PMC6701391_01
(a) Preoperative AP lower leg X-ray showing a periprosthetic fracture at the distal aspect of the metal plate with valgus deformity. (b, c) AP and lateral lower leg X-rays showing the stabilisation and restoration of alignment of the long bone with a tibial CFR-PEEK nail using proximal and distal locking screws. (d, e) Preoperative AP humerus X-rays showing failure of the metal plate and adjacent bone over time. (f) Intraoperative fluoroscopy image showing stabilisation of the long bone with a humeral CFR-PEEK nail.
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In the past, he had sustained stress fractures to his humeri, femora, and tibiae bilaterally, which were managed with conventional nails and plates (Figures 1(a), 1(d), and 1(e)). Indeed, over time, both his right tibial and left humeral plate-screw-osteosyntheses failed (Figures 1(a) and 1(e)). A 10 x 280 mm tibial and 8.5 x 240 mm humeral CFR-PEEK intramedullary nail with proximal and distal locking screws were used, respectively (Figures 1(b), 1(c), and 1(f)).
PMC6701391_02
(a) Coronal T1 MR image showing extensive disease in the left femoral head, neck, and proximal metaphysis without an actual fracture of the bone. A contralateral lesion is seen in the superolateral aspect of the right femoral neck with several deposits along the femoral shaft. (b) AP pelvic X-ray showing prophylactic nailing with a CFR-PEEK cephalomedullary nail. (c, d) CT planning images for radiotherapy with the absence of metal artefacts.
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Follow-up imaging showed a large left femoral lytic lesion with an impending fracture (Figure 2(a)). He therefore underwent prophylactic stabilisation using an 11 x 380 mm CFR-PEEK cephalomedullary nail to the left femur (Figure 2(b)). Radiotherapy planning was straightforward (Figures 2(c) and 2(d)) as there were no metal artefacts from the nail, and 5 times 4 Gy fractions were administered postoperatively to the left femoral lytic lesion.
PMC6701391_03
(a) Preoperative AP pelvic X-ray showing a pathological fracture through the trochanteric region of the right proximal femur. (b) Postoperative AP pelvic X-ray showing stabilisation of the fracture using a CFR-PEEK cephalomedullary nail. (c) Postoperative coronal CT image with minimal scattering showing massive progression of the right thigh sarcoma. (d-f) Postoperative MR images showing progression of tumour mass with an increase in cystic components but no signs of postoperative infection. (g-i) CT planning images for radiotherapy with the absence of metal artefacts.
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She subsequently underwent excision of the tumour, unfortunately complicated by a pathological fracture of the trochanteric region of the right proximal femur noted after a fall (Figure 3(a)). It was stabilised using an 11 x 380 mm CFR-PEEK cephalomedullary nail (Figure 3(b)). Due to the lack of metal artefact from the CFR-PEEK nail, it was possible to perform an MRI scan and therefore deep infection could be ruled out (Figures 3(d)-3(f)). Sadly, an increase in the size and number of the pulmonary metastases and a massive size progression of the known right thigh sarcoma were seen (Figure 3(c)). Five fractions over seven days with a total dose of 20 Gy were given using anterior and posterior parallel opposed post fields (Figures 3(g)-3(i)) and provided benefit to both the pain and swelling she experienced.