<b>SURGICAL INTERVENTION -- LONG BONES</b>

The chance of developing a fracture increases with the duration and extent of tumor growth in the bone. The development of a fracture is devastating. It is vital that patients are routinely assessed by a specialist orthopedic and/or spinal surgeon to advise on preventive surgery. <b>"A pathological long-bone fracture in a patient with known metastatic bone disease is really a reflection of inadequate clinical management."[5] Orthopedic management should enable intervention prior to fracture, enabling a simpler and safer operation.</b>

"Fractures are common through lytic metastases and weight bearing bones, the proximal femora being the most commonly affected sites... Although controversial, <b>several radiological features have been identified which may predict imminent fracture. These include pain, the anatomical site of a lesion, its radiological characteristics, and its size. Although the intensity of bone pain is not directly associated with fracture risk, pain that is exacerbated by movement does appear to be an important factor, which predicts impending fracture. Radiographic assessment gives information on the size of a lesion and the extent to which the bone is destroyed. When less than one-third of the diameter of a long bone is affected, pathological fracture is relatively unusual, but above this amount and especially when more than 50% of the cortex is destroyed, the fracture rate increases markedly to approximately 80%. </b>A practical scoring system incorporating the above factors has been described to give valuable guidance in the selection of patients for prophylactic fixation."  [8]


Prior to surgery, bone isotope scans, Xrays of the entire affected bone, and possibly also MRI scans of the area, should be done.  Other bony lesions will be seen, stabilized, and included in the field of irradiation.  A pathologic fracture from a second metastasis at the edge of a plate or nail fixation of the first metastasis, is much more difficult to treat.  "Providing the lesion is irradiated, there is no evidence to suggest that surgery increases the risk of disseminating tumor cells either locally or into the circulation. If the patient is not fit for surgery, then radiotherapy and nonweight-bearing is indicated." [5]
 

A fracture because of a bony metastasis [pathologic fracture] does not necessarily mean the patient is terminally ill.  <b>But untreated pathologic fractures rarely heal: large areas of bone destruction may not leave enough tissue for repair, and radiotherapy also inhibits fracture healing.  So primary internal stabilization followed by radiotherapy is usually the treatment of choice, and the most likely path to restore mobility as well as relieve pain. [5.87]</b>

"Coincident with improved overall cancer palliation during the past 2 decades has been an increasing incidence of clinically apparent bone metastases, and from these metastases subsequent pathologic fractures of the long bones, spine, and pelvis. Current techniques for surgical management of these fractures are extremely effective in alleviating pain and allowing patients to resume an ambulatory status, often without the need of external support. This, in turn, has significantly improved the quality of the remaining months or years of these individuals' lives. In fact, the long term survival of patients after their first long bone pathologic fracture from malignancy has more than tripled for the most common cancers (breast carcinoma, prostate carcinoma, lymphomas, and myelomas) during the past 25 years. Surgical techniques for stabilizing pathologic or impending fractures must be individualized for the area of involvement, the particular qualities of the bone involved, and the potential for involvement of adjacent soft tissue structures. Long bone fractures most commonly occur in the femur and humerus and are typically internally fixed by intramedullary devices that control impaction, distraction, and torquing stresses by the use of proximal and distal interlocking fixation. Such fixation must be able to withstand weight-bearing stresses on lower extremity long bones. Upper extremity pathologic fractures are often subjected to distractive forces inherent in lifting and pulling, but they are also subjected to heavy compressive forces, particularly in patients who require crutches or other devices to assist them in walking. Fixation of upper or lower extremity long bone fractures ordinarily may be accomplished with minimal blood loss or morbidity. In contrast, fractures or impending fractures involving the acetabulum necessitate extensive joint reconstruction, with inherent increased potential for morbidity and complications. For this reason, the anticipated prognosis for survival and mobility should be greater preoperatively for patients with acetabular fractures than for patients with fractures of either upper or lower extremity long bones. ... Ninety-six percent of patients experience good or excellent relief of pain after internal fixation of pathologic malignant long bone fractures. Eighty-four percent of patients with acetabular fractures experience good or excellent relief of pain after joint reconstruction. ... Patients with pathologic fractures from metastatic carcinoma of the breast had a mean survival of 24.6 months after surgical management of their fractures. There was a similarly encouraging improvement in the survival statistics for patients with other primary tumor types. Most malignant pathologic fractures of the pelvis, long bones, or spine are amenable to effective stabilization by the techniques described in this article. These techniques allow resumption of weight-bearing ambulation in all but a few patients, good or excellent relief of pain in the vast majority, and an enhanced anticipation of survival and improvement in quality of life." [87] 

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