{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,24]],"date-time":"2026-10-24T05:13:35Z","timestamp":1792818815011,"version":"4.5.0"},"reference-count":121,"publisher":"MDPI AG","issue":"15","license":[{"start":{"date-parts":[[2021,7,21]],"date-time":"2021-07-21T00:00:00Z","timestamp":1626825600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>Long bone pathological fractures very much reflect bone metastases morbidity in many types of cancer. Bearing in mind that they not only compromise patient function but also survival, identifying impending fractures before the actual event is one of the main concerns for tumor boards. Indeed, timely prophylactic surgery has been demonstrated to increase patient quality of life as well as survival. However, early surgery for long bone metastases remains controversial as the current fracture risk assessment tools lack accuracy. This review first focuses on the gold standard Mirels rating system. It then explores other unique imaging thresholds such as axial or circumferential cortical involvement and the merits of nuclear imaging tools. To overcome the lack of specificity, other fracture prediction strategies have focused on biomechanical models based on quantitative computed tomography (CT): computed tomography rigidity analysis (CT-RA) and finite element analysis (CT-FEA). Despite their higher specificities in impending fracture assessment, their limited availability, along with a need for standardization, have limited their use in everyday practice. Currently, the prediction of long bone pathologic fractures is a multifactorial process. In this regard, machine learning could potentially be of value by taking into account clinical survival prediction as well as clinical and improved CT-RA\/FEA data.<\/jats:p>","DOI":"10.3390\/cancers13153662","type":"journal-article","created":{"date-parts":[[2021,7,21]],"date-time":"2021-07-21T11:53:23Z","timestamp":1626868403000},"page":"3662","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":26,"title":["Fracture Risk of Long Bone Metastases: A Review of Current and New Decision-Making Tools for Prophylactic Surgery"],"prefix":"10.3390","volume":"13","author":[{"given":"M\u1ef9-V\u00e2n","family":"Nguy\u1ec5n","sequence":"first","affiliation":[{"name":"Orthopedics and Trauma Department, University Hospital H\u00f4tel-Dieu, UHC of Nantes, 44000 Nantes, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christophe","family":"Carlier","sequence":"additional","affiliation":[{"name":"Orthopedics and Trauma Department, University Hospital H\u00f4tel-Dieu, UHC of Nantes, 44000 Nantes, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christophe","family":"Nich","sequence":"additional","affiliation":[{"name":"Orthopedics and Trauma Department, University Hospital H\u00f4tel-Dieu, UHC of Nantes, 44000 Nantes, France"},{"name":"PhyOs 1238, INSERM, University of Nantes, 44000 Nantes, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5470-5776","authenticated-orcid":false,"given":"Fran\u00e7ois","family":"Gouin","sequence":"additional","affiliation":[{"name":"Leon B\u00e9rard Center, Surgery Department, 69008 Lyon, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6563-8895","authenticated-orcid":false,"given":"Vincent","family":"Crenn","sequence":"additional","affiliation":[{"name":"Orthopedics and Trauma Department, University Hospital H\u00f4tel-Dieu, UHC of Nantes, 44000 Nantes, France"},{"name":"PhyOs 1238, INSERM, University of Nantes, 44000 Nantes, France"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,7,21]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1655","DOI":"10.1056\/NEJMra030831","article-title":"Mechanisms of Bone Metastasis","volume":"350","author":"Roodman","year":"2004","journal-title":"N. Engl. J. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"6243s","DOI":"10.1158\/1078-0432.CCR-06-0931","article-title":"Clinical features of metastatic bone disease and risk of skeletal morbidity","volume":"12","author":"Coleman","year":"2006","journal-title":"Clin. Cancer Res. Off. J. Am. Assoc. Cancer Res."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"539","DOI":"10.3111\/13696998.2013.774279","article-title":"The economic burden associated with skeletal-related events in patients with bone metastases secondary to solid tumors in Belgium","volume":"16","author":"Body","year":"2013","journal-title":"J. Med. Econ."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1073","DOI":"10.1684\/bdc.2013.1837","article-title":"\u00c9pid\u00e9miologie et aspects cliniques des m\u00e9tastases osseuses","volume":"100","author":"Cvitkovic","year":"2013","journal-title":"Bull. Cancer (Paris)"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"483","DOI":"10.1586\/14737167.2013.820959","article-title":"Clinical, economic and humanistic burdens of skeletal-related events associated with bone metastases","volume":"13","author":"Carter","year":"2013","journal-title":"Expert Rev. Pharmacoecon. Outcomes Res."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1038\/bjc.1987.13","article-title":"The clinical course of bone metastases from breast cancer","volume":"55","author":"Coleman","year":"1987","journal-title":"Br. J. Cancer"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"223","DOI":"10.3816\/CLC.2009.n.030","article-title":"Skeletal Disease Contributes Substantially to Morbidity and Mortality in Patients with Lung Cancer","volume":"10","author":"Hirsh","year":"2009","journal-title":"Clin. Lung Cancer"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1005","DOI":"10.1016\/S0022-5347(05)64561-2","article-title":"Skeletal Fractures Negatively Correlate With Overall Survival in Men With Prostate Cancer","volume":"168","author":"Oefelein","year":"2002","journal-title":"J. Urol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1860","DOI":"10.1002\/cncr.22991","article-title":"Pathologic fractures correlate with reduced survival in patients with malignant bone disease","volume":"110","author":"Saad","year":"2007","journal-title":"Cancer"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"380","DOI":"10.1038\/pcan.2016.26","article-title":"Do skeletal-related events predict overall survival in men with metastatic castration-resistant prostate cancer?","volume":"19","author":"Howard","year":"2016","journal-title":"Prostate Cancer Prostatic Dis."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"110","DOI":"10.1038\/pcan.2016.62","article-title":"Skeletal-related events significantly impact health-related quality of life in metastatic castration-resistant prostate cancer: Data from PREVAIL and AFFIRM trials","volume":"20","author":"Saad","year":"2017","journal-title":"Prostate Cancer Prostatic Dis."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"570","DOI":"10.1200\/JCO.1993.11.3.570","article-title":"The Functional Assessment of Cancer Therapy scale: Development and validation of the general measure","volume":"11","author":"Cella","year":"1993","journal-title":"J. Clin. Oncol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"579","DOI":"10.1093\/annonc\/mdi122","article-title":"The significance of skeletal-related events for the health-related quality of life of patients with metastatic prostate cancer","volume":"16","author":"Weinfurt","year":"2005","journal-title":"Ann. Oncol."},{"key":"ref_14","first-page":"501","article-title":"Quality of life following surgical treatment of lower limb metastases in long bone","volume":"29","author":"Perisano","year":"2015","journal-title":"J. Biol. Regul. Homeost. Agents"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1563","DOI":"10.1007\/s11999-016-4739-x","article-title":"Is Prophylactic Intervention More Cost-effective Than the Treatment of Pathologic Fractures in Metastatic Bone Disease?","volume":"474","author":"Blank","year":"2016","journal-title":"Clin. Orthop."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1678","DOI":"10.1016\/j.juro.2013.12.042","article-title":"The Health Care Burden of Skeletal Related Events in Patients with Renal Cell Carcinoma and Bone Metastasis","volume":"191","author":"Antczak","year":"2014","journal-title":"J. Urol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1002\/jso.22061","article-title":"Survival analysis of patients with femoral metastases","volume":"105","author":"Mavrogenis","year":"2012","journal-title":"J. Surg. Oncol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"132","DOI":"10.1016\/j.suronc.2013.02.008","article-title":"Insight opinion to surgically treated metastatic bone disease: Scandinavian Sarcoma Group Skeletal Metastasis Registry report of 1195 operated skeletal metastasis","volume":"22","author":"Ratasvuori","year":"2013","journal-title":"Surg. Oncol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1007\/s00590-016-1857-9","article-title":"Treatment for long bone metastases based on a systematic literature review","volume":"27","author":"Errani","year":"2017","journal-title":"Eur. J. Orthop. Surg. Traumatol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"S138","DOI":"10.1016\/j.injury.2014.10.038","article-title":"Impending fracture: A difficult diagnosis","volume":"45","author":"Piccioli","year":"2014","journal-title":"Injury"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1016\/j.bonr.2016.02.003","article-title":"The insufficiencies of risk analysis of impending pathological fractures in patients with femoral metastases: A literature review","volume":"5","author":"Benca","year":"2016","journal-title":"Bone Rep."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1100","DOI":"10.1302\/0301-620X.100B8.BJJ-2018-0300.R1","article-title":"The validity of the Mirels score for predicting impending pathological fractures of the lower limb","volume":"100-B","author":"Howard","year":"2018","journal-title":"Bone Jt. J."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"S41","DOI":"10.1016\/j.otsr.2016.11.001","article-title":"Metastatic fractures of long limb bones","volume":"103","author":"Anract","year":"2017","journal-title":"Orthop. Traumatol. Surg. Res."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"56","DOI":"10.5435\/00124635-200001000-00006","article-title":"Surgical Treatment of Metastatic Disease of the Femur","volume":"8","author":"Swanson","year":"2000","journal-title":"J. Am. Acad. Orthop. Surg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"112","DOI":"10.1016\/j.clon.2011.11.004","article-title":"Update on the Systematic Review of Palliative Radiotherapy Trials for Bone Metastases","volume":"24","author":"Chow","year":"2012","journal-title":"Clin. Oncol."},{"key":"ref_26","first-page":"5","article-title":"Radiotherapy for neuropathic pain due to bone metastases","volume":"4","author":"Roos","year":"2015","journal-title":"Ann. Palliat. Med."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"620","DOI":"10.1080\/02841860310014895","article-title":"A Systematic Overview of Radiation Therapy Effects in Skeletal Metastases","volume":"42","author":"Falkmer","year":"2003","journal-title":"Acta Oncol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1186\/s13014-015-0374-z","article-title":"Effects of Radiotherapy in the treatment of multiple myeloma: A retrospective analysis of a Single Institution","volume":"10","author":"Matuschek","year":"2015","journal-title":"Radiat. Oncol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"345","DOI":"10.1016\/S0936-6555(03)00113-4","article-title":"Palliation of Metastatic Bone Pain: Single Fraction versus Multifraction Radiotherapy\u2014A Systematic Review of Randomised Trials","volume":"15","author":"Sze","year":"2003","journal-title":"Clin. Oncol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1423","DOI":"10.1200\/JCO.2006.09.5281","article-title":"Palliative Radiotherapy Trials for Bone Metastases: A Systematic Review","volume":"25","author":"Chow","year":"2007","journal-title":"J. Clin. Oncol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"220","DOI":"10.1038\/nrclinonc.2010.17","article-title":"Treatment of painful bone metastases","volume":"7","author":"Rades","year":"2010","journal-title":"Nat. Rev. Clin. Oncol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"750","DOI":"10.1002\/jor.24868","article-title":"Altered mechanical behavior of demineralized bone following therapeutic radiation","volume":"39","author":"Bartlow","year":"2021","journal-title":"J. Orthop. Res."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1398","DOI":"10.1016\/j.ejso.2018.04.012","article-title":"Fractures after multimodality treatment of soft tissue sarcomas with isolated limb perfusion and radiation; likely to occur and hard to heal","volume":"44","author":"Seinen","year":"2018","journal-title":"Eur. J. Surg. Oncol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1333","DOI":"10.1517\/14712598.6.12.1333","article-title":"Zoledronic acid in the management of metastatic bone disease","volume":"6","author":"Santini","year":"2006","journal-title":"Expert Opin. Biol. Ther."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"440","DOI":"10.1359\/jbmr.090810","article-title":"Effects of denosumab in patients with bone metastases with and without previous bisphosphonate exposure","volume":"25","author":"Body","year":"2010","journal-title":"J. Bone Miner. Res."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1002\/jlcr.3582","article-title":"Re-thinking the role of radiometal isotopes: Towards a future concept for theranostic radiopharmaceuticals","volume":"61","author":"Notni","year":"2018","journal-title":"J. Label. Compd. Radiopharm."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1177","DOI":"10.1080\/14737159.2016.1243057","article-title":"Prostate specific membrane antigen (PSMA) ligands for diagnosis and therapy of prostate cancer","volume":"16","author":"Barrio","year":"2016","journal-title":"Expert Rev. Mol. Diagn."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"2114","DOI":"10.1007\/s00259-016-3435-0","article-title":"Comparison of bone scintigraphy and 68Ga-PSMA PET for skeletal staging in prostate cancer","volume":"43","author":"Pyka","year":"2016","journal-title":"Eur. J. Nucl. Med. Mol. Imaging"},{"key":"ref_39","first-page":"85","article-title":"German Multicenter Study Investigating 177Lu-PSMA-617 Radioligand Therapy in Advanced Prostate Cancer Patients","volume":"58","author":"Rahbar","year":"2017","journal-title":"J. Nucl. Med. Off. Publ. Soc. Nucl. Med."},{"key":"ref_40","first-page":"255851","article-title":"Evaluation of safety and dosimetry of 177Lu DOTA-ZOL for therapy of bone metastases","volume":"120","author":"Fernandez","year":"2021","journal-title":"J. Nucl. Med. Off. Publ. Soc. Nucl. Med."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"S4","DOI":"10.1097\/01.blo.0000093045.56370.dd","article-title":"The Classic: Metastatic Disease in Long Bones A Proposed Scoring System for Diagnosing Impending Pathologic Fractures","volume":"415","author":"Mirels","year":"2003","journal-title":"Clin. Orthop."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"S201","DOI":"10.1097\/01.blo.0000093842.72468.73","article-title":"Critical Evaluation of Mirels\u2019 Rating System for Impending Pathologic Fractures","volume":"415","author":"Damron","year":"2003","journal-title":"Clin. Orthop."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1279","DOI":"10.1007\/s11999-008-0200-0","article-title":"Mirels\u2019 Rating for Humerus Lesions is Both Reproducible and Valid","volume":"466","author":"Evans","year":"2008","journal-title":"Clin. Orthop."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1007\/s00264-009-0941-8","article-title":"Inter- and intra-observer variability associated with the use of the Mirels\u2019 scoring system for metastatic bone lesions","volume":"35","author":"Quinlan","year":"2011","journal-title":"Int. Orthop."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1007\/s00256-009-0823-6","article-title":"Inter- and intra-observer variation in classification systems for impending fractures of bone metastases","volume":"39","author":"Coleman","year":"2010","journal-title":"Skelet. Radiol."},{"key":"ref_46","first-page":"566","article-title":"Comparative analysis of risk factors for pathological fracture with femoral metastases","volume":"86","author":"Dijkstra","year":"2004","journal-title":"J. Bone Jt. Surg. Br."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"160","DOI":"10.1016\/j.bone.2013.10.009","article-title":"Finite element analysis and CT-based structural rigidity analysis to assess failure load in bones with simulated lytic defects","volume":"58","author":"Derikx","year":"2014","journal-title":"Bone"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1350","DOI":"10.1002\/1097-0142(1971)28:5<1350::AID-CNCR2820280539>3.0.CO;2-6","article-title":"Prophylactic internal fixation of the femur in metastatic breast cancer","volume":"28","author":"Beals","year":"1971","journal-title":"Cancer"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"623","DOI":"10.3109\/17453678108992157","article-title":"Incidence of Fracture Through Metastases in Long Bones","volume":"52","author":"Fidler","year":"1981","journal-title":"Acta Orthop. Scand."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"1005","DOI":"10.1016\/j.otsr.2020.03.034","article-title":"High rate of fracture in long-bone metastasis: Proposal for an improved Mirels predictive score","volume":"106","author":"Crenn","year":"2020","journal-title":"Orthop. Traumatol. Surg. Res."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"S208","DOI":"10.1097\/01.blo.0000093851.72468.1d","article-title":"Risk of pathologic fracture: Assessment","volume":"415","author":"Damron","year":"2003","journal-title":"Clin. Orthop."},{"key":"ref_52","first-page":"120","article-title":"Predicting pathologic fracture risk in the management of metastatic bone defects","volume":"312","author":"Hipp","year":"1995","journal-title":"Clin. Orthop."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"642","DOI":"10.1007\/s10439-006-9237-y","article-title":"Predicting Failure Load of the Femur with Simulated Osteolytic Defects using Noninvasive Imaging Technique in a Simplified Load Case","volume":"35","author":"Lee","year":"2007","journal-title":"Ann. Biomed. Eng."},{"key":"ref_54","first-page":"282","article-title":"Metastatic Breast Cancer in the Femur A Search for the Lesion at Risk of Fracture","volume":"20","author":"Keene","year":"1986","journal-title":"Clin. Orthop."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"14133","DOI":"10.1038\/s41598-019-50636-9","article-title":"Prediction of pathological fracture in patients with metastatic disease of the lower limb","volume":"9","author":"Howard","year":"2019","journal-title":"Sci. Rep."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1016\/j.radonc.2019.10.007","article-title":"Axial cortical involvement of metastatic lesions to identify impending femoral fractures; a clinical validation study","volume":"144","author":"Eggermont","year":"2020","journal-title":"Radiother. Oncol."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1016\/S0167-8140(03)00232-9","article-title":"Simple radiographic parameter predicts fracturing in metastatic femoral bone lesions: Results from a randomised trial","volume":"69","author":"Kroon","year":"2003","journal-title":"Radiother. Oncol."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1186\/s13014-014-0227-1","article-title":"Assessment of the risk factors for impending fractures following radiotherapy for long bone metastases using CT scan-based virtual simulation: A retrospective study","volume":"9","author":"Tatar","year":"2014","journal-title":"Radiat. Oncol."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"202","DOI":"10.4329\/wjr.v7.i8.202","article-title":"Imaging of bone metastasis: An update","volume":"7","author":"Sullivan","year":"2015","journal-title":"World J. Radiol."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"1301","DOI":"10.3389\/fonc.2020.01301","article-title":"Progress and Future Trends in PET\/CT and PET\/MRI Molecular Imaging Approaches for Breast Cancer","volume":"10","author":"Ming","year":"2020","journal-title":"Front. Oncol."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"e180","DOI":"10.1097\/RLU.0000000000002057","article-title":"99mTc MDP SPECT-CT\u2013Based Modified Mirels Classification for Evaluation of Risk of Fracture in Skeletal Metastasis: A Pilot Study","volume":"43","author":"Riaz","year":"2018","journal-title":"Clin. Nucl. Med."},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1097\/RLU.0000000000001580","article-title":"FDG PET\/CT Assesses the Risk of Femoral Pathological Fractures in Patients With Metastatic Breast Cancer","volume":"42","author":"Ulaner","year":"2017","journal-title":"Clin. Nucl. Med."},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"7676","DOI":"10.1158\/1078-0432.CCR-09-0420","article-title":"Noninvasive Prediction of Fracture Risk in Patients with Metastatic Cancer to the Spine","volume":"15","author":"Snyder","year":"2009","journal-title":"Clin. Cancer Res."},{"key":"ref_64","first-page":"479","article-title":"Failure of trabecular bone with simulated lytic defects can be predicted non-invasively by structural analysis","volume":"22","author":"Hong","year":"2004","journal-title":"J. Orthop. Res."},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"1240","DOI":"10.2106\/00004623-200009000-00004","article-title":"Noninvasive Imaging Predicts Failure Load of the Spine with Simulated Osteolytic Defects*\u2020","volume":"82","author":"Whealan","year":"2000","journal-title":"J. Bone Jt. Surg.-Am. Vol."},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"100286","DOI":"10.1016\/j.bonr.2020.100286","article-title":"Finite element models for fracture prevention in patients with metastatic bone disease. A literature review","volume":"12","author":"Sas","year":"2020","journal-title":"Bone Rep."},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"1827","DOI":"10.2106\/JBJS.I.00871","article-title":"Computed Tomography-Based Structural Analysis for Predicting Fracture Risk in Children with Benign Skeletal Neoplasms: Comparison of Specificity with That of Plain Radiographs","volume":"92","author":"Leong","year":"2010","journal-title":"J. Bone Jt. Surg."},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"643","DOI":"10.1007\/s11999-015-4453-0","article-title":"CT-based Structural Rigidity Analysis Is More Accurate Than Mirels Scoring for Fracture Prediction in Metastatic Femoral Lesions","volume":"474","author":"Damron","year":"2016","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"2514","DOI":"10.1158\/1078-0432.CCR-14-2668","article-title":"Treatment Planning and Fracture Prediction in Patients with Skeletal Metastasis with CT-Based Rigidity Analysis","volume":"21","author":"Nazarian","year":"2015","journal-title":"Clin. Cancer Res."},{"key":"ref_70","doi-asserted-by":"crossref","first-page":"32397","DOI":"10.1038\/srep32397","article-title":"Curved Beam Computed Tomography based Structural Rigidity Analysis of Bones with Simulated Lytic Defect: A Comparative Study with Finite Element Analysis","volume":"6","author":"Oftadeh","year":"2016","journal-title":"Sci. Rep."},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1007\/s11845-014-1070-y","article-title":"The paradox of Wolff\u2019s theories","volume":"184","author":"Hammer","year":"2014","journal-title":"Ir. J. Med. Sci. (1971-)"},{"key":"ref_72","doi-asserted-by":"crossref","first-page":"483","DOI":"10.1002\/jor.1100140319","article-title":"Curved beam model of the proximal femur for estimating stress using dual-energy x-ray absorptiometry derived structural geometry","volume":"14","author":"Mourtada","year":"1996","journal-title":"J. Orthop. Res."},{"key":"ref_73","doi-asserted-by":"crossref","first-page":"e3892","DOI":"10.1097\/MD.0000000000003892","article-title":"The surgical management and treatment of metastatic lesions in the proximal femur","volume":"95","author":"Feng","year":"2016","journal-title":"Medicine"},{"key":"ref_74","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1097\/01.blo.0000164400.37905.22","article-title":"Predicting Proximal Femoral Strength Using Structural Engineering Models","volume":"427","author":"Keyak","year":"2005","journal-title":"Clin. Orthop."},{"key":"ref_75","doi-asserted-by":"crossref","first-page":"777","DOI":"10.1016\/j.bone.2009.06.009","article-title":"Pathological fracture prediction in patients with metastatic lesions can be improved with quantitative computed tomography based computer models","volume":"45","author":"Tanck","year":"2009","journal-title":"Bone"},{"key":"ref_76","doi-asserted-by":"crossref","first-page":"369","DOI":"10.1002\/jor.1100060308","article-title":"Strength reductions from metastatic cortical defects in long bones","volume":"6","author":"McBroom","year":"1988","journal-title":"J. Orthop. Res."},{"key":"ref_77","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1016\/0021-9290(93)90363-J","article-title":"Evaluation of finite element analysis for prediction of the strength reduction due to metastatic lesions in the femoral neck","volume":"26","author":"Cheal","year":"1993","journal-title":"J. Biomech."},{"key":"ref_78","doi-asserted-by":"crossref","first-page":"1175","DOI":"10.1002\/jor.24660","article-title":"Fracture risk assessment and clinical decision making for patients with metastatic bone disease","volume":"38","author":"Damron","year":"2020","journal-title":"J. Orthop. Res."},{"key":"ref_79","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1016\/S1350-4533(01)00045-5","article-title":"Improved prediction of proximal femoral fracture load using nonlinear finite element models","volume":"23","author":"Keyak","year":"2001","journal-title":"Med. Eng. Phys."},{"key":"ref_80","doi-asserted-by":"crossref","first-page":"180","DOI":"10.1016\/j.bone.2014.09.022","article-title":"Predicting the stiffness and strength of human femurs with real metastatic tumors","volume":"69","author":"Yosibash","year":"2014","journal-title":"Bone"},{"key":"ref_81","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1038\/s41598-019-46739-y","article-title":"QCT-based finite element prediction of pathologic fractures in proximal femora with metastatic lesions","volume":"9","author":"Benca","year":"2019","journal-title":"Sci. Rep."},{"key":"ref_82","first-page":"8","article-title":"The assessment of the risk of fracture in femora with metastatic lesions","volume":"94","author":"Derikx","year":"2012","journal-title":"J. Bone Jt. Surg."},{"key":"ref_83","doi-asserted-by":"crossref","first-page":"931","DOI":"10.1016\/j.jos.2017.05.015","article-title":"The risk assessment of pathological fracture in the proximal femur using a CT-based finite element method","volume":"22","author":"Kawabata","year":"2017","journal-title":"J. Orthop. Sci."},{"key":"ref_84","doi-asserted-by":"crossref","first-page":"S260","DOI":"10.1080\/10255842.2020.1815312","article-title":"Ex vivo experiments on femurs to assess metastatic bone strength","volume":"23","author":"Riglet","year":"2020","journal-title":"Comput. Methods Biomech. Biomed. Eng."},{"key":"ref_85","doi-asserted-by":"crossref","first-page":"215","DOI":"10.1016\/j.bone.2018.02.011","article-title":"Pathological fracture risk assessment in patients with femoral metastases using CT-based finite element methods. A retrospective clinical study","volume":"110","author":"Sternheim","year":"2018","journal-title":"Bone"},{"key":"ref_86","doi-asserted-by":"crossref","first-page":"638","DOI":"10.1302\/0301-620X.102B5.BJJ-2019-1328.R2","article-title":"When and where do patients with bone metastases actually break their femurs? A CT-based finite element analysis","volume":"102-B","author":"Sternheim","year":"2020","journal-title":"Bone Jt. J."},{"key":"ref_87","doi-asserted-by":"crossref","first-page":"115101","DOI":"10.1016\/j.bone.2019.115101","article-title":"Patient-specific finite element computer models improve fracture risk assessments in cancer patients with femoral bone metastases compared to clinical guidelines","volume":"130","author":"Eggermont","year":"2020","journal-title":"Bone"},{"key":"ref_88","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1016\/0141-5425(82)90009-7","article-title":"Finite-Element-Analysis and experimental investigation of stresses in a femur","volume":"4","author":"Rohlmann","year":"1982","journal-title":"J. Biomed. Eng."},{"key":"ref_89","doi-asserted-by":"crossref","first-page":"173","DOI":"10.1243\/095441103765212677","article-title":"Strain distribution within the human femur due to physiological and simplified loading: Finite element analysis using the muscle standardized femur model","volume":"217","author":"Polgar","year":"2003","journal-title":"Proc. Inst. Mech. Eng. Part H J. Eng. Med."},{"key":"ref_90","doi-asserted-by":"crossref","first-page":"1138","DOI":"10.1080\/10255842.2020.1789863","article-title":"Image-based finite-element modeling of the human femur","volume":"23","author":"Falcinelli","year":"2020","journal-title":"Comput. Methods Biomech. Biomed. Engin."},{"key":"ref_91","doi-asserted-by":"crossref","first-page":"1225","DOI":"10.1016\/j.medengphy.2014.06.010","article-title":"Inter-scanner differences in in vivo QCT measurements of the density and strength of the proximal femur remain after correction with anthropomorphic standardization phantoms","volume":"36","author":"Carpenter","year":"2014","journal-title":"Med. Eng. Phys."},{"key":"ref_92","doi-asserted-by":"crossref","first-page":"e699","DOI":"10.1016\/j.ejrad.2011.01.078","article-title":"Relationships of clinical protocols and reconstruction kernels with image quality and radiation dose in a 128-slice CT scanner: Study with an anthropomorphic and water phantom","volume":"81","author":"Paul","year":"2012","journal-title":"Eur. J. Radiol."},{"key":"ref_93","doi-asserted-by":"crossref","first-page":"153","DOI":"10.1016\/j.jbiomech.2014.09.016","article-title":"Quantitative computed tomography-based finite element analysis predictions of femoral strength and stiffness depend on computed tomography settings","volume":"48","author":"Salas","year":"2015","journal-title":"J. Biomech."},{"key":"ref_94","doi-asserted-by":"crossref","unstructured":"Eggermont, F., Verdonschot, N., van der Linden, Y., and Tanck, E. (2019). Calibration with or without phantom for fracture risk prediction in cancer patients with femoral bone metastases using CT-based finite element models. PLoS ONE, 14.","DOI":"10.1371\/journal.pone.0220564"},{"key":"ref_95","doi-asserted-by":"crossref","first-page":"679","DOI":"10.1016\/j.medengphy.2016.03.006","article-title":"The influence of the modulus\u2013density relationship and the material mapping method on the simulated mechanical response of the proximal femur in side-ways fall loading configuration","volume":"38","author":"Helgason","year":"2016","journal-title":"Med. Eng. Phys."},{"key":"ref_96","first-page":"2619","article-title":"Constructing anisotropic finite element model of bone from computed tomography (CT)","volume":"24","author":"Kazembakhshi","year":"2014","journal-title":"Biomed. Mater. Eng."},{"key":"ref_97","doi-asserted-by":"crossref","first-page":"36","DOI":"10.1016\/j.medengphy.2018.06.004","article-title":"Mapping anisotropy improves QCT-based finite element estimation of hip strength in pooled stance and side-fall load configurations","volume":"59","author":"Panyasantisuk","year":"2018","journal-title":"Med. Eng. Phys."},{"key":"ref_98","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1016\/j.jmbbm.2019.01.014","article-title":"Mechanical behavior of metastatic femurs through patient-specific computational models accounting for bone-metastasis interaction","volume":"93","author":"Falcinelli","year":"2019","journal-title":"J. Mech. Behav. Biomed. Mater."},{"key":"ref_99","doi-asserted-by":"crossref","first-page":"294","DOI":"10.1021\/acsbiomaterials.7b00041","article-title":"In Vitro Modeling of Mechanics in Cancer Metastasis","volume":"4","author":"Malandrino","year":"2018","journal-title":"ACS Biomater. Sci. Eng."},{"key":"ref_100","doi-asserted-by":"crossref","first-page":"1165","DOI":"10.1002\/jbmr.5650071008","article-title":"Mechanical properties of trabecular bone within and adjacent to osseous metastases","volume":"7","author":"Hipp","year":"1992","journal-title":"J. Bone Miner. Res."},{"key":"ref_101","doi-asserted-by":"crossref","first-page":"445","DOI":"10.1016\/S1350-4533(03)00030-4","article-title":"Relationships between material properties and CT scan data of cortical bone with and without metastatic lesions","volume":"25","author":"Kaneko","year":"2003","journal-title":"Med. Eng."},{"key":"ref_102","doi-asserted-by":"crossref","first-page":"430","DOI":"10.1302\/2046-3758.76.BJR-2017-0325.R2","article-title":"Can patient-specific finite element models better predict fractures in metastatic bone disease than experienced clinicians? Towards computational modelling in daily clinical practice","volume":"7","author":"Eggermont","year":"2018","journal-title":"Bone Jt. Res."},{"key":"ref_103","doi-asserted-by":"crossref","first-page":"1226","DOI":"10.1002\/jor.22887","article-title":"Simulating activities of daily living with finite element analysis improves fracture prediction for patients with metastatic femoral lesions: Fracture risk of metastatic lesions","volume":"33","author":"Goodheart","year":"2015","journal-title":"J. Orthop. Res."},{"key":"ref_104","doi-asserted-by":"crossref","first-page":"859","DOI":"10.1016\/S0021-9290(01)00040-9","article-title":"Hip contact forces and gait patterns from routine activities","volume":"34","author":"Bergmann","year":"2001","journal-title":"J. Biomech."},{"key":"ref_105","doi-asserted-by":"crossref","first-page":"565","DOI":"10.1177\/0272989X06295361","article-title":"Decision Curve Analysis: A Novel Method for Evaluating Prediction Models","volume":"26","author":"Vickers","year":"2006","journal-title":"Med. Decis. Mak."},{"key":"ref_106","doi-asserted-by":"crossref","first-page":"2534","DOI":"10.1200\/JCO.2015.65.5654","article-title":"Assessing the Clinical Impact of Risk Prediction Models With Decision Curves: Guidance for Correct Interpretation and Appropriate Use","volume":"34","author":"Kerr","year":"2016","journal-title":"J. Clin. Oncol."},{"key":"ref_107","doi-asserted-by":"crossref","first-page":"521","DOI":"10.1097\/CORR.0000000000001303","article-title":"Can a Novel Scoring System Improve on the Mirels Score in Predicting the Fracture Risk in Patients with Multiple Myeloma?","volume":"479","author":"Toci","year":"2021","journal-title":"Clin. Orthop."},{"key":"ref_108","doi-asserted-by":"crossref","first-page":"1236","DOI":"10.1093\/bib\/bbx044","article-title":"Deep learning for healthcare: Review, opportunities and challenges","volume":"19","author":"Miotto","year":"2018","journal-title":"Brief. Bioinform."},{"key":"ref_109","doi-asserted-by":"crossref","first-page":"350","DOI":"10.1016\/j.neucom.2017.01.026","article-title":"Machine Learning on Big Data: Opportunities and Challenges","volume":"237","author":"Zhou","year":"2017","journal-title":"Neurocomputing"},{"key":"ref_110","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1002\/mp.14602","article-title":"Real-time biomechanics using the finite element method and machine learning: Review and perspective","volume":"48","author":"Phellan","year":"2021","journal-title":"Med. Phys."},{"key":"ref_111","doi-asserted-by":"crossref","first-page":"8880786","DOI":"10.1155\/2020\/8880786","article-title":"Risk Assessment of Hip Fracture Based on Machine Learning","volume":"2020","author":"Galassi","year":"2020","journal-title":"Appl. Bionics Biomech."},{"key":"ref_112","doi-asserted-by":"crossref","first-page":"868","DOI":"10.1016\/j.jmbbm.2011.03.002","article-title":"Apparent damage accumulation in cancellous bone using neural networks","volume":"4","author":"Hambli","year":"2011","journal-title":"J. Mech. Behav. Biomed. Mater."},{"key":"ref_113","doi-asserted-by":"crossref","unstructured":"Forsberg, J.A., Eberhardt, J., Boland, P.J., Wedin, R., and Healey, J.H. (2011). Estimating Survival in Patients with Operable Skeletal Metastases: An Application of a Bayesian Belief Network. PLoS ONE, 6.","DOI":"10.1371\/journal.pone.0019956"},{"key":"ref_114","doi-asserted-by":"crossref","first-page":"100225","DOI":"10.1016\/j.jbo.2019.100225","article-title":"Prediction of survival after surgical management of femoral metastatic bone disease\u2014A comparison of prognostic models","volume":"15","author":"Meares","year":"2019","journal-title":"J. Bone Oncol."},{"key":"ref_115","doi-asserted-by":"crossref","first-page":"808","DOI":"10.1097\/CORR.0000000000001081","article-title":"External Validation of PATHFx Version 3.0 in Patients Treated Surgically and Nonsurgically for Symptomatic Skeletal Metastases","volume":"478","author":"Anderson","year":"2020","journal-title":"Clin. Orthop."},{"key":"ref_116","doi-asserted-by":"crossref","first-page":"585","DOI":"10.1002\/sim.4780100410","article-title":"Multiple imputation in health-are databases: An overview and some applications","volume":"10","author":"Rubin","year":"1991","journal-title":"Stat. Med."},{"key":"ref_117","doi-asserted-by":"crossref","first-page":"493","DOI":"10.1007\/s00264-008-0556-5","article-title":"Metastatic bone disease: The requirement for improvement in a multidisciplinary approach","volume":"33","author":"Cumming","year":"2009","journal-title":"Int. Orthop."},{"key":"ref_118","first-page":"2309499017716243","article-title":"Prediction of pathologic femoral fractures in patients with lung cancer using machine learning algorithms: Comparison of computed tomography-based radiological features with clinical features versus without clinical features","volume":"25","author":"Oh","year":"2017","journal-title":"J. Orthop. Surg. Hong Kong"},{"key":"ref_119","doi-asserted-by":"crossref","first-page":"12612","DOI":"10.18632\/oncotarget.7278","article-title":"Exploiting machine learning for predicting skeletal-related events in cancer patients with bone metastases","volume":"7","author":"Wang","year":"2016","journal-title":"Oncotarget"},{"key":"ref_120","doi-asserted-by":"crossref","first-page":"360","DOI":"10.1016\/j.jocd.2017.06.022","article-title":"FRAX Update","volume":"20","author":"Kanis","year":"2017","journal-title":"J. Clin. Densitom. Assess. Manag. Musculoskelet. Health"},{"key":"ref_121","doi-asserted-by":"crossref","first-page":"e10337","DOI":"10.1002\/jbm4.10337","article-title":"A Novel Fracture Prediction Model Using Machine Learning in a Community-Based Cohort","volume":"4","author":"Kong","year":"2020","journal-title":"JBMR Plus"}],"container-title":["Cancers"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6694\/13\/15\/3662\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T06:32:55Z","timestamp":1760164375000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6694\/13\/15\/3662"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,7,21]]},"references-count":121,"journal-issue":{"issue":"15","published-online":{"date-parts":[[2021,8]]}},"alternative-id":["cancers13153662"],"URL":"https:\/\/doi.org\/10.3390\/cancers13153662","relation":{},"ISSN":["2072-6694"],"issn-type":[{"value":"2072-6694","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,7,21]]}}}