Aims. The aim of this study was to report the patterns of symptoms and insufficiency fractures in patients with tumour-induced osteomalacia (TIO) to allow the early diagnosis of this rare condition. Methods. The study included 33 patients with TIO who were treated between January 2000 and June 2022. The causative tumour was detected in all patients. We investigated the symptoms and evaluated the radiological patterns of insufficiency fractures of the rib, spine, and limbs. Results. The mean age of the patients was 57 years (24 to 87), and the mean duration of pain from onset to time of presentation was 3.9 years (0.75 to 23). The primary symptoms were low back pain (ten patients), chest wall pain (eight patients), and hip pain (eight patients). There were symptoms at more sites at the time of presentation compared with that at the time of the onset of symptoms. Bone scans showed the uptake of tracer in the rib (100%), thoracic and lumbar vertebrae (83%), proximal femur (62%), distal femur (66%), and proximal tibia (72%). Plain radiographs or MRI scans identified femoral neck fractures in 14 patients, subchondral insufficiency fractures of the femoral head and knee in ten and six patients, respectively, distal femoral fractures in nine patients, and proximal tibial fractures in 12 patients. Thoracic or lumbar vertebral fractures were identified in 23 of 29 patients (79.3%) when using any imaging study, and a biconcave deformity was the most common type of fracture. Conclusion. Insufficiency fractures in patients with TIO caused spinal pain, chest wall pain, and periarticular pain in the lower limbs. Vertebral fractures tended to be biconcave deformities, and periarticular fractures of the hips and knees included subchondral insufficiency fractures and epiphyseal or metaphyseal fractures. In patients with a tumour, the presence of one or more of these symptoms and an insufficiency fracture should suggest the diagnosis of TIO. Cite this article: Bone Joint J 2023;105-B(5):568–574

Sacral insufficiency fractures are traditionally treated with bed rest and analgesia. The importance of early rehabilitation is generally appreciated; but pain frequently delays this, resulting in prolonged hospital stay and the risk of complications related to immobility. We describe three women with sacral insufficiency fractures who were treated with percutaneous sacroiliac screws and followed up for a mean of 18 months (12 to 24). They had immediate pain relief, uncomplicated rehabilitation and uneventful healing

Introduction. Long-term use of bisphosphonates has been known to induce femoral insufficiency fracture in osteoporotic patients. We followed patients who had femoral insufficiency fractures after a long-term use of bisphosphonates. Methods. Eleven patients (14 hips) were diagnosed as having an insufficiency fracture of the femur after long-term (> 4 years) use of bisphosphonate to treat osteoporosis between January 2002 and December 2008. All patients were women who had a mean age of 68 years (range, 57 to 82 years). The fracture site was located in the subtrochanteric area in 6 hips and the femoral shaft in 8 hips. Three patients had bilateral involvement. These patients were followed-up for a mean of 27 months (range, 12 to 60 months). Results. Five hips in five patients displaced during the follow-up period. The mean period from the diagnosis of insufficiency fracture to the displacement was 10 months (range, 1 to 19 months). Five hips (five patients) underwent internal fixation due to persistent pain. Thus, during the follow-up of 27 months, operation was necessary in 71% (10 hips) of 14 insufficiency fractures. Four hips (four patients) that did not undergo any operation had persistent pain at the latest follow-up. Conclusion. The insufficiency fractures after prolonged bisphosphonate therapy seldom healed spontaneously and most of them required operation due to fracture displacement or persistent pain. We recommend preventive surgery to prevent further fracture displacement and persistent pain

We describe a case of oncogenic osteomalacia in an adult male who presented with low back pain and bilateral hip pain. Extensive investigations had failed to find a cause. A plain pelvic radiograph showed Looser’s zones in both femoral necks. MRI confirmed the presence of insufficiency fractures bilaterally in the femoral head and neck. Biochemical investigations confirmed osteomalacia which was unresponsive to treatment with vitamin D and calcium. A persistently low serum phosphate level suggested a diagnosis of hypophosphataemic osteomalacia. The level of fibroblast growth factor-23 was highly raised, indicating the cause as oncogenic osteomalacia. This was confirmed on positron-emission tomography, MRI and excision of a benign fibrous histiocytoma following a rapid recovery. The diagnosis of oncogenic osteomalacia may be delayed due to the non-specific presenting symptoms. Subchondral insufficiency fractures of the femoral head may be missed unless specifically looked for

We carried out a retrospective review over ten months of patients who had presented with a low-energy subtrochanteric fracture. We identified 13 women of whom nine were on long-term alendronate therapy and four were not. The patients treated with alendronate were younger, with a mean age of 66.9 years (55 to 82) vs 80.3 years (64 to 92) and were more socially active. The fractures sustained by the patients in the alendronate group were mainly at the femoral metaphyseal-diaphyseal junction and many had occurred after minimal trauma. Five of these patients had prodromal pain in the affected hip in the months preceding the fall, and three demonstrated a stress reaction in the cortex in the contralateral femur. Our study suggests that prolonged suppression of bone remodelling with alendronate may be associated with a new form of insufficiency fracture of the femur. We believe that this finding is important and indicates the need for caution in the long-term use of alendronate in the treatment of osteoporosis

Introduction. Subchondral insufficiency fractures of the femoral head (SIFFH) occur with normal or physiological stress in patients with poor bone quality. We evaluated the clinical characteristics of SIFFH. Methods. Nine cases of SIFFH were treated and followed up for an average of 9 months. Femoral head collapse (FHC) on radiographs was classified as minimal (< 2 mm), moderate (2-4 mm), and severe (> 4 mm). The severity of osteopenia was scored by Singh index (SI). Other characteristics of SIFFH were ascertained by assessing the clinical course as well as Body Mass Index (BMI) and magnetic resonance imaging (MRI). Results. There were 8 women and 1 man who had a mean age of 67 years. FHC was identified in 6 cases (1 minimal, 3 moderate, and 2 severe). SI scores ranged from 1 to 4. Mean BMI was 22.4 Kg/m. 2. In all affected hips, MRI demonstrated a subchondral fracture line with localized or diffuse bone-marrow-edema pattern in the femoral head. Initially, all cases were treated with conservative nonweight bearing therapy. In 7 of 9 cases, the pain decreased gradually and disappeared almost completely within 5 months regardless of the extent of FHC, SI score, and BMI. The remaining 2 cases (1 moderate and 1 severe FHC) were treated with total hip arthroplasty due to intractable pain. Conclusion. This study showed that conservative treatment could be considered as the first treatment choice for SIFFH independent of predisposing factors

Sacral insufficiency fractures are not uncommon in elderly patients. We have diagnosed 20 cases in a five-year period, and have reviewed the clinical records, radiographs, CT and bone scans. We also assessed the degree of osteoporosis by measuring bone density using dual-energy X-ray absorptiometry and bone histomorphometry, and monitored the patients' functional outcome. Bone scans were positive in all 20 patients, CT showed a fracture or sclerosis in 7 of 12 patients and was useful in excluding malignancy. Plain radiographs were the least helpful, showing sclerosis in only 4 of the 20 patients. Involutional osteoporosis with a reduced bone formation rate was the most common underlying cause. Seventeen patients had complete resolution of pain within nine months, and no patient lost independence in daily activities. Increased awareness of these fractures may help to avoid unnecessary investigation and treatment. Bedrest and analgesia followed by rehabilitation provide good relief of symptoms

Similar to the radiological findings in rapidly destructive arthrosis of the hip joint (RDA), subchondral insufficiency fracture of the femoral head (SIF) can result in progressive femoral head collapse of unknown etiology. We thus examined the osteoclast activity in hip joint fluid in SIF with progressive collapse in comparison to that in RDA. Twenty-nine hip joint fluid samples were obtained intraoperatively with whole femoral heads from 12 SIF patients and 17 RDA patients. SIF cases were classified into subgroups based on the presence of ≥2mm collapse on preoperative radiographs: SIF with progressive collapse (n=5) and SIF without progressive collapse (n=7). The levels of tartrate-resistant acid phosphatase (TRACP)-5b, interleukin-8, vascular endothelial growth factor (VEGF), and matrix metalloproteinase (MMP)-9 were measured. Numbers of multinuclear giant cells at the subchondral region were assessed histopathologically using mid-coronal slices of each femoral head specimen. Median levels of all markers and median numbers of multinuclear giant cells in SIF with progressive collapse were significantly higher than those in SIF without progressive collapse, while there were no significant differences in SIF with progressive collapse versus RDA. Regression analysis showed that the number of multinuclear giant cells correlated positively with the level of TRACP-5b in joint fluid. This study suggests an association of increased osteoclast activity with the existing condition of progressive collapse in SIF, which was quite similar to the findings in RDA. Therefore, high activation of osteoclast cell may reflect the condition of progressive collapse in SIF as well as RDA

A 61-year-old woman was seen with diastasis of the symphysis pubis and insufficiency fractures of the wings of both ilia after irradiation for carcinoma of the cervix. The characteristics and treatment of these fractures are discussed

Introduction. Subchondral insufficiency fracture of the femoral head (SIF) often occurs in osteoporotic elderly patients. Patients usually suffer from acute hip pain without any obvious antecedent trauma. Radiologically, a subchondral fracture is seen mainly in the superolateral portion of the femoral head. The T1-weighted magnetic resonance (MR) images show a low-intensity band in the subchondral area of the femoral head, which tends to be irregular, disconnected, and convex to the articular surface. This low-intensity band in SIF was histologically proven to correspond to the fracture line with associated repair tissue. Some cases of SIF resolve after conservative treatment, while others progress until collapse, thereby requiring surgical treatment. The prognosis of SIF remains unclear. This study investigated the risk factors that influence the prognosis of SIF based on the progression of the collapse. Methods. Between June 2002 and June 2008, seventeen patients diagnosed as SIF were included in this study. Sequential radiographs were evaluated for the presence of progression of the collapse. The clinical profiles, including the age, body mass index (BMI), follow-up period and Singh index were examined. The morphological characteristics of the low intensity band on the T1-weighted magnetic resonance images were also examined, with regard to the band length, band thickness and band length ratio; which is defined as a proportion of the band length to the weight-bearing portion of the femoral head. Results. Radiographically, a progression of the collapse was observed in 8 of 17 (47.1%) patients. The band length in patients with progression of the collapse (mean: 22.6 mm) was significantly larger than that in those without progression of the collapse (mean: 12.3 mm; P < 0.05). The band length ratio in patients with progression of the collapse (mean: 73.3 %) was also significantly higher than that in those without progression of the collapse (mean: 42.3 %; P < 0.01). No significant differences were seen in the other variables (the age, BMI, follow-up period, Singh index, and band thickness). Conclusion. One of the important differential diagnoses in determining SIF may include osteonecrosis. The shape of the low signal intensity band on the T1-weighted MR images is one of the characteristic findings in SIF: namely, it is generally irregular, serpiginous, convex to the articular surface, and often discontinuous. This low-intensity band is generally surrounded by bone marrow edema. Histopathologically the band in SIF represents the fracture line with associated repair tissue. On the other hand, in osteonecrosis, since the low-intensity band represents repair tissue, it is generally smooth and circumscribes all of the necrotic segments. In this study, the prognosis of SIF varied even though all the patients received similar non-operative treatments. If the prognosis for SIF can be predicted at the early stage, it would allow the design of optimal treatments in each patient. In this preliminary investigation, both the band length and band length ratio were demonstrated to be useful when selecting the optimal treatment for SIF

Introduction. Subchondral insufficiency fracture of the femoral head (SIF) is a recently proposed concept. It is generally seen in elderly people, however, some young adults have also been reported to suffer from this fracture. The purpose of this study was to investigate the clinical results of a transtrochanteric anterior rotational osteotomy (ARO) performed in young adults with SIF. Methods. This study focused on young SIF cases (age range from 10 to 29 years). Five patients were diagnosed to have SIF at our institution and conservative treatment was initially performed. The symptoms resolved in 1 case while the other 4 cases showed progression of a collapse. In these 4 cases, ARO was performed, since the fractured area was located in the anterosuperior portion of the femoral head. The average age of the patients was 22 years (range, 16 to 29 years) at the time of surgery, consisting of 2 men and 2 women. Results. All cases were followed-up and the average follow-up period was 3.4 years (range, 1.8 to 6.8 years). The average preoperative Harris hip score was 67 points, which improved to an average of 93 points at the latest follow-up. Radiographically, the fractured lesion healed and no progression of a collapse was observed in any of the 4 cases. Conclusion. In the majority of SIF cases, only the anterosuperior portion of the femoral head is involved by the fracture. When considering the optimal surgical treatments for SIF, ARO may be one of the useful options, especially for the treatment of young patients

For over a decade, bisphosphonate administration has evolved and become the cornerstone of the prevention and treatment of fragility fractures. Millions of post-menopausal women have relied on, and continue to depend on, the long-acting, bone density-maintaining pharmaceutical drug to prevent low-energy fractures. In return, we have seen the number of fragility fractures decrease, along with associated costs and emotional benefits. However, with any drug, there are often concerns with side effects and complications, and this unique drug class is seeing one such complication in atypical subtrochanteric femoral fracture, counterproductive to that which it was designed to prevent. This has created concern over long-term bisphosphonate administration and its potential link to these atypical fractures. There is controversial evidence surrounding such a definitive link, and no protocol for managing these fractures.

This review offers the latest information regarding this rare but increasingly controversial adverse effect and its potential connection to one of the most successful forms of treatment that is available for the management of fragility fractures.

Introduction

Rising incidence of fracture neck of femur (NOF) are associated with rising geriatric population. Majority of patients are suffering from comorbid factors. Impaired renal function is a common comorbid factor and most of the time it is attributed to an acute renal impairment following the fracture and surgery.

Objective of this study was to identify the effect of renal comorbid factors and their probable relative risk for a fracture and compare the results with Asian and European data. Specific objective was to identify a possibility of presence of pretraumatic subclinical chronic renal failure among fractured Sri Lankans.

Emerging evidence has linked the long-term use of alendronate (fosamax) with subtrochanteric insufficiency fractures. However, findings to date have been anecdotal. The aims of this study were to determine the incidence of subtrochanteric insufficiency fractures and identify whether they were more prevalent following the introduction of alendronate in Australia. All patients that presented between January 2007 and February 2009 with low- energy subtrochanteric fracture were identified. Similar data were collected between January 1995 and February 1997 as this was immediately prior to introduction of alendronate in Australia. The radiographs were examined for failure due to pre- existing insufficiency fracture. Characteristic findings were a transverse fracture line on the tension side of the femur with lateral cortical thickening immediately adjacent to the fracture. Relevant details from the history were recorded. We also separately identified all patients that presented between 2007 and 2009 with a proximal femoral fracture and determined the proportion taking alendronate. One hundred and seventeen patients with low-energy subtrochanteric fracture were included. Seventy-nine patients presented between 2007 and 2009 and 38 presented between 1995 and 1997. Forty-one of the 79 (52%) patients were identified as having radiograph findings suggestive of underlying insufficiency fracture, whilst none were identified prior to the introduction of alendronate. Of the 41 patients with subtrochanteric insufficiency fracture, 40 (98%) had been taking alendronate and one had been taking risedronate. Twenty-nine of the 41 (71%) complained of prodromal pain in the affected femur. Eighteen of the 41 (44%) demonstrated subtrochanteric insufficiency changes on the contralateral side and 9 of 41 (22%) sustained spontaneous non-traumatic fracture during activities of daily living. Of the 38 patients without insufficiency changes, 12 (32%) had been taking alendronate. Alendronate use was therefore strongly suggestive of insufficiency fracture (sensitivity = 98%, specificity = 84%, PPV = 77%, NPV = 99%, LR+ = 6). The mean duration of alendronate use in those with insufficiency fracture was 7.1 years (95% CI, 6.6-7.6 years). The mean duration in those without was 3.2 years (95% CI, 2.6-3.8 years, P<0.0001). Three hundred and ninety eight patients presented with a low-energy proximal femur fracture between 2007 and 2009. Of these, only 52 (13%, P<0.0001) were taking alendronate. This is the largest study in the literature on subtrochanteric insufficiency fractures and alendronate therapy. Confirming recent reports, alendronate use was strongly suggestive of subtrochanteric insufficiency fracture. Our findings provide the most compelling evidence to date of the potential long-term sequelae of alendronate but more research is needed before definitive conclusions can be made

Fracture neck of femur (NOF) in elderly is a serious debilitating injury and has been presenting in increasing proportions. Some of these patients are unfortunate to come back with a contralateral injury. We attempted at looking into the incidence of these episodes in a cohort attending our trust and compared various parameters. We retrospectively assessed our hospital theatre data for fracture NOF in patients over 60 years in the last 3 years. We reviewed their demographics, mode of injury, time to contralateral injury, incidence of any other insufficiency fracture, operative procedure and any complications. There were 1435 patients who underwent surgery for fracture NOF over the 3 years. Forty-three of these had bilateral fractures. Females had 3 times more incidence as compared to males; average age at first injury was 84 years and at contralateral side was 85 years. Time between the two injuries ranged from 20 to 855 days (Median 242 days). Almost equal incidence of intra / extracapsular fractures was noted. Contralateral fracture pattern (Intra vs Extracapsular) for the was similar in 34 patients. Twelve patients had an associated insufficiency fracture. Fracture NOF in elderly is a rising epidemic. Only 3% of these patients suffer a contralateral fracture NOF which usually occurs within a year. The fracture pattern is frequently similar to the first fracture in and hence similar implants have been used. Only 21% patients were on bone protection medications. It is rather difficult to identify this small group and hence prevent a second contralateral incident

Background: Osteoporotic tibial fractures may be a challenge both in diagnosis and treatment. The aim of treatment is obtaining joint congruity and normal alignment, joint stability, adequate soft tissue healing and functional range of motion. The goal is prevention of degenerative osteoarthritis. In the majority of cases the treatment of tibial plateau fractures consists of open reduction and internal fixation. Objectives: The presentation of two aspects of the osteoporotic fracture – the insufficiency fracture and fixation of the fractures by a more appropriate method. Patients: We present our experience with 7 cases treated during the past 2 years. Two of these cases presented with no story of trauma, normal X-rays and were diagnosed clinically and on CT and bone scanning. The other 5 cases resulted of minor trauma and operative treatment was in order, using a modified fixation technique – a small fragment plate. Results: The patients suffering from fractures with normal X-rays suffered from insufficiency fractures and were treated conservatively. The patients suffering from depressed, split or comminuted fractures were treated by open reduction and internal fixation with a small fragment plate. Discussion and Conclusion: Insufficiency fractures often are misdiagnosed as exacerbation of chronic metabolic or inflammatory diseases and a fracture is not suspected until intense augmentation of radionuclide is seen on bone scan. Screening of patients presenting wit non-traumatic knee pain has shown a prevalence insufficiency fractures of the tibial plateau between 3 to 8% of the cases. These cases may be much more common than we commonly presume. The fractures in need of reduction and fixation of the plateau fracture involve raising the depressed articular fragment, the possible addition of bone graft augmentation and buttressing of the osteochondral fragment with a plate. These buttress plates may hold the cortical rim of the plateau but many times fail in maintaining the reduction of the intra-articular surface of the plateau. This again results in degenerative changes in the joint and pain. Internal fixation of these fractures with small fragment plates may be a solution to this problem, as demonstrated by the 5 presented cases treated operatively. The plates are smaller in size and are held by more screws, which are more proximal to the articular surface. This way they allow better control and maintenance of the anatomic reduction and in combination with an a-traumatic dissection and less stress shielding effect, result in a low rate of local complications

There have been recent reports linking alendronate and a specific pattern of subtrochanteric insufficiency fracture. We performed a retrospective review of all subtrochanteric fractures admitted to our institution between 2001 and 2007. There were 20 patients who met the inclusion criteria, 12 of whom were on long-term alendronate. Alendronate-associated fractures tend to be bilateral (Fisher’s exact test, p = 0.018), have unique radiological features (p < 0.0005), be associated radiologically with a pre-existing ellipsoid thickening of the lateral femoral cortex and are likely to be preceded by prodromal pain. Biomechanical investigations did not suggest overt metabolic bone disease. Only one patient on alendronate had osteoporosis prior to the start of therapy. We used these findings to develop a management protocol to optimise fracture healing. We also advocate careful surveillance in individuals at-risk, and present our experience with screening and prophylactic fixation in selected patients

Rapidly progressive osteoarthritis of the hip (RPOH) is an unusual subset of osteoarthritis. It is characterized by rapid joint space loss, chondroly­sis, and sometimes marked femoral head and acetabular destruction as a late finding. The exact pathogenetic mechanism is unknown. Potential causes of RPOH include subchondral insufficiency fracture resulting from osteoporosis, increasing posterior pelvic tilt as a mechanical factor, and high serum levels of matrix metalloproteinase (MMP)-3 as biological factors. This study was aimed to identify some markers that associate with the destructive process of RPOH by analyzing the proposed pathological factors of the disease, MMP-3, pelvic tilt, and osteoporosis. Of female patients who visited our hospital with hip pain from 2012 through 2018, this study enrolled female patients with sufficient clinical records including the onset of hip pain, age and body mass index (BMI) at the onset, a series of radiographs during the period of >12 months from the onset of hip pain, and hematological data of MMP-3 and C-reactive protein (CRP). We found the hip joints of 31 patients meet the diagnostic criteria of RPOH, chondrolysis >two mm in one year, or 50% joint space narrowing in one year. Those patients were classified into two groups, 17 and 14 patients with and without subsequent femoral head destruction in one year shown by computed tomography, respectively. Serum MMP-3 and CRP were measured with blood samples within one year after the hip pain onset. The cortical thickness index (CTI) as an indicator of osteoporosis and pelvic tilt parameters were evaluated on the initial anteroposterior radiograph of the hip. These factors were statistically compared between the two groups. This study excluded male patients because RPOH occurs mainly in elderly females and the reference intervals of MMP-3 are different between males and females. There was no difference in age at onset or bone mass index between the RPOH patients with and without subsequent femoral head destruction. Serum levels of MMP-3 were significantly higher in the RPOH patients with the destruction (152.1 ± 108.9 ng/ml) than those without the destruction (66.8 ± 27.9 ng/ml) (P = 0.005 by Mann-Whitney test). We also found increased CRP in the patients with femoral head destruction (0.725 ± 1.44 mg/dl) compared with those without the destruction (0.178 ± 0.187 mg/dl) (P = 0.032 by Mann-Whitney test). No difference in the duration between the hip pain onset and the blood examination was found between the two groups. There was no significant difference in CTI or pelvic tilt between the two groups. The pathological condition that may increase serum MMP-3 and CRP could be involved in femoral head destruction after chondrolysis of the hip in patients with RPOH

Historically spine surgeons have been powerless to help most patients with painful vertebral insufficiency fractures. Treatment was supportive, hoping that fractures could heal in situ, and accepting the resulting kyphosis and its consequences. Surgery was the court of last resort in instances of disabling neurologic deficits. The very same deficient skeleton that lead to the clinical issue, was simultaneously the principal limiting factor in surgical undertakings. Complications could be common and substantial. Vertebroplasty was born out necessity in the treatment of ‘inoperable’ vertebral metastases. The technique has become a widely adopted method of managing refractory painful vertebral insufficiency fractures, especially those due to osteoporosis. In skilled hands, vertebroplasty provides a high degree of pain relief and patient satisfaction. The fracture is fixed in situ as the marrow space is embolised with PMMA. Kyphoplasty is a technical evolution that enables active fracture reduction before fixation with PMMA. Much is made about the potential differences between the two treatment methods, but no direct comparative studies are available to allow objective conclusions. In any event, as medical therapies improve the treatment of osteoporosis in general, surgeons now have the opportunity to intervene when painful vertebral fractures are a primary source of functional impairment and life quality

It is well appreciated that thigh pain following recent arthroplasty surgery is likely to be due to prosthetic loosening or infection. Both these sequelae can lead to periprosthetic fracture presenting complex challenges to even experienced surgeons. Revision arthroplasty patients are prone to both fatigue and insufficiency fractures as they may have reduced bone stock after previous surgery and reduced bone density secondary to medical and immobility reasons. The post operative painfree condition will frequently permit early load bearing leading to a relatively rapid increase in activity and load bearing. Fatigue fractures occur in bone of normal quality subject to abnormal cyclical overloading, leading to resorption and eventual failure, before adequate time has passed to permit adaptive remodelling. Insufficiency fractures occur when normal physiological loads are applied to bone of abnormal quality. Surprisingly few periprosthetic stress fractures are reported in the literature but a series notes lateral tensile stress fractures associated with varus prosthetic alignment. These all occurred near the tip of the prosthesis. The case of an unusual Gruen Zone 2, Vancouver B1 stress fracture, 9 months following revision arthroplasty is reported. Initially loosening was suspected due to the development of load bearing thigh pain. Plain radiography revealed the development of a dreaded black line, consistent with a stress fracture. Bone scintigraphy revealed the typical appearance of a stress fracture in the absence of loosening or infection. The unusual location of this stress fracture allowed consideration of conservative non weight bearing management which lead to the alleviation of symptoms rather than further revision surgery. This report illustrates this unusual stress fracture and highlights the importance of careful loading practises to permit adequate remodelling following complex revision surgery