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Multidisciplinary approach aids management of pathologic hip fracture due to metastatic disease
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ORLANDO, Fla. — An isolated lesion discovered during diagnosis of a pathologic hip fracture should be treated as a primary tumor until proven otherwise, according to a presenter, here.
“An isolated lesion or an unknown primary [lesion] needs a full work up,” George J. Haidukewych, MD, said at the Current Concepts in Joint Replacement Winter Meeting. “Do not assume it is metastasis.”
According to Haidukewych, preoperative medical evaluation is key and orthopedic surgeons should work closely with the medical oncologist and radiation oncologist. Furthermore, using the Mirels scoring system can help manage treatment of pathologic fractures and provide an estimate of how likely it is for a fracture to occur in a lesion, he noted.
“As the Mirels score goes up, especially into the double digits, the probability of fracture goes up astronomically,” Haidukewych said. “If you have a low score of seven or less you can consider radiation therapy because that is a low likelihood to fracture. A high score should probably require prophylactic fixation.”
When fixing a proximal femur fracture, he noted long nails are preferred because they protect the entire bone and are superior to plates.
“Cement augmentation can be used for those [fractures] in between lesions, not quite bad enough to replace, but need a little bit of help,” Haidukewych said.
However, when there is not enough bone to work with, proximal femoral replacement may be indicated, according to Haidukewych. He noted orthopedic surgeons should always use cemented fixation and include enough cement to protect the entire bone. Venting the canal to prevent embolic complications is also something to consider, Haidukewych added.
When the acetabulum is involved, the Harrington technique can be valuable, and radiation following wound healing is recommended.
“If you do surgery, I do recommend you wait until the wound heals, about 3 weeks, before irradiating the area,” Haidukewych said. – by Casey Tingle
Reference:
Haidukewych GJ. Paper #17. Presented at: Current Concepts in Joint Replacement Winter Meeting; Dec. 9-12, 2015; Orlando, Fla.
Disclosure: Haidukewych reports he is a board or committee member for the American Academy of Orthopaedic Surgeons, received royalties and is a paid consultant for Zimmer Biomet and DePuy Synthes, is on the editorial or governing board for the Journal of Orthopaedic Trauma; has stock or stock options in Orthopediatrics, Institute for Better Bone Health, and received other financial or material support from DePuy Synthes.