Review Article Surgical Management of Metastatic Long Fractures: Principles and Techniques

Abstract John Alan Scolaro, MD Management of metastatic long bone fractures requires identifica- Richard D. Lackman, MD, FACS tion of the lesion and the use of sound fracture fixation principles to relieve pain and restore function. The treating surgeon must under- stand the principles of pathologic fracture fixation before initiating treatment. Because these fractures occur in the context of a pro- gressive systemic disease, management typically involves a multi- disciplinary approach. When considering surgical stabilization of these fractures, the abnormal (or absent) healing environment as- sociated with diseased bone and the overall condition of the patient must be taken into account. The goal of is to obtain a rigid mechanical construct, which allows for early mobility and weight bearing. This can be achieved using internal fixation with poly- methyl methacrylate cement or segmental resection and joint re- construction. Prosthetic joint arthroplasty is a more reliable means of fracture management when insufficient bone is present for fixa- tion. Prophylactic stabilization of impending pathologic fractures can reduce the morbidity associated with metastatic lesions.

anagement of pathologic long site to provide the immediate and From the Department of Mbone fractures differs from lasting stability required for pain- Orthopaedic Surgery, University of that of fractures of disease-free bone. free use of the limb. California, Irvine, Irvine, CA (Dr. Scolaro), and the Bone and The primary surgical goal is restora- Management of a pathologic long Joint Institute, Cooper University tion of anatomic limb length, align- requires consideration Health Care, Camden, NJ ment, and rotation by creating a sta- of the patient’s overall medical con- (Dr. Lackman). ble construct that allows early dition as well as the acute injury. Dr. Lackman or an immediate family motion and weight bearing. Unlike Frequently, patients with these inju- member serves as a paid consultant tumor-free bone, pathologic frac- ries are being treated with chemo- to Stryker. Neither Dr. Scolaro nor any immediate family member has tures typically occur in the setting of or radiotherapy in the peri- received anything of value from or a progressive systemic disease that operative period, which affects the has stock or stock options held in a affects not only the injured bone, but body’s ability to respond to the phys- commercial company or institution related directly or indirectly to the also the patient’s ability to undergo iologic stress of a fracture, the proce- subject of this article. surgery. Pathologic fracture ends dure, and postoperative recovery. In may respond with very limited heal- all patients with pathologic long J Am Acad Orthop Surg 2014;22:90- 1 100 ing. Because diseased bone has a de- bone fractures, surgical stabilization ficient healing response, strategies should be considered regardless of http://dx.doi.org/10.5435/ JAAOS-22-02-90 are frequently used to improve fixa- life expectancy or prognosis. Patho- tion. For example, polymethyl meth- logic fractures of the humerus may Copyright 2014 by the American Academy of Orthopaedic Surgeons. acrylate (PMMA) cement frequently be amenable to nonsurgical manage- is used in and around the fracture ment in a patient with limited life ex-

90 Journal of the American Academy of Orthopaedic Surgeons John Alan Scolaro, MD, and Richard D. Lackman, MD, FACS pectancy; however, fractures in the sion cannot be assumed to be part of medical condition, identifying cer- lower extremity should be managed the same pathologic process. tain primary tumors, and excluding a to restore mobility and improve the Adams et al4 reported on complica- diagnosis of . A remaining quality of life. tions associated with misdiagnosis of complete blood count with differen- Identification and diagnosis of an an osseous lesion. Eight patients un- tial and a basic metabolic panel, in- osseous lesion is crucial for success- derwent internal fixation for a lesion cluding liver and renal function tests, ful management of a pathologic frac- that was assumed to be metastatic should be obtained. Specific tumor ture. Because care of patients with and was later found to be a primary markers can help to identify a meta- metastatic has improved over- . The authors concluded static process (eg, prostate specific all, the number of metastatic bone le- that misdiagnosis was the result of antigen in prostate cancer) or a spe- sions and pathologic fractures seen incomplete patient history and radio- cific disease (eg, monoclonal anti- by orthopaedic oncologists and gen- graphic evaluation as well as im- bodies in serum, urine immunoelec- eral orthopaedists has increased.2 Ini- proper surgical biopsy techniques trophoresis in multiple myeloma). tiation of treatment without first (including histopathologic interpre- The patient’s blood should be typed identifying the pathologic process tation). They also found that treat- and cross-matched for blood prod- can result in significant patient mor- ment modalities violated compart- ucts if a surgical procedure is antici- bidity.3,4 Proper identification of this mental boundaries. Therefore, a pated; the risk of bleeding may be process and care of the patient with planned surgical biopsy should be considerable in the setting of some a pathologic fracture often require a performed if the skeletal lesion does pathologic processes (eg, renal cell multidisciplinary team of healthcare not demonstrate clinical and radio- providers, including pathologists and carcinoma, multiple myeloma) and is graphic characteristics consistent somewhat unpredictable. radiologists familiar with orthopae- with the known tumor process. dic oncologic diagnoses and inter- Radiographic Evaluation ventional radiologists who can per- History and Physical form image-guided biopsies or Examination Orthogonal plain radiographs of the directed arterial embolizations. Radi- affected limb and the joint above and ation and medical oncologists coor- The first step in management of a below the area of interest and a plain dinate additional treatment regimens fracture through a metastatic lesion radiograph of the chest are obtained to address the primary disease pro- is recognition that a pathologic pro- to evaluate a pathologic lesion or cess and improve patient survival. cess exists in the setting of an acute fracture secondary to an unknown Care of these patients involves not fracture. Therefore, the use of an or- primary carcinoma. The orthopaedic only accurate diagnosis of the patho- ganized and systematic approach is surgeon must always consider that a logic process and surgical stabiliza- required when evaluating a patient lesion is present when evaluating the tion of the fracture, but also collabo- with a carcinoma of unknown origin initial radiograph of the fracture, es- 5,6 ration with a multidisciplinary team metastatic to bone. A complete his- pecially in the setting of abnormal of . tory and physical examination must bone. CT and positron emission to- be performed. When possible, the mography–CT of the chest, abdo- history should be obtained from the men, and pelvis are obtained for di- Diagnosis patient and should include a com- agnostic and staging purposes. CT of plete review of systems and relevant the area of interest can help to define Patient workup must be thorough family history, especially if the pri- whether the lesion is contained, with and appropriate for the clinical con- mary lesion is of unknown origin. intact cortical boundaries, or uncon- text. If a definitive diagnosis cannot The physical examination should fo- tained, extending outside bone and be made based on a thorough his- cus on the affected extremity as well into the surrounding soft tissues. Ad- tory, physical examination, labora- as identification of abnormalities vanced imaging modalities, such as tory tests, and radiographic evalua- such as regional lymphadenopathy bone scintigraphy, are used to iden- tion, a biopsy should be performed or nodules within the thyroid, pros- tify other skeletal lesions. Occasion- and a histologic diagnosis must be tate (in men), or breast (in women). ally, MRI can aid the evaluation of made before fracture fixation. In pa- the soft tissues surrounding a patho- tients who have a history of cancer Laboratory Studies logic fracture, but this is not routine (even previous metastatic bone dis- Basic laboratory studies are useful or necessary. The radiographic ease), a newly diagnosed osseous le- for evaluating the patient’s overall workup for each patient reflects the

February 2014, Vol 22, No 2 91 Surgical Management of Metastatic Long Bone Fractures: Principles and Techniques

Table 1 The literature supports the use of healing response cannot be expected. percutaneous biopsy techniques, al- Therefore, surgical management of Principles of Open Biopsy though not specifically in the setting pathologic fractures requires the use Incision of a fracture. Retrospective studies of fixation techniques and strategies Created in line with long axis of extrem- have reported that core needle biop- that account for the abnormal heal- ity and centered over the lesion sies performed in the office have an ing response. No larger than necessary 7-9 accuracy rate >80% Advantages of When plate and screw fixation is Planned carefully for later excision if percutaneous techniques include de- necessary performed, plates of appropriate size creased soft-tissue contamination, Tourniquet/Exsanguination and length must be selected and ap- minimal anesthesia requirement, and plied correctly. If joint reconstruction Can be used decreased procedural cost. In certain is performed, lesion resection must Compressive exsanguination before anatomic locations, such as the pel- tourniquet application is discouraged. be complete and arthroplasty com- vis and spine, CT- and ultrasound- Biopsy ponents must be sized to allow im- guided percutaneous biopsy can be Surgical dissection must be performed mediate mobility and decrease the used. The drawback of these proce- carefully. risk of periprosthetic fracture. When dures is that often only a small Dissection around neurovascular struc- appropriate, PMMA bone cement amount of tissue is obtained, which tures should be used to increase the stabil- can result in normal or nondiagnos- Dissection through multiple muscular ity imparted by the fixation con- compartments should be minimized. tic findings. Errors in diagnosis can struct. Diagnosis also be made if the tissue sample is Sufficient tissue should be obtained for heterogeneous or if the operator is Preoperative Planning a fresh-frozen section for diagnostic not sampling directly from the area purposes. of interest. Therefore, the decision to Preoperative planning is crucial for Relevant clinical information should be proceed with open or percutaneous surgical management of any fracture. provided to pathologists. Many patients who present with a Closure and Postoperative Care biopsy is dependent on the prefer- ence and practice of the surgeon as metastatic long bone fracture have Meticulous hemostasis well as the available institutional other medical issues that can compli- Layered tension-free closure staff and resources. Regardless of the cate a surgical procedure. Excessive A drain can be used but should exit in bleeding from a tumor, poor-quality line with incision. technique used, if the pathologist or surgeon is unsure whether lesional bone or soft-tissue envelope, altered tissue represents a sarcoma, fixation anatomy, spread of tumor, and the should be delayed until a definitive patient’s inability to tolerate a long individual clinical scenario and clar- diagnosis is made. period of anesthesia are some factors ity of diagnosis. that can alter a surgical procedure. Therefore, anticipation of these fac- Biopsy Management tors and creation of an alternate plan Tissue biopsy can be done at the or plans are essential. The primary time of fracture fixation or in a Most metastatic long bone fractures surgical plan and other potential sur- staged fashion using a percutaneous encountered by the orthopaedic sur- gical possibilities must be communi- or an open approach. Lesional tissue geon occur as a result of cated to all members of the multidis- is obtained to identify a carcinoma from carcinomas of the breast, lung, ciplinary team. of unknown primary origin, confirm and kidney or multiple myeloma. a suspected diagnosis, and rule out Most metastatic lesions caused by Plate and Screw Fixation sarcoma. For diagnosis of an osseous prostate cancer are blastic and rarely Management of a pathologic fracture lesion, the standard of care is ; lytic prostate metastases do with open reduction and internal fix- surgical biopsy, which can be per- occur and behave in a fashion similar ation (ORIF) permits curettage of the formed during a separate surgical to that of other lytic metastatic le- pathologic lesion and, if necessary, procedure or at the time of fracture sions. The surgeon must understand application of bone cement to im- fixation. If an open biopsy is per- that pathologic bone does not re- prove construct stability (Figure 1). formed, the principles of surgical bi- spond to conventional fixation con- The location of the fracture, quality opsy must be followed to minimize structs in the same manner as non- of the adjacent host bone, and size of complications (Table 1). pathologic bone, and a normal any remaining osseous defect after

92 Journal of the American Academy of Orthopaedic Surgeons John Alan Scolaro, MD, and Richard D. Lackman, MD, FACS lesion curettage or resection deter- Figure 1 Figure 2 mine whether a nonlocking or lock- ing plate is selected for fracture fixa- tion. Compared with nonlocking fixation, locking plates provide im- proved fixation in the setting of poor bone quality, and a locked fixed- angle construct decreases screw pull- out.10 Locking plates have been used successfully for fixation of specific fractures (eg, proximal humerus, dis- tal femur, distal radius), especially in the setting of poor (nonpathologic) bone stock, leading to an increased use of these devices in orthopaedic tumor surgery, particularly when in- tramedullary (IM) nail fixation is not appropriate. Several retrospective studies have reported on the use of locking plates for management of pathologic lesions and fractures; however, additional research is A, AP radiograph of the humerus needed to further define the indica- demonstrating a mid diaphyseal tions for the use of these devices.11-13 A, AP radiograph of the proximal pathologic fracture. B, Postopera- humerus demonstrating a tive AP radiograph of the humerus pathologic fracture with extension following fixation with a locked in- Intramedullary Nailing of metastases into the proximal tramedullary nail. Cement was not used because no gap was present IM nail fixation is a safe and effec- humeral shaft. B, Postoperative AP at the fracture site, and a near ana- tive method for treating patients radiograph of the proximal humerus following fracture fixation with a tomic reduction of the humeral with pathologic long bone fractures periarticular plate. Cement was shaft was achieved. or a risk of impending fracture.14 applied within the humeral head, Once the lesion has been identified, neck, and shaft. IM nailing can be performed with or ity.19 Currently, many segmental without the use of a supplemental prostheses are modular and can be open incision or cement. Unlike non- placing the affected extremity at risk assembled to fit the anatomy of each pathologic bone, cortical discontinu- for later peri-implant fracture. Dia- patient. These “tumor prostheses” ity present in pathologic bone after physeal humeral lesions that do not are used frequently in the hip, knee, IM nailing may never heal and may involve the proximal or distal articu- and shoulder joints. Occasionally, in- result in continued pain and disabil- lar segments of the bone are fre- tercalary prostheses are used in the 17 ity that often is improved with sup- quently managed with IM nailing humerus and femur when the proxi- plemental use of cement.15 Femoral (Figure 2). Tibial fractures with iso- mal and distal articular block is not nails can be placed antegrade or ret- lated lesions also can be managed involved in the pathologic process. rograde. With antegrade placement, with this technique, although the Frequently, these prostheses are im- proximal interlocking screws can be tibia is not affected by metastatic dis- planted using cement, which imparts used to obtain purchase into the fem- ease as often as the spine, femur, and immediate stability, and do not rely 18 oral neck and head, increasing proxi- humerus. on bony ingrowth. mal nail fixation. The use of a short Several factors must be considered nail that does not span the entire Megaprostheses when these implants are used. The length of the femur is not recom- Conventional or segmental prosthe- surrounding muscular attachments mended.16 Short IM nails leave un- ses often allow immediate weight are reattached or reapproximated to necessary stress risers and do not bearing in addition to immediate res- the prosthesis (eg, rotator cuff and protect the length of the long bone, toration of limb length and stabil- tuberosities, hip abductors/external

February 2014, Vol 22, No 2 93 Surgical Management of Metastatic Long Bone Fractures: Principles and Techniques rotators and greater trochanter). Figure 3 However, a deficit of functional strength or range of motion may oc- cur. In some scenarios, particularly following prosthetic hip/proximal femoral arthroplasty, joint stability can be compromised if there is signif- icant soft-tissue disruption, placing these patients at risk of dislocation. When possible, repair of the hip cap- sule and reattachment of the hip ab- ductors and hip external rotators should be performed to increase joint stability. As with any procedure, postoperative and revision surgery can result in notable patient morbidity.

Cement and Bone Graft The adjunctive use of PMMA cement for fixation of pathologic fractures is A, AP radiograph demonstrating a pathologic fracture of the proximal third of 20 the humerus managed with a locked intramedullary nail with no cement well established. This cement is placed within the lesion cavity. B, AP radiograph of the same fracture used to fill an osseous void after cu- demonstrating fixation failure at 3 months. The patient presented with rettage or resection of a pathologic intractable shoulder pain. C, Final AP radiograph of the humerus lesion; it provides immediate stabil- demonstrating revised fixation with a locked nail and cement. The patient reported resolution of pain and excellent function. ity to the fixation construct. Axial and rotational stability are improved with the addition of cement to a fix- The use of cement has been shown logic fractures.27 The use of orthobi- ation construct. One study showed to improve the pullout strength of ologics (eg, calcium phosphate, cal- that postoperative pain and function orthopaedic screws.24-26 This tech- cium sulfate) in patients with improved with the use of PMMA ce- nique can be used when bone quality metastatic long bone fractures has ment in fixation of pathologic frac- is suboptimal, especially around the not been studied; therefore, orthobi- tures.21 Cement can be used with fracture. For plate fixation, locking ologics currently do not have a role plate fixation or can be placed or nonlocking screws can be inserted in management of pathologic frac- around an IM nail to restore cortical through bone cement after the in- tures. continuity (Figure 3). In addition, tended screw path is carefully pre- antibiotics can be incorporated into drilled and tapped, if necessary. Ce- the PMMA cement for elution. How- ment augmentation of IM nail Fixation Strategies By ever, nothing in the literature sup- fixation requires that the nail and in- Fracture Site ports the prophylactic addition of terlocking screws be placed before antibiotics to bone cement used for any cement is used and allowed to Humerus fixation of pathologic fractures. In- set. Pathologic lesions occur frequently terestingly, the addition of cytotoxic Nonstructural cancellous allograft in the humerus. Some fractures, espe- tumor drugs to PMMA cement to bone has been used in fixation of cially those in the proximal humerus, decrease both the local recurrence pathologic fractures, but it provides are amenable to nonsurgical manage- and development of additional meta- little mechanical support to the fixa- ment if the fracture is incomplete or static lesions has been investi- tion construct and relies on bone minimally displaced. Most complete gated.22,23 Thus, in addition to its that has limited healing potential. or displaced fractures require surgi- structural properties, PMMA can be Free vascularized autograft has been cal intervention (Figure 4). For used, at least theoretically, as a drug used in complex limb reconstruction pathologic fractures of the proximal delivery vehicle. following failed fixation of patho- humerus, plate fixation28 or endo-

94 Journal of the American Academy of Orthopaedic Surgeons John Alan Scolaro, MD, and Richard D. Lackman, MD, FACS

Figure 4

Treatment algorithm for metastatic fractures of the humerus. IM = intramedullary, PMMA = polymethyl methacrylate prosthetic replacement29 is used, of pathologic fractures of the hu- such as cancer type, the patient’s life based on the extent of bone in- meral diaphysis is recommended for expectancy, fracture displacement, volved. If doubt exists regarding the fractures that occur in an area that and the anatomic region involved.33 reliability of fixation of the proximal begins 2 to 3 cm distal to the greater These fractures can be managed with segment (even with cement), a ce- tuberosity to 5 cm proximal to the many different methods, including mented prosthesis should be used. In olecranon fossa.17 Stable fixation can IM nailing, ORIF, and endopros- the setting of proximal or humeral be difficult to achieve in the distal as- thetic reconstruction (Figure 5). Ce- head fractures, attenuation of the ro- pect of the humerus because of the ment is frequently used in IM nailing tator cuff muscles often has oc- shape and quality of the bone.30 An and ORIF. Pathologic lesions in the curred; thus, surgical goals focus on increased rate of construct failure femoral head and neck have poor maintaining glenohumeral stability healing potential. Fracture fixation has been reported in the setting of a and providing pain relief. at this site is rarely indicated. Hip pathologic lesion. In this anatomic In fractures of the humeral diaphy- hemiarthroplasty or total hip arthro- area, IM nailing does not provide ad- sis, deforming forces are often tor- plasty is indicated, however. The use equate stability, and dual plate fixa- sional but can also be compressive if of femoral endoprostheses (often ce- tion with cement is often necessary. patients use crutches or assistive de- mented) is preferred if no acetabular In some cases, a total elbow prosthe- vices. These fractures can be ad- is present (Figure 6, A). dressed with antegrade or retrograde sis should be considered if fracture Uncemented total hip arthroplasty 31 IM nailing or ORIF and are fre- fixation is unreliable. components have been used in pa- quently augmented with cement. IM tients with metastatic disease of the nail placement can be performed us- Hip and Femur hip;34 however, this is not the senior ing an open or closed technique de- Pathologic proximal femoral frac- author’s (R.D.L.) preferred tech- pending on whether the pathologic tures cause substantial morbidity in nique. Intertrochanteric and subtro- bone will be addressed, cement will patients with skeletal metastases.32 chanteric fractures are subject to the be used, and the radial nerve will be Management of proximal femoral same deforming forces as nonpatho- identified and protected. IM nailing fractures is often based on factors logic bone, and management should

February 2014, Vol 22, No 2 95 ugclMngmn fMtsai ogBn rcue:Picpe n Techniques and Principles Fractures: Bone Long Metastatic of Management Surgical 96 Figure 5 ora fteAeia cdm fOtoadcSurgeons Orthopaedic of Academy American the of Journal

Treatment algorithm for metastatic fractures of the femur. IM = intramedullary, PMMA = polymethyl methacrylate John Alan Scolaro, MD, and Richard D. Lackman, MD, FACS be determined by the factors men- taphysis. Development of new tibial Figure 6 tioned previously. Fractures amena- nails that have more interlocking op- ble to fixation with an IM device of- tions has resulted in increased use of ten require fixation that extends to these nails for fractures of the distal the proximal femoral head and neck tibia. Locking plates designed specif- in addition to cement augmentation ically for the proximal and distal (Figure 6, B). Full-length IM nails are tibia can be used as an alternative to used to protect the entire femur and nail fixation. The tibial soft-tissue prevent creation of a stress riser. The envelope is not as robust as that of use of a long implant also protects the femur or humerus, especially at the anteromedial aspect of the tibia. against recurrent metastatic lesions Therefore, a surgical incision or and the effects of postoperative radi- placement of a surface implant, such ation, such as osteonecrosis and os- as a plate and screw device, in this teopenia. Recent literature has sug- location may not be as desirable as gested that the use of an the use of an IM implant. When endoprosthesis to manage proximal pathologic fracture fixation cannot femur fractures may yield better be performed in the distal tibia due long-term results than IM nailing or to intra-articular extension or bone 35-37 ORIF. loss, limb salvage versus amputation In fractures of the femoral diaphy- must be discussed with the patient. sis, axial weight bearing and rota- tional torque are the primary de- forming forces; fixation with an IM Management of Impending nail that spans the entire length of Fractures A, AP radiograph of the proximal the bone is typically preferred. For femur showing a femoral prosthesis fractures of the mid or distal femur, a used to manage a pathologic In patients with metastatic skeletal fracture. Note the reattachment of retrograde nail can be used, but in- lesions, surgical fixation is war- the greater trochanter to the sertion may violate the knee joint; ranted if there is a risk of fracture proximal aspect of the prosthesis. therefore, this option is often B, AP radiograph demonstrating through the affected area with physi- fixation of a pathologic fracture of avoided. For distal diaphyseal and ologic loading. The radiographic ap- the proximal femur using a metadiaphyseal fractures of the fe- pearance of the lesion and the pa- cephalomedullary nail and mur, lateral locking plate fixation tient’s symptoms help the polymethyl methacrylate cement. with lesion curettage and PMMA to decide whether prophylactic treat- augmentation provides reliable fixa- ment is necessary. Historically, the phylactic fixation before irradiation. tion. criteria for risk of fracture included This scoring system is best used as a cortical destruction >50% or abso- guide because a patient’s pain and Tibia lute lesion size >2.5 cm.38 disability frequently dictate the deci- Metastatic lesions to the tibia are Mirels39 developed a scoring sys- sion to manage a skeletal lesion with rare and should be treated using the tem using several factors to deter- prophylactic fixation. In the senior same principles as those for lesions mine whether a pathologic lesion re- author’s (R.D.L.) experience, me- of the humerus and femur. If the le- quires surgical stabilization or can be chanical pain requires close scrutiny sion involves a substantial portion of managed with radiotherapy (Table and is nearly always an indication of the proximal third of the tibia and 2). The scoring system is based on an impending fracture; the surgeon fracture fixation will not result in a the presence or absence of pain and should maintain a low threshold for reliable construct, a cemented seg- the size, location, and radiographic surgical fixation. mental endoprosthesis should be appearance of the lesion. Each vari- Prophylactic fixation of skeletal le- used18 (Figure 7). In many cases, an able is given a value between 1 and sions has been shown to relieve pain, anterograde interlocking tibial nail 3. The author concluded that lesions shorten overall length of hospitaliza- can be used to manage a fracture with a score ≤7 could be managed tion, and improve survival.40 Fixa- anywhere from the proximal meta- with irradiation alone, whereas le- tion of impending fractures is based diaphyseal region to the distal me- sions with a score ≥9 required pro- on the same principles as those used

February 2014, Vol 22, No 2 97 Surgical Management of Metastatic Long Bone Fractures: Principles and Techniques

Figure 7

Treatment algorithm for metastatic fractures of the tibia. IM = intramedullary, PMMA = polymethyl methacrylate

Table 2 vironment of the fracture site is al- tered in patients with metastatic frac- Fracture Risk Scoring System for Metastatic Lesions tures. The surgical fixation plan Score must involve meticulous care of the Variable 1 2 3 soft tissues (Table 1). PMMA bone cement can be used as an adjunct to Site Upper limb Lower limb Peritrochanteric enhance the stability of a fixation Pain Mild Moderate Functional construct in the setting of pathologic Lesion Blastic Mixed Lytic bone. When stable fixation cannot Size <1/3 1/3 to 2/3 >2/3 be achieved or notable periarticular Reproduced with permission from Mirels H: Metastatic disease in long : A proposed tumor involvement exists, joint ar- scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res 1989; throplasty prostheses can be used. 249:256-264. The overall care of cancer patients, including those with metastatic long bone fractures and/or impending for fixation of displaced pathologic potential benefits to the patient be- fractures has improved the success of fractures. When possible, bone ce- fore deciding to proceed with sur- surgical intervention and improved ment should be used to fill lesional gery. the survival of these patients.2 voids. Fixation constructs that allow immediate weight bearing and mobi- lization, without concern for further Summary References injury, should be used. Drawbacks of prophylactic fixation include the po- Management of metastatic long bone Evidence-based : Levels of tential risk of perioperative and post- fractures requires an accurate diag- evidence are described in the table of operative medical and surgical com- nosis of the lesion before fixation is contents. In this article, references 5, plications. Ultimately, the surgeon performed. The orthopaedic surgeon 7, and 9 are level II studies. References must weigh these factors against the must understand that the healing en- 8, 13, 15, and 35-37 are level III

98 Journal of the American Academy of Orthopaedic Surgeons John Alan Scolaro, MD, and Richard D. Lackman, MD, FACS studies. References 1, 3, 4, 11, 12, 14, oncological reconstruction. Arch Orthop methacrylate cement. J Bone Joint Surg 17, 19-21, 27, 28, 30, 31, 34, and 38 Trauma Surg 2010;130(12):1493-1497. Br 1994;76(2):320-323. are level IV studies. Reference 6 is 13. Gregory JJ, Ockendon M, Cribb GL, 26. Wittenberg RH, Lee KS, Shea M, White Cool PW, Williams DH: The outcome of AA III, Hayes WC: Effect of screw level V expert opinion. locking plate fixation for the treatment diameter, insertion technique, and bone References printed in bold type are of periarticular metastases. Acta Orthop cement augmentation of pedicular screw Belg 2011;77(3):362-370. fixation strength. Clin Orthop Relat Res those published within the past 5 1993;296:278-287. years. 14. Sarahrudi K, Greitbauer M, Platzer P, Hausmann JT, Heinz T, Vécsei V: 27. Friedrich JB, Moran SL, Bishop AT, Surgical treatment of metastatic fractures Wood CM, Shin AY: Free vascularized 1. Gainor BJ, Buchert P: Fracture healing in of the femur: A retrospective analysis of fibular graft salvage of complications of metastatic bone disease. Clin Orthop 142 patients. J Trauma 2009;66(4): long-bone allograft after tumor Relat Res 1983;178:297-302. 1158-1163. reconstruction. J Bone Joint Surg Am 2008;90(1):93-100. 2. Harrington KD: Orthopedic surgical 15. Laitinen M, Nieminen J, Pakarinen TK: management of skeletal complications of Treatment of pathological humerus shaft 28. Sarahrudi K, Wolf H, Funovics P, malignancy. Cancer 1997;80(8 suppl): fractures with intramedullary nails with Pajenda G, Hausmann JT, Vécsei V: 1614-1627. or without cement fixation. Arch Orthop Surgical treatment of pathological Trauma Surg 2011;131(4):503-508. fractures of the shaft of the humerus. 3. Spence GM, Dunning MT, Cannon SR, J Trauma 2009;66(3):789-794. Briggs TW: The hazard of retrograde 16. Haidukewych GJ: Metastatic disease nailing in pathological fractures: Three around the hip: Maintaining quality of 29. Piccioli A, Maccauro G, Rossi B, cases involving primary musculoskeletal life. J Bone Joint Surg Br 2012;94(11 Scaramuzzo L, Frenos F, Capanna R: malignancy. Injury 2002;33(6):533-538. suppl A):22-25. Surgical treatment of pathologic fractures of humerus. Injury 2010; 4. Adams SC, Potter BK, Mahmood Z, 17. Redmond BJ, Biermann JS, Blasier RB: 41(11):1112-1116. Pitcher JD, Temple HT: Consequences Interlocking intramedullary nailing of and prevention of inadvertent internal pathological fractures of the shaft of the 30. Wedin R, Hansen BH, Laitinen M, et al: fixation of primary osseous sarcomas. humerus. J Bone Joint Surg Am 1996; Complications and survival after surgical Clin Orthop Relat Res 2009;467(2):519- 78(6):891-896. treatment of 214 metastatic lesions of 525. the humerus. J Shoulder Elbow Surg 18. Kelly CM, Wilkins RM, Eckardt JJ, 2012;21(8):1049-1055. 5. Rougraff BT, Kneisl JS, Simon MA: Ward WG: Treatment of metastatic Skeletal metastases of unknown origin: A disease of the tibia. Clin Orthop Relat 31. Athwal GS, Chin PY, Adams RA, prospective study of a diagnostic Res 2003;(415 suppl):S219-S229. Morrey BF: Coonrad-Morrey total strategy. J Bone Joint Surg Am 1993; elbow arthroplasty for tumours of the 75(9):1276-1281. 19. Lane JM, Sculco TP, Zolan S: Treatment distal humerus and elbow. J Bone Joint of pathological fractures of the hip by Surg Br 2005;87(10):1369-1374. 6. Rougraff BT: Evaluation of the patient endoprosthetic replacement. J Bone Joint with carcinoma of unknown origin Surg Am 1980;62(6):954-959. 32. Swanson KC, Pritchard DJ, Sim FH: metastatic to bone. Clin Orthop Relat Surgical treatment of metastatic disease Res 2003;(415 suppl):S105-S109. 20. Harrington KD, Johnston JO, Turner of the femur. J Am Acad Orthop Surg RH, Green DL: The use of 2000;8(1):56-65. 7. Adams SC, Potter BK, Pitcher DJ, methylmethacrylate as an adjunct in the Temple HT: Office-based core needle internal fixation of malignant neoplastic 33. Steensma M, Healey JH: Trends in the biopsy of bone and soft tissue fractures. J Bone Joint Surg Am 1972; surgical treatment of pathologic malignancies: An accurate alternative to 54(8):1665-1676. proximal femur fractures among open biopsy with infrequent Musculoskeletal Tumor Society complications. Clin Orthop Relat Res 21. Weiss KR, Bhumbra R, Biau DJ, et al: members. Clin Orthop Relat Res 2013; 2010;468(10):2774-2780. Fixation of pathological humeral 471(6):2000-2006. fractures by the cemented plate 8. Mitsuyoshi G, Naito N, Kawai A, et al: technique. J Bone Joint Surg Br 2011; 34. Thein R, Herman A, Chechik A, Accurate diagnosis of musculoskeletal 93(8):1093-1097. Liberman B: Uncemented arthroplasty lesions by core needle biopsy. J Surg for metastatic disease of the hip: Oncol 2006;94(1):21-27. 22. Wasserlauf S, Warshawsky A, Arad-Yelin Preliminary clinical experience. R, Mazur Y, Salama R, Dekel S: The J Arthroplasty 2012;27(9):1658-1662. 9. Skrzynski MC, Biermann JS, Montag A, release of cytotoxic drugs from acrylic Simon MA: Diagnostic accuracy and bone cement. Bull Hosp Jt Dis 1993; 35. Steensma M, Boland PJ, Morris CD, charge-savings of outpatient core needle 53(1):68-74. Athanasian E, Healey JH: biopsy compared with open biopsy of Endoprosthetic treatment is more musculoskeletal tumors. J Bone Joint 23. Wang HM, Galasko CS, Crank S, Oliver durable for pathologic proximal femur Surg Am 1996;78(5):644-649. G, Ward CA: Methotrexate loaded fractures. Clin Orthop Relat Res 2012; acrylic cement in the management of 470(3):920-926. 10. Tejwani NC, Guerado E: Improving skeletal metastases: Biomechanical, fixation of the osteoporotic fracture: The biological, and systemic effect. Clin 36. Harvey N, Ahlmann ER, Allison DC, role of locked plating. J Orthop Trauma Orthop Relat Res 1995;312:173-186. Wang L, Menendez LR: Endoprostheses 2011;25(suppl 2):S56-S60. last longer than intramedullary devices in 24. Cameron HU, Jacob R, Macnab I, Pilliar proximal femur metastases. Clin Orthop 11. Virkus WW, Miller BJ, Chye PC, Gitelis RM: Use of polymethylmethacrylate to Relat Res 2012;470(3):684-691. S: The use of locking plates in orthopedic enhance screw fixation in bone. J Bone reconstructions. Orthopedics Joint Surg Am 1975;57(5):655-656. 37. Wedin R, Bauer HC: Surgical treatment 2008;31(5):438. of skeletal metastatic lesions of the 25. Motzkin NE, Chao EY, An KN, proximal femur: Endoprosthesis or 12. Rastogi S, Kumar A, Khan SA: Do Wikenheiser MA, Lewallen DG: Pull-out reconstruction nail? J Bone Joint Surg Br locking plates have a role in orthopaedic strength of screws from polymethyl- 2005;87(12):1653-1657.

February 2014, Vol 22, No 2 99 Surgical Management of Metastatic Long Bone Fractures: Principles and Techniques

38. Beals RK, Lawton GD, Snell WE: 39. Mirels H: Metastatic disease in long 40. Ristevski B, Jenkinson RJ, Stephen DJ, Prophylactic internal fixation of the bones: A proposed scoring system for et al: Mortality and complications femur in . Cancer diagnosing impending pathologic following stabilization of femoral 1971;28(5):1350-1354. fractures. Clin Orthop Relat Res 1989; metastatic lesions: A population-based 249:256-264. study of regional variation and outcome. Can J Surg 2009;52(4):302-308.

100 Journal of the American Academy of Orthopaedic Surgeons