Abstract and Introduction
Abstract
The surgical management of patients with impending or realized pathologic fractures is fraught with multiple potential pitfalls. Many of these are unique to patients with metastatic bone disease and therefore warrant additional attention. An ordered systemic preoperative evaluation helps to prevent diagnostic omissions. A whole body bone scan and subsequent radiographic evaluation of all active lesions allows the identification of additional sites of concern that were not apparent on presentation. Determination of the tissue of origin, which is typically made with a thorough diagnostic evaluation, has implications for perioperative management and projected patient longevity that may influence operative planning. Before surgical intervention a histologic confirmation of metastatic disease must be obtained to prevent incidental intervention for a nonmetastatic lesion. Lastly, serum calcium levels should be assessed to rule out malignancy-associated hypercalcemia, a potentially fatal complication with nonspecific symptoms and an indolent progression. Both skeletal disease burden and projected patient longevity may influence whether skeletal fixation or arthroplasty is performed. Regardless of which modality is employed, a few general principles are constant. Surgical intervention should provide a durable reconstruction that allows immediate weight bearing and whose success is independent of osseous healing, which is unlikely to occur. As standard practice, long-stem, full-length implants are used to prophylactically splint the uninvolved segments of the operated bone, protecting against further disease progression. Optimal postoperative management requires use of localized and systemic therapies to limit metastatic disease progression and improve patient outcomes.
Introduction
In the management of any surgical patient, opportunities for treatment errors and complications are prevalent. Potential pitfalls that are unique to the management of patients with metastatic bone disease will be highlighted in this review. Patients with an impending or realized pathologic fracture represent a vulnerable and fragile patient population due to their advanced systemic illness and exposure to cytotoxic therapies. Regardless of the etiology, complications in this patient population are poorly tolerated and potentially fatal. The surgeon should be cognizant of the potential pitfalls in order to avoid them.