INDICATIONS FOR OPERATIVE TREATMENT

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Patients with metastatic carcinoma to bone frequently present to the orthopedic surgeon as a pathologic fracture, and the decision to stabilize the fracture is considered. Pathologic fractures of flat bones and vertebral bodies usually can be treated conservatively. Pathologic fractures of long bones are treated best with internal fixation if the patient's medical condition is capable of withstanding the surgical and anesthetic event. A long bone pathologic fracture is associated with significant morbidity from blood loss as well as risks of nonunion, implant failure, pulmonary emboli, and slow functional recovery. Patients with skeletal metastases should have durable fixation placed before a fracture whenever possible as an elective procedure. Because this procedure could be performed under more controlled surgical conditions and with the integrity of the bone intact, most of the aforementioned risks are less common if a prophylactic fixation is done. Because only a small percentage of metastatic lesions lead to a fracture,7 however, predicting impending fractures can be difficult.

The decision whether to perform prophylactic surgery on a patient with metastatic carcinoma to bone can be a difficult one, which depends on several complex factors. These factors include the biologic activity of the bone lesion; the responsiveness of the bone lesion to medical and radiation therapy; the anatomic location of the bone metastasis; and patient factors, such as overall health status, expected length of survival, compliance, and patient expectations and needs. These four topics are explored in detail in this article to formulate an appropriate clinical approach to patients with skeletal metastases. With the increased survival of patients with skeletal metastases and the improved nonsurgical treatment for these patients, a careful review is warranted on this subject. This article concludes with a discussion of resection and skeletal reconstruction versus internal fixation of metastatic lesions.

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BIOMECHANICS OF PATHOLOGIC FRACTURES

The bone defect size of a metastatic lesion commonly is used to assess the potential for pathologic fracture. Because bone defect size can be assessed with radiographs obtained at the initial evaluation, it is one of the most commonly used and helpful pieces of information for the surgeon assessing the need for prophylactic treatment. Any cortical defect of bone can greatly weaken it, especially in torsion. There are two general types of defects—lesions that are less than the diameter of bone

BIOLOGIC ACTIVITY OF BONE METASTASES AS A FACTOR IN DECISION MAKING

The aggressiveness of bone destruction cannot be accurately understood for each patient unless two or more radiographic studies are available over several months' time. These studies usually are available to the surgeon who is being consulted to evaluate a patient, who may have never had a previous study. In that case, purely mechanical parameters can be used to assess bone strength as described earlier. A purely biomechanical patient assessment without consideration of biologic issues is short

RESPONSE TO NONSURGICAL TREATMENT

It is important for the consulting surgeon to consider that at least some, if not most, patients with metastatic disease will receive some relief of bone pain after the start of medical and radiation treatment. In the 1990s, a rapid increase in the understanding of metastatic processes and its therapy has occurred. Radiation is associated with partial pain relief in 83% of patients and complete relief in 53%.12 That radiation-induced pain relief can be short lived. Breast carcinoma metastases

PATIENT FACTORS

Parrish and Murray17 provided the following indications for prophylactic treatment: sufficient life expectancy, surgeon must be able to improve the patient's lifestyle over nonoperative management, adequate surrounding bone for fixation, and procedure must expedite mobilization or facilitate general care. These patient factors continue to be relevant in the care of patients with skeletal metastases today. The amount of remaining life expectancy is difficult to predict and in the modern era is

INDICATIONS FOR RESECTION AND SKELETAL RECONSTRUCTION VERSUS INTERNAL FIXATION OF SKELETAL METASTASES

The assessment of patients for prophylactic fixation before fracture has been discussed, and the treatment of various pathologic fractures based on anatomic location is covered in other articles in this issue. There are rare instances that resection of a skeletal metastasis with skeletal reconstruction is necessary, however. Patients with progressive bone destruction despite medical and radiation therapy are candidates for resection if their overall medical condition warrants aggressive

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    Address reprint requests to Bruce Rougraff, MD, Orthopaedics Indianapolis, 8450 Northwest Boulevard, Indianapolis, IN 46278

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