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Pathologic Fractures H.T. Temple, MD Walter W. Virkus, MD Created March 2004; Revised December 2005, October 2008.

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Presentation on theme: "Pathologic Fractures H.T. Temple, MD Walter W. Virkus, MD Created March 2004; Revised December 2005, October 2008."— Presentation transcript:

1 Pathologic Fractures H.T. Temple, MD Walter W. Virkus, MD Created March 2004; Revised December 2005, October 2008

2 Pathologic Fractures Tumors –primary –secondary (metastatic) (most common) Metabolic –osteoporosis (most common) –Paget’s disease –hyperparathyroidism

3 Pathologic Fractures Benign Tumors Fractures more common in benign tumors (vs malignant tumors) –most asymptomatic prior to fracture –antecedent nocturnal/rest symptoms rare –most common in children humerus femur –unicameral bone cyst, NOF, fibrous dysplasia, eosinophilic granuloma

4 Unicameral Bone Cyst Fractures observed more often in males than females May be active or latent Almost always solitary First two decades Humerus and femur most common sites Fracture through UBC “fallen fragment”sign (arrow) Fractures through benign tumors

5 Unicameral Bone Cyst Treatment - impending fractures –observation –aspiration and injection methylprednisolone, bone marrow or bone graft –curetting and bone graft (+/-) internal fixation Treatment - fractures –allow fracture to heal and reassess –ORIF for femoral neck fractures

6 Fibroxanthoma Most common benign tumor Femur, distal tibia, humerus Multiple in 8% of patients (associated with neurofibromatosis) Increased risk of pathologic fracture in lesions >50% diameter of bone and >22mm length

7 Fibroxanthoma Treatment –observation –curetting and bone graft for impending fractures –immobilization and reassess after healing for patients with fracture

8 Fibrous Dysplasia Solitary vs. multifocal (solitary most common) Femur and humerus First and second decades May be associated with café au lait spots and endocrinopathy (Albright’s syndrome)

9 Fibrous Dysplasia Treatment –observation –curetting and bone graft (cortical structural allograft) to prevent deformity and fracture (+/-) internal fixation –expect resorption of graft and recurrence –pharmacologic—bisphosphonates

10 Pathologic Fractures through Primary Malignant Tumors Relatively rare (often unsuspected) May occur prior to or during treatment May occur later in patients with radiation osteonecrosis (Ewing’s, lymphoma) Osteosarcoma, Ewing’s, malignant fibrous histiocytoma, fibrosarcoma

11 Pathologic Fractures Primary Malignant Tumors Suspect primary tumor in younger patients with aggressive appearing lesions –poorly defined margins (wide zone of transition, lack of sclerotic rim) –matrix production –periosteal reaction Patients usually have antecedent pain before fracture, especially night pain

12 Pathologic Fractures Primary Malignant Tumors Pathologic fracture complicates but does not mitigate against limb salvage Local recurrence is higher Survival is not compromised Patients with fractures and underlying suspicious lesions or history should be referred for biopsy

13 A B A.Pathologic fracture through MFH arising in antecedent infarct B.(H&E 100x) Pleomorphic spindled cells with storiform growth pattern

14 Pathologic Fractures Primary Malignant Tumors Always biopsy solitary destructive bone lesions even with a history of primary carcinoma Case: A 62 year-old woman with a history of breast carcinoma presented with a pathologic fracture through a solitary proximal femoral lesion

15 Pre-op Post- Intermediate grade chondrosarcoma *fixation of primary bone tumors must not be performed until proper evaluation has been performed and the diagnosis has been established in order to prevent potential for spread of tumor.

16 Pathologic Fractures Primary Malignant Tumors Treatment –Immobilization Traction, ex fix, cast –staging –biopsy –adjuvant treatment (chemotherapy) –resection/amputation

17 Metabolic Bone Disease Osteoporosis –insufficiency fractures Paget’s disease –early and late stages; most fractures occur in the late stage of disease Hyperparathyroidism –dissecting osteitis –fractures through Brown tumors Fractures through non-neoplastic bone disease

18 Paget’s Disease Radiographic appearance –Thickened cortices –Purposeful trabeculae –Mixed sclerosis/lysis –Bowing deformities –Joint arthrosis Fracture –delayed healing –malignant transformation Treatment –Osteotomy to correct alignment –Excessive bleeding –Joint arthroplasty vs. ORIF Fracture through Pagetic bone (arrow). Transverse fracture suggests pathologic bone.

19 Hyperparathyroidism Adenoma Polyostotic disease Mental status changes Abdominal pain Nephrolithiasis Polyostotic disease –mixed radiolucent/radiodense Mixed radiodense and radiolucent lesions Multiple brown tumors in a patient with primary hyperparathyroidism

20 Hyperparathyroidism May be secondary to renal failure –secondary –tertiary Treatment –parathyroid adenectomy –ORIF for fracture –correct calcium Pathologic fracture through brown tumor (arrow)

21 Fractures in Patients with Metastatic Disease and Myeloma Aside from osteoporosis, most common causes of pathologic fracture Fifth decade and beyond Appendicular sites: femur and humerus most common All metastatic tumors are not treated the same

22 Not All Mets Created Equal Breast – radiosensitive, chemosensitive Lung – moderately radiosensitive, chemo sensitivity variable Prostate – radiosentive, chemosensitive Thyroid – radiosensitive, chemosensitive Renal – minimally radiosensitive, variable chemosensitivity

23 Overall Incidence of Metastases to Bone at Autopsy 70%Jaffe, %Clain, %Johnson, %Dominok, 1982

24 Incidence of Metastases at Autopsy by Primary Tumor Site Primary Site % metastasis to Bone Breast50-85 Lung30-50 Prostate50-70 Hodgkin’s50-70 Kidney30-50 Thyroid 40 Melanoma Bladder 12-25

25 Incidence of Metastases 60% of patients with early identified cancer may already have metastases 10-15% of all patients with primary carcinoma will have radiologic evidence of bone metastases during course of disease

26 Route of Metastases Contiguous Hematogenous –most common Destructive lesions in bone from lung carcinoma (arrows)

27 Mechanism of Metastases Release of cells from the primary tumor Invasion of efferent lymphatic or vascular channels Dissemination of cells Endothelial attachment and invasion at distant site Angiogenesis and tumor growth at distant site Metastatic carcinoma In body pedicle junction

28 Bone Destruction Early –most important –osteoclast mediated –(RANK L) Late –malignant cells may be directly responsible

29 Metastases of Unknown Origin 3-4% of all carcinomas have no known primary site 10-15% of these patients have bone metastases

30 Diagnostic Strategy for Patients with Unknown Primary % Primary Tumor Identified History and Physical8% Chest X-Ray43% Chest CT15% Abdominal CT13% Biopsy8% Rougraff, 1993

31 Defects Cortical defects weaken bone especially in torsion Two types –stress riser - smaller than the diameter of bone –open section defect - larger than the diameter of bone…. causes a 90% reduction in load to failure and demand augmentation and fixation

32 Impending Pathologic Fracture 61% of all pathologic fractures occur in the femur 80% are peritrochanteric fracture in this area results in significant morbidity historic data on impending pathologic fracture involves the proximal femur

33 Impending Pathologic Fracture Parrish and Murray, 1970 –increasing pain with advancing cortical destruction of lesions involving >50% of the shaft diameter Beals, 1971 –lesions >2.5 cm are at increased risk to fracture Murray, 1974 –increased fracture with destruction of > one- third of the cortex, pain after radiotherapy

34 Impending Pathologic Fracture Fidler, 1981 % shaft destroyed Incidence Fx (%) 0-25%0% 25-50%3.7% 50-75%61% >75%79% Conclusion: Patients with tumors destroying >50% of the diameter of bone require prophylactic internal fixation

35 Indication for Prophylactic Internal Fixation “Harrington criteria” –>50% of diameter of bone –>2.5 cm –pain after radiation –fracture of the lesser trochanter Limitations –only for proximal femur –doesn’t account for tumor biology Harrington, K.D.: Clin. Orthop. 192: 222, 1985

36 Mirels Scoring System Score Site upper limblower limbperitrochanteric Pain mildmoderatefunctional Lesion blastic mixed lytic Size 2/3 Score < 7 – no surgery Score > 7 – prophylactic fixation Mirels, H.: Clin. Orthop. 249: 256, 1989.

37 Adjuvant Treatment Radiation –Radiation alone Complete pain relief in 50% Partial pain relief in 35% Radiofrequency ablation Chemotherapy Hormone treatment Bisphosphonates

38 Adjuvant Treatment Radiation –Radiation alone Complete pain relief in 50% Partial pain relief in 35% Radiofrequency ablation Chemotherapy Hormone treatment Bisphosphonates

39 Radiation Therapy Overall 85% response rate Median duration of pain relief weeks Tumor necrosis followed by collagen proliferation, woven bone formation, and replacement by lamellar bone Recalcification by 2-3 months More than half respond within 1-2 weeks Various dose and fractionization schedules

40 Radiation Therapy Townsend, et al., Journal of Clinical Oncology, 1994 –64 surgical stabilization procedures, 35 with post-op radiation, 29 with no radiation –Functional use of extremity, avoidance of revision surgery, and survival time increased in radiation group

41 Radiotherapy Pre XRT Prostate CA Post XRT Prostate CA

42 Bisphosphonates “Long-term prevention of skeletal complications of metastatic breast cancer with pamidronate: Protocol 19 Aredia Breast Cancer Study Group” Hortobagyi, et al. Journal of Clinical Oncology, 1998 “Zoledronic acid reduces skeletal-related events in patients with osteolytic metastases” Berenson, et al. Cancer 2001

43 Treatment Objectives in Metastatic Disease Decrease pain Restore function Maintain/restore mobility Limit surgical procedures Minimize hospital time Early return to function (immediate weightbearing)

44 Pathologic Fracture Survival 75% of patients with a pathologic fracture will be alive after one year the average survival is ~ 21 months

45 Survival Time Poor prognostic factors –Presentation with metastatic disease –Short time from initial diagnosis to first met –Visceral mets –Non-small cell lung cancer 6 mos %1 yr %3 yrs % Breast Prostate Lung50223 Renal51 40

46 Healing of Path Fractures Healing rate of pathologic fractures –Myeloma- 67% –Renal- 44% –Breast- 37% –Lung- 0%

47 Fracture Healing 129 patients overall rate = 35% 74% for patients surviving > 6 months radiotherapy <30 GY did not adversely affect fracture healing Gainor, B.J.: CORR 178: 297, 1983

48 Pathologic Fracture Treatment Biopsy especially for solitary lesions Nails versus plates versus arthroplasty –plates, screws and cement superior for torsional loads –interlocked nails stabilize entire bone Cement augmentation Radiation/chemotherapy/bisphosphonates Aggressive rehabilitation

49 Indications for Surgical Treatment Ratio of survival time to surgical recovery time Ability to ambulate Ability to use extremity Capacity to return to full function Pain not controlled by analgesics Location of disease – high risk area

50 Indications for ORIF/IMN Diaphyseal lesion Good bone stock Histology sensitive to chemo/radiation Impending fractures Poor prosthetic options

51 Indications For Replacement Periarticular disease Fracture after radiation Failed fixation Renal cell ca

52 Pathologic Fracture Treatment Periarticular fractures, especially around the hip are more appropriately treated with arthroplasty Periacetabular fractures –protrusio shell, cement, arthroplasty –saddle prosthesis –Structural allograft-prosthesis composite

53 Cement PMMA no PMMA Pain relief97%83% Ambulation95%75% Fixation failure 2 cases6 cases Haberman, E.T: CORR, 169: 70, 1982

54 Resection for Pathologic and Impending Pathologic Fractures Radiation and chemotherapy resistant tumors –renal –thyroid –melanoma –occasionally lung Solitary metastases (controversial)

55 pre-op post-op Renal Cell Carcinoma *pre operative embolization of renal cell mets should be done

56 Pre-op renal cell carcinoma Post-op renal cell carcinoma

57 Solitary renal cell carcinoma Permeative lysis Soft tissue mass

58 Post-op intercalary allograft

59 Renal Cell Kollender, et al., Journal of Urology, 2000 –45 lesions treated with wide or marginal resection –91% with pain relief, 89% with good/excellent functional outcome Les, et al., CORR, 2001 –41 renal cell patients treated with intralesional excision, 37 treated with marginal or wide resection –Re-operation recommended for 41% in group I, 3% in Group II –Median survival 20 months in group I, 35 months in group II

60 Renal Cell Wedin, et al., CORR 1999 –228 metastatic lesions treated with endoprosthetic or osteosynthesis –24% failure rate in renal cell lesions –20% failure rate in diaphyseal and distal femur lesions –14% failure rate for osteosynthesis, 2% for endoprosthesis

61 Complications Infection –malnutrition –hematomyelopoetic suppression Hemorrhage –vascular tumors ( renal and thyroid) Tumor recurrence Failure of fixation Thromboembolic disease

62 Embolization Hypervascular tumors –Renal cell carcinoma –Thyroid carcinoma –Pheochomocytoma

63 Post embolization Pre embolization Pre-operative embolization can prevent hemorrhage with intra-lesional surgery

64 Summary Diagnosis and treatment requires a multidisciplinary approach Aggressive surgical treatment relieves pain, restores function, and facilitates nursing care Biopsy all solitary lesions or refer appropriately Understand tumor biology and tailor treatment

65 References Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop 1989; 249:256 Gainor BJ, Buchert P. Fracture healing in metastatic bone disease Clin Orthop 1983; 176: Eckardt JJ, Endoprosthetic reconstructions for bone metastases. Clin Orthop 2003; 415:S

66 References Ward WG, Metastatic disease of the femur: surgical treatment. Clin Orthop 2003; 415:S Kelly CM, Treatment of metastatic disease of the tibia. Clin Orthop 2003; S van der Linden YM, Simple radiographic parameter predicts fracturing in metastatic femoral bone lesions:results from a randomized trial. Radiotherapy and Oncology 2003; 69: 21-31

67 References Singletary SE, A role for curative surgery in the treatment of selected patients with metastatic breast cancer. Oncologist 2003; Wedin R. Surgical treatment for pathologic fracture. Acta Orthopaedica Scandinavica 2001; 72: 1-29

68 Thank You OTA about Questions/Comments Return to General/Principles Index If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an to

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