professor walid ebeid - orthopaedic oncologyorthopaediconcology.org/presentations/diaphyseal...
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Professor Walid Ebeid
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Professor Walid Ebeid
OOPS osteosarcoma!!
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Professor Walid Ebeid
SHOULD YOU INTERNALY FIX EVERY DIAPHYSEAL
FRACTURE?
NO
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Professor Walid Ebeid
Diaphyseal Pathological Fractures
Walid EbeidProfessor, orthopaedic department,
Cairo university, Cairo, Egypt
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Professor Walid Ebeid
How big is the problem ?
• Carcinomas are 500 times more common than sarcomas
• 50% of carcinomas develop bone metastases.• 25% of bone metastases progress to
pathological fractures.• Axial > long bones• Femur is the commonest followed by humerus• Only 7% occur distal to the knee and elbow
(usually lung and kidney)
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Professor Walid Ebeid
Role of the orthopaedic surgeon
• Diagnosis of the pathological fracture and staging of patient.
• Management of pathological fractures.• Management of impending fractures.
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Professor Walid Ebeid
• Definition of pathological fracture
• How do you suspect a pathological fracture?
• How do you diagnose the cause of the pathological fracture?
• How do you treat the patient who sustained a pathological fracture?
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Professor Walid Ebeid
Definition of a pathological fracture
• It is a fracture occurring in an abnormally weak bone.
• The cause of this weakness may be neoplastic, inflamatory, metabolic, etc..
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Professor Walid Ebeid
How do you suspect a pathological fracture?
• History• Xray
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Professor Walid Ebeid
How do you suspect a pathological fracture?
Patients could present to the orthopaedic surgeon with:
• Pathological fracture.• Impending fracture• Pain only.
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Professor Walid Ebeid
How do you suspect a pathological fracture?
History:• Trivial trauma• Pain (or limp) before the fracture• Known history of cancer• Symptoms suggestive of cancer (weight
loss, heamoptysis, heamatemesis, bleeding PR, urinary ..)
• History of previous irradiation
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Professor Walid Ebeid
How do you suspect a pathological fracture?
Xray:• abnormal bone quality• underlying lytic, blastic or mixed lesion• other lesions in the same or adjacent bone• abnormal fracture pattern
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
How do you diagnose & stage the cause of the pathological
fracture?
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Professor Walid Ebeid
• If it is a primary neoplasm, what type and what stage?
• If it is a secondary, where is the primary and are there other secondaries?
• If it is a non neoplastic cause, what is it?
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Professor Walid Ebeid
• General examination for LN, scars of previous operations, abnormal pigmentations or deformities.
• Breast: clinical exam. If not mammography + US & duplex
• Thyroid: clinical exam. If not U/S
• Prostate: PR • Rectum: PR
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Professor Walid Ebeid
• Laboratory investigations:
• CBC, ESR, kidney and liver functions.• Calcium, phosphorus, alkaline phosphatase, +/-
acid phosphatase.• Plasma protien electropheresis and
immunoelectropheresis.• CEA, CA 125 (ovary), CA 15-3 (breast), CA 19-9
(colon), B2 microglobulin (lymphoma) • PSA • Alpha feto protien.• PTH.
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Professor Walid Ebeid
• Chest & pelviabdominal CT.
• Bone scan.(false -ve in myeloma, lymphoma, histiocytosis. Extensive prostate mets .. Superscan looks normal but renal stealing)
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Professor Walid Ebeid
• Local MRI (includes the whole affected bone)
It is essential for detecting the exact extension of the lesion and the presence
of other lesions in the bone and thus allowing us to choose the most
appropriate method of fixation/replacement
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
• Investigations reveal the cause.• Investigations does not reveal the cause
Biopsy (core is preferable)diagnoses type of primary sarcoma and may give a clue to the site of
primary carcinoma
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Professor Walid Ebeid
Hence, you reach a diagnosis:
• Non neoplastic cause• Primary sarcoma and its stage• Myeloma (solitary or multiple)• Secondary
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Professor Walid Ebeid
If the fracture is due to secondary carcinoma
In addition to fracture management:• Is it solitary or multiple? Assess other lesions
for impending fracture.
• Known primary or unknown? Repeat investigations after 6 weeks.
• Primary tumour treated or not yet treated? Treat the primary
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Professor Walid Ebeid
How do you treat a pathological fracture?
In case of secondaries or myeloma
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Professor Walid Ebeid
Expectations!
• Level 1: normal unsupported ambulation• Level 2: supported ambulation.• Level 3: ambulation outside the bed.• Level 4: comfortable mobilization in bed.
This goal is determined according to the underlying cause, general condition, fracture
pattern, technical skills, economics…)
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Professor Walid Ebeid
Treatment options
• Non operative treatment
• Operative treatment
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Professor Walid Ebeid
• Is surgery associated with high risk mortality ?
• Will surgery achieve the proposed goal (bearing in mind the available implants, instruments, operative setting and technical skills) ?
YES
NO
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Professor Walid Ebeid
NON OPERATIVE TREATMENT
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Professor Walid Ebeid
Non operative treatment
• Biphosphonates (Zometa)• Radiotherapy• Pain control• Splints, traction, braces, etc..• DVT control• Ambulatory aids
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Professor Walid Ebeid
Non operative treatment
Biphosphonates:• blocks osteoclastic activity• decreases the incidence of fracture• decreases hypercalcaemia• decreases pain• reports on decreasing incidence of mets.Zoladronic acid (Zometa): 4 - 8mg short
infusion saline every 4 weeks.
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Professor Walid Ebeid
Non operative treatment
Radiotherapy:• partial pain relief in 80%• complete pain relief in 20%• it has a temporary effect.• It has no effect on renal cell carcinoma
mets, or sarcoma mets
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Professor Walid Ebeid
Non operative treatment
• Hormonal therapy: eg tamoxifen in breast cancer and LHRH agonist in prostate cancer.
• Chemotherapy.• Radioactive iodine in thyroid mets after
thyroidectomy.
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Professor Walid Ebeid
Non operative treatment
Pain control:• NSAI, neuroleptics, ms relaxants,
antidepressants• mild then strong opiods• Patient controlled analgesia (PCA)
+ biphosphonates+ radiotherapy
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Professor Walid Ebeid
Non operative treatment
DVT control:• used cautiously as there are circumstances of
increased bleeding tendency
Ambulatory aids:• crutches, walker, wheelchairs• splints, braces, slings
Vocational therapy
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Professor Walid Ebeid
• Is surgery associated with high risk mortality ?
• Will surgery achieve the proposed goal (bearing in mind the available implants, instruments, operative setting and technical skills) ?
NO
YES
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Professor Walid Ebeid
OPERATIVE TREATMENT
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Professor Walid Ebeid
Things you need to know before operating !!
What is the difference between treating a regular fracture and treating a
pathological fracture ?
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Professor Walid Ebeid
• The underlying lesion may continue to erode bone and no healing will occur so mechanics will depend totally on the implant.
• Surgery should be followed by radiotherapy to halt the disease process.
• There may be other weak areas in the bone present at the time of fracture or may appear later on.
• Survival may be limited thus rapid results is required to improve quality of life.
• Usually high risk patients for anaesthesia and they are liable to more complications intraoperatively and postoperatively.
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Professor Walid Ebeid
Prepare the patient:• Proper staging • Proper medical assessment and
preparation
Prepare Yourself• An array of various implant options and
sizes• Technically demanding
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Professor Walid Ebeid
Operative treatment
Perioperative considerations:• multidisciplinary anaesthesia, oncologist,
orthopaedist to assess risk• Cardiopulmonary high risk: recent MI, +ve
stress, severe heart failure, uncontrolled BP, pulm functions <35%.
• 10/30 rule, minimum platelets 50000, INR <1.5, serum albumin >2g/dl, normal Ca, P, Na, K.
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Professor Walid Ebeid
Adjunct procedures:
1. Preoperative embolization:• effective in 60 - 90%• gel foam, polyvinyl alcohol beads, coils..)• Operation should be done within 24 hrs if gel foam is
used and 24 - 36 hrs if alcohol is used.• Complications (rare): muscle and skin necrosis, paresis,
arrest.• Added value: decreases pain in inoperable cases !
2. IVC filters
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Professor Walid Ebeid
Operative treatment
Internal fixation(open reduction or minimally invasive)
ORReplacement
(after wide, marginal or intralesional resection)
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Professor Walid Ebeid
Internal fixation of fractures
• Preferablly intramedullary fixation or else a long plate.
• Reconstruction nails are better for femoral fixation than the regular interlocking nails.
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Professor Walid Ebeid
Internal fixation of fractures
Precautions during operation:1. Narrow fluted reamers2. Slow reaming3. Regular suction of contents4. Controlled insertion of implant5. Careful attention to heamodynamics and
oxygenation parameters during critical steps (anaesthesia).
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Professor Walid Ebeid
Internal fixation of fractures
When do you need to curette the lesion and cement it:
• Big cavities needing reinforcement• Lesions that you don’t expect to be
responsive to adjuvant therapy. • Whenever plates are used for fixation
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
Humeral lesions:
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Professor Walid Ebeid
Resection and replacement
Indications:• solitary lesions• lesions that are expected not to respond to
non operative treatment (RCC mets).• Lesions close to a joint so that ORIF is not
possible• expendable bones which are problematic• salvage of failed ORIF
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Professor Walid Ebeid
General principles in decision making:
• The first procedure has the best prognosis so do more rather than less to eliminate the need for a second procedure.
• Replace as much of the destroyed bone.• Do a procedure that will allow maximum
functional restoration.• Perform a wide surgical margin in resecting
solitary metastases aiming at cure.
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
Male, 61 yrs, colectomy 2rs ago
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Professor Walid Ebeid
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Professor Walid Ebeid
Male 38yrs, previous nephrectomy
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
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Professor Walid Ebeid
Impending pathological fracture or
Pain …. Staging …. Impending fracture
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Professor Walid Ebeid
Why do we need to do prophylactic fixation for impending
fractures?
• In comparison to fixing complete fractures:• Less blood loss.• Less hospital stay• Faster ambulation• May require a less morbid procedure and
a less expensive implant.
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Professor Walid Ebeid
Treatment of impending fractures
• Indications for prophylactic fixation (Mirels):
<6 = 0%, 12 = 100% incidence of fracture
1 2 3
S ite u p p e r lo w e r p e r i t r o c h a n te r ic
P a in m ild m o d e r a te fu n c t io n a l
L e s io n b la s t ic m ix e d ly t ic
S iz e < 1 /3 1 /3 - 2 /3 > 2 /3
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Professor Walid Ebeid
Technique of prophylactic fixation for diaphyseal lesions
• Proper entry point• Over reaming to avoid fracturing the bone
and to allow rotation to adjust anteversion.• Never use hammering for insersion
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Professor Walid Ebeid
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Professor Walid Ebeid
Radiotherapy
• If surgery is planned, radiotherapy should always be postop and not preop
• It has no effect on renal cell carcinoma mets, or sarcoma mets
• Some lesions (eg breast mets) may reconstitute after radiotherapy
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Professor Walid Ebeid
Relationship of fracture healing and irradiation
• irradiation affects chondrogenic phase of callus and not osteogenic phase.
• Higher incidence of healing with rigid internal fixation.
• Healing depends on type of tumour and expected survival (67% healing in myeloma, 37% in breast mets ..)
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Professor Walid Ebeid
Post radiotherapy
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Professor Walid Ebeid
Algorithm for management of pathological fractures
Diagnosis
Underlying cause revealed
Diagnosis
Biopsy
Underlying cause not revealed
Examination, Labs, Whole body scan, Bone scan, Local MRI
Suspect a pathological fractureHistoryXray
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Professor Walid Ebeid
Treat cause
Non neoplastic
SplintTreat accordingly
Primary bone tumour
Fixationchemo & radiotherapy
Myeloma
Assess impending fracturesMirels score
Multiple lesions
Repeat investigations after6 weeks
Unknown primary
Treat primary
Untreated primary
SecondaryManage fracture
+
Diagnosis
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Professor Walid Ebeid
Management of pathological fractures due tosecondaries
Radiotherapy
ORIF
Radiotherapy
Replacement
Assess:Location
Fracture patternRadiosensitivity
Favourable
Non operative treatment
Not favourable
ExpectationsGeneral condition
Facilities, technical skills, economics
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Professor Walid Ebeid
Managing pathological fractures requires the collaboration of:
• Orthopaedic surgeon• General surgeon• Clinical oncologist• Radiotherapist• Radiologist• Pathologist• Physiotherapist
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Professor Walid Ebeid
SHOULD YOU INTERNALY FIX EVERY DIAPHYSEAL
FRACTURE?
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Professor Walid Ebeid
Thank You