Review Article Surgical Management of Metastatic Long Bone 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 surgery 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- bone fracture 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 therapy 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 multiple myeloma. 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 cancer has improved over- bone tumor. 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 physicians. 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