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