Introduction

The incidence of pathologic fractures is rising and patients with metastatic disease are living longer. All orthopaedic surgeons providing trauma call coverage should have a sound knowledge of the principles and approach to the treatment of this subset of fractures. The approach to lesions of uncertain etiology should be systematic and complete starting with a detailed history and physical examination, laboratory evaluation, and imaging studies. Early return to maximal function by minimizing restrictions and surgical complications is paramount to provide patients with a meaningful quality of life. Most procedures are of palliative nature and an understanding of patient performance status, medical comorbidities, stage of disease, and establishing goals of care are most optimally provided through a co-management, team-based approach with internal medicine, palliative care, nutrition, medical oncology, radiation oncology, and physiotherapy services. A general knowledge of the behavior of tumor subtypes is vital for avoiding pitfalls. Construct stability must be durable and sustainable for the remainder of the patient’s life expectancy. The purpose of this chapter is to review the approach and work-up for patients with an impending or actual pathologic fracture and provide management principles that can be employed by the general orthopaedic surgeon to avoid pitfalls, maximize functional recovery, and limit complications in the treatment of patients with bone metastases (▶Video 11.1).

I. History and Physical Exam

1. 
   

   Include any personal or family history of malignancies, environmental exposures, and tobacco.

   
   
2. 
   

   Constitutional symptoms, such as fever/chills, fatigue, malaise, or weight loss, can be suggestive of some tumor subtypes.

   
   
3. 
   

   The physical exam should be more thorough than the typical focused musculoskeletal exam (lymphatics, abdomen, breast, rectal, integumentary).

II. Staging and Biopsy

1. 
   

   Full staging studies are ideally obtained prior to any surgical interventions including biopsies.

   
   
   
   
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      Radiographs in orthogonal planes of the entire bone to ensure there are no additional lesions.

      
      
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      Localized advanced imaging, such as magnetic resonance imaging or computed tomography (CT), is sometimes helpful for characterization of the lesion, endosteal extent, or soft tissue extension.

      
      
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      CT chest, abdomen, and pelvis to assess the most common sources of osseous metastases (lung, breast, thyroid, renal, prostate).

      
      
   4. 
      

      Whole-body nuclear medicine scan for complete osseous assessment of metastatic disease.

      
      
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      Skeletal survey when myeloma is suspected or has been diagnosed.

   
   
2. 
   

   Labs: complete blood count, comprehensive metabolic panel, serum/urine protein electrophoresis.

   
   
3. 
   

   If multiple osseous lesions are noted or a primary mass is identified (i.e., lung/renal), tissue can be obtained for confirmation at the time of surgical stabilization.

   
   
4. 
   

   A pitfall in the management of pathologic fractures is delay in definitive treatment by waiting for subspecialty services, such as interventional radiology and pathology, to obtain lesional and diagnostic tissue (▶ Table 11.1 ).

   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   

   Table 11.1 Pitfalls in the treatment of pathologic fractures

   Inadequate imaging/staging studies prior to proceeding with surgical intervention	Delay in definitive treatment waiting for various subspecialty services (interventional radiology, pathology, etc.)
   Lack of a “captain of the ship” directing care delivery and working with subspecialty teams	Not taking the time to understand patient goals of total care
   Inadequate tissue obtained (hematoma, callus/fibrosis, bone which needs to be decalcified, medullary reamings, crushed cells) for diagnosis	Local disease progression after surgical intervention due to lack of tumor control or adjuvant treatment (radiation)

   
   
5. 
   

   If the osseous lesion is solitary and staging studies reveal no clear site of primary disease, one should proceed with caution as a primary sarcoma of bone needs to be ruled out.

   
   
6. 
   

   Biopsy tissue can be obtained at the time of definitive fixation, but lesional tissue must be obtained.

   
   
   
   
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      Hematoma and cancellous/cortical bone have significant limitations in establishing an accurate diagnosis via frozen section. Decalcification of bone can be performed on permanent (formalin) samples only.

      
      
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      Tissue is best obtained with an angled curette/pituitary rongeur (▶ Fig. 11.1 ).

      

      
      
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      Do not crush or smear specimen; place on saline soaked nonadherent Telfa pad.

      
      
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      Do not place in formalin if intraoperative frozen section is requested/desired.

      
      
   5. 
      

      Medullary reamings are a poor source of tissue given crushing and distortion of cells.

III. Indications and Timing

1. 
   

   A sound understanding of baseline performance status, medical comorbidities, and current disease state is vital in the multidisciplinary approach to patients with impending or completed pathologic fractures.

   
   
2. 
   

   An active discussion with the medical oncology team is important in understanding immunosuppression, cytotoxic medications, and determining the most optimal time to surgery.

   
   
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   Involving palliative care or hospice services can be helpful in the decision-making and guiding expectations on operative risks and life expectancy, as many procedures are performed for pain palliation.

   
   
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   Decision to proceed with surgery should be a shared discussion with the patient, family or care givers, and the treating teams.

   
   
5. 
   

   Several scoring systems have been used in attempt to predict fracture risk. The Mirels score is a widely used system factoring location, pain, type of lesion, and size. A score of 8 or higher often warrants prophylactic fixation (▶ Table 11.2 ).

   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   

   Table 11.2 Mirels’ criteria

   Variable	1	2	3
   Site	Upper limb	Lower limb	Peritrochanter
   Pain	Mild	Moderate	Functional
   Lesion	Blastic	Mixed	Lytic
   Size	< 1/3	1/3–2/3	> 2/3
   Source: Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res 1989(249):256–264

   
   
6. 
   

   In general, lytic lesions of the peritrochanteric or diaphyseal region of the femur that are associated with functional weight-bearing pain and are greater than half the diameter of the bone, are at highest risk for fracture (▶ Fig. 11.2 ).

   

   
   
7. 
   

   Lytic lesions appear “dark” or radiolucent on radiographs as bone is destroyed/lost from the underlying destructive process. In contrast, blastic lesions appear “light,” sclerotic, or radiopaque. Lytic lesions impart a higher risk for pathologic fracture as compared to blastic lesions as the flexural rigidity of the bone is lowered.

   
   
8. 
   

   A multidisciplinary approach with the radiation and medical oncology teams is instrumental in management as radiation and bisphosphonate therapies play an important role in management.