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Updated: Sep 28 2021

Impending Fracture & Prophylactic Fixation

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  • 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
        • Mirels' criteria
    • Prophylactic fixation is preferred to fixation of actual pathological fracture due to
      • shorter operative time
      • decreased morbidity
      • quicker recovery
  • Harington's criteria
    • Haringtons' 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
  • Mirels' criteria
    • Mirels' classification
      • score > 8 suggests prophylactic fixation
      • size of lesion is expressed as a fraction of the cortical thickness. 
      • Mirels' criteria
      • 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
    • Radiation therapy
      • indications
        • painful lesion with Mirels' score =< 8
    • 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
        • humerus
          • proximal humerus lesions
            • endoprosthesis
          • diaphysis
            • intramedullary nail
            • resection and intercalary spacer
            • plates and screws (less preferred)
          • distal humerus lesions
            • flexible nails
            • elbow replacement
        • femur
          • peritrochanteric lesions
            • intramedullary nail
          • femoral neck and head lesions
            • hemiarthroplasty
    • 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
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