0.70/100,000 population during the observation period. Fifty-four female patients and 41 male patients were included. Mean age was 65.3 years, with a very wide age range (18-90 years). Most patients had metastasis of solid tumors. Twenty-nine percent of patients were treated conservatively and the rest of them required surgery that included from osteosynthesis to prosthetic arthroplasty. The mean length of stay was over one week. Conclusions: The reported incidence of this type of fractures is relatively low. We found a wide variety of anatomical origins and locations. As of now, it is not possible to generalize the treatment or predict the survival.

Therapeutic Approach to Humeral Pathologic Fracture Caused by Benign Bone Tumor / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to suggest an appropriate therapeutic approach by making a comparison between conservative therapy and surgical therapy for a pathologic fractures of the humerus caused by benign bone tumor. MATERIALS AND METHODS: We selected 15 cases with a pathologic fracture of the humerus caused by benign bone tumor from January 2000 to April 2014 to evaluate the fracture union period and remission of primary bone tumor. Eight cases were treated with conservative therapy, and 7 cases by surgical therapy. The mean age was 13.1 years, and the age range was between 1 year and 19 years; there were 8 male cases and 7 female cases. The mean follow-up period was 24.9 months, with a range from 4 months to 72 months. We evaluated the remission of primary benign tumor in accordance with the ‘Modified Neer classification’ system. RESULTS: There was no statistically significant difference in age, sex, and mean follow-up period between the two groups. The pathologic fracture was united in all cases without secondary displacement. There was no statistically significant difference in the fracture union period (p=0.164) and remission of primary benign tumor (p=0.931) between the two groups. CONCLUSION: We suggest that both conservative and surgical therapies can be a treatment for pathologic fracture of the humerus caused by benign bone tumor.

Intramedullary Nailing for Pathological Fractures of the Proximal Humerus

BACKGROUND: Endoprosthetic reconstruction is widely applied for pathological fractures of the proximal humerus; however, functional impairment is usually unsatisfactory. The aims of the current study are to evaluate the reliability of interlocking intramedullary (IM) nailing with cement augmentation as a fixation method in proximal humeral lesions and to assess functional outcomes. METHODS: We reviewed 32 patients with pathological fractures of the proximal humerus who underwent interlocking IM nailing and cement augmentation. Functional scores and pain relief were assessed as outcomes. RESULTS: The mean follow-up period was 14.2 months. The mean Musculoskeletal Tumor Society functional score and Karnofsky performance status scale score were 27.7 and 75.6, respectively. Improvement of pain assessed using the visual analogue scale was 6.2 on average. Thirty-one patients (97%) experienced no pain after surgery. The mean ranges of forward flexion and abduction were 115° and 112.6°, respectively. All patients achieved stability and had no local recurrence without failure of fixation until the last follow-up. CONCLUSIONS: Proximal interlocking IM nailing with cement augmentation appears to be a reliable treatment option for pathological or impending fractures of the proximal humerus in selected patients with metastatic tumors, even with extensive bone destruction.

Effect of pathological fracture on the prognosis of patients with limb osteosarcoma: A meta-analysis / 肿瘤

Objective: To evaluate the effect of pathological fracture on the prognosis of patients with limb osteosarcoma. Methods: A computer-based online search was performed by using EMBASE, Cochrane Library, PubMed, CNKI (China National Knowledge Infrastructure), Wanfang database, VIP database and Chinese Biomedical Literature Database. Relevant studies on clinical outcome of limb osteosarcoma patients with pathological fracture vs without pathological fracture were collected and the quality of the studies were assessed using Newcastle-Ottawa Scale. The data of the studies were abstracted. Meta-analysis was performed using Stata 12.0 software. Results: Ten studies of 2604 cases entered the Meta-analysis, including 356 cases of osteosarcoma with pathological fracture (study group) and 2248 cases of osteosarcoma without pathological fracture (control group). This Meta-analysis revealed that the patients in the study group had poor three-year overall survival (OS) [odds ratio (OR) = 2.57, 95% confidence Interval (CI): 1.54-4.29; P = 0.000) and five-year OS (OR = 1.57, 95% CI: 1.05-2.34; P = 0.029) than those in the control group. Furthermore, there were significant differences in three-year event-free survival (EFS) (OR = 1.87, 95% CI: 1.21-2.87; P = 0.005) and five-year EFS (OR = 1.52, 95% CI: 1.16-1.99; P = 0.002) between the study group and control group. No significant difference was found in the rate of local recurrence between the two groups (P > 0.05), and there was also no significant difference in the rate of local recurrence between patients who were treated with amputation and limb salvage in pathological fracture subgroup (P > 0.05). Conclusion: This meta-analysis suggests that the prognosis of limb osteosarcoma patients with pathological fracture is more worse than that of the patients without pathological fracture. There is no higher risk in the rate of local recurrence after limb salvage in patients with pathological fracture.

Thoracic Vertebral Fracture due to Spinal Tuberculosis which was Misdiagnosed as Matastatic Cancer: A Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report the case of a patient whose preoperative imaging results seemed to show metastatic spine tumor but who actually had a vertebral pathologic fracture caused by spine tuberculosis. SUMMARY OF LITERATURE REVIEW: Tuberculosis spondylitis is classified into peridiscal, central, anterior, and posterior spondylitis according to the portion involved, and central spondylitis can be mistaken as a tumor. MATERIALS AND METHODS: Imaging studies were performed in a 79-year-old female with progressive lower extremity weakness. We found a T12 pathologic vertebral fracture, which was suspected to be metastatic cancer. RESULTS: We performed surgery and found spine tuberculosis in the pathological and immunological examinations. Two weeks postoperatively, the patient could walk with crutches and underwent anti-tuberculosis therapy. CONCLUSIONS: Even when the results of imaging studies predict spinal metastasis, we should keep in mind the possibility of spinal tuberculosis.

Treatment of pathologic fracture following postoperative radiation therapy: clinical study / 대한악안면성형재건외과학회지

BACKGROUND: Pathologic fractures are caused by diseases that lead to weakness of the bone structure. This process sometimes occurs owing to bony change after radiation therapy. Treatment of pathologic fractures may be difficult because of previous radiation therapy. METHODS: In this study, we analyzed clinical and radiographic data and progress of five patients with mandibular pathological fractures who had received postoperative radiation therapy following cancer surgery. RESULTS: Patients received an average radiation dose of 59.2 (SD, 7.2) Gy. Four of five patients exhibited bone union regardless of whether open reduction and internal fixation (OR/IF) was performed. Patients have the potential to heal after postoperative radiation therapy. Treatment of a pathologic fracture following postoperative radiation therapy, such as traditional treatment for other types of fractures, may be performed using OR/IF or CR. OR/IF may be selected in cases of significant bone deviation, small remaining bone volume, or occlusive change. CONCLUSION: Patients have the potential to heal after postoperative radiation therapy.

A meta-analysis of limb-salvage versus amputation in the treatment of patients with Enneking II pathologic fracture osteosarcoma.

Introduction: The aim of this meta-analysis was to further explore whether the relapse, 5-year survival and metastasis the same or not between limb-salvage and amputation in the treatment of patients with limited stage Enneking‡U pathologic fracture osteosarcoma. Materials and Methods: An electronic search of the Medline, EMBASE and CNKI was done on October 2014. The clinical studies about amputation or limb-salvage surgery in the treatment of patients with limited stage Enneking‡U pathologic fracture osteosarcoma were searched and reviewed. The effect size of relapse, 5-year survival and metastasis between the amputation and limb-salvage surgery were pooled by stata11.0 software (Stata Corporation, College Station, TX, USA, http://www.stata.com;) using random or fixed effect model. The funnel plot and Egger's line regression test were used for evaluation of publication bias. Results: A total of 89 studies were identified and seven articles with 200 cases in the limb-salvage surgery group and 84 subjects in the amputation group were finally included in the meta-analysis. The pooled data indicated that no statistical different of risk for developing relapse between limb-salvage and amputation was found relative risk (RR) =1.40, 95% confidence interval (CI): 0.71-2.79, (P = 0.33). The 5-year survival rate of patients underwent limb-salvage surgery was smaller than patients received amputation RR = 1.86, 95%CI: 1.19-2.89, (P = 0.01); the metastasis rate of patients underwent limb-salvage surgery was significant decreased compared with patients received amputation RR = 0.56, 95% CI: 0.34-0.94, (P = 0.03). No publication bias was existed in this meta-analysis. Conclusion: Limb-salvage surgery does not increased the risk of relapse compared with amputation in the treatment of patients with limited stage Enneking‡U pathologic fracture osteosarcoma.

Intraosseous Ganglion with Pathologic Fracture of the Lunate / 계명의대학술지

Although intraosseous ganglion of the carpal bones is an uncommon lesion, it can be a cause of chronic wrist pain. Especially, pathologic fracture as complication of idiopathic intraosseous ganglion of the lunate is extremely rare. We report a rare case of idiopathic intraosseous ganglion with pathologic fracture of the lunate that was successfully treated by curettage and autogenous cancellous bone graft.

Single System Langerhans' Cell Histiocytosis with Multifocal Bone Lesions and Pathologic Fracture: A Case Report / 대한골관절종양학회지

Langerhans cell histiocytosis is known as one of the diseases related to excessive proliferation of normal monocytes and has the variety of clinical courses and treatment. Especially, in cases with the spine, it shows a feature of single or multiple osteolysis. According to the location, disease progression and concomitant symptom, variety of treatments (observation, radiotherapy, chemotherapy, surgery, etc.) have been attempted, however, appropriate treatment has not been established yet. The authors introduce the case of single system Langerhans cell histiocytosis which involves cervical and lumbar vertebrae simultaneously with bone marrow destruction and pathologic fracture.

A case of refractory multiple myeloma.

Multiple myeloma is a plasma cell cancer in which antibody-producing plasma cells grow in an uncontrolled and invasive way. The known incidence of multiple myeloma in India ranges from 0.5 to 1.2 per 100,000 & is a rare in India. It usually occurs in persons older than 55 years and the ratio of men: women is 3:2. Multiple myeloma affects the bones, immune system, kidneys and red blood cell count. We report a case of refractory multiple myeloma.

Pathologic Fractures of the Mandible

Pathologic Fracture in Radiation-induced Osteosarcoma Misdiagnosed as Delayed Femoral Neck Fracture / 대한정형외과학회잡지

Secondary osteosarcoma has a relatively higher incidence in middle aged persons than in children. Radiation-induced osteosarcoma occurs in approximately 1% of patients who have been treated with more than 2,500 cGy. The time interval from radiation to onset of secondary osteosarcoma is approximately 10 to 15 years. A 51-year-old female who have been treated with radiation for angiomyxoma was hospitalized due to right hip pain. She had a minor trauma 2 weeks prior to hospitalization. A day before hospitalization, she experienced a second trauma by fall, and then, severe hip pain developed. A radiograph of the patient showed femoral neck fracture with sclerotic change of fractured margin. We diagnosed the patient as having a neglected femoral neck fracture and treated it with closed reduction using cannulated screw fixation. At 6 months post-surgery, the patient had residual pain of the right hip and we could find overproduced callus at the fracture site. Through further evaluation, we diagnosed this as secondary osteosarcoma with pulmonary metastasis. We report this case to make a warning about a misdiagnosed osteosarcoma as a simple femoral neck fracture.

Two Solitary Lesions of Fibrous Dysplasia in the Tibia (A Case Report) / 대한족부족관절학회지

Fibrous dysplasia is a benign disease that causes replacement of the medullary bone with fibrous tissue in one or more bones. Long bone like femur, tibia and fibular are often affected and occurring under 30 years old. We report a case of two solitary lesions of fibrous dysplasia with pathologic fracture treated with bone curettage, bone graft, plate fixation, who complains of lower leg pain.

Pathologic Fracture of Unicameral Bone Cyst / 대한골관절종양학회지

PURPOSE: The purpose of this study is to observe unicameral bone cyst (UBC) outcome after the fracture has healed and if there is any identifiable prognostic factors. MATERIALS AND METHODS: 13 UBC patients with pathologic fracture from 2001 to 2010 were reviewed. The mean follow up were 26 months (3-90 months). There were 11 male and 2 female patients and the mean age of the patients were 10.2 years old (6-16 years). 9 involved proximal humerusand 2 involved humerus shaft and 1 involved proximal femur and 1 involved proximal tibia. The treatment of UBC fracture was conservative cast application to heal the fracture initially, and 1 patient was treated with primary auto bone graft and open reduction with internal fixation. 5 patients were treated with steroid injection during follow up period and 2 patients with auto bone graft. We analyzed the change of UBC during pathologic fracture healing period and prognostic factor about age, the size of UBC, the involvement of physis. RESULTS: The mean duration of the fracture healing was 8.2 months. Complete healing were occurred at 4 patients (31%). No statiscal difference was checked with age about UBC healing (p=0.42). But, more larger size about UBC and more closer to physis, the healing was difficult (p=0.05, p=0.03). CONCLUSION: While pathologic fracture of UBC was possibly healed, active treatment should be applied especially those cysts that involvescloser area of the physis or large size.

Percutaneous Anterolateral Vertebroplasty for a Myelomatous Pathologic Fracture of the Subaxial Cervical Spine: A Case Report

The authors describe a patient with multiple myeloma who was treated for an acute cervical vertebra body fracture by percutaneous vertebroplasty. A 48-year-old female patient presented a severe neck pain without neurologic deficit. A myelomatous pathologic fracture of C4 was diagnosed, and percutaneous vertebroplasty was performed successfully through a left anterolateral approach. Her posterior neck pain was immediately relieved with vertebroplasty and no instability was observed over 18 months of follow-up.

Pathologic Fracture Due to an Osteoblastoma of the Humerus Shaft: A Case Report / 대한골관절종양학회지

Osteoblastoma is rare, benign, bone-forming tumor that often occur in the spine. There are few reports of osteoblastomas resulting in pathologic fractures involving long bones. Authos report a unique case of a pathologic fracture due to an osteoblastoma of the humerus shaft. The tumor was treated successfully by curettage, intramedullary nailing and bone allograft.

Pathologic Fracture in a Subchondral Cystic Lesion at the Superior Acetabulum / 대한정형외과학회잡지

Subchondral cyst is a benign cystic lesion, and it is often found in patients with rheumatoid arthritis or osteoarthritis. However, its occurrence in those joints without preexisted disease is rare. Furthermore, there has been no report in the medical literature regarding pathologic fracture in the bony plate of a subchondral cyst at the superior acetabulum. We report here on a case of the 44-year-old woman for whom a pathologic fracture was found in the bony plate of a subchondral cyst at the superior acetabulum.

Metastatic Pathologic Fractures in Lower Extremities Treated with the Locking Plate / 대한골관절종양학회지

PURPOSE: The skeleton is commonly affected by metastatic cancer. The purpose of this study was to evaluate the results of treating metastatic pathologic fractures in lower extremities using locking plates. MATERIALS AND METHODS: Between 2004 and 2010, we evaluated 12 patients (13 cases) of metastatic pathologic fractures in lower extremities, treated with the locking plate. Mean patient age was 62.2 years (range, 50-81 years), the locations of the fractures were; proximal femur in 2 cases, femoral mid-shaft in 3, distal femur in 3, proximal tibia in 4, and distal tibia in 1 case. The interval to wheelchair ambulation, pain relief and complications were evaluated. Additionally, we assessed operation time and postoperative blood loss. RESULTS: Mean time from operation to wheelchair ambulation was 3.2 days (range, 1-6 days). Mean VAS scores improved from a preoperative score of 8.1 points (range, 7-9 points) to a score of 2.7 points (range, 2-4 points) at 1 week postoperatively. No early complications associated with surgery were encountered. Mean operation time was 88.4 minutes (range, 70-105 minutes), and mean postoperative blood loss was 246.5 ml (range, 130-320 ml). CONCLUSION: Internal fixation of metastatic pathologic fractures using a locking plate in the lower extremity can be an effective treatment option in the meta- or diaphyseal area of long bones with massive bony destruction or poor bone stock by offering early ambulation, pain relief and low postoperative complications.