Management of pathologic fractures of long bones in malignant disease

Archives of Orthopaedic and Trauma Surgery -     

Blastomycosis of long bones

The presentation of blastomycosis clinically and radiographically is nonspecific and often mistaken for a neoplasm. Delay in diagnosis is common. Patients with osseous blastomycosis present with pain and swelling. Radiographs usually show an eccentric lucency in the distal ends of long bones. These patients frequently are referred for a neoplastic workup and a diagnosis is made only after biopsy. We review the cases of five patients diagnosed with a bone tumor who had blastomycosis osteomyelitis. The time to diagnosis from original symptoms was 4.7 months (range, 3-8 months). The average age of the patients was 45.6 years (range, 20-59 years). A Musculoskeletal Tumor Society functional assessment was done. Early radiographs of the current patients ranged from normal to showing faint osteopenia in the involved location. As the disease progressed, the area of lucency appeared with either diffuse or well-marginated borders. Treatment included surgical debridement with antifungals. The mean functional score was 93.3%. All patients are disease-free. Blastomycosis, similar to tuberculosis, often is mistaken for a neoplasm. Blastomycosis osteomyelitis can be treated with excellent results. The key is diagnosis and including endemic fungal infections in the differential diagnosis of bone tumors. In addition, every potential neoplasm should include cultures of specimens obtained at biopsy.     

Infected nonunion of the long bones

BACKGROUND: Although definitions vary, infected nonunion has been defined as a state of failure of union and persistence of infection at the fracture site for 6 to 8 months.>). Infected nonunions of the supracondylar region of the femur are uncommon and are mostly due to a severe open fracture with extensive comminution and segmental bone loss or after internal fixation of a comminuted closed fracture.Associated factors include exposed bone devoid of vascularized periosteal coverage for more than 6 weeks, purulent discharge, a positive bacteriological culture from the depth of the wound, and histologic evidence of necrotic bone containing empty lacunae. Soft-tissue loss with multiple sinuses, osteomyelitis, osteopenia, complex deformities with limb-length inequality, stiffness of the adjacent joint, polybacterial multidrug-resistant infection, and smoking all complicate treatment and recovery.Although uncommon in incidence, infected nonunions of the long bones present a great challenge to the orthopaedic surgeon in providing optimal treatment of this entity. To give direction to the optimal strategy, this systematic review was performed. OBJECTIVE: We aimed to review the highest level of available evidence on the operative management of infected nonunions of the long bones.     

Infected nonunion of the long bones

The problems in infected nonunion include multiple sinuses, osteomyelitis, bone and soft tissue loss, osteopenia, adjacent joint stiffness, complex deformities, limb-length inequalities, and multidrug-resistant polybacterial infection. Bone gap and active infection are the crucial factors relating to treatment and prognosis. Gaps larger than 4 cm likely cannot be effectively bridged by corticocancellous bone grafting. If the limb has intact distal circulation and sensation, limb salvage and reconstruction generally is preferable to amputation. The fracture generally unites if adequate debridement of the nonunion site is done with fracture stabilization and bone grafting. We reviewed 42 consecutive patients with infected nonunion of the long bones. These patients have been categorized into two groups. Type A is infected nonunion of long bones with nondraining (quiescent) infection, with or without implant in situ; Type B is infected nonunion of long bones with draining (active) infection. Both are classified further into two subtypes: 1) nonunion with a bone gap smaller than 4 cm or 2) nonunion with a bone gap larger than 4 cm. Single-stage debridement and bone grafting with fracture stabilization are the methods of choice for Type A1 infected nonunions. Adequate debridement, fracture stabilization, and second-stage bone grafting gives desirable results in Type B1 infected nonunions. Distraction histiogenesis is the preferred procedure for Type A2 and B2. The autogenous nonvascularized fibular graft, posterolateral bone grafting for the tibia, and centralization of the ulna over distal radial remnant (single bone forearm) may be good treatment options in selected cases.     

Osteomyelitis in long bones

Osteomyelitis in long bones remains challenging and expensive to treat, despite advances in antibiotics and new operative techniques. Plain radiographs still provide the best screening for acute and chronic osteomyelitis. Other imaging techniques may be used to determine diagnosis and aid in treatment decisions. The decision to use oral or parenteral antibiotics should be based on results regarding microorganism sensitivity, patient compliance, infectious disease consultation, and the surgeon's experience. A suppressive antibiotic regimen should be directed by the results of cultures. Standard operative treatment is not feasible for all patients because of the functional impairment caused by the disease, the reconstructive operations, and the metabolic consequences of an aggressive therapy regimen. Operative treatment includes debridement, obliteration of dead space, restoration of blood supply, adequate soft-tissue coverage, stabilization, and reconstruction.     

Metastatic fractures of long bones

Summary Forty-two patients with a total of 52 metastatic fractures of long bones were analysed retrospectively with regard to the type of treatment, complications, general mobility and survival. Endoprosthetic replacement appeared to be better than osteosynthesis in the proximal femur, and this method should also be considered in pathological fractures of the distal femur. Nailing is indicated in fractures of the shafts of long bones in the lower limb, and also in the humerus. Osteosynthesis with a plate has only limited indications. Cement should be added to an osteosynthesis or replacement of a pathological fracture in order to achieve immediate stability. On the whole, the life expectancy of these patients has improved; five in our series lived for more than 6 years after the treatment of their metastases. The method of surgical treatment therefore needs more consideration.

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Résumé Analyse rétrospective de quarante deux patients présentant en tout 52 fractures métastatiques des os longs, en fonction du type de traitement, des complications, de la mobilité globale et de la survie. Le remplacement prothétique semble meilleur que l'ostéosynthèse pour l'extrémité supéireure du fémur et cette méthode de traitement peut également être envisagée pour les fractures pathologiques de l'extrémité distale. L'enclouage est indiqué dans les fractures diaphysaires du membre inférieur, et aussi de l'humérus. L'ostéosynthèse par plaque n'a que des indications restreintes. Du ciment peut être ajouté à l'ostéosynthèse ou au remplacement prothétique afin d'obtenir d'emblée la stabilisation de la fracture. Dans l'ensemble, l'espérance de vie de ces malades a augmenté; cinq dans notre serie sont encore en vie plus de six ans après le traitement de leurs métastases. Le traitement chirurgical mérite donc de plus en plus d'être pris en considération.

     

Management of burned long bones

The management of severely burned and exposed supportive osseous tissues is not fully standardized. We present two patients in whom extensive debridement and decortication of the involved bone may have contributed to subsequent stress fractures. We propose an alternative therapeutic approach for this problem, including: minimal debridement of the bone, early coverage of the exposed bone with vascularized muscle, and adequate prophylactic protection.     

Nonunion of the diaphysis of long bones

The treatment of diaphyseal nonunion of long bones is difficult and controversial. We retrospectively reviewed 113 patients with diaphyseal nonunion treated by various modalities, during 15 years at one institution. There were 36 cases of nonunion of the tibia, 23 nonunions of the femur, 21 nonunions of the humerus, 13 nonunions of the radius, 18 nonunions of the ulna and two nonunions of the clavicle. The minimum followup was 24 months (average, 40 months, range 2-15 years). The nonunions were classified as aseptic (84) and septic (29) and additionally classified as hypertrophic (61) and atrophic (52) in order to determine the treatment. The treatment was individualized based on the stability at the nonunion site, need for bone grafting, and control of infection. All fractures healed and every patient in the study regained functional use of the limb without pain or instability and functional range of movements that they had at the time of presentation with nonunion. Residual problems seen in some patients were joint stiffness, limb length discrepancy, and angular deformity. Twenty-six patients required repeat surgery using bone grafting because no satisfactory progress of fracture healing was seen in 4 months. Complications were related to the iliac crest donor site and persistent infection at the nonunion site.     

Bifurcation of long tubular bones

Summary Five cases of bifurcation of long tubular bones, 2 on the lower and 3 the upper extremity, are described. In all cases they were accompanied by severe adjacent skeletal defects. If the proximal part of the bone was bifurcated the skeletal defect was observed proximally from this anomaly, if the distal bone end was forked than bones were missing distally from the bifurcation. In some early observations and a unique case with double epiphysis the shape of the anomalous branches of the bifurcation supported the theory of ectopic bone formation.

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Zusammenfassung Fünf Fälle von Gabelung langer Röhrenknochen, 2 davon an der unteren and 3 an der oberen Extremität, werden beschrieben. In allen Fällen konnten schwere Skelettdefekte neben der Gabelung beobachtet werden; bei einer Bifurkation des proximalen Knochenendes, proximal des betreffenden Knochens und bei einer Gabelung des distalen Knochenendes distal von diesem. Die Form der Äste der Bifurkation in einigen Beobachtungen and ein einziger Fall mit Doppelepiphyse unterstützten die Theorie einer ektopischen Knochenentwicklung.

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The author is indebted to Dr. K. Aszódi for preparing the histologic section