Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Evaluation and management of complete and impending pathologic fractures in patients with metastatic bone disease, multiple myeloma, and lymphoma

Timothy A Damron, MD
Jeffrey A Bogart, MD
Mark Bilsky, MD
Section Editors
Reed E Drews, MD
Thomas F DeLaney, MD
Janet Abrahm, MD
Deputy Editor
Diane MF Savarese, MD


Bone metastases are a common manifestation of distant relapse from many types of solid cancers, especially those arising in the lung, breast, and prostate. Bone involvement can also be extensive in patients with multiple myeloma, and bone may be a primary or secondary site of disease involvement in patients with lymphoma. (See "Clinical features, laboratory manifestations, and diagnosis of multiple myeloma" and "Primary lymphoma of bone".)

Among patients with advanced malignancy, bone metastases represent a prominent source of morbidity [1,2]. Skeletal-related events (SREs) due to bone metastases include pain, pathologic fracture, hypercalcemia, and spinal cord compression. Across a wide variety of tumors with bone involvement, the frequency of SREs can be reduced through use of osteoclast inhibitors such as bisphosphonates or denosumab. (See "Osteoclast inhibitors for patients with bone metastases from breast, prostate, and other solid tumors" and "The use of bisphosphonates in patients with multiple myeloma".)

A fracture that develops through an area of bone pathology is termed a pathologic fracture. In some cases, the extent of bone destruction is such that a fracture is imminent, but not complete (termed an impending fracture). Pathologic fractures can be secondary to a benign lesion (eg, Paget disease, giant cell tumor of bone, hemangioma) or a malignant tumor, which may be a primary bone tumor (osteosarcoma, chondrosarcoma, lymphoma) or metastatic carcinoma, multiple myeloma, or lymphoma. The goals of treatment, regardless of underlying etiology, are to minimize morbidity and maximize function and skeletal integrity. For most patients with a completed or impending pathologic fracture of a long bone, this will necessitate surgical fixation. (See "Clinical manifestations and diagnosis of Paget disease of bone" and "Giant cell tumor of bone" and "Osteosarcoma: Epidemiology, pathogenesis, clinical presentation, diagnosis, and histology" and "Chondrosarcoma" and "Clinical features, laboratory manifestations, and diagnosis of multiple myeloma".)

This topic review will cover the epidemiology, clinical presentation, imaging evaluation, and therapeutic options for a complete or impending pathologic fracture in patients with metastatic cancer, multiple myeloma, and lymphoma. An overview of the epidemiology, clinical presentation, diagnosis, and therapeutic options for bone metastases in general, issues related to pathologic fractures in Paget disease and in patients with a primary bone tumor such as osteosarcoma, and the use of radiation therapy for the management of painful bone metastases without a pathologic fracture are discussed elsewhere. (See "Overview of the epidemiology, clinical presentation, diagnosis, and management of adult patients with bone metastasis" and "Treatment of Paget disease of bone", section on 'Role of surgery' and "Giant cell tumor of bone", section on 'Surgery' and "Bone sarcomas: Preoperative evaluation, histologic classification, and principles of surgical management", section on 'Patient selection' and "Radiation therapy for the management of painful bone metastases".)


Bone is one of the most common sites of distant metastases from cancer and is particularly common in multiple myeloma. Among visceral cancers, breast, prostate, lung, thyroid, and kidney cancer account for 80 percent of all skeletal metastases, but many other primary malignant tumors can spread to bone including multiple myeloma, lymphoma, uterine leiomyosarcoma, and hepatocellular and uterine carcinomas. (See "Overview of the epidemiology, clinical presentation, diagnosis, and management of adult patients with bone metastasis", section on 'Epidemiology'.)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Oct 6, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Coleman RE. Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res 2006; 12:6243s.
  2. Pockett RD, Castellano D, McEwan P, et al. The hospital burden of disease associated with bone metastases and skeletal-related events in patients with breast cancer, lung cancer, or prostate cancer in Spain. Eur J Cancer Care (Engl) 2010; 19:755.
  3. Buggay D, Jaffe K. Metastatic bone tumors of the pelvis and lower extremity. J Surg Orthop Adv 2003; 12:192.
  4. Melton LJ 3rd, Kyle RA, Achenbach SJ, et al. Fracture risk with multiple myeloma: a population-based study. J Bone Miner Res 2005; 20:487.
  5. Hu YC, Lun DX, Wang H. Clinical features of neoplastic pathological fracture in long bones. Chin Med J (Engl) 2012; 125:3127.
  6. Sim FH. Metastatic bone disease of the pelvis and femur. Instr Course Lect 1992; 41:317.
  7. Yoo JH, Yang BK, Kim JH, et al. A case of pathologic fracture of femur whose primary tumor and occult metastases were ascertained by PET-CT. Arch Orthop Trauma Surg 2009; 129:155.
  8. Bickels J, Dadia S, Lidar Z. Surgical management of metastatic bone disease. J Bone Joint Surg Am 2009; 91:1503.
  9. Fayad LM, Kamel IR, Kawamoto S, et al. Distinguishing stress fractures from pathologic fractures: a multimodality approach. Skeletal Radiol 2005; 34:245.
  10. Nazarian A, Entezari V, Zurakowski D, et al. Treatment Planning and Fracture Prediction in Patients with Skeletal Metastasis with CT-Based Rigidity Analysis. Clin Cancer Res 2015; 21:2514.
  11. Yuh WT, Zachar CK, Barloon TJ, et al. Vertebral compression fractures: distinction between benign and malignant causes with MR imaging. Radiology 1989; 172:215.
  12. Aggarwal A, Salunke P, Shekhar BR, et al. The role of magnetic resonance imaging and positron emission tomography-computed tomography combined in differentiating benign from malignant lesions contributing to vertebral compression fractures. Surg Neurol Int 2013; 4:S323.
  13. Baur A, Stäbler A, Brüning R, et al. Diffusion-weighted MR imaging of bone marrow: differentiation of benign versus pathologic compression fractures. Radiology 1998; 207:349.
  14. Spuentrup E, Buecker A, Adam G, et al. Diffusion-weighted MR imaging for differentiation of benign fracture edema and tumor infiltration of the vertebral body. AJR Am J Roentgenol 2001; 176:351.
  15. Herneth AM, Philipp MO, Naude J, et al. Vertebral metastases: assessment with apparent diffusion coefficient. Radiology 2002; 225:889.
  16. Byun WM, Jang HW, Kim SW, et al. Diffusion-weighted magnetic resonance imaging of sacral insufficiency fractures: comparison with metastases of the sacrum. Spine (Phila Pa 1976) 2007; 32:E820.
  17. Karchevsky M, Babb JS, Schweitzer ME. Can diffusion-weighted imaging be used to differentiate benign from pathologic fractures? A meta-analysis. Skeletal Radiol 2008; 37:791.
  18. Chen WT, Shih TT, Chen RC, et al. Blood perfusion of vertebral lesions evaluated with gadolinium-enhanced dynamic MRI: in comparison with compression fracture and metastasis. J Magn Reson Imaging 2002; 15:308.
  19. Scherer A, Wittsack HJ, Strupp C, et al. Vertebral fractures in multiple myeloma: first results of assessment of fracture risk using dynamic contrast-enhanced magnetic resonance imaging. Ann Hematol 2002; 81:517.
  20. Rupp RE, Ebraheim NA, Coombs RJ. Magnetic resonance imaging differentiation of compression spine fractures or vertebral lesions caused by osteoporosis or tumor. Spine (Phila Pa 1976) 1995; 20:2499.
  21. Jacofsky DJ, Haidukewych GJ. Management of pathologic fractures of the proximal femur: state of the art. J Orthop Trauma 2004; 18:459.
  22. Fogelman I, Cook G, Israel O, Van der Wall H. Positron emission tomography and bone metastases. Semin Nucl Med 2005; 35:135.
  23. Kao CH, Hsieh JF, Tsai SC, et al. Comparison and discrepancy of 18F-2-deoxyglucose positron emission tomography and Tc-99m MDP bone scan to detect bone metastases. Anticancer Res 2000; 20:2189.
  24. Gallowitsch HJ, Kresnik E, Gasser J, et al. F-18 fluorodeoxyglucose positron-emission tomography in the diagnosis of tumor recurrence and metastases in the follow-up of patients with breast carcinoma: a comparison to conventional imaging. Invest Radiol 2003; 38:250.
  25. Kato K, Aoki J, Endo K. Utility of FDG-PET in differential diagnosis of benign and malignant fractures in acute to subacute phase. Ann Nucl Med 2003; 17:41.
  26. Shin DS, Shon OJ, Byun SJ, et al. Differentiation between malignant and benign pathologic fractures with F-18-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography. Skeletal Radiol 2008; 37:415.
  27. Bredella MA, Essary B, Torriani M, et al. Use of FDG-PET in differentiating benign from malignant compression fractures. Skeletal Radiol 2008; 37:405.
  28. Mulligan M, Chirindel A, Karchevsky M. Characterizing and predicting pathologic spine fractures in myeloma patients with FDG PET/CT and MR imaging. Cancer Invest 2011; 29:370.
  29. Gerety EL, Lawrence EM, Wason J, et al. Prospective study evaluating the relative sensitivity of 18F-NaF PET/CT for detecting skeletal metastases from renal cell carcinoma in comparison to multidetector CT and 99mTc-MDP bone scintigraphy, using an adaptive trial design. Ann Oncol 2015; 26:2113.
  30. Jadvar H, Desai B, Conti PS. Sodium 18F-fluoride PET/CT of bone, joint, and other disorders. Semin Nucl Med 2015; 45:58.
  31. Wedin R, Bauer HC, Skoog L, et al. Cytological diagnosis of skeletal lesions. Fine-needle aspiration biopsy in 110 tumours. J Bone Joint Surg Br 2000; 82:673.
  32. Datir A, Pechon P, Saifuddin A. Imaging-guided percutaneous biopsy of pathologic fractures: a retrospective analysis of 129 cases. AJR Am J Roentgenol 2009; 193:504.
  33. Yang YJ, Damron TA. Comparison of needle core biopsy and fine-needle aspiration for diagnostic accuracy in musculoskeletal lesions. Arch Pathol Lab Med 2004; 128:759.
  34. Mankin HJ, Mankin CJ, Simon MA. The hazards of the biopsy, revisited. Members of the Musculoskeletal Tumor Society. J Bone Joint Surg Am 1996; 78:656.
  35. Rougraff BT, Kneisl JS, Simon MA. Skeletal metastases of unknown origin. A prospective study of a diagnostic strategy. J Bone Joint Surg Am 1993; 75:1276.
  36. Katagiri H, Takahashi M, Inagaki J, et al. Determining the site of the primary cancer in patients with skeletal metastasis of unknown origin: a retrospective study. Cancer 1999; 86:533.
  37. Maillefert JF, Tavernier C, Tebib J. Determining the site of the primary cancer in patients with skeletal metastasis of unknown origin: A retrospective study. Cancer 2000; 88:1759.
  38. Simon MA, Bartucci EJ. The search for the primary tumor in patients with skeletal metastases of unknown origin. Cancer 1986; 58:1088.
  39. Saad F, Lipton A, Cook R, et al. Pathologic fractures correlate with reduced survival in patients with malignant bone disease. Cancer 2007; 110:1860.
  40. Sonmez M, Akagun T, Topbas M, et al. Effect of pathologic fractures on survival in multiple myeloma patients: a case control study. J Exp Clin Cancer Res 2008; 27:11.
  41. Blank AT, Lerman DM, Patel NM, Rapp TB. Is Prophylactic Intervention More Cost-effective Than the Treatment of Pathologic Fractures in Metastatic Bone Disease? Clin Orthop Relat Res 2016; 474:1563.
  42. Fidler M. Incidence of fracture through metastases in long bones. Acta Orthop Scand 1981; 52:623.
  43. Piccioli A, Maccauro G, Rossi B, et al. Surgical treatment of pathologic fractures of humerus. Injury 2010; 41:1112.
  44. Harrington KD. Impending pathologic fractures from metastatic malignancy: evaluation and management. Instr Course Lect 1986; 35:357.
  45. van der Linden YM, Kroon HM, Dijkstra SP, et al. Simple radiographic parameter predicts fracturing in metastatic femoral bone lesions: results from a randomised trial. Radiother Oncol 2003; 69:21.
  46. Parrish FF, Murray JA. Surgical treatment for secondary neoplastic fractures. A retrospective study of ninety-six patients. J Bone Joint Surg Am 1970; 52:665.
  47. Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res 1989; :256.
  48. Damron TA, Morgan H, Prakash D, et al. Critical evaluation of Mirels' rating system for impending pathologic fractures. Clin Orthop Relat Res 2003; :S201.
  49. El-Husseiny M, Coleman N. Inter- and intra-observer variation in classification systems for impending fractures of bone metastases. Skeletal Radiol 2010; 39:155.
  50. Evans AR, Bottros J, Grant W, et al. Mirels' rating for humerus lesions is both reproducible and valid. Clin Orthop Relat Res 2008; 466:1279.
  51. Van der Linden YM, Dijkstra PD, Kroon HM, et al. Comparative analysis of risk factors for pathological fracture with femoral metastases. J Bone Joint Surg Br 2004; 86:566.
  52. Mac Niocaill RF, Quinlan JF, Stapleton RD, et al. Inter- and intra-observer variability associated with the use of the Mirels' scoring system for metastatic bone lesions. Int Orthop 2011; 35:83.
  53. Leong NL, Anderson ME, Gebhardt MC, Snyder BD. Computed tomography-based structural analysis for predicting fracture risk in children with benign skeletal neoplasms: comparison of specificity with that of plain radiographs. J Bone Joint Surg Am 2010; 92:1827.
  54. Snyder BD, Hauser-Kara DA, Hipp JA, et al. Predicting fracture through benign skeletal lesions with quantitative computed tomography. J Bone Joint Surg Am 2006; 88:55.
  55. Damron TA, Nazarian A, Entezari V, et al. CT-based Structural Rigidity Analysis Is More Accurate Than Mirels Scoring for Fracture Prediction in Metastatic Femoral Lesions. Clin Orthop Relat Res 2016; 474:643.
  56. Goodheart JR, Cleary RJ, Damron TA, Mann KA. Simulating activities of daily living with finite element analysis improves fracture prediction for patients with metastatic femoral lesions. J Orthop Res 2015; 33:1226.
  57. van den Munckhof S, Zadpoor AA. How accurately can we predict the fracture load of the proximal femur using finite element models? Clin Biomech (Bristol, Avon) 2014; 29:373.
  58. Harrington KD. The management of acetabular insufficiency secondary to metastatic malignant disease. J Bone Joint Surg Am 1981; 63:653.
  59. Fehlings MD, Furlan J, Bilsky M, et al. Defining spinal instability of the cervical spine: Can the available evidence guide clinical practice? Spine 2014 [in press].
  60. Weber MH, Burch S, Buckley J, et al. Instability and impending instability of the thoracolumbar spine in patients with spinal metastases: a systematic review. Int J Oncol 2011; 38:5.
  61. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976) 1983; 8:817.
  62. DeWald RL, Bridwell KH, Prodromas C, Rodts MF. Reconstructive spinal surgery as palliation for metastatic malignancies of the spine. Spine (Phila Pa 1976) 1985; 10:21.
  63. Kostuik JP, Errico TJ, Gleason TF, Errico CC. Spinal stabilization of vertebral column tumors. Spine (Phila Pa 1976) 1988; 13:250.
  64. Fisher CG, DiPaola CP, Ryken TC, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976) 2010; 35:E1221.
  65. Snyder BD, Cordio MA, Nazarian A, et al. Noninvasive Prediction of Fracture Risk in Patients with Metastatic Cancer to the Spine. Clin Cancer Res 2009; 15:7676.
  66. Soldatos T, Chalian M, Attar S, et al. Imaging differentiation of pathologic fractures caused by primary and secondary bone tumors. Eur J Radiol 2013; 82:e36.
  67. Laufer I, Lis E, Pisinski L, et al. The accuracy of [(18)F]fluorodeoxyglucose positron emission tomography as confirmed by biopsy in the diagnosis of spine metastases in a cancer population. Neurosurgery 2009; 64:107.
  68. Damron TA, Sim FH. Surgical treatment for metastatic disease of the pelvis and the proximal end of the femur. Instr Course Lect 2000; 49:461.
  69. Parker MJ, Khan AZ, Rowlands TK. Survival after pathological fractures of the proximal femur. Hip Int 2011; 21:526.
  70. Toyoda Y, Shinohara N, Harabayashi T, et al. Survival and prognostic classification of patients with metastatic renal cell carcinoma of bone. Eur Urol 2007; 52:163.
  71. Sherry MM, Greco FA, Johnson DH, Hainsworth JD. Breast cancer with skeletal metastases at initial diagnosis. Distinctive clinical characteristics and favorable prognosis. Cancer 1986; 58:178.
  72. Scheid V, Buzdar AU, Smith TL, Hortobagyi GN. Clinical course of breast cancer patients with osseous metastasis treated with combination chemotherapy. Cancer 1986; 58:2589.
  73. Maximum androgen blockade in advanced prostate cancer: an overview of the randomised trials. Prostate Cancer Trialists' Collaborative Group. Lancet 2000; 355:1491.
  74. Utzschneider S, Schmidt H, Weber P, et al. Surgical therapy of skeletal complications in multiple myeloma. Int Orthop 2011; 35:1209.
  75. Shallop B, Starks A, Greenbaum S, et al. Thromboembolism After Intramedullary Nailing for Metastatic Bone Lesions. J Bone Joint Surg Am 2015; 97:1503.
  76. Ratasvuori M, Wedin R, Keller J, et al. Insight opinion to surgically treated metastatic bone disease: Scandinavian Sarcoma Group Skeletal Metastasis Registry report of 1195 operated skeletal metastasis. Surg Oncol 2013; 22:132.
  77. Nathan SS, Healey JH, Mellano D, et al. Survival in patients operated on for pathologic fracture: implications for end-of-life orthopedic care. J Clin Oncol 2005; 23:6072.
  78. Tokuhashi Y, Matsuzaki H, Toriyama S, et al. Scoring system for the preoperative evaluation of metastatic spine tumor prognosis. Spine (Phila Pa 1976) 1990; 15:1110.
  79. Bauer H, Tomita K, Kawahara N, et al. Surgical strategy for spinal metastases. Spine (Phila Pa 1976) 2002; 27:1124.
  80. Leithner A, Radl R, Gruber G, et al. Predictive value of seven preoperative prognostic scoring systems for spinal metastases. Eur Spine J 2008; 17:1488.
  81. Tokuhashi Y, Matsuzaki H, Oda H, et al. A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis. Spine (Phila Pa 1976) 2005; 30:2186.
  82. Tomita K, Kawahara N, Kobayashi T, et al. Surgical strategy for spinal metastases. Spine (Phila Pa 1976) 2001; 26:298.
  83. van der Linden YM, Dijkstra SP, Vonk EJ, et al. Prediction of survival in patients with metastases in the spinal column: results based on a randomized trial of radiotherapy. Cancer 2005; 103:320.
  84. Bollen L, Wibmer C, Van der Linden YM, et al. Predictive Value of Six Prognostic Scoring Systems for Spinal Bone Metastases: An Analysis Based on 1379 Patients. Spine (Phila Pa 1976) 2016; 41:E155.
  85. Gainor BJ, Buchert P. Fracture healing in metastatic bone disease. Clin Orthop Relat Res 1983; :297.
  86. Yazawa Y, Frassica FJ, Chao EY, et al. Metastatic bone disease. A study of the surgical treatment of 166 pathologic humeral and femoral fractures. Clin Orthop Relat Res 1990; :213.
  87. Dijstra S, Wiggers T, van Geel BN, Boxma H. Impending and actual pathological fractures in patients with bone metastases of the long bones. A retrospective study of 233 surgically treated fractures. Eur J Surg 1994; 160:535.
  88. Dijkstra S, Stapert J, Boxma H, Wiggers T. Treatment of pathological fractures of the humeral shaft due to bone metastases: a comparison of intramedullary locking nail and plate osteosynthesis with adjunctive bone cement. Eur J Surg Oncol 1996; 22:621.
  89. Wedin R, Bauer HC, Wersäll P. Failures after operation for skeletal metastatic lesions of long bones. Clin Orthop Relat Res 1999; :128.
  90. Wedin R, Bauer HC. Surgical treatment of skeletal metastatic lesions of the proximal femur: endoprosthesis or reconstruction nail? J Bone Joint Surg Br 2005; 87:1653.
  91. Steensma M, Healey JH, Boland PJ, et al. One Bone, One Operation? An analysis of reoperation for Failed surgical Treatment of Femur Metastases. In: Proceedings of the American Academy of Orthopedic Surgeons Annual Meeting, New Orleans 2010. p.780.
  92. Sarahrudi K, Greitbauer M, Platzer P, et al. Surgical treatment of metastatic fractures of the femur: a retrospective analysis of 142 patients. J Trauma 2009; 66:1158.
  93. Ward WG, Spang J, Howe D. Metastatic disease of the femur. Surgical management. Orthop Clin North Am 2000; 31:633.
  94. Sharma H, Bhagat S, McCaul J, et al. Intramedullary nailing for pathological femoral fractures. J Orthop Surg (Hong Kong) 2007; 15:291.
  95. Steensma M, Boland PJ, Morris CD, et al. Endoprosthetic treatment is more durable for pathologic proximal femur fractures. Clin Orthop Relat Res 2012; 470:920.
  96. Tanaka T, Imanishi J, Charoenlap C, Choong PF. Intramedullary nailing has sufficient durability for metastatic femoral fractures. World J Surg Oncol 2016; 14:80.
  97. Gregory JJ, Ockendon M, Cribb GL, et al. The outcome of locking plate fixation for the treatment of periarticular metastases. Acta Orthop Belg 2011; 77:362.
  98. Peterson JR, Decilveo AP, O'Connor IT, et al. What Are the Functional Results and Complications With Long Stem Hemiarthroplasty in Patients With Metastases to the Proximal Femur? Clin Orthop Relat Res 2016.
  99. Harvey N, Ahlmann ER, Allison DC, et al. Endoprostheses last longer than intramedullary devices in proximal femur metastases. Clin Orthop Relat Res 2012; 470:684.
  100. Herrenbruck T, Erickson EW, Damron TA, Heiner J. Adverse clinical events during cemented long-stem femoral arthroplasty. Clin Orthop Relat Res 2002; :154.
  101. Leddy LR. Rationale for reduced pressure reaming when stabilizing actual or impending pathological femoral fractures: a review of the literature. Injury 2010; 41 Suppl 2:S48.
  102. Patterson BM, Healey JH, Cornell CN, Sharrock NE. Cardiac arrest during hip arthroplasty with a cemented long-stem component. A report of seven cases. J Bone Joint Surg Am 1991; 73:271.
  103. Pitto RP, Koessler M, Kuehle JW. Comparison of fixation of the femoral component without cement and fixation with use of a bone-vacuum cementing technique for the prevention of fat embolism during total hip arthroplasty. A prospective, randomized clinical trial. J Bone Joint Surg Am 1999; 81:831.
  104. Randall RL, Aoki SK, Olson PR, Bott SI. Complications of cemented long-stem hip arthroplasties in metastatic bone disease. Clin Orthop Relat Res 2006; 443:287.
  105. Moon B, Lin P, Satcher R, Lewis V. Simultaneous nailing of skeletal metastases: is the mortality really that high? Clin Orthop Relat Res 2011; 469:2367.
  106. Alvi HM, Damron TA. Prophylactic stabilization for bone metastases, myeloma, or lymphoma: do we need to protect the entire bone? Clin Orthop Relat Res 2013; 471:706.
  107. Xing Z, Moon BS, Satcher RL, et al. A long femoral stem is not always required in hip arthroplasty for patients with proximal femur metastases. Clin Orthop Relat Res 2013; 471:1622.
  108. Moon B, Lin P, Satcher R, et al. Intramedullary nailing of femoral diaphyseal metastases: is it necessary to protect the femoral neck? Clin Orthop Relat Res 2015; 473:1499.
  109. Wedin R, Hansen BH, Laitinen M, et al. Complications and survival after surgical treatment of 214 metastatic lesions of the humerus. J Shoulder Elbow Surg 2012; 21:1049.
  110. Redmond BJ, Biermann JS, Blasier RB. Interlocking intramedullary nailing of pathological fractures of the shaft of the humerus. J Bone Joint Surg Am 1996; 78:891.
  111. Damron TA, Rock MG, Choudhury SN, et al. Biomechanical analysis of prophylactic fixation for middle third humeral impending pathologic fractures. Clin Orthop Relat Res 1999; :240.
  112. Al-Jahwari A, Schemitsch EH, Wunder JS, et al. The biomechanical effect of torsion on humeral shaft repair techniques for completed pathological fractures. J Biomech Eng 2012; 134:024501.
  113. Weiss KR, Bhumbra R, Biau DJ, et al. Fixation of pathological humeral fractures by the cemented plate technique. J Bone Joint Surg Br 2011; 93:1093.
  114. Abudu A, Carter SR, Grimer RJ. The outcome and functional results of diaphyseal endoprostheses after tumour excision. J Bone Joint Surg Br 1996; 78:652.
  115. Ahlmann ER, Menendez LR. Intercalary endoprosthetic reconstruction for diaphyseal bone tumours. J Bone Joint Surg Br 2006; 88:1487.
  116. Damron TA, Leerapun T, Hugate RR, et al. Does the second-generation intercalary humeral spacer improve on the first? Clin Orthop Relat Res 2008; 466:1309.
  117. Damron TA, Sim FH, Shives TC, et al. Intercalary spacers in the treatment of segmentally destructive diaphyseal humeral lesions in disseminated malignancies. Clin Orthop Relat Res 1996; :233.
  118. Heck R, Marinescu R, Janda H, et al. Is humeral segmental defect replacement device a stronger construct than locked IM nailing? Clin Orthop Relat Res 2010; 468:252.
  119. Henry JC, Damron TA, Weiner MM, et al. Biomechanical analysis of humeral diaphyseal segmental defect fixation. Clin Orthop Relat Res 2002; :231.
  120. Townsend PW, Smalley SR, Cozad SC, et al. Role of postoperative radiation therapy after stabilization of fractures caused by metastatic disease. Int J Radiat Oncol Biol Phys 1995; 31:43.
  121. Townsend PW, Rosenthal HG, Smalley SR, et al. Impact of postoperative radiation therapy and other perioperative factors on outcome after orthopedic stabilization of impending or pathologic fractures due to metastatic disease. J Clin Oncol 1994; 12:2345.
  122. Wolanczyk MJ, Fakhrian K, Adamietz IA. Radiotherapy, Bisphosphonates and Surgical Stabilization of Complete or Impending Pathologic Fractures in Patients with Metastatic Bone Disease. J Cancer 2016; 7:121.
  123. Bonarigo BC, Rubin P. Nonunion of pathologic fracture after radiation therapy. Radiology 1967; 88:889.
  124. Expert Panel On Radiation Oncology-Bone Metastases, Lutz ST, Lo SS, et al. ACR Appropriateness Criteria® non-spine bone metastases. J Palliat Med 2012; 15:521.
  125. British Association of Surgical Oncology Guidelines. The management of metastatic bone disease in the United Kingdom. The Breast Specialty Group of the British Association of Surgical Oncology. Eur J Surg Oncol 1999; 25:3.
  126. Guidelines for treatment of metastatic bone disease from the British Orthopedic Oncology Association available online at http://www.boa.ac.uk/Publications/Documents/Forms/Article%20Date%20Sort.aspx (Accessed on August 27, 2013).
  127. Lutz S, Balboni T, Jones J, et al. Palliative radiation therapy for bone metastases: Update of an ASTRO Evidence-Based Guideline. Pract Radiat Oncol 2016.
  128. Harada H, Katagiri H, Kamata M, et al. Radiological response and clinical outcome in patients with femoral bone metastases after radiotherapy. J Radiat Res 2010; 51:131.
  129. Cheng DS, Seitz CB, Eyre HJ. Nonoperative management of femoral, humeral, and acetabular metastases in patients with breast carcinoma. Cancer 1980; 45:1533.
  130. A Prospective Cohort Study of the Role of Surgery and/or Radiotherapy for Bone Metastases of the Femur at High Risk of Pathological Fracture (NCT01428895). http://www.cancer.gov/clinicaltrials/search/view?cdrid=711085&version=HealthProfessional&protocolsearchid=10911500 (Accessed on September 04, 2013).
  131. Harrington KD. Orthopedic surgical management of skeletal complications of malignancy. Cancer 1997; 80:1614.
  132. Rose PS, Halasy M, Trousdale RT, et al. Preliminary results of tantalum acetabular components for THA after pelvic radiation. Clin Orthop Relat Res 2006; 453:195.
  133. Khan FA, Rose PS, Yanagisawa M, et al. Surgical technique: Porous tantalum reconstruction for destructive nonprimary periacetabular tumors. Clin Orthop Relat Res 2012; 470:594.
  134. Marco RA, Sheth DS, Boland PJ, et al. Functional and oncological outcome of acetabular reconstruction for the treatment of metastatic disease. J Bone Joint Surg Am 2000; 82:642.
  135. Mendel E, Bourekas E, Gerszten P, Golan JD. Percutaneous techniques in the treatment of spine tumors: what are the diagnostic and therapeutic indications and outcomes? Spine (Phila Pa 1976) 2009; 34:S93.
  136. Lee SH, Cox KM, Grant R, et al. Patient positioning (mobilisation) and bracing for pain relief and spinal stability in metastatic spinal cord compression in adults. Cochrane Database Syst Rev 2012; :CD007609.
  137. Laufer I, Iorgulescu JB, Chapman T, et al. Local disease control for spinal metastases following "separation surgery" and adjuvant hypofractionated or high-dose single-fraction stereotactic radiosurgery: outcome analysis in 186 patients. J Neurosurg Spine 2013; 18:207.
  138. Bates T. A review of local radiotherapy in the treatment of bone metastases and cord compression. Int J Radiat Oncol Biol Phys 1992; 23:217.
  139. Moulding HD, Elder JB, Lis E, et al. Local disease control after decompressive surgery and adjuvant high-dose single-fraction radiosurgery for spine metastases. J Neurosurg Spine 2010; 13:87.
  140. Itshayek E, Yamada J, Bilsky M, et al. Timing of surgery and radiotherapy in the management of metastatic spine disease: a systematic review. Int J Oncol 2010; 36:533.
  141. Prince EA, Ahn SH. Interventional management of vertebral body metastases. Semin Intervent Radiol 2013; 30:278.
  142. Jawad MS, Fahim DK, Gerszten PC, et al. Vertebral compression fractures after stereotactic body radiation therapy: a large, multi-institutional, multinational evaluation. J Neurosurg Spine 2016; 24:928.
  143. Berenson J, Pflugmacher R, Jarzem P, et al. Balloon kyphoplasty versus non-surgical fracture management for treatment of painful vertebral body compression fractures in patients with cancer: a multicentre, randomised controlled trial. Lancet Oncol 2011; 12:225.
  144. Molloy S, Sewell MD, Platinum J, et al. Is balloon kyphoplasty safe and effective for cancer-related vertebral compression fractures with posterior vertebral body wall defects? J Surg Oncol 2016; 113:835.
  145. Bickels J, Kollender Y, Wittig JC, et al. Function after resection of humeral metastases: analysis of 59 consecutive patients. Clin Orthop Relat Res 2005; :201.
  146. Vena VE, Hsu J, Rosier RN, O'Keefe RJ. Pelvic reconstruction for severe periacetabular metastatic disease. Clin Orthop Relat Res 1999; :171.
  147. Ward WG, Holsenbeck S, Dorey FJ, et al. Metastatic disease of the femur: surgical treatment. Clin Orthop Relat Res 2003; :S230.
  148. Algan SM, Horowitz SM. Surgical treatment of pathologic hip lesions in patients with metastatic disease. Clin Orthop Relat Res 1996; :223.
  149. Atesok K, Liebergall M, Sucher E, et al. Treatment of pathological humeral shaft fractures with unreamed humeral nail. Ann Surg Oncol 2007; 14:1493.
  150. Behr JT, Dobozi WR, Badrinath K. The treatment of pathologic and impending pathologic fractures of the proximal femur in the elderly. Clin Orthop Relat Res 1985; :173.
  151. Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 2005; 366:643.
  152. Kollender Y, Bickels J, Price WM, et al. Metastatic renal cell carcinoma of bone: indications and technique of surgical intervention. J Urol 2000; 164:1505.
  153. Bauer HC. Posterior decompression and stabilization for spinal metastases. Analysis of sixty-seven consecutive patients. J Bone Joint Surg Am 1997; 79:514.
  154. Kay PR. Cement augmentation of pathological fracture fixation. J Bone Joint Surg Br 1989; 71:702.
  155. Camnasio F, Scotti C, Peretti GM, et al. Prosthetic joint replacement for long bone metastases: analysis of 154 cases. Arch Orthop Trauma Surg 2008; 128:787.
  156. Manoso MW, Frassica DA, Lietman ES, Frassica FJ. Proximal femoral replacement for metastatic bone disease. Orthopedics 2007; 30:384.
  157. Samsani SR, Panikkar V, Venu KM, et al. Breast cancer bone metastasis in femur: surgical considerations and reconstruction with Long Gamma Nail. Eur J Surg Oncol 2004; 30:993.
  158. Talbot M, Turcotte RE, Isler M, et al. Function and health status in surgically treated bone metastases. Clin Orthop Relat Res 2005; 438:215.
  159. Van Geffen E, Wobbes T, Veth RP, Gelderman WA. Operative management of impending pathological fractures: a critical analysis of therapy. J Surg Oncol 1997; 64:190.
  160. Enneking WF, Dunham W, Gebhardt MC, et al. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res 1993; :241.
  161. Davis AM, Wright JG, Williams JI, et al. Development of a measure of physical function for patients with bone and soft tissue sarcoma. Qual Life Res 1996; 5:508.
  162. Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982; 5:649.
  163. Ware JE Jr, Gandek B. Overview of the SF-36 Health Survey and the International Quality of Life Assessment (IQOLA) Project. J Clin Epidemiol 1998; 51:903.
  164. Baloch KG, Grimer RJ, Carter SR, Tillman RM. Radical surgery for the solitary bony metastasis from renal-cell carcinoma. J Bone Joint Surg Br 2000; 82:62.
Topic Outline