Oncological and functional outcomes of pathological fractures of lower extremities in patients with malignant bone tumors

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We aimed to suggest our treatment algorithm for lower bone malignancies. Methods: Thirty-eight patients with impending and pathological fractures treated at our department were included. Age, sex, fracture site, type of primary malignancy, number of metastases, pre-fracture Eastern Cooperative Oncology Group performance status (ECOG-PS) score, adjuvant therapy, treatment modality, operative time, blood loss, postoperative complications, Musculoskeletal Tumor Society (MSTS) score, outcomes, and follow-up period were retrospectively surveyed. Post-treatment MSTS scores in cases of impending and pathological fractures were compared. The MSTS scores were compared between intramedullary nail fixation and surgical procedures other than intramedullary nail fixation. The postoperative 1-year survival rate was calculated using the Kaplan–Meier method. Results: The median age of the sample was 68 years. The disease sites were the subtrochanteric femur in 10 patients, the trochanteric femur in eight, the femoral diaphysis in seven, the femoral neck in five, the bilateral trochanteric femur in three, the proximal tibia in three, and the distal femur in two. Ten patients had metastases in ≤3 and 20 sites. The median pre-fracture ECOG-PS score was 1. As adjuvant chemotherapy, radiotherapy was administered to five, chemotherapy to eight, and radiotherapy and chemotherapy to 10 patients. Surgical procedures included intramedullary nails in 18 patients; tumor arthroplasty in four; plate fixation in three; artificial head replacement in three; compression hip screw (CHS) in three; conservative treatment in two; bilateral intramedullary nail fixation in two; and artificial bone stem with combined intramedullary nail and plate fixation, right-sided artificial head replacement, and left-sided CHS in one each. The operating time was 100±45.8 minutes, and blood loss was 63±153.4 mL. The MSTS score was 19.9±8.95 for intramedullary nail fixation and 24.3±7.45 for other procedures, with a negative correlation between the MSTS score and pre-fracture ECOG-PS. The median follow-up period was 8 months. The outcomes were as follows: alive with disease, 23 patients; continued disease-free, 1 patient; and dead due to disease, 14 patients. The 1-year postoperative overall survival rate was 60.5%. Conclusions: Our treatment algorithm for malignant bone tumors of the lower extremity was useful. pathological fractures impending fractures malignancy bone tumor surgical treatment Figures Figure 1 Figure 2 Figure 3 Background Primary bone tumors, whether benign or malignant, can cause pathological fractures [ 1 , 2 ]. In particular, cystic bone tumors in the long bones of the extremities are prone to pathological fractures [ 3 ]. In contrast, approximately 10% of patients with primary malignancies develop metastases to the proximal femur. Most bone metastases originate from the breast, kidney, thyroid, prostate, or myeloma. Most metastases are soluble or mixed; therefore, patients are at high risk of pathologic fractures [ 4 ]. In 2001, Capanna and Campanacci published an algorithm for the treatment of long bone and pelvic metastases. The patients were divided into four classes: 1, isolated lesions with a good prognosis; 2, pathologic fractures; 3, incisional fractures; and 4, other lesions [ 5 ]. The important factors in selecting the appropriate treatment for the long bones and pelvis include prognosis, disease type, visceral metastases, time from the primary site, risk of pathologic fracture, sensitivity to chemotherapy, hormonal therapy, and irradiation. Pathologic fractures also occur in 5–10% of the patients with osteosarcoma, both at diagnosis and during chemotherapy [ 6 , 7 ]. The role of orthopedic surgeons in the evaluation of patients with skeletal metastases is likely to increase over time, as improved treatment of cancer patients increases survival [ 8 ]. In addition, pathological fractures of the proximal femur are 3.5 times more likely to occur than pathological fractures of the proximal humerus [ 9 ]. However, there is a lack of literature describing cases of pathological or impending fractures of the lower extremities in patients with primary and metastatic malignancies. Therefore, the aim of this study was to provide a detailed description of the clinical characteristics of patients with pathological or impending fractures who underwent surgical treatment. We also aimed to examine the benefits and drawbacks of our treatment strategy. Methods Thirty-eight patients with impending and pathological fractures treated in our department between March 2011 and November 2023 were included in this study. Data on age, sex, pathology, number of metastases, pre-fracture Eastern Cooperative Oncology Group performance status (ECOG-PS) [ 10 ], adjuvant therapy, treatment modality, operative time, blood loss, postoperative complications, Musculoskeletal Tumor Society (MSTS) score [ 11 ], follow-up period, and outcomes were retrospectively studied. Post-treatment MSTS scores in cases of impending and pathological fractures were compared. The MSTS scores were also compared between intramedullary nail fixation and surgical procedures other than intramedullary nail fixation. In addition, we investigated the 1-year overall survival of patients using the Kaplan–Meier method. We treated all the patients using the algorithm shown in Fig. 1 . Briefly put, our algorithm was as follows: First, patients were divided by their ECOG-PS (0–3 or 4). If 4, conservative treatment was chosen. Patients were then further divided by the site (proximal, distal, or diaphyseal), followed by the focus (primary or metastasis), and the number of metastases throughout the body (oligo or multiple). Finally, patients were divided by ECOG-PS (0, 2, or 3). This study was approved by the Ethics Committee of Kinki University. Results This study included 19 males and 19 females (Table 1 ). The median patient age was 68 years (range: 13–83 years). The cancer sites were the subtrochanteric femur in 10 patients, the trochanteric femur in eight, the femoral diaphysis in seven, the femoral neck in five, the bilateral trochanteric femur in three, the tibia in three, and the distal femur in two. Primary nodal pathology included lung cancer in nine patients; breast cancer in seven; renal cancer in three; multiple myeloma in three; osteosarcoma in three; liver cancer in two; gastric cancer in two; cancer of unknown primary origin in two; and esophageal cancer, hemangiopericytoma, hemangiosarcoma, Paget's disease, neuroblastoma, and chondrosarcoma in one each. In all, 10 patients had metastases in ≤ 3 and 20 sites. The median ECOG-PS score before the fracture was 1 (range 0–4: 0, two patients; 1, 18 patients; 2, 12 patients; 3, four patients; 4, two patients). As adjuvant chemotherapy, radiotherapy was administered to five, chemotherapy to eight, and radiotherapy and chemotherapy to 10 patients. Surgical procedures included intramedullary nail fixation in 18 patients, endoprosthesis in four, plate fixation in three, bipolar head arthroplasty in three, compression hip screw (CHS) in three, conservative treatment in two, bilateral intramedullary nail fixation in two, and artificial bone stem with combined intramedullary nail and plate fixation, right-sided artificial head replacement, and left-sided CHS in one. The operating time was 100 ± 45.8 minutes, and blood loss was 63 ± 153.4 mL. The MSTS score was 19.9 ± 8.95 for intramedullary nail fixation and 24.3 ± 7.45 for procedures other than intramedullary nail fixation, with no significant difference (p = 0.13) and a negative correlation between the MSTS score and pre-fracture ECOG-PS (r=-0.32; Fig. 2 ). Postoperative complications included implant failure after intramedullary nail fixation, which was replaced by tumor arthroplasty in one patient. The median observation period was 8 months (range: 1–150 months). The outcomes were as follows: alive with disease, 23 patients; continued disease-free, 1 patient; and dead due to disease, 14 patients. The 1-year postoperative survival rate was 60.5% (Fig. 3 ). Table 1 Characteristics of the study population Factor Patients, n Age (mean years) 68 ≤ 70 22 > 70 16 Sex Male 19 Female 19 Fracture site Femoral neck 5 Femoral diaphysis 7 Intertrochanteric 8 Subtrochanteric 10 Bilateral intertrochanteric 3 Proximal tibia 3 Distal femur 2 Type of cancer Lung 9 Breast 7 Kidney 3 Multiple Myeloma 3 Osteosarcoma 2 Liver 2 Gastric 2 Unknown 2 Esophageal 1 Hemangiopericytoma 1 Paget 1 Neuroblastoma 1 Chondrosarcoma 1 N. metastasis Equal or less than 3 10 More than 3 20 ECOG-PS 3 2 Adjuvant therapy Radiotherapy 5 Chemotherapy 8 Chemotherapy and radiotherapy 10 None 2 Treatment modality Intermedullary nail 18 Endoprosthesis 4 Fixation with plate 3 Bipolar head arthroplasty 3 Fixation with CHS 3 Bilateral intermedullary nail 2 Conservative 2 Artificial bone stem 1 Rt. Bipolar head arthroplasty, Lt. fixation with CHS 1 Operating time (min) 0-100 18 > 100 18 Blood loss 0–60 17 > 60 19 MSTS score 0–10 9 11–20 7 21–30 22 Outcome CDF 1 AWD 23 DOD 14 Follow-up periods (months) mean 8 range 1-150 N, number; Rt, right side; Lt, left side; ECOG-PS, Eastern Cooperative Oncology Group (ECOG) score for performance status; CHS, compression hip screw; MSTS, Musculoskeletal Tumor Society; CDF, continuous disease-free; AWD, alive with disease; DOD, dead of disease. Discussion The present study retrospectively investigated the treatment outcomes for malignant bone tumors of the lower extremities. The treatment outcomes according to our treatment algorithm were favorable. The most commonly reported sites of pathological fractures are the femur, humerus, and tibia [ 12 ]. The other reported sites of pathological fractures besides the lower extremities include the neck (50%), adductor region (30%), and sub-acetabulum (20%) [ 12 ]. Other studies have reported 47.5% fractures in the femoral head and neck, 27.5% in the femoral metaphyseal area, and 25% in the region below the femoral metaphyseal area [ 13 ]. In the present study, fractures were more common in the femoral and subtrochanteric areas than in the femoral neck area. In previous reports, the most common primary sites of pathological femoral fractures were breast cancer, myeloma, renal cancer, colorectal cancer, thyroid cancer, and lung cancer [ 14 ]. Breast, lung, myeloma, and kidney cancers are the most common primary lesions resulting in pathological fractures of the proximal femur [ 13 ]. Lung cancer was relatively common in the current study. Reconstructive surgery with oncological arthroplasty, intramedullary nail fixation, or plate fixation were the commonly adopted options [ 15 – 17 ]. The advantages of tumor arthroplasty include a quick return to stability, independent of the degree of fracture healing, and minimal risk of local progression or implant failure [ 18 ]. The disadvantages include surgical invasiveness, bleeding, relative difficulty in muscle reconstruction, and high costs [ 18 ]. The advantages of intramedullary nail fixation include relatively low surgical invasion, the possibility of additional radiation therapy, and the ability to load immediately after radiation [ 18 ]. The disadvantages of plate fixation include the need for adequate bone stock, a lack of stability in close proximity to the joint, the risk of implant fracture, a large incision, a long surgical procedure, and a lack of prophylactic fixation of the entire bone [ 18 ]. The advantages of plate fixation include prevention of damage to the muscle cuff, strong fixation with locking screws, fixation of distal fractures, and a relatively large operative field that allows visual resection of the tumor [ 18 ]. Intramedullary nail fixation was used in this study. Our policy is to reconstruct pathological fractures of the femoral neck using either artificial head replacement or tumor arthroplasty. The choice is based on tumor spread, prognosis, invasiveness, and the patient's ability to engage in rehabilitation, including load-bearing. For pathological fractures of the femoral condyle and subtrochanteric region, reconstruction using an intramedullary nail was performed in anticipation of postoperative radiotherapy. Impending fractures of the femoral neck or transverse condyle are treated with bipolar head arthroplasty or fixation using intramedullary nails or CHS plates. The selection of reconstruction was based on a comprehensive evaluation of postoperative radiotherapy, fixation stability, and the amount of lesion removed. The functional prognosis was generally good for both types of fixation but was poor when rehabilitation did not proceed as expected because of the patient's general condition. Several studies have reported different outcomes and failure rates between the use of an intramedullary nail and endoprosthesis [ 19 – 22 ]. Patients with malignancies are at the highest risk of thromboembolic complications and infections [ 14 ]. The rate of infectious complications ranges from 1.2–19.5%. Preoperative radiotherapy is one of the most important risk factors for radiotherapy [ 14 ]. In addition, location in the proximal lower extremity has been reported as a risk factor for major wound complications such as infection [ 23 ]. Complications have been reported in 9–20% of the patients who undergo intramedullary nail fixation. The primary complications include deep infection, myocardial infarction, and stroke. Further, 20% of the patients require revision surgery within 3 months. On the other hand, dislocation was reported to occur in 3–22% of the patients as a complication of tumor arthroplasty. The risk of periprosthetic failure has also been reported previously. In this study, implant failure occurred in one patient who underwent intramedullary nail fixation, which was subsequently replaced by an oncological prosthesis. Previous reports have reported MSTS scores of 6.4–25.2 after implant use for pathological fractures [ 13 , 14 , 24 ]. The results of this study are comparable, and we believe that our surgical indications (Fig. 1 ) are generally recommended. Typically, the treatment is tailored since these patients are in the terminal disease stage [ 25 , 26 ]. In terms of overall patient survival, the 1-year survival rate reported in the literature ranges from 42–75% [ 21 , 27 , 28 ]. Fractures are also associated with an increased mortality risk in patients with malignant bone disease [ 29 ]. Although the survival rate of patients with metastases remains low, some differences related to tumor histology have been found, probably because of medical advances. In this situation, “improving the survival rate of the implant relative to the patient's lifespan” is essential, and the best treatment for the patient should be considered with life expectancy in mind. The current study had several limitations. First, the sample size was small, and there were few cases of primary malignancies. However, no problems were encountered during statistical analyses. Second, this was a retrospective study, which might have resulted in selection bias. Finally, the follow-up period was relatively short. Despite these limitations, we enrolled as many patients as possible during the study period. Prospects for future research would be to increase the number of cases and conduct a prospective randomized control study. Conclusions The treatment of primary and metastatic malignant bone tumors should be based on a comprehensive assessment of the extent of malignant tumor resection, surgical invasiveness, and the patient's general condition and prognosis. Abbreviations CHS compression hip screw ECOG-PS Eastern Cooperative Oncology Group performance status MSTS Musculoskeletal Tumor Society Declarations Ethics approval and consent to participate : Ethical approval for this study was obtained from the Ethics Committee of Kindai University Hospital, Osaka, Japan (approval no.: 31–153). Informed consent : We obtained comprehensive consent for the current study. Written informed consent by individual signature is waived by the Ethics Committee of Kindai University Hospital, Osaka, Japan (approval no.: 31–153). Consent for publication: Not applicable. Competing interests : The authors declare that they have no competing interests. Funding: The authors did not receive support from any organization for the submitted work. Author Contribution The authors would like to thank Editage (www.editage.jp) for English language editing. Acknowledgements: The authors would like to thank Editage ( www.editage.jp ) for English language editing. Availability of data and materials: The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. References Hoshi M, Iwai T, Oebisu N, Shimatani A, Takada N, Nakamura H. Pathological fracture of a solitary bone cyst in the calcaneus: a case series and literature review. Arch Orthop Trauma Surg. 2023;143:1155–62. Salunke AA, Chen Y, Tan JH, Chen X, Khin LW, Puhaindran ME. Does a pathological fracture affect the prognosis in patients with osteosarcoma of the extremities? a systematic review and meta-analysis. 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Functional outcome of surgical treatment of adults with extremity osteosarcoma after megaprosthetic reconstruction-single-center experience. J Orthop Surg Res. 2019;14:346. Roudier MP, True LD, Higano CS, Vesselle H, Ellis W, Lange P, et al. Phenotypic heterogeneity of end-stage prostate carcinoma metastatic to bone. Hum Pathol. 2003;34:646–53. Ganesh K, Massagué J. Targeting metastatic cancer. Nat Med. 2021;27:34–44. Mavrogenis AF, Pala E, Romagnoli C, Romantini M, Calabro T, Ruggieri P. Survival analysis of patients with femoral metastases. J Surg Oncol. 2012;105:135–41. Chandrasekar CR, Grimer RJ, Carter SR, Tillman RM, Abudu A, Buckley L. Modular endoprosthetic replacement for tumours of the proximal femur. J Bone Joint Surg Br. 2009;20:108–12. Saad F, Lipton A, Cook R, Chen YM, Smith M, Coleman R. Pathologic fractures correlate with reduced survival in patients with malignant bone disease. Cancer. 2007;110:1860–7. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3877674","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":268202430,"identity":"81efb8a1-724b-4703-9e8f-d33017389870","order_by":0,"name":"Kazuhiko Hashimoto","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIie2QMUsDMRTH3xGwy2nXV5R+hgcH7RXEz5IQuC6HFlwcigRci7PSL3EgOEcOrsvBbRK46Sg4ORQK4lDBWB10SGs3kfzgkbwHP94/AfB4/iBkiwFxaNsLgkYAHShYT7cpHbWbAhxIrxXb6i3B+q3ZfDkaJd3oMX8wUManB7NcwesYWn2HMphwHt1QGvXqRMZg8LxTChVMCmAD5QimuZYhXYj7Ou0hLFBkWijYV8DIkZCqRuUfyt307OVTsZPgbZNiZHAVUiqyw3QPbTCRGaHYxi3mibGQkgjrJIp5ieLW2L1HBbrfUg3ny3Alu+2pbMyiuBTX1bBpnsfH0vVjP+Ffp42Ekn6lfOdkd8Xj8Xj+Ke+RaGDphtrt8AAAAABJRU5ErkJggg==","orcid":"","institution":"Kindai University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Kazuhiko","middleName":"","lastName":"Hashimoto","suffix":""},{"id":268202431,"identity":"560928e7-c427-485a-bb5e-f411ae647dc1","order_by":1,"name":"Shunji Nishimura","email":"","orcid":"","institution":"Kindai University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shunji","middleName":"","lastName":"Nishimura","suffix":""},{"id":268202432,"identity":"046858d5-f880-425c-bed2-f93d3ddd8c21","order_by":2,"name":"Tomohiko Ito","email":"","orcid":"","institution":"Kindai University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tomohiko","middleName":"","lastName":"Ito","suffix":""},{"id":268202433,"identity":"2ab711c2-0ba8-4357-a970-811a93cdf1f3","order_by":3,"name":"Ryosuke Kakinoki","email":"","orcid":"","institution":"Kindai University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ryosuke","middleName":"","lastName":"Kakinoki","suffix":""},{"id":268202434,"identity":"7d7fcccf-afdb-47e4-a1ca-864134e3e8e4","order_by":4,"name":"Koji Goto","email":"","orcid":"","institution":"Kindai University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Koji","middleName":"","lastName":"Goto","suffix":""}],"badges":[],"createdAt":"2024-01-19 04:59:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3877674/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3877674/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50053336,"identity":"6ae44978-5203-4c5b-9e29-f8ec658951d3","added_by":"auto","created_at":"2024-01-23 17:02:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":408863,"visible":true,"origin":"","legend":"\u003cp\u003eTree diagram showing the treatment algorithm for lower leg malignancy in our hospital.\u003c/p\u003e\n\u003cp\u003eFirst, patients were divided by their ECOG-PS (0–3 or 4). If 4, conservative treatment was chosen. Patients were then further divided by the site (proximal, distal, or diaphyseal), followed by the focus (primary or metastasis), and the number of metastases throughout the body (oligo or multiple).\u003c/p\u003e\n\u003cp\u003eABS, artificial bone stem; BHA, bipolar head arthroplasty; EP, endoprosthesis; IMN, intermedullary nail; Multiple, multiple metastasis in whole body; Oligo, oligo metastasis in whole body; PS, performance status.\u003c/p\u003e","description":"","filename":"Figure1TIFF.png","url":"https://assets-eu.researchsquare.com/files/rs-3877674/v1/b2f8b8492fc6f318954f979f.png"},{"id":50052653,"identity":"7b9dee01-66c8-405e-87c5-ecd5c057b035","added_by":"auto","created_at":"2024-01-23 16:54:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":189396,"visible":true,"origin":"","legend":"\u003cp\u003eGraph showing the negative correlation between the MSTS score and ECOG-PS (r = -0.32). ECOG-PS, Eastern Cooperative Oncology Group performance status; MSTS, Musculoskeletal Tumor Society.\u003c/p\u003e","description":"","filename":"Figure2TIFF.png","url":"https://assets-eu.researchsquare.com/files/rs-3877674/v1/e6e6a8ba56d1a21e64c8e075.png"},{"id":50052656,"identity":"465b2431-5e98-4b59-984b-c5c1f67b0617","added_by":"auto","created_at":"2024-01-23 16:54:01","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":519269,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan–Meier curve showing the survival rate.\u003c/p\u003e\n\u003cp\u003eThe 1-year survival rate was 60.5%.\u003c/p\u003e","description":"","filename":"Figure3TIFF.png","url":"https://assets-eu.researchsquare.com/files/rs-3877674/v1/c21ce169ee2e10ec90ee8e64.png"},{"id":52477701,"identity":"6b1f930c-017f-40b6-ab32-05e445bd00f0","added_by":"auto","created_at":"2024-03-12 05:08:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":707422,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3877674/v1/715fea0a-0ffc-4d2b-b003-0a44b3b4c8f1.pdf"},{"id":50052655,"identity":"94700804-f1f4-461a-81ae-9e382df9ea8e","added_by":"auto","created_at":"2024-01-23 16:54:01","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":20080,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-3877674/v1/35a9feb83f07a3957c3e7318.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Oncological and functional outcomes of pathological fractures of lower extremities in patients with malignant bone tumors","fulltext":[{"header":"Background","content":"\u003cp\u003ePrimary bone tumors, whether benign or malignant, can cause pathological fractures [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In particular, cystic bone tumors in the long bones of the extremities are prone to pathological fractures [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In contrast, approximately 10% of patients with primary malignancies develop metastases to the proximal femur. Most bone metastases originate from the breast, kidney, thyroid, prostate, or myeloma. Most metastases are soluble or mixed; therefore, patients are at high risk of pathologic fractures [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In 2001, Capanna and Campanacci published an algorithm for the treatment of long bone and pelvic metastases. The patients were divided into four classes: 1, isolated lesions with a good prognosis; 2, pathologic fractures; 3, incisional fractures; and 4, other lesions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The important factors in selecting the appropriate treatment for the long bones and pelvis include prognosis, disease type, visceral metastases, time from the primary site, risk of pathologic fracture, sensitivity to chemotherapy, hormonal therapy, and irradiation. Pathologic fractures also occur in 5\u0026ndash;10% of the patients with osteosarcoma, both at diagnosis and during chemotherapy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The role of orthopedic surgeons in the evaluation of patients with skeletal metastases is likely to increase over time, as improved treatment of cancer patients increases survival [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In addition, pathological fractures of the proximal femur are 3.5 times more likely to occur than pathological fractures of the proximal humerus [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, there is a lack of literature describing cases of pathological or impending fractures of the lower extremities in patients with primary and metastatic malignancies. Therefore, the aim of this study was to provide a detailed description of the clinical characteristics of patients with pathological or impending fractures who underwent surgical treatment. We also aimed to examine the benefits and drawbacks of our treatment strategy.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThirty-eight patients with impending and pathological fractures treated in our department between March 2011 and November 2023 were included in this study. Data on age, sex, pathology, number of metastases, pre-fracture Eastern Cooperative Oncology Group performance status (ECOG-PS) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], adjuvant therapy, treatment modality, operative time, blood loss, postoperative complications, Musculoskeletal Tumor Society (MSTS) score [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], follow-up period, and outcomes were retrospectively studied. Post-treatment MSTS scores in cases of impending and pathological fractures were compared. The MSTS scores were also compared between intramedullary nail fixation and surgical procedures other than intramedullary nail fixation. In addition, we investigated the 1-year overall survival of patients using the Kaplan\u0026ndash;Meier method. We treated all the patients using the algorithm shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Briefly put, our algorithm was as follows: First, patients were divided by their ECOG-PS (0\u0026ndash;3 or 4). If 4, conservative treatment was chosen. Patients were then further divided by the site (proximal, distal, or diaphyseal), followed by the focus (primary or metastasis), and the number of metastases throughout the body (oligo or multiple). Finally, patients were divided by ECOG-PS (0, 2, or 3). This study was approved by the Ethics Committee of Kinki University.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis study included 19 males and 19 females (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The median patient age was 68 years (range: 13\u0026ndash;83 years). The cancer sites were the subtrochanteric femur in 10 patients, the trochanteric femur in eight, the femoral diaphysis in seven, the femoral neck in five, the bilateral trochanteric femur in three, the tibia in three, and the distal femur in two. Primary nodal pathology included lung cancer in nine patients; breast cancer in seven; renal cancer in three; multiple myeloma in three; osteosarcoma in three; liver cancer in two; gastric cancer in two; cancer of unknown primary origin in two; and esophageal cancer, hemangiopericytoma, hemangiosarcoma, Paget's disease, neuroblastoma, and chondrosarcoma in one each. In all, 10 patients had metastases in \u0026le;\u0026thinsp;3 and 20 sites. The median ECOG-PS score before the fracture was 1 (range 0\u0026ndash;4: 0, two patients; 1, 18 patients; 2, 12 patients; 3, four patients; 4, two patients). As adjuvant chemotherapy, radiotherapy was administered to five, chemotherapy to eight, and radiotherapy and chemotherapy to 10 patients. Surgical procedures included intramedullary nail fixation in 18 patients, endoprosthesis in four, plate fixation in three, bipolar head arthroplasty in three, compression hip screw (CHS) in three, conservative treatment in two, bilateral intramedullary nail fixation in two, and artificial bone stem with combined intramedullary nail and plate fixation, right-sided artificial head replacement, and left-sided CHS in one. The operating time was 100\u0026thinsp;\u0026plusmn;\u0026thinsp;45.8 minutes, and blood loss was 63\u0026thinsp;\u0026plusmn;\u0026thinsp;153.4 mL. The MSTS score was 19.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.95 for intramedullary nail fixation and 24.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.45 for procedures other than intramedullary nail fixation, with no significant difference (p\u0026thinsp;=\u0026thinsp;0.13) and a negative correlation between the MSTS score and pre-fracture ECOG-PS (r=-0.32; Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Postoperative complications included implant failure after intramedullary nail fixation, which was replaced by tumor arthroplasty in one patient. The median observation period was 8 months (range: 1\u0026ndash;150 months). The outcomes were as follows: alive with disease, 23 patients; continued disease-free, 1 patient; and dead due to disease, 14 patients. The 1-year postoperative survival rate was 60.5% (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the study population\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients, n\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (mean years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFracture site\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemoral neck\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemoral diaphysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntertrochanteric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubtrochanteric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral intertrochanteric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProximal tibia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistal femur\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLung\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKidney\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiple Myeloma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOsteosarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEsophageal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemangiopericytoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaget\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeuroblastoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChondrosarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN. metastasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEqual or less than 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eECOG-PS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjuvant therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemotherapy and radiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment modality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermedullary nail\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndoprosthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFixation with plate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBipolar head arthroplasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFixation with CHS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral intermedullary nail\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConservative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArtificial bone stem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRt. Bipolar head arthroplasty, Lt. fixation with CHS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperating time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0-100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMSTS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAWD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDOD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up periods (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003erange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1-150\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eN, number; Rt, right side; Lt, left side; ECOG-PS, Eastern Cooperative Oncology Group (ECOG) score for performance status; CHS, compression hip screw; MSTS, Musculoskeletal Tumor Society; CDF, continuous disease-free; AWD, alive with disease; DOD, dead of disease.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study retrospectively investigated the treatment outcomes for malignant bone tumors of the lower extremities. The treatment outcomes according to our treatment algorithm were favorable.\u003c/p\u003e \u003cp\u003eThe most commonly reported sites of pathological fractures are the femur, humerus, and tibia [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The other reported sites of pathological fractures besides the lower extremities include the neck (50%), adductor region (30%), and sub-acetabulum (20%) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Other studies have reported 47.5% fractures in the femoral head and neck, 27.5% in the femoral metaphyseal area, and 25% in the region below the femoral metaphyseal area [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In the present study, fractures were more common in the femoral and subtrochanteric areas than in the femoral neck area.\u003c/p\u003e \u003cp\u003eIn previous reports, the most common primary sites of pathological femoral fractures were breast cancer, myeloma, renal cancer, colorectal cancer, thyroid cancer, and lung cancer [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Breast, lung, myeloma, and kidney cancers are the most common primary lesions resulting in pathological fractures of the proximal femur [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Lung cancer was relatively common in the current study. Reconstructive surgery with oncological arthroplasty, intramedullary nail fixation, or plate fixation were the commonly adopted options [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe advantages of tumor arthroplasty include a quick return to stability, independent of the degree of fracture healing, and minimal risk of local progression or implant failure [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The disadvantages include surgical invasiveness, bleeding, relative difficulty in muscle reconstruction, and high costs [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The advantages of intramedullary nail fixation include relatively low surgical invasion, the possibility of additional radiation therapy, and the ability to load immediately after radiation [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The disadvantages of plate fixation include the need for adequate bone stock, a lack of stability in close proximity to the joint, the risk of implant fracture, a large incision, a long surgical procedure, and a lack of prophylactic fixation of the entire bone [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The advantages of plate fixation include prevention of damage to the muscle cuff, strong fixation with locking screws, fixation of distal fractures, and a relatively large operative field that allows visual resection of the tumor [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Intramedullary nail fixation was used in this study. Our policy is to reconstruct pathological fractures of the femoral neck using either artificial head replacement or tumor arthroplasty. The choice is based on tumor spread, prognosis, invasiveness, and the patient's ability to engage in rehabilitation, including load-bearing. For pathological fractures of the femoral condyle and subtrochanteric region, reconstruction using an intramedullary nail was performed in anticipation of postoperative radiotherapy. Impending fractures of the femoral neck or transverse condyle are treated with bipolar head arthroplasty or fixation using intramedullary nails or CHS plates. The selection of reconstruction was based on a comprehensive evaluation of postoperative radiotherapy, fixation stability, and the amount of lesion removed. The functional prognosis was generally good for both types of fixation but was poor when rehabilitation did not proceed as expected because of the patient's general condition.\u003c/p\u003e \u003cp\u003eSeveral studies have reported different outcomes and failure rates between the use of an intramedullary nail and endoprosthesis [\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Patients with malignancies are at the highest risk of thromboembolic complications and infections [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The rate of infectious complications ranges from 1.2\u0026ndash;19.5%. Preoperative radiotherapy is one of the most important risk factors for radiotherapy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In addition, location in the proximal lower extremity has been reported as a risk factor for major wound complications such as infection [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eComplications have been reported in 9\u0026ndash;20% of the patients who undergo intramedullary nail fixation. The primary complications include deep infection, myocardial infarction, and stroke. Further, 20% of the patients require revision surgery within 3 months. On the other hand, dislocation was reported to occur in 3\u0026ndash;22% of the patients as a complication of tumor arthroplasty. The risk of periprosthetic failure has also been reported previously. In this study, implant failure occurred in one patient who underwent intramedullary nail fixation, which was subsequently replaced by an oncological prosthesis. Previous reports have reported MSTS scores of 6.4\u0026ndash;25.2 after implant use for pathological fractures [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The results of this study are comparable, and we believe that our surgical indications (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) are generally recommended.\u003c/p\u003e \u003cp\u003eTypically, the treatment is tailored since these patients are in the terminal disease stage [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In terms of overall patient survival, the 1-year survival rate reported in the literature ranges from 42\u0026ndash;75% [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Fractures are also associated with an increased mortality risk in patients with malignant bone disease [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Although the survival rate of patients with metastases remains low, some differences related to tumor histology have been found, probably because of medical advances. In this situation, \u0026ldquo;improving the survival rate of the implant relative to the patient's lifespan\u0026rdquo; is essential, and the best treatment for the patient should be considered with life expectancy in mind.\u003c/p\u003e \u003cp\u003eThe current study had several limitations. First, the sample size was small, and there were few cases of primary malignancies. However, no problems were encountered during statistical analyses. Second, this was a retrospective study, which might have resulted in selection bias. Finally, the follow-up period was relatively short. Despite these limitations, we enrolled as many patients as possible during the study period. Prospects for future research would be to increase the number of cases and conduct a prospective randomized control study.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe treatment of primary and metastatic malignant bone tumors should be based on a comprehensive assessment of the extent of malignant tumor resection, surgical invasiveness, and the patient's general condition and prognosis.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCHS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecompression hip screw\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eECOG-PS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEastern Cooperative Oncology Group performance status\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMSTS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMusculoskeletal Tumor Society\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003e \u003cb\u003eEthics approval and consent to participate\u003c/b\u003e:\u003c/strong\u003e \u003cp\u003e Ethical approval for this study was obtained from the Ethics Committee of Kindai University Hospital, Osaka, Japan (approval no.: 31\u0026ndash;153).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e \u003cb\u003eInformed consent\u003c/b\u003e:\u003c/strong\u003e \u003cp\u003eWe obtained comprehensive consent for the current study. Written informed consent by individual signature is waived by the Ethics Committee of Kindai University Hospital, Osaka, Japan (approval no.: 31\u0026ndash;153).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003e \u003cb\u003eCompeting interests\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThe authors did not receive support from any organization for the submitted work.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eThe authors would like to thank Editage (www.editage.jp) for English language editing.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003eThe authors would like to thank Editage (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"http://www.editage.jp\" target=\"_blank\"\u003ewww.editage.jp\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.editage.jp\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) for English language editing.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials:\u003c/h2\u003e \u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHoshi M, Iwai T, Oebisu N, Shimatani A, Takada N, Nakamura H. 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Clin Exp Metastasis. 2015;32:819\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScorianz M, Gherlinzoni F, Campanacci DA. Metastases to the long bones: algorithm of treatment. In: Denaro V, Di Martino A, Piccioli A, editors. Management of bone metastases. Berlin: Springer; 2019. pp. 93\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScully SP, Ghert MA, Zurakowski D, Thompson RC, Gebhardt MC. Pathologic fracture in osteosarcoma: prognostic importance and treatment implications. J Bone Joint Surg Am. 2002;84:49\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChung L-H, Wu PK, Chen CF, Weng HK, Chen TH, Chen WM. Pathological fractures in predicting clinical outcomes for patients with osteosarcoma. BMC Musculoskelet Disord. 2016;17:503.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHage WD, Aboulafia AJ, Aboulafia DM. 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J Surg Oncol. 2012;105:135\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChandrasekar CR, Grimer RJ, Carter SR, Tillman RM, Abudu A, Buckley L. Modular endoprosthetic replacement for tumours of the proximal femur. J Bone Joint Surg Br. 2009;20:108\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaad F, Lipton A, Cook R, Chen YM, Smith M, Coleman R. Pathologic fractures correlate with reduced survival in patients with malignant bone disease. Cancer. 2007;110:1860\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"pathological fractures, impending fractures, malignancy, bone tumor, surgical treatment","lastPublishedDoi":"10.21203/rs.3.rs-3877674/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3877674/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Managing pathological fractures of the extremities can be difficult. We aimed to suggest our treatment algorithm for lower bone malignancies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Thirty-eight patients with impending and pathological fractures treated at our department were included. Age, sex, fracture site, type of primary malignancy, number of metastases, pre-fracture Eastern Cooperative Oncology Group performance status (ECOG-PS) score, adjuvant therapy, treatment modality, operative time, blood loss, postoperative complications, Musculoskeletal Tumor Society (MSTS) score, outcomes, and follow-up period were retrospectively surveyed. Post-treatment MSTS scores in cases of impending and pathological fractures were compared. The MSTS scores were compared between intramedullary nail fixation and surgical procedures other than intramedullary nail fixation. The postoperative 1-year survival rate was calculated using the Kaplan–Meier method.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The median age of the sample was 68 years. The disease sites were the subtrochanteric femur in 10 patients, the trochanteric femur in eight, the femoral diaphysis in seven, the femoral neck in five, the bilateral trochanteric femur in three, the proximal tibia in three, and the distal femur in two. Ten patients had metastases in ≤3 and 20 sites. The median pre-fracture ECOG-PS score was 1. As adjuvant chemotherapy, radiotherapy was administered to five, chemotherapy to eight, and radiotherapy and chemotherapy to 10 patients. Surgical procedures included intramedullary nails in 18 patients; tumor arthroplasty in four; plate fixation in three; artificial head replacement in three; compression hip screw (CHS) in three; conservative treatment in two; bilateral intramedullary nail fixation in two; and artificial bone stem with combined intramedullary nail and plate fixation, right-sided artificial head replacement, and left-sided CHS in one each. The operating time was 100±45.8 minutes, and blood loss was 63±153.4 mL. The MSTS score was 19.9±8.95 for intramedullary nail fixation and 24.3±7.45 for other procedures, with a negative correlation between the MSTS score and pre-fracture ECOG-PS. The median follow-up period was 8 months. The outcomes were as follows: alive with disease, 23 patients; continued disease-free, 1 patient; and dead due to disease, 14 patients. The 1-year postoperative overall survival rate was 60.5%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Our treatment algorithm for malignant bone tumors of the lower extremity was useful.\u003c/p\u003e","manuscriptTitle":"Oncological and functional outcomes of pathological fractures of lower extremities in patients with malignant bone tumors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-23 16:53:56","doi":"10.21203/rs.3.rs-3877674/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"814af0b0-9684-4e77-ad19-d9c15f0d1ab6","owner":[],"postedDate":"January 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-12T05:07:25+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-23 16:53:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3877674","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3877674","identity":"rs-3877674","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}