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7/21/2019 Pathological Fractures - Nov 2013
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PREVENTION OF PATHOLOGICAL
FRACTURE
AUDIT RESULTS & NEW STANDARDS & GUIDELINES14THNOVEMBER 2013PREVENTION OF PATHOLOGICAL FRACTURE (PPF) GUIDELINE DEVELOPMENT GROUP
DR MARIA DEBATTISTA
PAULA HORTON
SUSAN HOWARTH
BARBARA HUMPHRIES
DR ANDREW KHODABUKUS
JOANNE REYNOLDS
DR JENNY SMITH
MR PAUL COOL
DR AZMAN IBRAHIM
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POWERPOINT
PRESENTATIONJULY 2012
V1.0
POWERPOINT
PRESENTATIONJULY 2012
V1.0
SESSION OUTLINE
Overview
Existing Standards & Audit
Results
Updated Standards &
Guidelines
Mr Paul Cool - ExternalReview
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PROVENANCE
April 2005 initial guidelines produced
3rdMay 2012 Review meeting of MCPCNAG,majority quorate vote to review guidelines
Meetings of membership of Prevention ofPathological Fracture (PPF) guideline developmentgroup
17thJuly 2012
25thSeptember 2012
13thNovember 2012
11thJune 2013
12thSeptember 2013
16thOctober 2013
4thNovember 2013
Presentation of Literature Review on 4thJuly 2013
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PRESENTATIONJULY 2012
V1.0
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PRESENTATIONJULY 2012
V1.0
LITERATURE REVIEW
Main changes to evidencebase:
Mirels Score
upgraded to Level 2+ evidence Denosumab licensed for PPF
Breast cancer and solid tumours ifbisphosphonates would otherwise
be prescribed Not used in prostate cancer
Level 1+ Evidence
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PRESENTATIONJULY 2012
V1.0
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PRESENTATIONJULY 2012
V1.0
EXISTING STANDARDS & AUDITRESULTS
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PRESENTATIONJULY 2012
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DATA COLLECTION
Period
13thFebruary 201326thApril
2013
Collection Method
Case Note Audit
Evaluation of ProfessionalPractice
Disseminated to all ICNs
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PRESENTATIONJULY 2012
V1.0
POWERPOINT
PRESENTATIONJULY 2012
V1.0
CASE NOTE REVIEW
EVALUATION OF PROFESSIONAL
PRACTICE
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DEMOGRAPHICSEVALUATION OF PROFESSIONAL PRACTICE
38 Responses
8 ICNs
CNS 21 (55%), Doctors 17 (45%)
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DEMOGRAPHICSCASE NOTE REVIEW
69 Responses
6 ICNs, CNS 22 (32%), Doctors 37 (68%)
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PRESENTATIONJULY 2012
V1.0
POWERPOINT
PRESENTATIONJULY 2012
V1.0
DEMOGRAPHICSCASE NOTE REVIEW
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PRESENTATIONJULY 2012
V1.0
POWERPOINT
PRESENTATIONJULY 2012
V1.0
DEMOGRAPHICSCASE NOTE REVIEW
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PRESENTATIONJULY 2012
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PRESENTATIONJULY 2012
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DEMOGRAPHICSCASE NOTE REVIEW
N = 68
TotalResponses= 157 as
multiplemetastasesin some
9 (13%)
had bonepain and noknownmetastases
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PRESENTATIONJULY 2012
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PRESENTATIONJULY 2012
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DEMOGRAPHICSCASE NOTE REVIEW
Pain
62 responses
4 had missing data
100% one pain 43.5% two
12.9% three
3.2% four
0% five
24 (36%)
21 (32%)
19 (29%)
12 (18%)
10 (15%)
5 (8%)4 (6%)
3 (5%) 21 1
0
5
10
15
20
25
30
Location of Pain
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STANDARD 1
Reports of bone pain should be promptly andappropriately investigated following British
Association of Surgical Oncology (BASO)
Guidelines. [Grade D]
Source: Breast Specialty Group of the British Association of Surgical Oncology. The management of metastatic bone disease in the
United Kingdom. Eur J Surg Oncol 1999: 25: 323
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ASSESSMENTBRITISH ASSOCIATION OF SURGICAL ONCOLOGY GUIDELINES
Level of clinical
suspicion of
metastatic disease
Clinical Features Action
Minimal
Known cause for pain.
Resolves well usually 23
weeks from onset
Normal outpatients review. Return to GP if resolution
not complete
LowProbable cause known. Good
resolution over 46 weeks.
Plain radiograph.
If negative: no action.
If positive: follow advice regarding the need fororthopaedic assessment.
ModerateNo clear cause for pain which is
persistent but not progressive.
Plain radiographs, serum calcium and bone scan
within 10 working days. Review one week later.
If all negative, review in 8 weeks if symptomatic.
If one or more tests positive, follow advice regarding
the need for orthopaedic assessment.
High
No identified cause for pain.
Night pain, severe and/or
progressive pain.
Neurological symptoms and
signs.
Plain radiographs, serum calcium and bone scanwithin 10 working days. Review one week later.
If all negative but suspicion high, review in 1 week
(appendicular skeleton). If pain in spine then arrange
MRI
If one or more tests positive, follow advice regarding
the need for orthopaedic assessment.
Source: Breast Specialty Group of the British Association of Surgical Oncology. The management of
metastatic bone disease in the United kingdom. Eur J Surg Oncol1999: 25: 323
Level 4Expert Opinion
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STANDARD 1EVALUATION OF PROFESSIONAL PRACTICE
What awareness is there of the BASO criteria?
6
11
21
Unsure/Seek further help Scoring System Clinical assessment0
5
10
15
20
25
How would you assess risk of bone disease and fracture?
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STANDARD 1EVALUATION OF PROFESSIONAL PRACTICE
What awareness is there of the BASO criteria?
1
1
3
4
6
7
12
12
MSCC Guidelines
Trust Policy
BASO
NICE
MCCN Guidelines
Hartington
Mirels
None/Don't Know
0 2 4 6 8 10 12 14
What guidelines are you aware of that assess risk ofbone disease and pathological fracture?
Harrington
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STANDARD 1CASE NOTE REVIEW
WAS THE RISK OF METASTATIC BONE DISEASE ASSESSED?
28.8%(19)
0.0% (0)
0.0% (0)
0.0% (0)
0.0% (0)
37.9%(25)
37.9%(25)
0 5 10 15 20 25 30
Yes - risk assessed as probable metastaic disease butnot graded as one of options below
Yes - risk assessed according to BASO Guidelines as"minimal"
Yes - risk assessed according to BASO Guidelines as"low"
Yes - risk assessed according to BASO Guidelines as"moderate"
Yes - risk assessed according to BASO Guidelines as
"high"
No/Not documented
Not applicable-already known to have metastatic diseasein the area(s) of pain
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STANDARD 1CASE NOTE REVIEW
35 (57%)34 (55%)
33 (53%)
30 (48%)
22 (36%)
0
5
10
15
20
25
30
35
40
MRI scan CT scan Ca2+ & Alk Phos Plain radiograph (x-ray Isotope bone scan
What investigations has the patient had up to this assessmentdate?
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STANDARD 1CASE NOTE REVIEW
24 (39%)
14 (23%)
10 (16%)
8 (13%) 8 (13%)
5 (8%)
2 21
0
5
10
15
20
25
30
No-allappropriate
MRI scan Ca2+ & AlkPhos
Plainradiograph (x-
ray)
No - patienttoo unwell
CT Scan Isotope bonescan
No-reasonunclear
No-lowseverity/risk
What new investigations were organised after SPC assessment?
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STANDARD 1CASE NOTE REVIEW
28 (45%) 28 (45%)
8 (13%)
3 (5%) 3 (5%)
12 (19%)
0
5
10
15
20
25
30
Not applicable Increased pain Pain on weight-bearing
Pain at night Results of other investigations
Other symptoms orreasons
What prompted these investigations to be ordered or advised?
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POWERPOINT
PRESENTATIONJULY 2012
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Standard 1 Low knowledge of
BASO guidelines
Clinical reasoning isbetter
Reports of bone painshould be promptly
and appropriately
investigated following
British Association of
Surgical Oncology
(BASO) Guidelines.
[Grade D]
Source: Breast Specialty Group of the British Association of Surgical Oncology. The management of metastatic bone disease in the
United Kingdom. Eur J Surg Oncol 1999: 25: 323
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STANDARD 2
Patients presenting with a lesion due to metastatic
bone disease must be discussed with an
oncologist for consideration of further therapy(e.g. hormonal manipulation, bisphosphonates,
chemotherapy, radiotherapy) regardless of
orthopaedic intervention. [Grade C]
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PRESENTATIONJULY 2012
V1.0
POWERPOINT
PRESENTATIONJULY 2012
V1.0
STANDARD 2EVALUATION OF PROFESSIONAL PRACTICE
ORTHOPAEDIC ONCOLOGY
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PRESENTATIONJULY 2012V1.0
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PRESENTATIONJULY 2012V1.0
STANDARD 2EVALUATION OF PROFESSIONAL PRACTICE
Summary (from additional comments madeon questionnaire responses) Referral to an oncologist is likely to arise from a
combination of factors, primarily severe pain withradiological evidence of metastatic disease at thatsite.
Location is also a factor. Spinal disease,particularly where there is suspicion of impending
cord compression, is more likely to result in areferral than either upper or lower limb disease(74% compared to 55/56% respectively)
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STANDARD 2CASE NOTE REVIEW
11 (31%)
23 (64%)
7 (19%)
1 (2.8%)
0
5
10
15
20
25
Orthopaedic surgeon Oncologist None Missing Data
What discussions took place when investigations were completed?
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Standard 2 Evaluation of
professional practice
less than 100%
Case note analysis64%
But impact of poor
performance status
(affecting 35% of
sample)
Patients presentingwith a lesion due to
metastatic bone
disease must be
discussed with an
oncologist for
consideration of
further therapy (e.g.
hormonalmanipulation,
bisphosphonates,
chemotherapy,
radiotherapy)
regardless of
orthopaedic
intervention. [GradeC]
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STANDARD 3
If there is evidence of significant risk of apathological fracture, orthopaedic review should
be urgently sought and the patient seen within
one week. [Grade D]
Source: Breast Specialty Group of the British Association of Surgical Oncology. The management of metastatic bone disease in the
United Kingdom. Eur J Surg Oncol 1999: 25: 323
British Orthopaedic Association Working Party on Metastatic Bone Disease. Metastatic Bone Disease: A Guide to Good Practice. London.
2001.
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STANDARD 3CASE NOTE REVIEW
ALL DISCUSSED WITHORTHOPAEDICS
N = 11
Hospital 9 (82%),Community 1 (9%), Hospice
1 (95) 5 clearly discussed with
them within 1 week, 6 hadmissing data
Outcome 4 (36%) had treatment
4 (36%) none needed
2 (18%) poor PS
1 (9%) patient declined op
WHEN THERE WAS AN OVERTRISK GRADING
N = 1
Mirels of 8 graded by
ortho SHO Discussed within 1 week
Offered IM nail but patient
declined
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Standard 3 From data all had an
urgent orthopaedic
review
Hospital bias?
If there is evidence ofsignificant risk of a
pathological fracture,
orthopaedic review
should be urgently
sought and the
patient seen within
one week. [Grade D]
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PRESENTATIONJULY 2012V1.0
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STANDARD 4
When a fracture is likely to occur, prophylacticfixation, appropriate to the site of the lesion,
should be performed prior to treatment with
radiotherapy. [Grade D]
Source: Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathological fracture. Clin
Orthop Rel Res 1989; 249: 256-264.
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STANDARD 4EVALUATION OF PROFESSIONAL PRACTICE
Orthopaedic procedures in last 12 months
Procedure Number of responses
Femoral nail4
(2 bilateral, 1 post fracture on 1 side)
Total hip replacement1
(after fracture)
Nail of humerus3
(1 offered post fracture)
Vertebroplasty
2
(1 post spinal fracture)
Amputation 1
NOS IM nail 1
Other commentsusually too poorly to have treatment
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STANDARD 4EVALUATION OF PROFESSIONAL PRACTICE
Weeks38%
Months31%
Last Days oflife
31%
If so how long should that prognosis be?
45%
24%
21%
Yes No Unsure
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Do you think there is a minimal likelyprognosis needed for referral to an
orthopaedic surgeon to be appropriate?
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STANDARD 4CASE NOTE REVIEW
N = 3
IM Nail of humerus, IM nail of femur,
curettage and cementoplasty of femur
1 had radiotherapy, 2 did not due to
performance status
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Standard 4 All had consideration
re: radiotherapy
When a fracture islikely to occur,
prophylactic fixation,
appropriate to the
site of the lesion,
should be performed
prior to treatment
with radiotherapy.
[Grade D]
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STANDARD 5
Following any orthopaedic intervention
(prophylactic stabilisation or fracturemanagement) a patient must be discussed with
an oncologist regarding the possibility of further
therapy. [Grade D]
Source: Breast Specialty Group of the British Association of Surgical Oncology. The management of metastatic bone disease in the
United Kingdom. Eur J Surg Oncol 1999: 25: 323
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STANDARD 5EVALUATION OF PROFESSIONAL PRACTICE
Treatment Percentage
Single Fraction Radiotherapy 86.8%
Multiple fraction Radiotherapy 73.7%
Bisphosphonate Therapy 92.1%
Denosumab 23.7%
Other
10.5%
What oncological treatments to reduce risk of pathological
fractures have your patients received in the last 12 months?
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STANDARD 5EVALUATION OF PROFESSIONAL PRACTICE
39%
36%
9%
Yes No Unsure
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Do you think there is an appropriateminimal prognosis for referral to an
oncologist?
Few weeks62%
1-3 months30%
> 3 months8%
If so how long should that prognosis be?
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STANDARD 5CASE NOTE REVIEW
N = 3
IM Nail of humerus, IM nail of femur,
curettage and cementoplasty of femur
1 already on biologic agent, 2 did not due
to performance status
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Standard 5 All had consideration
re: chemotherapy
Following anyorthopaedic
intervention
(prophylactic
stabilisation or
fracture
management) a
patient must be
discussed with anoncologist regarding
the possibility of
further therapy.
[Grade D]
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POWERPOINT
PRESENTATIONJULY 2012V1.0
REVISED GUIDELINES FOR
THE PREVENTION OF
PATHOLOGICAL FRACTURESIN PALLIATIVE
CARE
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1.GENERAL PRINCIPLES (1)
Bone is one of the commonest sites of metastatic
disease. The most likely primary tumours to spread
to bone are breast, bronchus, kidney, thyroid and
prostate. The axial skeleton (skull, ribs, spine and
pelvis) is more likely to develop metastatic disease
than the appendicular skeleton. l
The major associated morbidities of bone metastasesinclude pain (the most common symptom occurring
in 70% of patients), pathological fractures (occurring
in 8-30% of patients) and hypercalcaemia.2,3
Advances in hormonal treatments, use of
bisphosphonates and chemotherapy treatments have
meant that the prognosis of patients with bone
metastases, without visceral metastatic disease, has
greatly improved. 4
1 GENERAL PRINCIPLES (2)
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1.GENERAL PRINCIPLES (2)
Survival rates for people with bone metastases vary
depending on the primary tumour type. In breast
cancer, median survival is 24 months with a 5-year
survival rate of 20% and in prostate cancer there is a5-year survival rate of 25% and a median survival of
40 months5.
Prediction of pathological fractures before the event
is a relevant clinical problem. Prophylactic fixation oflong bone metastases is generally easier for the
surgeon and less traumatic for the patient.
Therefore, prophylactic fixation of long bones prior
to radiotherapy should be considered. Stabilisation
of impending pathological fractures is likely to result
in shorter hospital stays, with patients more likely tobe discharged to their own homes.9
The prevention and management of pathological
fractures should be within the context of a multi-
disciplinary team. 5,10
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2. GUIDELINES
2.1 Investigation of bone pain (1)
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2.1 Investigation of bone pain (1)
Pain may be described as a dull ache to a deep
intense pain; pain at rest; pain exacerbated by weight
bearing and importantly, pain which is worse at night.2Patients should be encouraged to report skeletal
symptoms promptly.4
Bone pain may be due to structural damage,
periosteal irritation, nerve entrapment or secretion of
chemical mediators causing osteolysis e.g.prostaglandins and cytokines. These mediators
activate both osteoclasts and nociceptors.2
The clinical conundrum is to determine which pains
are due to new or existing metastatic disease and
which of these lesions may progress to a pathological
fracture.As such, reports of bone pain should be
investigated following the British Association of
Surgical Oncology (BASO) Guidelines (see Table 2.1).10[Level 4]
BASO GUIDELINES FOR THE INVESTIGATION OF
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BONE PAIN10[LEVEL 4]
Level of clinical suspicion of
metastatic disease
Clinical features
Action
Minimal
Known cause for pain.
Resolves well usually 2-3
weeks from onset.
Normal outpatient review.
Return to GP if resolution not
complete.
Low
Probable cause known. Good
resolution over 4-6 weeks.
Plain radiograph. If negative:
no action.
If positive: follow advice
regarding the need for
orthopaedic assessment.
Moderate
No clear cause for pain whichis persistent but not
progressive.
Plain radiographs, serum
calcium and bone scan within
10 working days. Review one
week later.
If all negative, review in 8
weeks if symptomatic.
If one or more tests positive,
follow advice regarding the
need for orthopaedic
assessment.
High
No identified cause for pain.
Night pain, severe and / or
progressive pain.
Neurological symptoms and
signs.
Plain radiographs, serum
calcium and bone scan within
10 working days. Review one
week later.
If all negative but suspicion
high, review in 1 week
(appendicular skeleton). If
pain in spine, then arrange
MRI.
If one or more tests positive,
then follow advice regarding
need for orthopaedic
assessment.
2 1 Investigation of bone pain (2)
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2.1 Investigation of bone pain (2)
Plain radiographs should be of the entire bone,
including the joint above and below the site of pain.
Specific radiographs should be centralised over thepainful area in an AP and lateral view.
Bone metastases may be described as osteolytic (bone
appears less dense on imaging), osteoblastic (where
bone looks denser or whiter on imaging) or mixed in
nature.4 [Level 4]
Any plain radiograph report that details the presence of
a lytic lesion in a long bone should be discussed with a
radiologist regarding its size and degree of cortical
involvement, if not already stated. 7, 8, 10[Level 4]
Plain radiographs are relatively insensitive at detecting
bone metastases.19Thus if clinical suspicion is highand radiographs are normal, further imaging is
warranted. This should be an isotope scan if the
appendicular skeleton is suspected, and an MRI if the
spine is potentially involved.19
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2.1 Investigation of bone pain (3)
Areas of increased uptake in any long bones on anisotope bone scan should be followed up by plain
radiographs of the whole bone in two planes at 90 to
each other, to assess for size and cortical
involvement.10[Level 4]
Patients with symptomatic bone metastases shouldbe referred urgently to an orthopaedic clinic or be
discussed at a site-specific multidisciplinary team
meeting if they have any of the following:
Structurally significant bone destruction.Uncertainty whether the destruction is
significant.
Pain of sudden onset (or change in character)
that is exacerbated by movement.10[Level 4]
PREDICTION OF PATHOLOGICAL
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PREDICTION OF PATHOLOGICAL
FRACTURE
Clinical features of impending pathological fractureinclude pain on movement, persistent pain and
increasing pain. Pain in an area which has already
been treated with radiotherapy, but has not
responded, may also be considered as a clinical
indicator of possible impending fracture.7,8
The risk of a pathological fracture occurring, and
therefore the need to consider prophylactic
fixation, may be assessed using either Mirels
scoring system (for use in long weight bearing
bones) or Harrington's classic definitions (use
restricted to the proximal femur).7
In Mirels scoring system (Table 32.2) [Level 2+], the
maximum possible score is 12. If a lesion scores 8
or above, then prophylactic fixation is
recommended pr ior to radiotherapy.
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Table 32.2 Mirels scoring system for the prediction of
pathological fractures 6[Level 2+]
ScoreClinicalfeatures
1 2 3
Site Upper limb Lower limb Peritrochanter
ic
Pain severity Mild Moderate Functional
Type of lesion Blastic Mixed Lytic
Size (Maximumdestruction of cortexin any view as seen on
plain x-ray)
2/3
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ANY ONE OF HARRINGTON'S CLASSIC DEFINITIONS
INDICATES A HIGH RISK OF PATHOLOGICAL
FRACTURE IN THE PROXIMAL FEMUR (SEE TABLE
2.3).8[LEVEL 3].
Table 2.3 Harrington's classic definitions. Risk of a pathological fracture 8 [Level 3]
1. 50% of circumferential cortical bone has been destroyed.
2. Where pain with weight bearing stresses persists, increases or recurs, despiteadequate localirradiation.
3. Lesions in the proximal femur in excess of 2.5cm in any dimension.
4. Lesions in the proximal femur associated with avulsion of the lesser trochanter.
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2.3 ROLE OF ORTHOPAEDIC SURGEON
A lead orthopaedic surgeon for appendicular
metastatic bone disease should be identified in
each local NHS trust. 4[Level 4]
Referral to an orthopaedic surgeon is appropriate in
the following situations:
Prophylactic fixation of metastatic deposits
when there is a high risk of fracture i.e.Mirelsscore equal or greater than 8 (see Table 32.2) or
the presence of any one of Harrington's classic
definitions (see Table 32.3).
Stabilisation or reconstruction after
pathological fracture.
Decompression of the spinal cord and nerve
roots and / or stabilisation for spinal
instability. 4[Level 4] (see Guidel ines on the
Management of Metastat ic Spinal Cord
Compress ion).
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2.4 RADIOTHERAPY
Radiotherapy has a major role in the treatment of
bone metastases. 70% of patients will achieve pain
relief with palliative external beam radiotherapy. It
may also prevent additional bone destruction, help
to maintain function, prevent neurologicalcompromise and maintain qualityof life.6
Following nailing of a bone, radiotherapy should be
considered by appropriate specialists
within the context of the multidisciplinary team. 5, 11,
12[Level 2-]
2.5 OTHER TREATMENT MODALITIES (1)
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( )
Bisphosphonates should be considered, where
clinically appropriate, for the prevention of
skeletal related events and treatment of malignantbone pain in patients with bone metastases
from breast cancer or hormone refractory prostate
cancer, and also patients with multiple
myeloma.13[Level 1+] Decisions to treat should be
based on an assessment of their general
medical condition and expected survival time (seeGuidel ines on the Use of Bisphos phonates in
the Management of Malignant Bone Disease).
[Level 4].
Radiofrequency ablation of bone metastases is anemerging alternative therapy for the
management of bony metastatic disease. Referral to
an appropriate specialist may be beneficial
for effective pain palliation and local control of
disease. 15[Level 3]
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2.5 OTHER TREATMENT MODALITIES (2)
Percutaneous cementoplasty is indicated forpatients with painful vertebral metastases. It is a
minimally invasive technique involving injection of
polymethylmethacrylate to strengthen a
vertebra. It may provide fast pain relief for patients
when traditional surgical options are considered to
be too invasive.16,17
[Level 3] Denosumab is recommended as an option for
preventing skeletal-related events from breast
cancer and from solid tumours, if bisphosphonates
would otherwise be prescribed. It can be used in
poor renal function. It is however not
recommended by NICE for use in prostate cancer,and carries the risk of potential osteonecrosis of
the jaw5. [Level 1+]
2 3 STANDARDS
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2.3 STANDARDS1. Reports of bone pain should be promptly and
appropriately investigated following British
Association of Surgical Oncology (BASO) Guidelines.10
[Grade D].
2. If there is evidence of significant risk of a pathological
fracture, urgent orthopaedic review should be
considered.4, 10[Grade D]
3. Following any orthopaedic intervention (prophylactic
stabilisation or fracture management) a patient shouldbe discussed with an oncologist regarding the
possibility of further therapy.10
[Grade D]
4. Patients presenting with a NEW OR SYMPTOMATIC
lesion due to metastatic bone disease must be
discussed with an oncologist for consideration of
further therapy (e.g. hormonal manipulation,
bisphosphonates,chemotherapy, radiotherapy)
regardless of orthopaedic intervention.10[Grade C]
2 4 REFERENCES (1)
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2.4 REFERENCES (1)
Tubiana-Hulin M. Incidence, prevalence and distribution of bone
metastases. Bone 1991; 12(Suppll):S9-S10.
Mercadante S. Malignant bone pain. Pathophysiology and treatment. Pain
1997; 69: 1-18.
Orthoteers Orthopaedic resource. Bone metastases. Available from
www.orthoteers.orgUpdated 29 May 2009. [Last accessed 1 June 2009]
British Orthopaedic Association Working Party on Metastatic Bone Disease.
Metastatic Bone Disease: A Guide to Good Practice. London. 2001.
NICE (2012) Denosumab for prevention of skeletal related events in adults
with bone metastases from solid tumours Accessed electronically at
http://www.nice.org.uk/nicemedia/live/13939/61129/61129.pdf Frassica DA. General principles of external beam radiation therapy for
skeletal metastases. Clin Orthop Rel Res 2003; 415 (Suppl): S158-164.
Mirels H. Metastatic disease in long bones. A proposed scoring system for
diagnosing impending pathological fracture. Clin Orthop Rel Res 1989; 249:
256-264.
Harrington KD. Impending pathological fractures from metastatic malignancy:
evaluation andmanagement. Instr Course Lect 1986; 35: 357-381. Ward WG, Spang J, Howe D, Gordan S. Femoral recon nails for metastatic
disease:
Indications, technique and results.AmJOrthop 2000; 29(9 Suppl): 34-42.
Breast Specialty Group of the British Association of Surgical Oncology. The
management ofmetastatic bone disease in the United Kingdom. Eur JSurg
Oncol 1999; 25: 3-23
2 4 REFERENCES (2)
http://www.orthoteers.org/http://www.nice.org.uk/nicemedia/live/13939/61129/61129.pdfhttp://www.nice.org.uk/nicemedia/live/13939/61129/61129.pdfhttp://www.nice.org.uk/nicemedia/live/13939/61129/61129.pdfhttp://www.orthoteers.org/7/21/2019 Pathological Fractures - Nov 2013
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2.4 REFERENCES (2)
Saarto T, James R, Tenhunen M, Kouri M. Palliative radiotherapy in the treatment of
skeletalmetastases. Eur J Pain 2002; 6(5): 323-330.
Townsend PW, Smalley SR, Cozad SC, Rosenthal HG, Hassanein RES. Role of
postoperative radiation therapy after stabilisation of fractures caused by metastaticdisease. Int J Radiat Oncol Biol Phys 1995; 31: 43-49.
Wong R, Wiffen PJ. Bisphosphonates for the relief of pain secondary to bone
metastases. Cochrane Database of Systematic Reviews 2002. Issue 2. Art
No.:CD002068. DOI:10.1002/14651858. CD002068.
Rosen LS, Gordon D, Tchekmedyian S, Yanaghihara R, Hirsh V, Krzakowski M et al.
Zoledronic acid versus placebo in the treatment of skeletal metastases in patients with
lungcancer and other solid tumours: a phase III double blind randomised trial - the
Zolendronic Acid Lung Cancer and Other Solid Tumour Groups Study Group. J Clin
Oncol 2003; 21(16): 3150-3157.
Thannos L, Mylona S, Galani P, Tzavoulis D, Kalioras V, Tanteles S et al.
Radiofrequency ablation of osseous metastases for the palliation of pain. Skeletal
Radio! 2008; 37: 189-194.
National Institute for Health and Clinical Excellence. Percutaneous cementoplasty
forpalliative treatment of bony malignancies (interventional procedures overview)
January 2006. Available from: www.nice.org.uk/ip304overview. [Last accessed 1 June
2009]
Lieberman I, Reinhardt MK. Vertebroplasty and kyphoplasty for osteolytic vertebralcollapse.
Clin Orthop Relat Res 2003; 415 (Suppl): S176-186.
Edelyston GA, Gillipsie PJ, Grebbell FS. The radiological demonstration of osseous
metastases: Experimental Observations. CLin Radiol 1967;18:158-62.
Eastley N, Newey M, Ashford. Skeletal metastases - The role of the orthopaedic and
spinal surgeon. Surg Oncol. 2012 Sep;21(3):216-22.