Talk
- Where is the lesion?
- How big it is?
- What is the tumor doing? Wide/narrow margin of transition
- What is the bone doing in response?
- Zone of transition
- Periosteal reaction
- Is the lesion making matrix?
- Is cortex eroded?
- Is there soft tissue mass?
Approach
- Screen for the primary:
- history and examination
- Lab tests: FBC, electrophoresis,Biochemical markers
- Imaging: ct chest abdomen and pelvis
- Get more information about lesion
- Xray
- CT,MRI, Isotope scan
- Biopsy if primary source cannot be identified
- Never assume a solitary lesion to be metastasis
- Do not rush to fix
- MDT approach
Presentation
- A/C admission: Fracture/neurological compromise
- Ref by oncologist
- Unexplained MS Pain
Role of Orthopaedic surgeon in MDT
- Biopsy
- Solitary
- Primary unknown
- Long disease free interval
- More than 1 cancer
- Surgical treatment of metastasis for pain and to prevent fracture
- Stabilise/reconstruct pathological fracture
- Decompress spinal cord and nerve roots and stabilise spine
Aims of surgery
- Primary tumor should be excluded
- Immediate stability and allow wt bearing
- Assume fracture may not unite
- Fixation should last life time of patient
- All lesions should be stabilised
expectancy
- <12 mo: fixation
12 mo: endoprosthetic
Risk of fracture
- Mirel
- Pain (Most important)
- Type of lesion
- Location
- Size
9 risk of pathological fracture more, suggesting fixation
Appropriateness of operation
- Biological age
- Functional ability
- Comorbidities and ASA grade
- Patient motivation and life expectancy
General considerations
- Optimise comorbidities
- Hypercalcemia, fluid and electrolytes
- Xray entire affected bone
- MDT
- Preop embolisation
- VTE prophylaxis
- Analgesia
Hip
- Head, neck: Cemented semi
- Subtr
- limited loss: Nail
- Extensive: end prosthetic
- No BG
Pelvis: periacetabular
- Debulk
- Fill or bypass the defect
- Durable joint reconstruction
- Harrington classification
- 1:Intact walls
- II:Deficient medial wall
- III: All walls are affected
- IV: Solitary
SPINE
- Back pain in isolation
- Inpending neurology
- Complete neurology
- Extradural tumors are metastatic
- Intra dural extra medullary are benign
- Intramedullary are malignant
Risk assessment
- Tokuhasi
9 indicate longer life
- General condition
- Neurology
- No of bony spinal mets
- No of extra spinal bony mets
- No of visceral mets
- Tissue of origin
Timing
- with in 24 hr of neurology
- with in 7 days of mechanical instability