Long term treatment of recurring pathological fractures due to Mccune Albright Syndrome: Case report and literature review

doi:10.4236/crcm.2013.29142

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Vol.2, No.9, 562-567 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.29142

Long term treatment of recurring pathological

fractures due to Mccune Albright Syndrome: Case

report and literature review

Yoshvin Sunnassee, Yuhui Shen, Rong Wan, Jianqiang Xu, Weibin Zhang*

Department of Orthopedics, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Institute of

Traumatology and Orthopedics, Shangha i, China; *Corresponding Author: [email protected]

Received 17 June 2013; revised 15 July 2013; accepted 10 August 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In

ABSTRACT

McCune Albright syndrome is a rare genetic

disorder which is characterized by café au lait

skin pigment ation, precocious pubert y and poly -

ostotic fibrous dysplasia. Treating recurring pa-

thological fractures due to Albright syndrome is

a very challenging endeavor, and more so w hen

it is accompanied by poor bone quality and de-

formity. We hereby presen t the case of a 23-year-

old male patient who is treated several times for

recurrent pathological fractures of the femur at

our center. We analyze the difficulties associ-

ated with treating a patient w ith poor bone qual-

ity over several years, discuss our treatment

options, review the literature for similar cases

and look at what we could have done differently.

We weigh in on the difficulties in treating a se-

verely deformed shepherd’s crook, the ways of

achieving proper internal fixation and the dan-

gers of using plating instead of an IM nail as

suggested in the literature. Our main goal in

reporting this case is to bring forth the unusual

challenges encountered when treating patients

with Albright syndrome and discussing the op-

tions of the orthopedic surgeons when treating

these types of patients.

Keywords: McCune Albright Syndrome; Surgical

Treatment; Polyostotic Fibrous Dysplasia

1. INTRODUCTION

Mccune Albright syndrome (MAS) is a rare genetic

disorder which is characterized by café au lait skin pig-

mentation, precocious puberty and polyostotic fibrous

dysplasia (PFD) [1,2]. Patients with PFD have poor bone

quality and are liable to pathological fractures. We here-

by report the case of a male patient who is treated for 7

years in our center for recurring pathological fractures of

the femur due to MAS. When the patient was first seen,

he presented with a shepherd’s crook deformity of the

proximal femur. The condition was associated with un-

equal lower limbs’ length, inability to ambulate and pain

on motion. He had already undergone several surgeries

for recurring femoral neck fractures at another centre. We

discuss the challenges of treating this patient, review the

literature on the subject and anticip ate the challeng es that

future pathological fracture s might pose.

2. CASE REPORT

The patient suffered a fracture of the femur while

swimming at the age of 10 in 1997. The fracture did not

occur as a result of an impact or a fall. He was treated

surgically two times in the pediatrics orthopedics depart-

ment of another hospital. The first time, bone grafts and a

flexible intramedullary nail were used. The fracture did

not unite and a subsequent surgery was carried out in

1999 to remedy to the non-united fracture. The exact

information of both surgeries and of the post-surgical

protocol was not available. The patien t still had a painful

right lower limb and was dependent on crutches to be

able to ambulate. Following the surgery, the patient wit-

nessed weakness in his right lower limb, with pain on

ambulation. In 2005, at 16 years of age the patient was

first seen at our outpatient department. He presented with

a shepherd’s crook deformity of the proximal femur, with

a fracture in the subtrochanteric region. Physical exami-

nation revealed unequaled lower limbs length, difficulty

Y. Sunnasse e et al. / Case Reports in Clinical Medicine 2 (2013) 562-567 563

ambulating, pain in th e right thigh, deformity of th e right

thigh and dispersed café au lait spots on the abdomen.

Roentgenographic examination showed that the patient

had several fibrous lesions of the bone in the right pro-

ximal femur (Figure 1), craniofacial bone, ribs and bil-

ateral tibia and fibula. The initial diagnosis was Mccune

Albright’s syndrome with PFD and Type 1 diabetes. He

was placed on a course of oral biphosphonates and moni-

tored on a monthly basis. After two years of treatment

the patient’s dysplastic lesions did not resolve signifi-

cantly and he was admitted for surgery. Pre-operative

tests showed that the patient’s blood sugar oscillated

between 13 mmol/L and 18 mmol/L; so we opted for the

patient to be discharged. After a course of treatment in

our endocrinology department, the daily dose of insulin

was re-adjusted. He was re-admitted to our center in

2009 for surgical treatment.

The treatment protocol was limited by several factors

which rest r i c t e d our options:

1. The patient had an unusually small and dysplastic

right actebula, when compared to the left side, in which

the femoral head could not fit completely.

2. MRI scans showed that a large part of the femoral

head was also affected by fibrous dysplasia. This raised

the question of improper screw purchase in dysplastic

bone. We did not consider the femoral head to be ne-

crotic because the fracture was largely subtrochanteric

and would not have affected the blood supply to the fe-

moral head.

3. The bone strip at the point of the fracture, along the

shepherd’s crook deformity, was very thin which ren-

dered the use of an intramedullary nail very difficult.

4. The diameter of the femur and of the medullary

canal was unusually small which would have rendered

reaming and the implantation of an intramedullary nail

very difficult, with the smallest IM nail available to us

being 9 mm in diameter. A CT examination showed the

Figure 1. Shows an anterior-posterior view of the pelvis. The

right proximal femur has fibrous dysplasia lesions.

medullary canal to be also affected by fibrous lesions and

was less than 5 mm in diameter at the point of the lesion

and less than 7 mm diameter distally.

5. Due to the fact that the patient exhibited fibrous

bony lesions in the tibia and fibula, we were reluctant to

make use of a fibular strut for the corrective osteotomy,

as has been su gg ested by ot her authors.

6. The patient’s severe diabetes could negatively affect

bone healing, prompting us to use plating and screws

which ensured absolute fixation.

After re-admission, blood sugar level was lower than

14 mmol/L and a corrective osteotomy with internal fix-

ation and autologous bone grafting was carried out. The

intertrochanteric fracture was treated with a DCS plate

(Smith & Nephew, Memphis, Tennessee, United States)c,

through a Hardinge approach to the proximal femur.

Autologous bone grafts was obtained from the femoral

condyles and was used to make up for the considerable

bone deficiency at the site of fracture. The patient was

given prophylactic antibiotics as post-surgical treatment

and was advised to refrain from ambulation. Following

the surgery, he was followed at our outpatient depart-

ment, continued using oral biphosphonates and was able

to achieve complete weight-bearing 3 months after the

surgery. Subsequent X-rays showed that the fracture

united completely after one year and the patien t was able

to ambulate normally. However, he still had weakness in

the affected limb and was only able to walk for a dis-

tance of around 50 meters, without resting. The manual

muscle test was a grade 4. Continuou s use of biphospho-

nates did not decrease pain level s.

In November 2011, the patient suffered a fall and he

was unable to ambulate. In January 2012, he was once

again admitted to our center after roentgenograph ic scans

showed a fatigue fracture of the femur at the distal part

of the DCS plate with bending deformity of the femur

(Figure 2). The patient was once more treated with an

open reduction and internal fixation of the femur. We still

faced the same obstacles as during the first surgery but

with the added difficulty of having a structurally com-

promised femur, severe bone deficiency along the fibrous

lesions and a femoral head which was both dysplastic

and bone deficient. We opted to use a longer plate (DCS,

Synthes) and placed the proximal nails in the lower part

of the femoral head to allow for better purchase of the

nails in normal bone and made up for bony deficiency

through bone grafting (Figure 3). The patient was dis-

charged with advice to refrain from ambulation and to

undergo rehabilitation under the guidance of the main

surgeon. Following the surgery, the patient restarted am-

bulation after one month and slowly regained the ability

to ambulate without walking aids.

The patient was admitted again in April 2012 after he

suffered a fracture after another fall. The fracture was

Y. Sunnasse e et al. / Case Reports in Clinical Medicine 2 (2013) 562-567

564

Figure 2. Shows the anterior-posterior

view of the femur with bending defor-

mity of the femur at the distal part of

the plate.

Figure 3. Shows two anterior posterior views of the femur. The

left X-ray shows the femur after use of a DCS plate with the

proximal nails placed in the lower part of the femoral head. The

right X-ray shows the femur after placement of a second plate

at the distal part of the femur.

located in the distal part of the femur and was considered

to be a result of stress shielding due to the distal part of

the DCS plate. We fixed the distal fracture with plating

and screws. The fracture line involved a screw which had

to be removed and could not be fixed again. The LC-

DCP plate was placed in the antero-medial part of the

femur due to the fact that there was already another plate

placed laterally (Figure 3).

At the latest check-up, in June 2012, at 3 months after

the last surgery, the patient had regained ambulation, had

unequal lower limbs length with the right leg being

shorter than the left leg by 3 cm. The patient is still wit-

nessing weakness in the affected limb and is unwilling to

make use of corrective shoes. MMT was grade 4. The

fracture healed partially as was seen on follow-up post-

operative X-rays.

3. DISCUSSION

PFD is a benign bony lesion but can however lead to

severe deformity which eventually requires surgery. The

shepherd’s crook presentation develops as a result of the

mechanical load bearing acting on the structurally

weakened proximal femoral bone, is a well documented

phenomenon [3-5]. Intracapsular fracture may occur due

to a shearing force against severe valgus deformity [5]

coupled with the fact that the proximal femur has poor

bone quality. According to Russell and Chandler, who

reported on the surgical treatment of PFD, the indications

for surgery in fibrous dysplasia are continued pain in the

region of a localized bone lesion, fracture through a le-

sion, or severe deformity [6]. The medical literature offer

very few reports of long term treatment of patient with

this disease. Studies have noted that bone dysplasia have

normal bone healing capacities [7,8]. Surgical options

should take into account the quality of the bone affected

and the deformity present. Monostotic fibrous dysplasia,

once treated surgically, is unlikely to reoccur while poly-

ostotic fibrous dysplasia, whether it is a presentation of

MAS or not, is likely to progress with the disease reach-

ing a quasi-static phase once adulthood is reached [7,9].

Several ways of treating PFD of the proximal femur

have been previously discussed in the medical literature,

with methods such as intralesional resection and bone

grafting or corrective osteotomy with internal fixation

which can either be plating or an intramedullary nail. The

medical literature supports the idea that in cases of fi-

brous dysplasia of the proximal femur, an intramedullary

device should be used with a screw fixed in the femoral

head [10]. The idea of fixing the screw in the femoral

head is based on the premise that the femoral head is not

affected or rarely affected by fibrous dysplasia and as

such can provide proper purchase for screws [9,11,12].

The IM nail can be very useful when dealing with cases

of proximal femur PFD with a shepherd’s crook deform-

ity, where a wedge osteotomy can be performed to re-

store the natural geometry of the bone [3,13,14]. Correc-

tive osteotomy is particularly useful in cases where there

is no fracture of the proximal femur. Success of correc-

tive osteotomy resides on the presence of healthy sub-

trochanteric bone or in cases where bone grafting is used,

autologous healthy bone grafts might be preferred. Jung

et al. reported on cases where multiple osteotomies were

performed to restore the neck shaft angle using an in-

Y. Sunnasse e et al. / Case Reports in Clinical Medicine 2 (2013) 562-567 565

tramedullary nail with neck cross-pinning [3]. Further-

more, when we reviewed the literature we found that

most instances where IM nails were used were cases with

comparatively mild shepherd’s crook deformity. Use of

plating and screws has been met with mixed success.

Chen et al. reported on a case of an intracapsular fracture

with shepherd’s crook deformity which was treated with

corrective osteotomy and internal fixation with a dy-

namic hip screw. The patient in the report healed com-

pletely and did not suffer subsequent fractures [4].

However, other reports have either underlined the risk of

bending deformity of the femur or fatigue fracture [3].

According Guile et al., metal plate removal will nor-

mally lead to refracture.

The success of plating depends on proper purchase of

the screws in healthy bone, which in this case will de-

pend on the state of the femoral head bone and femoral

stem bone. Proper purchase guarantees stability of the

fixation. It has been noted that restoring the mechanical

axis reduces the deforming forced on the bone, with me-

dial displacement varus osteotomy being a possible solu-

tion [12]. Decreased neck fracture in PFD patient is a

concern and is associated with decreased functional mo-

bility for sports [15]. However, these considerations are

at times a luxury in patients with PFD. Restoring ambu-

lation ability remains the goal in most severe cases of

polyostotic fibrous dysplasia. Surgical treatments that

aim at restoring the proper neck-shaft angle, especially in

patients with lower extremity deformity [10] or even in

patients with unequal lower limbs length is questionable,

because the mechanical axis is not properly restored. An

important part of treating PFD induced fracture of the

proximal femur is dealing with a structurally compro-

mised stability [7]. Therefore, our choice of surgical

protocol mainly focused on allo wing the patient to retain

ambulation capacity while assuring that the fracture

would unite, while having to contour the several restric-

tions posed by this patien t’s case.

Intralesional resection and bone grafting was popular-

ized by Enneking [16]. He obtained positive results with

this method. However, subsequent studies by other au-

thors revealed that the bone grafts subsequently resolved

leaving place to dysplastic lesions. Treatment of PFD

with bone grafting, independently of the type of bone

strut used or the age of the patient, is unlikely to offer

positive results in PFD [7,17]. After the initial surgical

treatment in this case, following fractures were all due to

trauma. However, even if we were left with no other

choices, the use of plating and screws is normally not

advised in the treatment of PFD of the proximal femur.

As seen in this case, following treatment with plating and

screws there was a bending deformity of the proximal

femur. It is a controversy in certain cases whether sur-

gery would be the best course of actions, especially in

patients with severe bone deformity and deficiency. It

has been noted by other authors that in certain cases of

PFD, the best approach is to not operate [10], however,

we also think that allowing the patient to retain ambula-

tion without walking aids should be a primary goal of

PFD surgery of the lower limbs.

The use of biphosphonates in the treatment of PFD has

proven its merits with no harmful side-effects, especially

when it comes to the ability of bone growth in younger

patients [10]. Oral or intravenous biphosphonates both

have a positive effect on pain and bone metabolism

markers [18,19]. However, we noticed that the patient’s

bone was hard during internal fixation; we cannot con-

firm whether this change in the quality of bone is directly

related to the use of biphosphon a tes.

Other considerations are important in the peri-opera-

tive management of a PFD patient. It is especially im-

portant to check bone markers metabolism in the build-

up to the surgery. A state of hyperparathyroidism would

be an indication against surgical treatment. High levels

of parathyroid hormones are likely to signal negative

post-surgical results. MAS has been known to develop

with endocrinopathies, with patients exhibiting hyper-

parathyroidism or diabetes with MAS. Even if this pa-

tient has type 1-diabetes and his blood sugar level cannot

be controlled properly, we chose not to discuss this as-

pect of the patient’s condition as being related to MAS.

Even though there has been reports of MAS causing en-

docrinopathies and a few reports of MAS being related to

type 1 diabetes, we could not ascertain that our patient’s

diabetic condition was a direct resu lt of MAS. It must be

noted that the type 1 diabetes represented an obstacle in

the peri-operative management of the patient; we think

that it should not affect treatment protocol but as is

known high blood sugar level can severely affect bone

healing.

3.1. What Would We Do Differently?

When surgeons face this type recurrent fracture they

always need to review their treatment protocol in light of

new advances and assess whether they made the right

decisions throughout the treatment. These cases of MAS

with severe deformity of the proximal femur are always

difficult to treat, however, we think that there are a few

things that we could c on si der doing dif ferently.

1. Using a longer plate with fewer screws in the shaft

of the femur and placing a cortical screw at the distal end

of the plate so as to decrease the stress shielding on the

bone would be an operative option that could have bene-

fited the patient. Placing a co rtical screw at the distal end

has been shown to be beneficial towards decreasing the

risk of stress fracture [20]. Using a 3.5 inch pediatric

plate instead of a 4.5 inch would also may be have been a

Y. Sunnasse e et al. / Case Reports in Clinical Medicine 2 (2013) 562-567

566

better fit since the patient’s bone was small in size.

2. Placing the femoral neck at an increased valgus

angle instead of 90˚ varus is also another option but it

would have been difficult to achieve due to the very thin

strip of bone left along the shepherd’s hook. When the

patient was operated we placed the femoral neck at a

varus angle of 90˚, which exposed the non-weight bear-

ing part of the articular cartilage of the femoral head (the

more lateral side of the femoral head) to greater loading.

Furthermore, the weight from the hip was transferred

onto a 90˚ varus femoral neck which could have caused

instability at the site of fracture, rendering the internal

fixation unstable and thus unlikely to heal. The patient

should have been advised to refrain from weight bearing

until the fracture heals completely. Furthermore, placing

the femoral neck at a valgus angle could have helped to

slightly lengthen the leg; however this would be limited

by the atrophied muscles and by the sciatic nerve.

3. The degree of aggressivity of the treatment in early

childhood is an important question when dealing with

these types of patients. Funk et al. noted that the progr ess

of the disease subsides, therefore aggressive surgical

intervention must be practiced in children to prevent the

possibility of difficult procedures in adults [7]. In this

specific case, it is difficult to assess whether a more

aggressive course of treatment in early childhood would

have made any difference in the prognosis.

3.2. Future Considerations

Even if at the last follow-up the patient had regained

ambulation, we must consider the surgical protocol in

cases of subsequent fractures. The quality of bone of the

proximal femur is poor, coupled with the fact that plates

were used; it is highly likely that the patient will suffer

more fatigue fractures at the distal part of the plate.

Treating these fractures will be increasingly difficult. He

is still at the very beg inning of adulthood, and we do not

know yet if the fibrous dysplasia will advance or cease to

progress. Furthermore, in old age, when osteopenic

changes occur, the patient is likely to suffer more frac-

tures and the subsequent treatment protocol will have to

take into consideration the impoverished bone quality.

This patient’s condition will not improve and is likely to

become worse in case of more fractures of the proximal

femur, unless major reconstructive surgery of the ace-

tabula and of the femur is undertaken, with the use of

total length femoral pro sthesis. And even then, the diffe-

rence of 3 cm between the lower limbs will not be

corrected because a drastic increase in the right lower

limb length might damage nerves and blood vessels

which are already being taxed by the patient’s diabetic

condition. We hope to be able to continue fixing future

fractures with open reduction and internal fixation until

the bone quality is too poor or deformity too severe to

continue doing so at which point major reconstructive

surgery will be required.

4. CONCLUSION

The treatment of polyostotic fibrous dysplasia asso-

ciated with shepherd’s crook deformity can represent a

considerable challen g e to th e o r thoped ic su rgeon. Ev en if

common knowledge had indicated the use of IM nails, in

our patient’s case, the use of an IM nail would have been

much more difficult. However, our primary goal of sup-

plying an absolute fixation at the proximal femur to

allow for fracture union and allow the patient to re-

acquire his ambulating capacities in his right leg was

attained. In su ch cases of PFD, the d ifficulty of treatment

lies in the fact that eventual fatigue fractures are d ifficult

to treat and the end-goal is allowing the patient to retain

ambulation and remain pain free.

5. ACKNOWLEDGEMENTS

We would like to thank Dr Edward P. Southern for his insight and

invaluable help in the conception of this work.

REFERENCES

[1] Albright, F., Butler, A.M., Hampton, A.O. and Smith, P.

(1937) Syndrome characterised by osteitis fibrosa disse-

minata, areas of pigmentation and endocrine dysfunction

with precocious puberty in females: Report of five cases.

New England Journal of Medicine, 216, 727-746.

http://dx.doi.org/10.1056/NEJM193704292161701

[2] McCune, D. (1936) Osteitis fibrosa cystica: The case of a

nine-year-old girl who also exhibits precocious puberty,

multiple pigmentation of the skin and hyperthyroidism.

American Journal of Diseases of Children, 52, 743-744.

[3] Jung, S.T., Chung, J.Y., Seo, H.Y., Bae, B.H. and Lim,

K.Y. (2006) Multiple osteotomies and intramedullary nai-

ling with neck cross-pinning for shepherd’s crook de-

formity in polyostotic fibrous dysplasia: 7 femurs with a

minimum of 2 years follow-up. Acta Orthopadica, 77,

469-473. http://dx.doi.org/10.1080/17453670610046415

[4] Chen, W.J., Chen, W.M., Chiang, C.C., Huang, C.K.,

Chen, T.H. and Lo, W.H. (2005) Shepherd’s crook de-

formity of polyostotic fibrous dysplasia treated with cor-

rective osteotomy and dynamic hip screw. Journal of the

Chinese Medical Association, 68, 343-346.

http://dx.doi.org/10.1016/S1726-4901(09)70173-X

[5] Tsuchiya, H., Tomita, K., Mat sumoto, T. and Watanabe, S.

(1995 ) Shepherd’s crook deformity with an intracapsular

femoral neck fracture in fibrous dysplasia. Clinical Or-

thopaedics and Related Research, 310, 160-164.

http://dx.doi.org/10.1097/00003086-199501000-00025

[6] Russell, L.W. and Chandler, F.A. (1950) Fibrous dyspla-

sia of bone. The Journal of Bone & Joint Surgery [Amer-

ican], 32, 323-337.

[7] Funk Jr., F.J. and Wells, R.E. (1973) Hip problems in

Y. Sunnassee et al. / Case Reports in Clinical Medicine 2 (2013) 56 2-567

567

fibrous dysplasia. Clinical Orthopaedics, 90, 77-82.

[8] Harris, W.H., Dudley Jr., H.R. and Barry, R.J. (1962) The

natural history of fibrous dysplasia: An orthopaedic, path-

ological, and roentgenographic st udy. The Journal of Bone

& Joint Surgery [American], 44, 207-233.

[9] Ozaki, T., Sugihara, M., Nakatsuka, Y., Kawai, A. and

Inoue, H. (1996) Polyostotic fibrous dysplasia: A long

term follow up of 8 patients. International Orthopaedics,

20, 227-232.

http://dx.doi.org/10.1007/s002640050069

[10] Leet, A. and Collins, M.T. (2007) Current approach to fi-

brous dysplasia of bone and Mc-Cune Albright syndrome.

Journal of Children’s Orthopaedics, 1, 3-17.

http://dx.doi.org/10.1007/s11832-007-0006-8

[11] Harris, W.H., Dudley Jr., H.R. and Barry, R.J. (1962) The

natural history of fibrous dysplasia: An orthopaedic, path-

ological, and roentgenographic st udy. The Journal of Bone

& Joint Surgery [American], 44, 207-233.

[12] Guille, J.T., Kumar, S.J. and MacEwen, G.D. (1998) Fi-

brous dysplasia of the proximal part of the femur: Long-

term results of curettage and bone-grafting and mechani-

cal realignment. The Journal of Bone & Joint Surgery

[American], 80, 648-658.

[13] Ippolito, E., Caterini, R., Farsetti, P. and Potenza, V. (2002)

Surgical treatment of fibrous dysplasia of bone in Mc-

Cune. Journal of Pediatric Endocrinology and Metabo-

lism, 15, 939-944.

[14] O’Sullivan, M. and Zacharin, M. (2002) Intramedullary

rodding and bisphosphonate treatment of polyostotic fi-

brous dysplasia associated with the McCune-Albright

syndrome. Journal of Pediatric Orthopaedics, 22, 255-

260.

http://dx.doi.org/10.1097/01241398-200203000-00025

[15] Leet, A.I., Wientroub, S., Kushner, H., Brillante, B., Kelly,

M.H., Robey, P.G., et al. (2006) The correlation of spe-

cific orthopaedic features of polyostotic fibrous dysplasia

with functional outcome scores in children. The Journal

of Bone & Joint Surgery [American], 88, 818-823.

http://dx.doi.org/10.2106/JBJS.E.00259

[16] Enneking, W.F. and Gearen, P. (1986) Fibrous dysplasia

of the femoral neck. Treatment by cortical bone-grafting.

The Journal of Bone & Joint Surgery [American], 68,

1415-1422.

[17] Guille, J.T., Kumar, S.J. and MacEwen, G.D. (1998) Fi-

brous dysplasia of the proximal femur. Long-term results

of curettage and bone-grafting and mechanical realign-

ment. The Journal of Bone & Joint Surgery [American],

80, 648-658.

[18] Weinstein, R. (1997) Long-term aminobisphosphonate treat-

ment of fibrous dysplasia: Spectacular increase in bone

density. Journal of Bone and Mi neral Research, 12, 1314-

1315. http://dx.doi.org/10.1359/jbmr.1997.12.8.1314

[19] Lane, J.M., Khan, S.N., O’Connor, W.J., Nydick, M., Hom-

men, J.P., Schneider, R., et al. (2001) Bis-phosphonate

therapy in fibrous dysplasia. Clinical Orthopaedics, 382,

6-12.

http://dx.doi.org/10.1097/00003086-200101000-00003

[20] Bottlang, M., Doornink, J., Fitzpatrick, D.C. and Madey,

S.M. (2009) Far cortical locking can reduce stiffness of

locked plating constructs while retaining construct strength.

The Journal of Bone & Joint Surgery [American], 91,

1985-1994. http://dx.doi.org/10.2106/JBJS.H.01038