2002 OITE Question 196

Question

What is the most important factor when determining if surgery should be performed for a painful impending pathologic femur fracture in a patient with widely metastatic cancer?

1- Projected length of survival

2- Difficulty of the planned procedure

3- Prior local radiation therapy

4- Age of patient

5- Number of bony lesions

Figures

Answer (click for answer)

Preferred Answer 1

Controversy still surrounds the issue of the need and timing for prophylactic nailing of metastatic lesions without fracture of the femur shaft . Radiographic guidelines have been developed based on retrospective clinical studies. Prophylactic nailing is recommended if (1) the ratio between the width of the metastasis and the bone is greater than 0.6, (2) the axial cortical destruction is greater than 30 mm in length, or (3) the cortical destruction is greater than 50% of the circumference of the shaft. Smaller lesions in the subtrochanteric region are especially likely to act as stress risers for pathologic fractures. Many investigators considered contraindications to surgical stabilization to include a survival expectancy of less than 4 weeks, a premorbid general condition that precluded a safe general anesthesia and surgery, and complete mental deterioration of the patient to the point at which pain relief was not an issue.

Reference: Cancer Facts and Figures. Atlanta: American Cancer Society, 1999, pp 1-36


Frytak S, McLeod RA, Gunderson LL, Pritchard DJ, Unni KK: Lung cancer, in Sim FH (ed): Diagnosis and Management of Metastatic Bone disease: Amultidisciplinary approach. New York, NY, Raven Press, 1988, pp 305-317.