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In the Name of GodIn the Name of God
Dr. A. BorjianDr. A. Borjian
Isfahan University of Isfahan University of Medical ScienceMedical Science
Pathologic fracturePathologic fracture
Benign tumorsBenign tumors
Malignant primary tumorsMalignant primary tumors
Mtastatic tumors Mtastatic tumors
Pathologic Fx:Pathologic Fx:
A pathologic Fx is defined, Fx occur in Abnormal BoneA pathologic Fx is defined, Fx occur in Abnormal Bone
Bone lack of normal biomechanical and viscoelastic Bone lack of normal biomechanical and viscoelastic
propertiesproperties
Weakened bone predispose the patient to failure in Weakened bone predispose the patient to failure in
normal activity or after minor trauma.normal activity or after minor trauma.
Pathologic fracture Pathologic fracture (Incidence)(Incidence)::
Osteoprosis most common condition Osteoprosis most common condition associated with pathologic Fxassociated with pathologic Fx
10 million American>50 have osteoprosis10 million American>50 have osteoprosis 34 million have osteomalacia and at risk 34 million have osteomalacia and at risk
devalping osteoporosisdevalping osteoporosis 1.5 million sustain P. Fx related to 1.5 million sustain P. Fx related to
osteoprosis eah yearosteoprosis eah year
Classification:Classification:
Intrinsic: Intrinsic: Osteopenia of osteogensis imperfect Osteopenia of osteogensis imperfect & Replacement of Bone with tumor& Replacement of Bone with tumor
Extrinsic: Lessen the inherent structural integrity Extrinsic: Lessen the inherent structural integrity of bone of bone Radiation or hole in bone Radiation or hole in bone
Localize Localize Bone cyst Bone cyst Generalize Generalize Osteopetrosis Osteopetrosis Correctable Correctable Rickets Rickets Un correctable Un correctable Metastatic cancer Metastatic cancer In normal bone In normal bone Vascular foramina Vascular foramina
Classification:Classification:
A: Correctable disease:A: Correctable disease: Renal osteodystrophyRenal osteodystrophy Hyper parathyroidismHyper parathyroidism OsteomalaciaOsteomalacia Disuse osteoprosisDisuse osteoprosis
Classification:Classification:
B: Uncorrectable disease:B: Uncorrectable disease: Osteogesis imperfectaOsteogesis imperfecta Polyostatic fibrous dysplasiaPolyostatic fibrous dysplasia Postmonoposal osteoprosisPostmonoposal osteoprosis Paget diseasePaget disease Osteo petrosisOsteo petrosis
Pathologic fracture:Pathologic fracture:
Fx callus may not form normally Fx callus may not form normally
healing slowlyhealing slowly
Increase incidence of nonunion & delay Increase incidence of nonunion & delay
unionunion
Diagnoses has been made on clinical Diagnoses has been made on clinical findingfinding HistoryHistory Physical examinationPhysical examination XrayXray Laboratory findingLaboratory finding Often the history is most helpfulOften the history is most helpful
Evaluation of a pediatric patientEvaluation of a pediatric patient
Age of patientAge of patient Location of the lesionLocation of the lesion
Epiphysis- metaphysis- diaphysisEpiphysis- metaphysis- diaphysis What is the lesion doing to the boneWhat is the lesion doing to the bone Zone of transitionZone of transition Pathern of lesionPathern of lesion
What is the bone doing to the lesionWhat is the bone doing to the lesion Periosteal responsePeriosteal response
Lytic- blastic- calsified- osified- ground glassLytic- blastic- calsified- osified- ground glass
Table 6-2Table 6-2
Table 6-3Table 6-3
Benign tumor Benign tumor
U.B.C:U.B.C:
Radiolucent centric fluid filled cystic Radiolucent centric fluid filled cystic
70% proximal Humerus or femor, 70% proximal Humerus or femor,
75% present with pathologic Fx, 75% present with pathologic Fx,
if diameter of cyst 85% or more if diameter of cyst 85% or more
pathologic Fxpathologic Fx
Complication patho Fx:Complication patho Fx:
MalunionMalunion
Growth arrestGrowth arrest
Osteo necrosisOsteo necrosis
Collapse of articular surface Collapse of articular surface
Treatment:Treatment:
Undisplace FxUndisplace Fx
I.I. TractionTraction
II.II. Curtage & Bone graft (autograft or allograft)Curtage & Bone graft (autograft or allograft)
Displace Fx or Unstable FxDisplace Fx or Unstable Fx
Internal fixation + curettage & bone graftInternal fixation + curettage & bone graft
Classification for treatment of proximal Classification for treatment of proximal femur:femur:
Malignant tumors:Malignant tumors:
OsteosarcomaOsteosarcomaChondrosarcomaChondrosarcomalymphomalymphoma
lymphomalymphoma
LymphomaLymphoma Primary or secondaryPrimary or secondary
Sixth and seven decadesSixth and seven decades Male/female = 1.5/1Male/female = 1.5/1 Femor pelvic spine ribsFemor pelvic spine ribs
LymphomaLymphoma
Chief complainChief complain
Localized painLocalized pain
SwellingSwelling
Nerve root or cord compression Nerve root or cord compression
lymphomalymphoma
X ray X ray DiaphysialDiaphysial Illdefined Illdefined Bone distractionBone distraction Permeative apperancePermeative apperance Ticking of cortexTicking of cortex Periosteal reaction rarely seenPeriosteal reaction rarely seen
Radiogarph can be normal Radiogarph can be normal
Bone scanBone scan
MRIMRI
StagingStaging CBCCBC Serom chemistrySerom chemistry Bone scanBone scan CT (chest abdomen pelvic)CT (chest abdomen pelvic) Bone marrow biopsyBone marrow biopsy
patologypatology
Patology?Patology?
PrognosisPrognosis
Primary 55% 5-year survivalPrimary 55% 5-year survival
Secondary <25%Secondary <25%
TreatmentTreatment
ChemotherapyChemotherapy
RadiotherapyRadiotherapy
surgurysurgury
Case 1Case 1
Case 2Case 2
Case 3Case 3
Osteosarcoma:Osteosarcoma:
Osteosarcom & Ewing 10% pathologic Fx Osteosarcom & Ewing 10% pathologic Fx
Colse treatment in cast (After Biopsy)Colse treatment in cast (After Biopsy)
Neoadjuvan chemotherapyNeoadjuvan chemotherapy
Surgery (Limbsalvage or amputation)Surgery (Limbsalvage or amputation)
Chondrosarcoma:Chondrosarcoma:
Middle age or older adultMiddle age or older adult
Proximal femor most common for P. FxProximal femor most common for P. Fx
Serious mistake with metastatic carcinomaSerious mistake with metastatic carcinoma
Displace Fx Displace Fx amputation amputation
Chondrosarcoma:Chondrosarcoma:
LymphomaLymphoma
Metastatic tumorMetastatic tumor
Metastatic carcinoma most common Metastatic carcinoma most common
malignancy treated by orthopedic surgeon malignancy treated by orthopedic surgeon
8000 sarcoma every year.8000 sarcoma every year.
1.3 million carcinoma 1.3 million carcinoma
50-80% carcinoma have bone metastase 50-80% carcinoma have bone metastase
at time of death.at time of death.
Metastatic tumor:Metastatic tumor:
BreastBreast
ProstateProstate
LungLung
KidneyKidney
ThyroidThyroid
Gastro intestinalGastro intestinal
Evaluation of patient with lytic bone Evaluation of patient with lytic bone lesionlesion
I.I. History:History:
Thyroid, breast or prostate noduleThyroid, breast or prostate nodule
II.II. Review of system:Review of system:
Gastrointestinal symptom, weight loss, flank pain, hematuriaGastrointestinal symptom, weight loss, flank pain, hematuria
III.III. Physical examination:Physical examination:
Lymph nocles, thyroid, breast, lungs, abdomen, prostate, teslicle and Lymph nocles, thyroid, breast, lungs, abdomen, prostate, teslicle and
rectumrectum
Evaluation of patient with lytic bone Evaluation of patient with lytic bone lesion:lesion:
IV.IV. Plain X-Ray: Plain X-Ray:
IV.IV. Chest, affected bone, humerus, pelvis, femur, spineChest, affected bone, humerus, pelvis, femur, spine
V.V. In affected bone (osteopenia, periostal reaction cortical In affected bone (osteopenia, periostal reaction cortical
thinning, looser line)thinning, looser line)
VI.VI. Breast & Prostate Breast & Prostate Blastic Blastic
VII.VII. Kidney & Thyroid Kidney & Thyroid Lytic Lytic
VIII.VIII. Lung Lung Mixed Mixed
IX.IX. Isolated avulsion Fx lesser trochanterIsolated avulsion Fx lesser trochanter
If lesion distal to elbow or knee lung cancer is most likely If lesion distal to elbow or knee lung cancer is most likely
primary lesionprimary lesion
Evaluation of patient with lytic bone Evaluation of patient with lytic bone lesionlesion
V.V. Bone scanBone scan 99 MTC99 MTC Pet Scan (Positron emission tomography) gold standard in Pet Scan (Positron emission tomography) gold standard in
metabolic imagingmetabolic imaging FDG (Fluorine- 18 deoxy glucose)FDG (Fluorine- 18 deoxy glucose) Pet CT. Scan (higher sensivity) & Specificity than pet scan for Pet CT. Scan (higher sensivity) & Specificity than pet scan for
detection of malignant bone lesion)detection of malignant bone lesion)
VI.VI. CT. Scan (Chest- Abdomen- Pelvis)CT. Scan (Chest- Abdomen- Pelvis)
VII.VII. Laboratory:Laboratory: CBC, ESR, Ca-P, UA, PSA, Alkphos, Immunoelectrotherosis, CBC, ESR, Ca-P, UA, PSA, Alkphos, Immunoelectrotherosis,
carcino embryonic antigen, CA 125, N-Telopeptide & C- carcino embryonic antigen, CA 125, N-Telopeptide & C- TelopheptideTelopheptide
Associated Medical problem: (Patient Associated Medical problem: (Patient with bone metastase):with bone metastase):
I.I. PainPain
II.II. Pathologic FxPathologic Fx
III.III. AnemiaAnemia
IV.IV. HypercalcemiaHypercalcemia
When and how to biopsy:When and how to biopsy:
Staging studyStaging study
Needle or open incisionalNeedle or open incisional
a.a. Carcinoma from sarcomaCarcinoma from sarcoma
b.b. Contamination from open biopsyContamination from open biopsy
Biopsy of site un affected by FxBiopsy of site un affected by Fx
Even if a patient has a known history of Even if a patient has a known history of
carcinoma a biopsy of first sitecarcinoma a biopsy of first site
Impending pathologic Fx:Impending pathologic Fx:
Bone metastases are painfulBone metastases are painful
Fiddler:Fiddler:
If 50-75% cortical involvement If 50-75% cortical involvement moderate moderate
to severe pain to severe pain
After prophylactic internal fixation After prophylactic internal fixation no or no or
slight painslight pain
Goals of surgical treatment:Goals of surgical treatment:
Alleviate painAlleviate pain
Reduce narcotic useReduce narcotic use
Restore skeletal stabilityRestore skeletal stability
Regain functional independenceRegain functional independence
Impending fracture (Risk of Fx):Impending fracture (Risk of Fx):
Pain not respond to radiationPain not respond to radiation
Lesion greater than 2.5 cmLesion greater than 2.5 cm
Lesion destroy >50% cortexLesion destroy >50% cortex
Avulsion Fx of lessen trochonter Avulsion Fx of lessen trochonter
Scoring 7 or lower Scoring 7 or lower Irradiated Irradiated
Scoring 8 or higher Scoring 8 or higher prothylatic prothylatic
internal fixation before irradiationinternal fixation before irradiation
Benefit of fixation:Benefit of fixation:
Shorter hospitalization (average 2 days)Shorter hospitalization (average 2 days)
More immediate pain reliefMore immediate pain relief
Less blood lossLess blood loss
Return to premorbid functionReturn to premorbid function
Fewer hardware complicationFewer hardware complication
Treatment:Treatment:
A.A. General treatmentGeneral treatmentI.I. Cytotoxic agentCytotoxic agent
II.II. Hormone therapyHormone therapy
III.III. Radioactive iodineRadioactive iodine
IV.IV. Biphosthonate:Biphosthonate:a)a) Prevent new metastasePrevent new metastase
b)b) Inhibit osteoclast resorbtionInhibit osteoclast resorbtion
V.V. Most metastatic carcinoma sensitive Most metastatic carcinoma sensitive radiation except kidney cancerradiation except kidney cancer
Pathologic FxPathologic Fx
B.B. Local treatmentLocal treatment
1.1. Fixation stable Fixation stable
2.2. Tumor should be debulkTumor should be debulk
3.3. Reconstricle durableReconstricle durable
4.4. Cavity filled with PMMACavity filled with PMMA
Treatment:Treatment:
Pathologic Fx of femoral head & neck Pathologic Fx of femoral head & neck
rarely headrarely head
For head & neckFor head & neck cemented prosthesis cemented prosthesis
Hemi arthroplasty versus total hipHemi arthroplasty versus total hip
When adjacent lesion in subtrochantrick or When adjacent lesion in subtrochantrick or
proximal diaphysis proximal diaphysis long stem femoral long stem femoral
Treatment (Inter trochantric):Treatment (Inter trochantric):
DHS DHS high rate of failure even use PMMA high rate of failure even use PMMA
+ radiation+ radiation
Standard choice:Standard choice:
Cephalomedulary nail (Head & Neck Cephalomedulary nail (Head & Neck
bone)bone)
Prosthesis (Severe destruction)Prosthesis (Severe destruction)
Sub trochontric:Sub trochontric:
Subject to force of up 4-6 weight Subject to force of up 4-6 weight
Static locked intramedullaryStatic locked intramedullary
Extensive bone destruction Extensive bone destruction modular modular
proximal prosthesisproximal prosthesis
ConclusionConclusion
The most common cause for a pathologic fracture is The most common cause for a pathologic fracture is osteoporosis or osteomalacia.osteoporosis or osteomalacia.
Patients with osteoporosis or osteomalacia require Patients with osteoporosis or osteomalacia require evaluation and management of the underlying disorder evaluation and management of the underlying disorder
Patients more than 45 years of age with a pathologic Patients more than 45 years of age with a pathologic fracture or lytic lesion are much more likely to have fracture or lytic lesion are much more likely to have metastatic bone disease than a primary bone tumor.metastatic bone disease than a primary bone tumor.
The prognosis for patients with metastatic bone disease The prognosis for patients with metastatic bone disease is improving because of early recognition and better is improving because of early recognition and better adjuvant treatment; therefore, many patients will live adjuvant treatment; therefore, many patients will live more than 2 years.more than 2 years.
conclusionconclusion
Do not immediately assume that a lytic lesion or Do not immediately assume that a lytic lesion or pathologic fracture is from metastatic disease. A pathologic fracture is from metastatic disease. A thorough workup and possible biopsy are required.thorough workup and possible biopsy are required.
Prophylactic fixation for impending fractures from Prophylactic fixation for impending fractures from metastatic disease is technically easier for the surgeon metastatic disease is technically easier for the surgeon and allows a quicker patient recovery.and allows a quicker patient recovery.
The mirels scoring system is available to guide the The mirels scoring system is available to guide the treatment of an impending fracture from metastatic bone treatment of an impending fracture from metastatic bone disease.disease.
conclusionconclusion
Femoral neck fractures from metastatic bone disease require a Femoral neck fractures from metastatic bone disease require a
cemented hip prosthesis, because internal fixation has a high rate of cemented hip prosthesis, because internal fixation has a high rate of
failure with disease progression.failure with disease progression.
When surgery is required for metastatic disease to the spine, When surgery is required for metastatic disease to the spine,
decompression and stabilization with internal fixation are generally decompression and stabilization with internal fixation are generally
necessary.necessary.
Surgical reconstruction for pathologic fractures should be durable Surgical reconstruction for pathologic fractures should be durable
enough to allow immediate weightbearing and last throughout the enough to allow immediate weightbearing and last throughout the
patient’s expected lifespan.patient’s expected lifespan.
A pathologic fracture through a primary malignant bone tumor is A pathologic fracture through a primary malignant bone tumor is
treated much differently than a fracture through a metastatic lesion.treated much differently than a fracture through a metastatic lesion.
Treatment of a patients with pathologic fractures requires the Treatment of a patients with pathologic fractures requires the
presence of a multidisciplinary team composed of orthopaedic presence of a multidisciplinary team composed of orthopaedic
surgeons, medical oncologists, radiation oncologists, surgeons, medical oncologists, radiation oncologists,
endocrinologists, radiologists, pathologists, pain specialists, endocrinologists, radiologists, pathologists, pain specialists,
nutritionists, physical therapists, and psycholognutritionists, physical therapists, and psycholog
Thank you for Thank you for your Attentionyour Attention
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