Version May 2024
INTRODUCTION — Pathologic fractures (complete or impending) are skeletal-related events (SREs) that can occur in patients with bone metastases from advanced cancer. Other SREs include pain, hypercalcemia, and spinal cord compression. A pathologic fracture is defined as a fracture that develops through an area of bone pathology. In some cases, the extent of bone destruction is such that a fracture is imminent but not complete (termed an impending pathologic fracture). The goals of treatment of pathologic fractures are to maximize function and skeletal integrity while minimizing morbidity. For most patients with a completed or impending pathologic fracture of a long bone, surgical bone fixation will be required.
The treatment options for a complete or impending pathologic fracture in patients with metastatic cancer, multiple myeloma, and lymphoma, emphasizing the indications for surgery, and various options for fixation and reconstruction, are reviewed in this topic.
The clinical features of pathologic fractures are presented elsewhere as is an overview of the clinical features of bone metastases in general, pathologic fractures in Paget disease and giant cell tumor of bone, and primary bone tumors such as osteosarcoma are discussed separately. Radiation therapy for the management of painful bone metastases without a pathologic fracture is also reviewed separately:
●(See "Epidemiology, clinical presentation, and diagnosis of bone metastasis in adults".)
●(See "Treatment of Paget disease of bone", section on 'Role of surgery'.)
●(See "Giant cell tumor of bone".)
●(See "Radiation therapy for the management of painful bone metastases".)
MANAGEMENT PRINCIPLES
Goals of surgery
Palliation to exceed expected survival — Operative intervention for a complete or impending pathologic fracture is generally a palliative procedure. However, most complete and impending pathologic fractures, especially those in a weight-bearing bone, should be treated with durable fixation or reconstruction procedure that will outlast the patient's expected survival [1]. Fixation or reconstruction may be contraindicated for a patient with a limited expected survival or a very poor performance status if addressing the fracture will not improve the performance status. In such cases, palliative radiation therapy (RT) may be preferred, if consistent with the goals of care.
Although the expected survival time is short in some cases (especially with late non-small cell lung and colorectal carcinoma [2]), although this has been changing with the availability of biologics and checkpoint inhibitors. Survival may be prolonged in other diseases, particularly multiple myeloma, and breast, prostate, or renal cell carcinoma [3-7]. Prediction of survival in the setting of bony metastatic disease has become increasingly refined, and predictive tools have been developed for specific settings of both extremity and spinal metastatic bone disease. Utilization of these nomograms and algorithms is especially important when a complex reconstruction requiring longer recovery is under consideration. This subject is discussed further below. (See 'Contraindications' below.)
Because of the possibility that survival may be prolonged, fixation should not rely upon fracture healing to achieve stability, and it should allow the patient full use or at least full weight-bearing immediately postoperatively. Liberal use of cement should be considered an adjunct to internal fixation to achieve these goals. For long bone fractures, consideration should always be given to abandoning internal fixation in favor of resecting diseased bone and endoprosthetic reconstruction when internal fixation will not accomplish the aforementioned goals [1].
Identify and stabilize at-risk synchronous bone lesions — Another goal of managing patients with bone metastases is prophylactic fixation of bones that are at risk for pathologic fracture before they actually fracture. In general, treatment of an impending pathologic fracture is less complicated than treatment of an actual fracture, and some evidence suggests improved survival with prophylactic stabilization compared with fixation after fracture [8]. Furthermore, elective fixation prevents the intense pain and loss of function associated with pathologic fracture; quality of life improvements are questionable, however [9].
Guidelines are available to help identify patients at risk for a fracture. One such example is Mirels scoring system (table 1) [10]. (See "Clinical presentation and evaluation of complete and impending pathologic fractures in patients with metastatic bone disease, multiple myeloma, and lymphoma", section on 'Assessing the risk of fracture'.)
For patients who present with a pathologic fracture, operative planning for the bone in which a fracture has occurred may also be impacted by other lesions in the vicinity, as well as adjacent and distant bones. As such, radiographs of the entire affected long bone and a whole-body skeletal evaluation should be scrutinized to identify other lesions that should be managed concurrently. (See "Clinical presentation and evaluation of complete and impending pathologic fractures in patients with metastatic bone disease, multiple myeloma, and lymphoma", section on 'Radiographic studies' and "Clinical presentation and evaluation of complete and impending pathologic fractures in patients with metastatic bone disease, multiple myeloma, and lymphoma", section on 'Whole body skeletal evaluation'.)
As examples:
●The identification of associated lesions in the same bone warrants consideration for intramedullary devices rather than plate fixation, and of longer-stem endoprostheses rather than standard length stems.
●Involvement of the acetabulum in a patient with a femur fracture may be better treated with a total hip reconstruction rather than a hemiarthroplasty. Alternatively, the acetabular lesion may be treated with minimally invasive image-guided Ablation, Osteoplasty, Reinforcement, and Internal Fixation (AORIF) [11], and the femur fracture with a conventional hemiarthroplasty. (See 'Alternatives to surgery' below.)
●Similarly, periacetabular lesions in a patient being considered for total hip arthroplasty might necessitate extending the fixation into the supra-acetabular bone with screws, cement, and/or acetabular cage constructs or supplemental treatment by AORIF.
Contraindications — Moribund or severely medically ill patients, who are not expected to survive the procedure let alone the hospitalization, should not be offered operative intervention. In general, patients should have an estimated survival duration that is equal to or greater than the time needed to recover from the procedure. For procedures such as intramedullary nailing, plate fixation of a long bone fracture, or a straightforward hip or shoulder hemiarthroplasty, this time is around six weeks or less, but for more complicated procedures, such as complex acetabular reconstructions, the recovery period is between three and six months.
Models to predict prognosis that are based on the number of skeletal metastases, presence of organ metastases, primary site, hemoglobin level, and performance status (table 2) have been developed [12-26], several of which are specific to femoral [27-29], or spine metastases [12-16,19-26,30]. All have some limitations in their ability to accurately predict overall survival, and it is not clear that any one is more reliable than the others [31]. Additional tools for estimating survival in patients with advanced cancer are discussed elsewhere. (See "Survival estimates in advanced terminal cancer".)
Other considerations
VTE prophylaxis — Patients with pathologic fractures undergoing orthopedic surgery are at high risk for venous thromboembolism (VTE) and should receive prophylactic anticoagulation. Prophylactic anticoagulation may also be indicated for patients who are not being treated surgically, but are immobilized by their fracture.
Patients with metastatic cancer are known to be at increased risk for VTE, and this risk is amplified in patients undergoing orthopedic surgery for completed or impending pathologic fractures [32,33]. In a multi-institutional series of 287 patients with 336 actual or impending fractures, the overall rate of venous thromboembolism was 7.1 percent, including a pulmonary embolism rate of 3.9 percent and a deep vein thrombosis rate of 3.3 percent [32]. This subject is discussed in detail elsewhere. (See "Risk and prevention of venous thromboembolism in adults with cancer" and "Prevention of venous thromboembolism in adults undergoing hip fracture repair or hip or knee replacement".)
Analgesia — Opioid therapy is the first-line approach for moderate or severe cancer-related pain, including pain from a complete or impending pathologic fracture, but in patients without contraindications to their use nonsteroidal anti-inflammatory drugs (such as oral ibuprofen or naproxen or intravenous ketorolac) may offer significant adjuvant analgesia. While opioids are effective analgesics, patients using them are at risk for unwelcome side effects and aberrant substance use. Issues related to optimizing opioid therapy, the use of adjuvant analgesics (including nonsteroidal anti-inflammatory drugs), risk assessment, and management of side effects in patients receiving opioids are discussed in detail elsewhere. (See "Cancer pain management with opioids: Optimizing analgesia" and "Cancer pain management: Use of acetaminophen and nonsteroidal anti-inflammatory drugs" and "Cancer pain management: Role of adjuvant analgesics (coanalgesics)" and "Cancer pain management: General principles and risk management for patients receiving opioids" and "Prevention and management of side effects in patients receiving opioids for chronic pain".)
Use of osteoclast inhibitors — Osteoclast inhibitors reduce the frequency of skeletal-related events (ie, need for radiation and/or surgery to bone, pathologic fractures, spinal cord compression, and hypercalcemia of malignancy) in patients with bone metastases from metastatic carcinoma and myeloma. Use of an osteoclast inhibitor (bisphosphonates, denosumab) is recommended for patients with multiple myeloma with bone lesions or metastatic carcinoma regardless of histology, if they are considered at risk for fracture. Specific recommendations for use, including the frequency of treatment and duration, are provided elsewhere. (See "Osteoclast inhibitors for patients with bone metastases from breast, prostate, and other solid tumors" and "Multiple myeloma: The use of osteoclast inhibitors".)
MANAGEMENT OF LONG BONE FRACTURES — Although surgical fixation of pathologic fractures is a palliative procedure, long bone fractures or impending fractures warrant operative fixation for several reasons:
●Nonoperative care, particularly for lower extremity fractures, frequently disables the patient for the remainder of their life. So while, the overall lifespan of these patients is generally short, particularly in the setting of metastases from lung cancer [2], quality of life is of immediate and utmost importance.
●Unlike nonpathologic fractures, pathologic fractures always require an extended time to heal, and a significant proportion will never heal at all with closed reduction and immobilization. In an older study of 129 pathologic long bone fractures in 123 patients who were treated with a variety of methods and followed until death or at least one year postfracture, 26 of 30 patients (87 percent) treated with internal fixation and radiation therapy (RT) healed their fracture compared with only 13 of 23 patients (57 percent) who underwent cast immobilization and RT; none of the 17 fractures in patients with lung cancer healed with nonoperative management [34]. The markedly reduced fracture healing rates are a consequence of effects of local tumor destruction on the bone, local effects of irradiation in slowing healing, and systemic effects of treatments such as chemotherapy.
●Patients frequently have or will develop multiple skeletal sites of disease, which cause pain and dysfunction. Care for these sites would be complicated by inability to use an extremity due to an untreated pathologic fracture.
Options for fixation/reconstruction — Operative treatment of pathologic fractures related to bone metastases differs considerably from those used to fix a traumatic fracture with respect to the need to remove malignant tissue (or malignant tissue may have simply destroyed the bone, creating a segmental defect), and because pathologic fractures are associated with impaired bone healing. In general, three operative strategies are commonly used, each of which features a different implant: endoprosthetic reconstruction (eg, arthroplasty), internal fixation with intramedullary nailing, or internal fixation with a plate/screw device. An overview of surgical options for fixation and reconstruction of lower and upper extremity complete or impending pathologic fractures according to anatomic site is provided (table 3 and table 4). In general, endoprosthetic reconstruction is usually used for juxta-articular destruction when too little bone remains to allow stable and durable internal fixation. For femoral shaft lesions, an intramedullary nail is standard of care. For humeral lesions, plate fixation may be used as an alternative to an intramedullary nail. A less widely accepted approach is percutaneous treatment with cementoplasty, which is generally reserved for patients who are not surgical candidates, although this may also be used in the pelvis as an alternative to a complex total hip reconstruction [35,36]. (See 'Alternatives to surgery' below.)
The choice of procedure must be individualized to the anatomic site and extent of tumor destruction. One important aspect of decision-making is the estimated life span of the patient. Guidelines from the Musculoskeletal Tumor Society (MSTS), American Society of Clinical Oncology (ASCO), and American Society for Radiation Oncology (ASTRO) on treatment of metastatic carcinoma and myeloma of the femur recommend that surgeons utilize a validated method of estimating patient survival when choosing the surgical construction method [37]. (See 'Palliation to exceed expected survival' above and 'Contraindications' above.)
Controversies in surgical techniques — Beyond the broad well-accepted principles for surgical treatment of metastatic disease to bone, there are numerous controversies in surgical management, only some of which are summarized in the following paragraphs:
●Arthroplasty versus internal fixation – In general, arthroplasty procedures are associated with greater potential morbidity and higher health care costs than internal fixation; however, reconstruction may be preferable in select patients with longer expected survival and a better performance status because of better durability/longevity and faster postoperative mobilization. In addition, for proximal femoral lesions, limited evidence suggests that arthroplasty may reduce the need for postoperative RT [37], although we do not recommend this approach.
Although this controversy potentially exists for any juxta-articular site, the proximal femur is perhaps the most controversial area due to its common occurrence as a location of metastatic disease, and due to the profound impact failure has on ambulatory capacity. Most agree that femoral neck pathologic lesions, particularly associated with a fracture, are best served with an arthroplasty. However, for intertrochanteric and subtrochanteric impending fracture (picture 1) and pathologic fractures, numerous series report high success rates for both arthroplasty and internal fixation. There are trade-offs for these two alternative approaches.
The advantages of internal fixation (image 1) include durable fixation in the majority of cases with a more cost-effective result using devices generally familiar and accessible to the general orthopedic surgeon. The durability of internal fixation is underscored by the success rate, which approaches 90 percent [38-43].
Advances in internal fixation devices, more routine use of locked intramedullary reconstruction nails over plate fixation, and more common usage of RT have reduced the failure rate to approximately 0 to 6 percent among modern studies [39-42,44,45]. Although published detailed long-term cost-analyses are lacking, internal fixation implants are generally one order of magnitude less costly than their arthroplasty implant counterparts. A role for locked plate fixation has yet to be defined, but there may be a role in juxta-articular fractures around the knee [46].
Compared with internal fixation, the advantages of hip arthroplasty (hemi- or total-hip) are potentially improved durability and longevity, often with more rapid mobilization of the patient without the need to worry about potential fixation failure [39,47-50]. Whether RT can routinely be omitted after arthroplasty is not clear. A recently published MSTS/ASCO/ASTRO joint guideline for managing metastatic carcinoma and myeloma involving the femur suggested that the need for adjuvant RT may be reduced for patients undergoing arthroplasty [37], presumably because the entire tumor has been excised. However, there is limited clinical experience directly addressing the role of RT in this setting, and the decision to include adjuvant RT should be individualized based on patient and tumor characteristics. Highlighting the lack of clarity on the issue is a series of 101 patients with surgical tumor resection where six of the nine patients with local tumor recurrence did not receive adjuvant RT [51].
However, the disadvantages of arthroplasty include complications such as dislocation and deep surgical site infection that are sometimes more difficult to manage than are complications of internal fixation [52].
There are no randomized trials directly comparing internal fixation with arthroplasty for any anatomic site. Early retrospective series comparing internal fixation and arthroplasty devices suggested potentially lower failure rates with arthroplasty [38,39,53,54], but these studies were often not restricted to single anatomic sites or type of fracture, most used older and now abandoned means of internal fixation, and postoperative RT was used in as few as 25 percent of cases. More contemporary studies have suggested somewhat better outcomes using modern internal fixation devices [39,42,45].
This issue was addressed in a systematic review of 10 retrospective reports (between 1994 and 2013) totaling 1107 patients with proximal femoral metastases with a fracture or impending fracture managed surgically by either endoprosthetic reconstruction (n = 645) or internal fixation (n = 468) [43]. The use of adjuvant RT was variable. The main finding was that all patients treated for proximal femur metastases were at high risk of revision surgery (needed in 113 of 1107 patients) and complications regardless of the implant used. However, most studies reported a higher incidence of reoperation and implant failure with internal fixation as compared with arthroplasty. The most common reason for reoperation was dislocation after endoprosthetic reconstruction, while the most common cause of reoperation was loosening after internal fixation. Time to reintervention ranged from 3 to 12 months in the endoprosthetic group compared with 8 to 22 months in the internal fixation group. In the few studies reporting nonsurgical complications, patients undergoing arthroplasty developed more complications than did those with internal fixation. Infections requiring intravenous antibiotics occurred after arthroplasty in 17 of the 18 reported circumstances of this complication.
Prospective studies are much needed to develop evidence-based treatment recommendations. Unfortunately, a multi-institutional prospective randomized study comparing internal fixation with arthroplasty for proximal femoral metastatic lesions in the United States was ongoing but closed to accrual in 2020 because of low enrollment.
●Long versus standard length stem – Routine use of a long-stem device is not warranted for most patients undergoing arthroplasty for a femoral neck fracture.
One of the general principles in the surgical care of patients with metastatic carcinoma is to try to protect the entire involved bone when possible. However, the decision to do so, particularly in the femur by using a long-stem device, has been associated with potential adverse outcomes. Embolic phenomena (fat or air embolism with oxygen desaturation, hypotension, and pulmonary emboli) potentially leading to prolonged intubation, coma, cardiac arrest, and even death are reported in association with use of longer arthroplasty devices in patients with metastatic disease [55-59]. This has been predominantly demonstrated with long-stem cemented femoral arthroplasty devices, although there are reports of similar problems occurring rarely with unilateral or bilateral femoral nails in this patient population [60].
Although the data are limited, the incidence of disease progression in the distal femur does not appear to be sufficiently high to warrant routine use of longer devices [61,62]. As an example, in a series of 96 patients with metastases, myeloma, or lymphoma of the bone who had undergone stabilization or arthroplasty for impending or actual femoral or humeral pathologic fractures using an approach that favored long intramedullary implants and long-stem arthroplasty where possible, the risk of progression apart from the originally identified lesion (1 in 96) was markedly lower than the complication rate (12 of 96, all potentially attributable to embolic phenomena) of the long stem placement [61]. Thus, routine use of long devices is not warranted for most patients. This recommendation is consistent with a joint MSTS/ASCO/ASTRO guideline on treatment of metastatic carcinoma or myeloma of the femur, which recommends that a long stem should only be used in patients with additional lesions in the femur, given the higher rate of complications [37].
An important point is that when distal lesions are identified, they should be addressed in some fashion to avoid subsequent fractures distal to the implant. In those cases, a longer stem femoral component should be strongly considered.
●Cephalomedullary versus standard femoral nail fixation for diaphyseal lesions – As a corollary to the question posed regarding the need to protect the distal femur, others have evaluated whether proximal cephalomedullary nail devices are needed to protect the femoral neck for femoral diaphyseal metastases [63]. Among the 145 femoral nailings performed for femoral diaphyseal disease in this series, none (0 percent) subsequently developed femoral neck metastases. The authors concluded that, for femoral diaphyseal disease alone, cephalomedullary devices are unnecessary for treatment of either pathologic fractures or impending fractures due to metastatic carcinoma, myeloma, or lymphoma. However, they conceded that their series was relatively small, and a stronger recommendation to avoid cephalomedullary nailing in these cases awaits confirmation from other large centers.
The consensus panel that developed the joint MSTS/ASCO/ASTRO guideline on treatment of metastatic carcinoma or myeloma of the femur concluded that there was no advantage to routine use of cephalomedullary nails for diaphyseal metastatic lesions [37], and we agree with this position. However, we would emphasize that more proximal femoral disease is more common than diaphyseal lesions and should be addressed with a cephalomedullary nail when present.
●Cemented versus press-fit femoral arthroplasty – Traditional recommendations in patients with metastatic disease undergoing arthroplasty are for use of a cemented femoral device, as it affords immediate stability without the need for delayed weight bearing or dependence upon bone ingrowth for stability. However, as noted previously, cemented arthroplasties, particularly those with long stems, have been associated with embolic phenomenon that can lead to catastrophic complications. Further, with the evolution of arthroplasty care, many clinicians also mobilize patients with noncemented arthroplasties without restricted weight bearing.
In our view, cemented femoral components remain the standard of care for metastatic disease in most orthopedic oncology practices. There are no published reports on the use of these noncemented arthroplasties in this patient population, and the potential exists for early loosening due to lack of bone ingrowth either from local tumor effects, irradiation, or the combination.
●Open versus closed approach for intramedullary nailing – There are two general schools of thought relative to intramedullary nailing for long bone pathologic fracture and prophylactic fixation. One advocates an open approach to the fracture and/or lesion, thorough curettage of the tumor mass, and open cementing of the defect around or through the fixation device. Those advocating this approach cite improved local control with disease debulking and better strength with a cemented defect.
An alternative approach is closed reaming and nailing without approaching the lesion directly. Advocates of this approach suggest less blood loss, shorter operative time, and less general morbidity of the procedure when the lesion is not approached directly. There are no published reports directly comparing these two approaches. An intermediate approach is to limit the application of an open procedure to those patients requiring an open biopsy with frozen section at the time of fixation or for patients with very large or poorly radio-responsive lesions.
●Plate versus rod versus segmental defect replacement fixation for the humeral diaphysis – Although intramedullary stabilization is typically used for long bone fixation in patients with metastatic disease, the humeral diaphysis uniquely lends itself to the alternatives of plate fixation or intercalary prosthetic replacement using a segmental defect device. Although humeral intramedullary stabilization may generally be done either with or without bone cement (as discussed above), for plate fixation and segmental defect devices, cement is recommended. The advantages of intramedullary stabilization include the potential for a closed approach with protection of a generally larger percentage of the length of the bone, biomechanically superior fixation over plating for impending pathologic fractures, and a lower complication rate in some series [64-66]. Advantages of the plating technique include the potential to combine an open approach with direct application of the fixation device, biomechanical superiority over intramedullary nailing when the pathologic fracture has occurred, and avoidance of rotator cuff irritation sometimes seen with nails [67,68]. The third alternative, the cemented segmental defect device, is more costly than either intramedullary fixation or plating, but has some biomechanical advantages over intramedullary nailing in complete and impending pathologic fractures [69-74]. In a series of these devices implanted in multiple anatomic sites from 2008 to 2013, 18 humeral implants did not result in any complications [75]. However, based on a 57 percent complication rate in femoral intercalary modular devices overall, higher in noncemented implants, cement fixation is recommended at this site.
Postoperative radiation therapy — Despite the paucity of data regarding benefit, we and others [37,76-80] suggest postoperative RT for most patients with solid tumors or lymphoma after fixation of a complete or impending pathologic fracture. Postprocedure RT for patients with multiple myeloma is controversial and is discussed separately. (See "Multiple myeloma: Overview of management", section on 'Skeletal lesions and bone health'.)
The entire surgical field should be treated. Postoperative treatment is generally started within two to four weeks of surgery, typically after the wound has adequately healed. Consistent with MSTS/ASCO/ASTRO guidelines [37], we suggest a fractionation scheme of 20 Gy in 5 fractions or 30 Gy in 10 fractions rather than single-fraction RT given the lack of experience with single-fraction RT in the postoperative setting. (See "Radiation therapy for the management of painful bone metastases", section on 'External beam radiation therapy'.)
The rationale for RT includes promotion of remineralization and bone healing, alleviation of pain, improved functional status, and reduction in the risk for subsequent fracture or loss of fixation by treating residual metastatic disease [81,82]. More recent reports underscore the importance of postoperative RT, even in the current setting of routine treatment with an osteoclast inhibitor for metastatic disease, as this approach alone diminishes the risk of a skeletal-related event (fracture, pain) but does not appear to prevent disease progression [83].
The efficacy of palliative RT must be balanced with its potential effects on uninvolved bone and on postoperative wound healing [81,84]. The palliative benefit of RT in patients with painful bone metastases is covered in detail elsewhere. (See "Radiation therapy for the management of painful bone metastases".)
Although postoperative RT is commonly recommended, there are only limited data addressing the benefits of postoperative RT after fixation for bone metastases [54,81,85]:
●A report from the University of Kansas included 64 stabilization procedures in 60 consecutive patients with metastatic disease to weight-bearing bones with pathologic or impending pathologic fracture [81]. Outcomes at 35 sites receiving postoperative RT were compared with 29 sites that were treated with surgery alone. On multivariate analysis, postoperative RT was the only factor that predicted good functional status (defined as normal use either pain free or with pain), which was achieved by 53 percent of irradiated patients compared with 12 percent of patients treated with surgery alone. Second orthopedic procedures were also more common in patients treated initially with surgery alone, and median survival was significantly improved for the cohort of patients treated with surgery plus RT. Given the retrospective nature of the study and the potential for selection bias, outcomes must be interpreted cautiously.
●In a retrospective study of 192 patients treated surgically for 228 metastatic lesions of the long bones, 60 percent of the patients received preoperative or postoperative RT [54]. The reoperation rate in irradiated fracture sites was not significantly different as compared with nonirradiated sites (13 versus 10 percent). However, five of the six patients who required surgery for local tumor progression had not received RT. On the other hand, 8 of 10 nonunions and all five patients who developed a postoperative stress fracture had been treated with RT. Given that stress fracture and nonunion are less of a problem with endoprostheses, the authors concluded that skeletal complications after RT may be circumvented by the use of endoprostheses.
Alternatives to surgery
Pathologic fracture — Alternatives to operative management of pathologic fractures may be appropriate for selected patients with pathologic fracture of a non-weight-bearing bone and in those who are not good surgical candidates. Alternative treatment options include bracing, RT alone, osteoclast inhibiting agents (bisphosphonates, denosumab), systemic therapies (chemotherapy, hormone therapy, immunotherapy, directed therapies), alone or in combination, and use of percutaneous or other minimally invasive techniques:
●Some fractures, such as unusual acral fractures occurring distal to the elbow and knee, may be treated successfully with bracing and nonoperative care, although each case should be considered individually. For the humeral shaft, Sarmiento clamshell braces may be used. For distal humeral and forearm fractures, custom hinged elbow braces may be devised. For some tibial and more distal lower-extremity fractures, patellar-tendon bearing braces may be provided, although the tibia is also amenable to internal fixation with either intramedullary or plate fixation, depending on the specific anatomic location.
●RT may provide good palliation of pain but is unlikely to permit full use or weight bearing on the extremity, particularly if the femur is affected. RT may be a reasonable alternative to surgical fixation for a patient with a slow-growing tumor that is radioresponsive (such as multiple myeloma) who has a nondisplaced pathologic fracture in a non-weight-bearing bone.
●Systemic anticancer therapies are frequently used for treatment of metastatic disease from a chemosensitive tumor, myeloma, and lymphoma, but they do little independently to assist in the healing or treatment of pathologic fractures.
Similarly, the use of osteoclast inhibitors (bisphosphonates, denosumab) can prevent skeletal complications, such as fractures in patients with bone metastases, and may also improve pain related to bone metastases, but they are not adequate by themselves to aid healing of a pathologic fracture. (See "Osteoclast inhibitors for patients with bone metastases from breast, prostate, and other solid tumors".)
●Percutaneous treatment with cementoplasty in the past had generally been reserved for patients who are not open surgical candidates [11,35,36]. However, the newly characterized minimally invasive imaged-guided Ablation, Osteoplasty, Reinforcement, and Internal Fixation (AORIF) has provided the basis for expanded consideration of this technique to avoid the higher risk of more substantial complications with open treatment by complex hip arthroplasty in these patients. This technique has been applied successfully most commonly in the periacetabular pelvis and proximal femur. In a single center prospective study of 26 painful pathologic lesions and some pathologic fractures predominately about the hip, AORIF yielded significant improvement in pain and function without need for conversion to open surgery and without reported infection, bleeding requiring transfusion, or postoperative embolization [11]. (See 'Identify and stabilize at-risk synchronous bone lesions' above.)
RT as an alternative to surgery for an impending fracture — The decision whether to consider radiation therapy (RT) in lieu of stabilization must be individualized and will depend on consideration of several variables including the extent and nature of the bone metastases, overall disease burden, the performance status and life expectancy of the patient, associated symptoms, and tumor histology.
There are no reported prospective trials evaluating the role of RT as an alternative to stabilization in patients with long bone metastases and impending fractures, and no generally agreed upon characteristics defining which patients can safely avoid surgical intervention and be treated with primary RT. Although many impending fractures will not progress to actual fractures, surgical treatment of an impending pathologic fracture is less complicated than treatment of an actual fracture. Moreover, development of an actual fracture with resultant hospitalization and debilitation may negatively impact the ability of a patient to receive systemic therapy.
While it is more common practice to consider initial surgical fixation and adjuvant RT for lesions with a high risk of associated fracture, select series suggest that RT can result in metastatic bone healing and reduce the need for surgical intervention:
●From a prospectively maintained database, radiologic response and clinical outcome were reported for 72 patients with femoral bone metastases, including 43 impending fractures assessed according to the Mirels scoring system [86]. A median RT dose of 30 Gy was given, and radiologic responses were observed in 42 percent of lesions at a median of three months after RT. Among 43 impending fracture lesions, 36 percent showed a radiologic response and 81 percent did not require surgical stabilization. The treatment failure rate was high in lesions with radiologic progressive disease following RT.
●In a retrospective analysis of 59 patients with metastatic breast carcinoma to long bones (97 bone lesions) treated with RT as the initial therapeutic modality, seven had pathologic fractures at presentation, two sustained fractures while receiving RT, and two developed fractures after RT [87]. One-third of patients had radiographic evidence of bone healing. None of the lesions defined as high risk for impending fracture resulted in a pathologic fracture after the completion of RT. The authors concluded that the use of RT in initial management of bone metastases in patients with breast cancer is usually effective and that prophylactic surgical intervention is not warranted in most cases.
●Risk factors for development of pathologic fracture were analyzed for 102 patients with 110 femur lesions treated with palliative RT on the randomized phase III Dutch Bone Metastasis Study [88,89]. Fourteen fractures occurred during follow-up. Only axial cortical involvement >30 mm (p = 0.01) and circumferential cortical involvement >50 percent (p = 0.03) were predictive of fracture, while application of Mirels scoring system was not predictive of fracture risk (p = 0.36). The authors suggested that conventional risk factors overestimate the actual occurrence of pathologic fractures of the femur and the need for surgical stabilization. Femur lesions with axial cortical involvement of >30 mm on plain radiograph did have a 25 percent chance of fracture, and initial surgical stabilization was recommended for these patients if deemed fit for surgery.
While randomized trials would be challenging to perform, an ongoing prospective nonrandomized cohort study is evaluating clinical outcomes of patients with femoral metastases at high risk of pathologic fracture following either surgery (with or without RT) or primary RT (NCT01428895). Eligibility for the study includes femoral metastases with a Mirels score of 8 or higher (table 1). The primary outcome measure is ambulatory status at three months, and secondary endpoints include pain score, quality of life, and limb function at six months. (See "Clinical presentation and evaluation of complete and impending pathologic fractures in patients with metastatic bone disease, multiple myeloma, and lymphoma", section on 'Assessing the risk of fracture'.)
Dose and fractionation — For most patients with femur lesions at risk for fracture who are selected for palliative RT, we suggest treatment with fractionated RT (eg, 30 Gy in 10 fractions or 20 Gy in 5 fractions) rather than single-fraction irradiation. This recommendation is consistent with recommendations from a joint guideline from MSTS/ASCO/ASTRO on the treatment of metastatic carcinoma of the femur [37]. We also suggest fractionated palliative RT for patients with impending fractures of other long bones. Ultimately, the choice of the palliative RT regimen should be guided by patient performance status, life expectancy, and goals of care; single fraction therapy (8 Gy) may be an appropriate choice in select circumstances (eg, estimated life expectancy <3 months). (See "Radiation therapy for the management of painful bone metastases", section on 'Single-dose versus fractionated treatment'.)
In the phase III Dutch Bone Metastasis Study described above, in which the vast majority of patients had primary tumors in the breast, prostate, or lung, the risk of fracture in femoral metastases was low overall [88]. Nevertheless, significantly more fractures were observed in the 8 Gy x 1 cohort (4 percent) compared with the 4 Gy x 6 cohort (2 percent), presumably due to improved bone healing with the higher dose regimen. The median time to fracture was 7 weeks in the 8 Gy x1 cohort and 20 weeks 4 Gy x 6 cohort. Fractionated RT was specifically recommended for femur lesions with >30 mm cortical involvement if surgical stabilization was not performed, while single-fraction irradiation may be an option for lesser cortical involvement.
Higher doses and fractionated schedules of palliative conventional RT for bone metastases are not associated with an increase in long-term side effects, including pathologic bone fractures [79]. (See "Radiation therapy for the management of painful bone metastases", section on 'External beam radiation therapy'.)
Another option, especially for oligometastatic bone disease involving the long bones is stereotactic body radiotherapy. (See "Radiation therapy for the management of painful bone metastases", section on 'Stereotactic radiation therapy'.)
PELVIS LESIONS — Operations are rarely required for stabilization of complete or impending pathologic fractures of the pelvis, other than for those involving the acetabulum [90,91]. Assessing the risk of fracture in acetabular lesions is discussed elsewhere. (See "Clinical presentation and evaluation of complete and impending pathologic fractures in patients with metastatic bone disease, multiple myeloma, and lymphoma", section on 'Acetabulum'.)
Frequently, pathologic acetabular fractures involve superior migration or medial (protrusio acetabuli) fracture/dislocation into the associated osteolytic defect. Healing of acetabular fractures, even after open reduction and internal fixation, cannot be relied upon. Further, many of these sorts of fractures are simply not amenable to standard means of fixation. Therefore, most pathologic acetabular fractures are addressed with a complex acetabular prosthetic arthroplasty reconstruction that distributes the stresses away from the diseased bone and into the intact bone of the superior ilium, when intact.
These reconstructions may involve modular porous tantalum total hip components to replace the missing bone, secured with screws [92,93]. Early results utilizing these newer implants suggest an advantage in survivorship over traditional cemented components with threaded pins and antiprotrusio cages [94-96].
Increasingly, to prevent fracture, painful osteolytic defects at risk for fracture around the pelvis and acetabulum have begun to be treated with percutaneous procedures, including cementoplasty (osteoplasty), and various methods of ablation, including radiofrequency ablation, cryoablation, and focused ultrasound. As noted above, combined osteoplasty with ablation (Ablation, Osteoplasty, Reinforcement, and Internal Fixation [AORIF]) has also been reported by orthopedic surgeons as well as interventional radiologists [11]. (See 'Alternatives to surgery' above and "Image-guided ablation of skeletal metastases".)
METASTATIC SPINE TUMORS — Optimal treatment of spine metastases can be complex and may require multimodality treatment strategies to achieve optimal outcomes. Decision making about surgical versus nonsurgical treatment in patients with metastatic spine tumors can be particularly difficult. A decision framework that is based on neurologic (extent of cord compression, presence or absence of myelopathy), oncologic (radiosensitivity of the malignancy, prior irradiation), mechanical (presence of spinal instability), and systemic factors (able to tolerate surgery) has been developed to assist in the decision-making process [97].
Indications for surgical treatment — In general, operative treatment may be indicated for patients with spinal metastases that are causing spinal instability or epidural spinal cord compression (ESCC) from a radioresistant tumor:
●Unstable spine – An unstable spine must be stabilized either by surgery with fixation or by percutaneous vertebral repair (in the absence of epidural disease) [98]. Pain from an unstable spine will not be relieved with radiation therapy (RT), and there is a lack of evidence on whether spinal bracing is an effective technique for reducing pain [99]. (See "Clinical presentation and evaluation of complete and impending pathologic fractures in patients with metastatic bone disease, multiple myeloma, and lymphoma", section on 'Assessing spinal stability'.)
●Epidural spinal cord compression – ESCC is a devastating complication of metastatic bone disease. It is defined as a mass lesion caused by tumor extension into the epidural space or a pathologic spine fracture with displacement of the cord. It may present as a surgical emergency with rapidly evolving neurologic deficit or with slowly progressive neurologic dysfunction and pain.
Patients with ESCC are a heterogeneous group, and treatment decisions (especially surgical versus nonsurgical treatment) must be individualized. Major considerations that inform both the urgency and selection of definitive treatment include the degree of neurologic compromise, the oncologic characteristics of the primary tumor (if known), the mechanical stability of the spine, and the systemic burden of cancer and medical comorbidities (the Neurologic, Oncologic, Mechanical, Systemic [NOMS] framework) [100]. This subject is discussed in detail elsewhere. (See "Treatment and prognosis of neoplastic epidural spinal cord compression", section on 'Baseline assessment' and "Treatment and prognosis of neoplastic epidural spinal cord compression", section on 'Selection of definitive treatment'.)
Postoperative radiation therapy — For most patients with solid tumor metastases, such as carcinomas and sarcomas, or lymphoma, we suggest postoperative RT following surgical treatment (decompression and/or stabilization) of spinal metastases due to the potentially catastrophic consequences of local tumor relapse or progression. While there are limited data assessing the specific benefit of postoperative RT in this setting, the addition of RT appears to improve functional outcomes, including the likelihood of maintaining ambulation and local control [101]. The role of RT after decompression in patients with ESCC is discussed in more detail elsewhere. (See "Treatment and prognosis of neoplastic epidural spinal cord compression", section on 'Selection of definitive treatment' and "Treatment and prognosis of neoplastic epidural spinal cord compression", section on 'Surgical decompression and spine stabilization'.)
Postprocedure RT for patients with multiple myeloma is controversial and is discussed separately. (See "Multiple myeloma: Overview of management", section on 'Skeletal lesions and bone health'.)
There are potential adverse events associated with RT delivered in proximity to surgery, particularly complications related to wound healing. The time interval between RT and surgery (or surgery and RT) should be at least one week to minimize wound complications, although there is a paucity of high-level evidence directly addressing this issue [102]. The optimal dose and fractionation of RT following surgery for spine metastasis are also not well defined, although conventionally fractionated schedules (eg, 20 Gy in 5 fractions or 30 Gy in 10 fractions) are commonly used. (See "Treatment and prognosis of neoplastic epidural spinal cord compression", section on 'Dose and fractionation'.)
While use of osteoclast inhibitors such as bisphosphonates or denosumab has become increasingly common to prevent skeletal-related events among patients with bone metastases, use of these agents does not obviate the need for RT after surgical stabilization for bone metastases. In one study, the need for secondary surgical intervention, local tumor progression, and pain were observed more frequently in patients who had stabilization surgery without adjuvant RT, despite the use of bisphosphonates [83]. This subject is discussed in detail elsewhere. (See "Osteoclast inhibitors for patients with bone metastases from breast, prostate, and other solid tumors".)
RT as an alternative to surgical decompression — In the absence of spinal instability, primary radiation therapy (RT) is a reasonable treatment for symptomatic skeletal metastases, including those associated with vertebral compression fractures. (See "Radiation therapy for the management of painful bone metastases".)
RT is not an effective alternative to surgical stabilization in a patient with vertebral compression fracture and an unstable spine, as RT cannot relieve the pain associated with an unstable spine. (See "Treatment and prognosis of neoplastic epidural spinal cord compression", section on 'Patients with spinal instability'.)
Whether RT (conventional fractionation or stereotactic body radiotherapy [SBRT]) represents a suitable alternative to surgical intervention for ESCC related to vertebral metastases is a controversial subject, and several factors, including spinal stability, patient age, and disease extent/performance status are important considerations (see "Treatment and prognosis of neoplastic epidural spinal cord compression", section on 'Selection of definitive treatment'):
In the absence of ESCC, RT is often used as an alternative to surgical management, especially in the following circumstances:
●The older patient population is generally less likely to be managed surgically. A multicenter retrospective German study of palliative RT was limited to 322 patients aged 70 years or older [103]. The group included 183 patients with unstable spinal metastases and 68 patients with pathologic fractures. Significant recalcification and stabilization were observed in 40 percent (31 of 78) of surviving patients at six months. New pathologic fractures were noted in only 5 percent of patients after RT, and breast cancer histology was associated with higher rates of stabilization.
●For patients with extensive systemic disease and a poor performance status with expected survival of only a few months, RT alone is a reasonable option for symptom palliation.
●SBRT provides an effective alternative to conventional external beam RT in patients with radioresistant or recurrent spinal metastases that are diagnosed early, before high-grade ESCC has developed [104]. (See "Treatment and prognosis of neoplastic epidural spinal cord compression", section on 'Stereotactic body radiotherapy'.)
Vertebral augmentation procedures — Vertebroplasty and kyphoplasty are percutaneous injection techniques that may reduce pain and, in some cases, stabilize the fracture. Vertebroplasty involves the percutaneous injection of bone cement (methylmethacrylate) under fluoroscopic guidance into a collapsed vertebral body. Kyphoplasty involves the introduction of inflatable bone tamps into the vertebral body; once inflated, the bone tamps variably restore the height of the vertebral body while creating a cavity that can then be filled with viscous bone cement.
Vertebroplasty and kyphoplasty are accepted options for carefully selected patients with symptomatic pathologic vertebral compression fractures without epidural disease, endplate fractures, or retropulsion of bone fragments into the spinal canal and with pain that is refractory to noninvasive therapies. Most centers restrict percutaneous cement augmentation procedures to thoracic, lumbar, and sacral fractures. Although clinical experience is limited, we agree with American Society for Radiation Oncology guidelines, and suggest that RT be used in conjunction with kyphoplasty or vertebroplasty for most patients with vertebral metastases [79]. Postprocedure RT for patients with multiple myeloma is controversial and is discussed separately. (See "Multiple myeloma: Overview of management", section on 'Skeletal lesions and bone health'.)
The evidence in support of vertebroplasty and kyphoplasty is well established. Among patients with malignant vertebral compression fractures, systematic reviews of studies conducted in cancer populations reported improved pain control and reductions in analgesic use and pain-related disability scores [105-108]. Two randomized trials have specifically addressed the benefit of vertebral augmentation procedures in patients with pathologic fractures:
●One trial evaluated kyphoplasty versus initial nonsurgical management in 134 patients with cancer and one to three painful vertebral compression fractures (37 percent with myeloma) [109]. Crossover to kyphoplasty was allowed for patients undergoing initial nonsurgical management at one month. In an intention-to-treat analysis, kyphoplasty resulted in decreased back-specific disability at one month and a lower percentage of patients requiring walking aids (46 versus 25 percent), bracing (22 versus 2 percent), bed rest (46 versus 23 percent), and medications of any kind (82 versus 52 percent). All patients who underwent kyphoplasty (whether initially or after crossover from the control group) had sustained improvements over 12 months. There were two adverse events in the kyphoplasty group: one non-Q wave infarction attributed to anesthesia, and adjacent vertebral fracture attributed to the procedure.
●The second randomized trial compared two different percutaneous methods for balloon kyphoplasty in 47 patients with malignant vertebral compression fractures and did not have a non-surgical control group for comparison [110]. One month postprocedure, all patients in both groups experienced meaningful improvements in back pain. No patient survived beyond three months.
A completed phase III trial compared combined kyphoplasty and intraoperative radiotherapy versus external beam radiotherapy for painful vertebral metastases [111]. However, results are not yet available.
Kyphoplasty versus vertebroplasty — Given the limitations in the available data, the choice between kyphoplasty and vertebroplasty generally is based on clinician preference and available expertise, patient factors, and cost. As an example, guidelines for use of a recommends that most individuals undergo the less costly vertebroplasty procedure [112], with the more expensive kyphoplasty procedure used in defined clinical scenarios (eg, acute vertebral compression fractures that should be treated within six weeks of fracture, fractures with a gas-filled cleft (ie, un-united fracture) or a fracture with a soft tissue tumor and absent cortex).
Data comparing kyphoplasty with vertebroplasty in cancer patients are limited. In one small study of 34 patients with symptomatic vertebral compression fractures related to multiple myeloma, patients with >50 percent compression underwent kyphoplasty, whereas patients with <50 percent compression underwent vertebroplasty [113]. Both procedures reduced overall pain and analgesic use, with modestly greater reductions in pain at six months and one year with kyphoplasty. There was no difference in the rate of complications.
Although kyphoplasty is more expensive, cement extravasation is more common with vertebroplasty. Some clinicians favor kyphoplasty patients with significant kyphosis (deformity more than 20 degrees) or if there is posterior vertebral cortex involvement, which make cement extravasation from vertebroplasty more likely [114]. On the other hand, vertebroplasty may be preferred when insertion of the balloon device is technically difficult due to severe vertebral collapse (>65 percent reduction in vertebral height) or if the fracture is more than three months old, in which case elevation of the endplate is unlikely [114].
This approach differs somewhat from the recommendation of an international myeloma working group, that suggests the use of kyphoplasty rather than vertebroplasty for patients with painful vertebral compression fractures [115]. However, a pooled analysis of 34 published case series conducted after this guideline was established concluded that both procedures were equally effective in patients with a vertebral compression fracture related to myeloma [116]. This subject is discussed in more detail elsewhere. (See "Multiple myeloma: Overview of management", section on 'Skeletal lesions and bone health'.)
Although there is a lack of evidence to support benefit in this setting, we suggest postprocedure RT (fractionated RT or SBRT) for most patients after vertebroplasty/kyphoplasty except for those with multiple myeloma. For many patients, pre-RT stabilization improves tolerance for positioning for RT planning and administration.
Contraindications — Vertebroplasty/kyphoplasty should be restricted to patients with symptomatic vertebral body fractures without epidural disease, endplate fractures, or retropulsion of bone fragments into the spinal canal. Other contraindications include the presence of neurologic damage related to fracture, systemic or local infection, an uncorrected hypercoagulable state, and severe cardiopulmonary disease [114,117]. Most centers restrict percutaneous cement augmentation procedures to thoracic, lumbar, and sacral fractures. These procedures are contraindicated in the cervical spine.
A vertebral body fracture with a posterior cortical breach is a relative contraindication to kyphoplasty/vertebroplasty. However, at least some data suggest that balloon kyphoplasty is safe and effective in experienced hands, albeit with a higher incidence of cement extravasation [118]. Patients who have involvement of the posterior elements (facet joints or laminae) require an additional posterior tension band. This can be accomplished with the placement of percutaneous pedicle screws at adjacent levels in addition to cement augmentation at the index level. In the cervical spine, open procedures are still required, although transoral vertebroplasty of the C2 level has been attempted. Gross instability of the cervical and upper thoracic spine requires an open instrumented fusion.
Patients with burst or compression fractures with additional lytic destruction of the posterior elements (ie, pedicles and/or joints) may require a posterior tension band in addition to kyphoplasty or vertebroplasty at the index level. A posterior tension band is most often created using percutaneous pedicle screws with polymethyl methacrylate augmentation delivered via fenestrated screws or vertebroplasty to secure the screws [119].
Complications — The risk of adverse outcomes appears to be low when the procedure is performed by an experienced clinician. Nevertheless, serious complications have occurred, including pulmonary embolism, spinal cord compression, and paraplegia. Intradural cement leakage requiring spinal surgery is a rare complication [106,120].
FUNCTIONAL AND ONCOLOGIC OUTCOMES — Local tumor control, pain relief, and function are the main criteria for evaluating the outcomes of treatment for completed or impending pathologic fractures. The most consistent result of operative intervention is alleviation of pain, which occurs in most patients. The survival of patients with cancer is usually determined more by the metastatic load in other sites than by metastases in the skeleton.
Although operative treatment is often carried out for metastatic bone disease, there are surprisingly few reports that detail functional and oncologic outcomes. The most consistent result of operative intervention is alleviation of pain, which occurs in most patients [95,121-126]. Most series report an ability to walk or good to excellent function in >50 percent of patients who have undergone surgery for metastatic bone disease [39,95,121,122,127-135]. However, the available studies vary considerably regarding the outcome parameters used to evaluate success. In particular, measures by which functional outcomes in the upper and lower extremities are evaluated are unique, and not directly comparable.
Instruments used for the assessments have included the Musculoskeletal Tumor Society [136] and Toronto Extremity Salvage Score [137] scales, which were designed to evaluate function following limb-sparing tumor resection for primary bone sarcomas, the response criteria of the Eastern Cooperative Oncology Group, which were designed to evaluate progression of disease and its impact on daily living abilities [138], and the Short-Form-36 questionnaire, for evaluating general health status [139].
One difficulty in evaluating functional results of treatment in these patients is that the natural history is one of inevitable disease progression. Therefore, as the disease progresses to involve other sites, any early success with initial treatment may be masked by the devastating effects of the next site of progression. Ultimately, longer term follow-up is limited by the patients' limited lifespans. Furthermore, at least for patients with spine metastases and epidural spinal cord compression, functional outcomes (especially the ability to ambulate post-treatment) are highly dependent on neurologic status prior to treatment. (See "Treatment and prognosis of neoplastic epidural spinal cord compression", section on 'Prognosis'.)
Reoperation either because of local tumor progression or failure of fixation is reported in less than 10 percent of patients who are treated with operative intervention followed by radiation therapy [39-42,54,121,128,129,140].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Cancer pain" and "Society guideline links: Management of bone metastases in solid tumors".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.):
●Basics topics (see "Patient education: Hip fracture (The Basics)" and "Patient education: Bone metastases (The Basics)")
●Beyond the Basics topics (see "Patient education: Treatment of metastatic breast cancer (Beyond the Basics)" and "Patient education: Treatment for advanced prostate cancer (Beyond the Basics)" and "Patient education: Non-small cell lung cancer treatment; stage IV cancer (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Goals of treatment – The goals of treatment for a complete or impending pathologic fracture are to palliate pain, minimize morbidity, and maximize function and skeletal integrity for the duration of the patient's remaining life span, while maintaining the patient's quality of life and goals of care. (See 'Goals of surgery' above.)
●General management principles:
•Operative intervention for a complete or impending pathologic fracture is generally a palliative procedure. Patients being considered for surgical fixation should have an estimated survival duration that is at least as long as the time needed to recover from the procedure. Effective surgical palliation should last the expected survival duration. (See 'Contraindications' above and 'Palliation to exceed expected survival' above.)
Fixation or reconstruction may not be indicated for a patient with a very short prognosis or a very poor performance status or who is bedbound. In such cases, palliative radiation therapy (RT) may be preferred, if consistent with the goals of care. (See "Radiation therapy for the management of painful bone metastases" and 'RT as an alternative to surgery for an impending fracture' above.)
•Synchronous bone metastases should be managed appropriately.
•It is better to identify and manage at-risk lesions before they fracture, as outcomes are generally better with surgical management of impending compared with completed pathologic fractures.
•Patients with pathologic fractures undergoing orthopedic surgery are at high risk for venous thromboembolism and should receive prophylactic anticoagulation. Prophylactic anticoagulation may also be indicated for patients who are not being treated surgically, but are immobilized by their fracture. (See 'VTE prophylaxis' above.)
•Osteoclast inhibitors such as bisphosphonates and denosumab reduce the frequency of skeletal-related events and use of one of these agents is indicated for patients with bone involvement from lymphoma, multiple myeloma, or metastatic carcinoma, regardless of histology, if they are considered at risk of fracture. Specific recommendations are provided separately. (See "Osteoclast inhibitors for patients with bone metastases from breast, prostate, and other solid tumors".)
●Long bone fractures
Untreated, pathologic fracture of the long bones frequently leads to life-long disability; thus, surgery is required unless survival is extremely limited.
For complete or impending pathologic fractures of the long bones, the specific operative strategy is individualized to the anatomic site and extent of tumor destruction. (See 'Options for fixation/reconstruction' above.)
•For most patients undergoing surgery for an impending or completed pathologic fracture from a solid tumor or lymphoma, we suggest postoperative RT (Grade 2C). (See 'Postoperative radiation therapy' above.)
Postprocedure RT for patients with multiple myeloma is controversial and is discussed separately. (See "Multiple myeloma: Overview of management", section on 'Skeletal lesions and bone health'.)
●Pelvis fractures
•Operations are rarely required for complete or impending pathologic fractures of the pelvis, other than for those involving the acetabulum. (See 'Pelvis lesions' above.)
•Most pathologic acetabular fractures are addressed with a complex acetabular prosthetic arthroplasty reconstruction that distributes the stresses away from the diseased bone and into the intact bone of the superior ilium, when intact.
●Metastatic spine tumors
•For patients with malignant vertebral compression fractures, operative treatment is required if the spinal metastases are causing spinal instability. (See 'Indications for surgical treatment' above.)
Specific recommendations for epidural spinal cord compression are provided separately. (See 'Metastatic spine tumors' above and "Treatment and prognosis of neoplastic epidural spinal cord compression", section on 'Selection of definitive treatment'.)
•For most patients with metastatic solid tumors or lymphoma, we suggest postoperative RT following decompression and/or stabilization (Grade 2C). (See 'Postoperative radiation therapy' above.)
Postprocedure RT for patients with multiple myeloma is controversial and is discussed separately. (See "Multiple myeloma: Overview of management", section on 'Skeletal lesions and bone health'.)
•In the absence of spinal instability, both surgical fixation (with postoperative RT) and primary RT are reasonable treatment options for symptomatic axial skeletal metastases, including those causing vertebral compression fractures. These treatment decisions are individualized. (See 'RT as an alternative to surgical decompression' above and "Radiation therapy for the management of painful bone metastases" and "Treatment and prognosis of neoplastic epidural spinal cord compression", section on 'Patients with spinal instability'.)
•Vertebroplasty and kyphoplasty are accepted nonsurgical options for carefully selected patients. (See 'Kyphoplasty versus vertebroplasty' above.)
We suggest postprocedure RT for most patients after vertebroplasty/kyphoplasty except for those with multiple myeloma (Grade 2C).
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Jerome Posner, MD, and Thomas F DeLaney, MD, who contributed to an earlier version of this topic review.
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