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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
 
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
 
Mirels' 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
  • Radiation therapy
    • indications
      • low Mirels' score  
  • 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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(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? Review Topic

QID: 50
1

Proximal femur

55%

(478/869)

2

Distal femur

0%

(4/869)

3

Proximal humerus

2%

(20/869)

4

Humeral shaft

1%

(9/869)

5

Thoracic spine

41%

(354/869)

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PREFERRED RESPONSE 1

(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?
Review Topic

QID: 903
FIGURES:
1

Lung

87%

(1517/1752)

2

Thyroid

3%

(55/1752)

3

Prostate

1%

(21/1752)

4

Breast

1%

(23/1752)

5

Renal

7%

(130/1752)

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PREFERRED RESPONSE 1
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