INDICATIONS FOR OPERATIVE TREATMENT
Section snippets
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
References (25)
- et al.
Effects of oral clodronate on bone mineral density in patients with relapsing breast cancer
Bone
(1996) - et al.
Progression delay of prostate tumor skeletal metastasis effects by bisphosphonates
J Urol
(1992) - et al.
Prognostic factors and surgical treatment of osseous metastases secondary to renal cell carcinoma
Cancer
(1997) - et al.
Metastatic disease of the hip: Evaluation and treatment
J Am Acad Orthop Surg
(1997) - et al.
Metastatic bone disease: Evaluation, prognosis, and medical treatment considerations of metastatic bone tumors
Orthopedics
(1992) - et al.
Bone strength: The effect of screw holes
J Bone Joint Surg Am
(1972) Skeletal complications of malignancy
Cancer
(1997)- et al.
Reduction in new metastases in breast cancer with adjuvant clodronate treatment
N Engl J Med
(1998) Incidence of fracture through metastases in long bones
Acta Orthop Scand
(1981)- et al.
Pamidronate: A review of its pharmacological properties and therapeutic efficacy in resorptive bone disease
Drugs
(1991)
Orthopaedic Biomechanics
Orthopaedic management of extremity and pelvic lesions
Clin Orthop
Cited by (22)
Surgical treatment of pathologic fractures of humerus
2010, InjuryCitation Excerpt :An impending or actual pathologic humeral fracture may impair the day to day activities of living and may influence the patient's quality of remaining life.1,9,23 Non-operative management rarely provides complete pain relief or return of arm function, thus, surgery is now recommended for intractable pain and impending or established pathologic fractures.3,9,22 Surgical intervention aims to achieve local tumour control, durable stability, immediate reduction of pain, and acceptable function of the affected extremity as quickly as possible, minimizing the morbidity associated with the operative procedure and the hospitalisation.9,10,12
Management of Symptomatic Bone Metastases
2006, Cancer Pain: Pharmacological, Interventional, and Palliative Care ApproachesManagement of Symptomatic Bone Metastases
2006, Cancer PainProximal humerus fractures treatment in adult patients with bone metastasis
2022, European Review for Medical and Pharmacological SciencesSurgical treatment of pathological fractures occurring at the proximal femur
2015, Yonsei Medical Journal
Address reprint requests to Bruce Rougraff, MD, Orthopaedics Indianapolis, 8450 Northwest Boulevard, Indianapolis, IN 46278
- *
Orthopaedics Indianapolis, Indianapolis, Indiana