Impending Fracture & Prophylactic Fixation

Criteria for prophylactic fixation

Several methods exist to predict the risk of pathologic fracture. These include
- the presence of significant functional pain
- > 50% destruction of cortical bone
- formal staging systems
  - Harington's criteria
  - Mirel's criteria
Prophylactic fixation is preferred to fixation of actual pathological fracture due to
- shorter operative time
- decreased morbidity
- quicker recovery

Harington's criteria

Harington's criteria
> 50% destruction of diaphyseal cortices > 50-75% destruction of metaphysis (> 2.5 cm) Permeative destruction of the subtrochanteric femoral region Persistent pain following irradiation

Mirel's criteria

Mirels criteria score > 8 suggests prophylactic fixation
Score	1	2	3
Site	upper limb	lower limb	peritrochanteric
Pain	mild	moderate	functional
Lesion	blastic	mixed	lytic
Size	< 1/3	1/3 to 2/3	> 2/3

Treatment algorithm

Obtain tissue diagnosis
- unless patient has a known primary neoplasm with bone biopsy proven skeletal metastasis, the treating surgeon should biopsy the lesion in question
  - biopsy may require separate incision than the incision used for IM nailing of bone
  - if biopsy suggests primary neoplasm of bone (like sarcoma) that may benefit from neoadjuvant chemo/radiotherapy then close wound and refer to local sarcoma center prior to surgical stabilization
    - surgical treatment of primary sarcoma will contaminate entire bone with sarcoma and affect ability to perform limb-salvage surgery
Surgical Fixation
- do not proceed with fixation until primary neoplasm of bone has been ruled out with biopsy
- goals of fixation
  - maximize ability for immediate mobilization and weight-bearing
  - protect the entire bone in setting of systemic or metastatic disease
  - optimize implant choice in the context of the patient's overall prognosis
- type of fixation depends on location of lesion and type of disease
  - eg. femur
    - cephalomedullary nailing for peritrochanteric lesions
    - hemiarthroplasty for femoral neck and head lesions
Postoperative radiation
- following surgery refer the patient to radiation oncology for post-operative radiotherapy treatment to
  - decrease pain
  - slow progression
  - treat remaining tumor burden not removed at surgery

TAG

(OBQ07.242) A 75-year-old man is brought to the ER after a fall. He complains of right leg pain, and a radiograph is shown in Figure A. Prior to operative fixation of the fracture, biopsy and staging procedures reveal that this is a metastatic lesion. Which of the following primary cancer diagnoses is associated with the shortest life expectancy following pathologic fracture? Topic

Review Topic

FIGURES: A

1. Lung
2. Thyroid
3. Prostate
4. Breast
5. Renal

PREFERRED RESPONSE ▶

DISCUSSION: This patient is presenting with a pathologic fracture of the proximal tibia. Prior to definitive fixation, the nature of the tumor needs to be determined through biopsy and staging to assist with operative planning. In terms of life expectency, lung cancer and melanoma have the worst median survival (<6 months) and 5 year survival (<5%) when bone metastases are present.

Rougraff et al were able to determine the primary site of the tumor in 85% of their forty patients by using their unique diagnostic protocol, which did not include biopsy. They report that biopsy alone failed to identify the primary malignant tumor in 65% of patients.

The instructional course lecture by Simon et al reviews how to outline an effective diagnostic strategy when evaluating potential malignancies. They specifically state that if the diagnosis of malignancy or aggressive tumor is favored, or a soft-tissue mass greater than 5cm in diameter is present, that these should be referred to an orthopedic oncologist prior to biopsy.

REFERENCES:

1. Simon, Finn: Diagnostic strategy for bone and soft tissue tumors. Instr Course Lect 1994; 43:527-536 PMID:9097183 (Link to Abstract)

2. Rougraff BT, Kneisl JS, Simon MA: Skeletal metastases of unkown origin: A prospective study of a diagnostic strategy. J Bone Joint Surg Am 1993; 75:1276-1281 PMID:8408149 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Patrick McCulloch MD, Michael Hughes MD,

Please Rate Educational Value!

3.0

Average 3.0 of 8 Ratings

TAG

(OBQ05.13) An elderly female has just been diagnosed with lung cancer. If her cancer metastasizes to bone, what is the most common site of subsequent pathologic fracture? Topic

Review Topic

1. Proximal femur
2. Distal femur
3. Proximal humerus
4. Humeral shaft
5. Thoracic spine

PREFERRED RESPONSE ▶

DISCUSSION: The most common site for pathologic fracture secondary to metastatic carcinoma is the proximal femur secondary to the fact that the femur is the most common long bone associated with metastatic disease and the stress risers around the proximal femur make it easy to fracture. The spine however is the most common site of all bone metastasis. Both Mirel's criteria and Harrington's criteria are used to predict the risk of pathologic fracture in the presence of a metastatic lesion and indications for prophylactic fixation.

The cited reference by Ward et al emphasizes the benefit of prophylactic stabilization in improving the quality of life in patients with metastatic disease.

The cited reference by Weber et al provides a treatment algorithms for metastatic disease, including the use of radiation and bisphosphonates, augmenting the primary fixation. Recent literature from the UK and Memorial Sloan Kettering suggests improved patient related outcomes and decreased mechanical failure in proximal femoral metastatic lesions treated with megaprostheses rather than intramedullary nails.

REFERENCES:

1. Review of Orthopaedics, 4th Edition, Mark D. Miller, W B Saunders Co, March 2004

2. Ward WG, Spang J, Howe D. Metastatic disease of the femur. Surgical management. Orthop Clin North Am. 2000 Oct;31(4):633-45. Review. PMID:11043102 (Link to Abstract)

3. Weber KL, Lewis VO, Randall RL, Lee AK, Springfield D. An approach to the management of the patient with metastatic bone disease. Instr Course Lect. 2004;53:663-76. Review. PMID:15116657 (Link to Abstract)

Question Authors:

Patrick O'Donnell MD/PhD,

Please Rate Educational Value!

2.0

Average 2.0 of 19 Ratings

Level of Evidence 4 (Case Series)

Rougraff BT, Kneisl JS, Simon MA: Skeletal metastases of unkown origin: A prospective study of a diagnostic strategy. J Bone Joint Surg Am 1993; 75:1276-1281 PMID:8408149 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Simon, Finn: Diagnostic strategy for bone and soft tissue tumors. Instr Course Lect 1994; 43:527-536 PMID:9097183 (Link to Abstract)
Ward WG, Spang J, Howe D. Metastatic disease of the femur. Surgical management. Orthop Clin North Am. 2000 Oct;31(4):633-45. Review. PMID:11043102 (Link to Abstract)
Weber KL, Lewis VO, Randall RL, Lee AK, Springfield D. An approach to the management of the patient with metastatic bone disease. Instr Course Lect. 2004;53:663-76. Review. PMID:15116657 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Review of Orthopaedics, 4th Edition, Mark D. Miller, W B Saunders Co, March 2004

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