Bone tumor and Pathological fractures seminar and evidence based medicine based on a clinical case of pathological fracture humerus

1. EVIDENCE BASED MEDICINE
SEMINAR – PATHOLOGICAL
FRACTURE AND BONE TUMORS
CHAIRPERSON: DR. S. K. SAIDAPUR
PRESENTER: DR. ANMOL R MITTAL

2. CASE PRESENTATION: HISTORY
• A 76 year old male
• Ex-military man by occupation, now retired.
• h/o RTA, patient a 2 wheeler rider which was hit by
another 2 wheeler, fell on his right arm 2 days back.
• No h/o head injury (vomiting/loss of consciousness/ENT
bleed)
• c/o pain and inability to move right arm.
• Not a k/c/o diabetes mellitus, hypertension, asthma,
tuberculosis.
• No h/o radiation exposure, previously diagnosed or
treated cancer, weight loss, night cries.
• Not on any medication.

3. ON EXAMINATION
• GENERAL PHYSICAL EXAMINATION AND VITALS WERE
WITHIN NORMAL LIMITS
• ON LOCAL EXAMINATION:
INSPECTION: Swelling + ; Deformity over proximal third
of
arm ; ROM at shoulder: Painful ; Active
finger
movements +; overylying skin normal
PALPATION: Tenderness + ; Crepitus + ; Distal
pulsations +
Sensations +

4. • As per protocol, routine
investigations were done and
the relevant X rays of the
affected limb were taken.
• All routine investigations
were within normal limits
except for ESR which was
raised to 59mm /1st hour
(N: 0-10)
• X rays revealed an expansile
lytic lesion involving the
metaphyseo-diaphyseal
region of proximal humerus.
• This was evident of it being a
fracture through an already
diseased bone and the
management protocol shifted
towards that of a
pathological fracture.

5. DIFFERENTIAL DIAGNOSIS
• BASED ON AGE:
 METABOLIC: Osteoporosis, Osteomalacia , Paget’s disease,
Renal osteodystrophy, Hyperparathyroidism.
ONCOLOGICAL: Metastasis, Multiple myeloma, Lymphoma,
Chondrosarcoma, Osteosarcoma.
• BASED ON LOCATION:
Simple bone cyst, Aneurysmal bone cyst, Metastasis,
Mutiple
Myeloma, Giant cell tumour, Fibrous cortical, Non Ossifying
fibroma, Metabolic.

6. • Having immobilized the fractured limb in a U-slab, special
investigations were carried out in order to reach the
diagnosis.
• CT scan of thorax revealed no obvious evidence of any
primary tumor in the chest.
• CT scan of abdomen and pelvis revealed enlarged
prostate with the rest of the organ systems being normal.
• CT scan of the affected limb confirmed the X ray findings
and was suggestive of (?)Paget’s disease of the bone,
asking for clinical co-relation simultaneously.
• Prostate specific antigen level was 4.92ng/ml which
effectively ruled out bony metastasis from prostate, even
if a subclinical primary was present.
• Liver and Kidney function tests were also within normal
limits except high ALP (732 IU/L)

7. • Serum electrophoresis showed a fall in albumin level with
raised Alpha1, Beta 2 and Gamma components which
raised a suspicion of multiple myeloma.
• X ray of the skull was then taken which showed no obvious
deviations from the normal.
• Hence, an oncological predilection was ruled out as all
investigations pointed more towards an underlying
metabolic condition.
• Serum calcium and phosphate were within normal limits
• Urine analysis showed normal levels of excreted calcium
and phosphorous with no traces of hydroxyproline.
• Biopsy and immunofixation reports pending.

9. TREATMENT
• Surgical intervention in the form of closed reduction
internal fixation with an Intramedullary interlocking
nail was carried out, stabilizing the entire bone.
• Patient was started on routine calcium and vitamin
D3 medications.
• Patient was also explained about the option of
bisphosphonate therapy and the more costly
alternative, Denosumab.

10. POST OP X RAY

11. 1. EVIDENCE FOR IMIL NAILING
• TITLE: Intramedullary Nailing for Pathological Fractures of the Proximal
Humerus
• CITATION: Choi ES, Han I, Cho HS, Park IW, Park JW, Kim HS. Intramedullary
Nailing for Pathological Fractures of the Proximal Humerus. Clin Orthop Surg.
2016;8(4):458-464.
• PLACE: Department of Orthopedic Surgery, Seoul National University Hospital,
Seoul, Korea.
• Methods:32 patients with pathological fractures of the proximal humerus
underwent interlocking IM nailing. Functional scores and pain relief were
assessed as outcomes.
• Results: Improvement of pain assessed using the visual analogue scale was 6.2
on average. Thirty-one patients (97%) experienced no pain after surgery. The
mean ranges of motion tended towards normal. All patients achieved stability
and had no local recurrence without failure of fixation until the last follow-up.
• Conclusions: Proximal interlocking IM nailing is a reliable treatment option for
pathological or impending fractures of the proximal humerus.

12. 2. EVIDENCE FOR BISPHOSPHONATE AND
DENOSUMAB THERAPY
• TITLE: Treatment of osteopenia
• CITATION: Eriksen EF. Treatment of osteopenia. Rev Endocr Metab Disord.
2011;13(3):209-23.
• PLACE: Department of Clinical Endocrinology, Oslo University Hospital, Aker,
Trondheimsveien 235, 0514 Oslo, Norway
• CONCLUSION: Bisphosphonates remain the dominant treatment modalities
for osteopenia. They reduce fracture risk or recurrence in osteoporotic as
well as osteopenic individuals. Denosumab constitutes a future, more
compliant alternative to bisphosphonates.

13. PATHOLOGICAL FRACTURES
Fractures occurring in a bone already weakened by an
underlying local or systemic disease process.
Weakened bone predisposes the patient for failure
during normal activity or after minor trauma.

14. SYSTEMIC NON-NEOPLASTIC CAUSES
Correctable
• Renal osteodystrophy
• Hyperparathyroidism
• Osteomalacia
• Osteoporosis
Uncorrectable
• Osteogenesis
imperfecta
• Polyostotic fibrous
dysplasia
• Postmenopausal
osteoporosis
• Paget disease
• Osteopetrosis

15. NEOPLASTIC CAUSES
Benign
• Osteochondroma
• Enchondroma
• Periosteal Chondroma
• Chondroblastoma
• Osteiod osteoma
• Osteoblastoma
• Non ossifying fibroma
• Desmoplastic fibroma
• Giant cell tumor
• Bone cysts
• Fibroud dysplasia
• Osteofibrous dysplasia
• Langerhan cell histiocytosis
Malignant
• Osteosarcoma
• Chondrosarcoma
• Ewing’s sarcoma
OTHERS
• Multiple myeloma
• Primary Lymphoma
• Chordoma
• Adamantinoma
• Hemangiomas
• Angiosarcomas
• Metastasis

16. BURDEN
• Osteopenia affects 55% people over 50 years.
• 80% of these being women.
• 24% who suffer hip fracture in this bracket die
within 1 year.
• One out of every two women have osteoporosis
related fracture atleast once in her life.
• Spine, proximal femur, distal femur, distal radius
fractures are most common.

17. EVALUATION OF THE UNDERLYING DISEASE PROCESS
HISTORY
1. Degree of trauma
2. Presence of prodromal pain- dull aching to intense
pain exacerbated by weight bearing
3. Previously diagnosed or treated cancer
4. H/o radiation
5. Weight loss, fever, night sweats, fatigue
6. Dietary habits, smoking, alcohol intake, toxic
exposure

18. HISTORY SUGGESTING PATHOLOGICAL FRACTURE
• Spontaneous fracture
• Fractures after minor trauma
• Pain at the site before the fracture
• Multiple recent fractures
• Unusual fracture patterns
(Banana fracture)
• Patient older than 45 years
• History of malignancy.

19. PHYSICAL EXAMINATION
• Palpation of soft tissue mass at the fracture site
• Identification of an obvious deformity
• Neurovascular examination of the extremities and spine
• Evaluation of possible primary sites
( Breast, prostate, lung, thyroid, rectal )
• Lymphadenopathy.

20. INVESTIGATIONS
• CBC
• ESR
• Electrolytes
• BUN
• Serum glucose
• Liver function tests
• Total protein
• Albumin
• Serum and urinary calcium, phosphorus, and alkaline
phosphatase.

21. • Serum and urine electrophoresis- multiple myeloma
• Urinalysis and RFT - RCC
• Tumour markers: TFT, CEA, CA-125, PSA.
• N-telopeptide and C-telopeptide are markers of bone
collagen breakdown measured in serum and urine.
• Stool guaiac
• 24 hour urine hydroxyproline
• Parathyroid hormone levels
• Bone turnover markers: TRAP, RANKL, Cathepsin K,
Osteoprotegerin, Hydroxyproline, Sclerostin

22. 3. EVIDENCE FOR APPLICATIONS OF BONE
TURNOVER MARKERS (BTM)
• TITLE: Bone turnover markers: Emerging tool in the management of
osteoporosis
• CITATION: Shetty S, Kapoor N, Bondu JD, Thomas N, Paul TV. Bone
turnover markers: Emerging tool in the management of
osteoporosis. Indian J Endocrinol Metab. 2016;20(6):846-852.
• PLACE: Department of Endocrinology, Diabetes and Metabolism,
Christian Medical College, Vellore, Tamil Nadu, India
• CONCLUSION: BTMs are important tools for management of
osteoporosis gaining acceptance in clinical practice worldwide.
Estimation of fracture risk based on bone remodeling rates and
monitoring the adherence and response to therapy is the most
important application of BTMs.

23. DISORDERS PRODUCING OSTEOPENIA
DISORDER SERUM CA SERUM PO4 SERUM ALP URINE
OSTEOPOROSIS NORMAL NORMAL NORMAL NORMAL
OSTEOMALACIA NORMAL
TO LOW
NORMAL TO
LOW
NORMAL
TO HIGH
LOW Ca,
HIGH PO4, HP
HYPER-
PARATHYROIDIS
M
NORMAL
TO HIGH
NORMAL TO
LOW
NORMAL
TO HIGH
HIGH Ca, PO4, HP
RENAL
OSTEODYSTROPHY
LOW HIGH HIGH HIGH BUN
PAGETS DISEASE NORMAL NORMAL VERY HIGH HP+++
MULTIPLE
MYELOMA
NORMAL NORMAL NORMAL BENCE JONES
PROTEIN
HP: HydroxyProline, Ca: Calcium, PO4: Phosphorous, ALP: Alkaline Phosphate

24. SERUM CA,
PO4
~NORMAL
ALP
VERY HIGH
PAGET’S
DISEASE
NORMAL TO
HIGH
URINALYSIS
NORMAL CA
OSTEOPOROSIS
LOW CA
OSTEOMALACIA
HIGH CA
H(IGH)YPERPARAT
HYROIDISM
BENCE JONES
PROTEIN
MULTIPLE
MYELOMA
LOW CA, HIGH PO4, HIGH
ALP, HIGH BUN
RENAL
OSTEODYSTROPHY

25. HYPERCALCEMIA
• More than a sign of metastatic destruction, it is a prognostic factor.
• 60% patients with hypercalcemia on presentation survive less than 3 months
and 20% survive live for another year.
• Treatment should be directed towards correction with rigorous volume
repletion and bisphosphonate therapy.
CLINICAL FEATURES
• Neurologic- Headache, confusion, irritability, blurred vision.
• GI- Anorexia, Nausea, Vomiting, Weight loss. Constipation, abdominal pain.
• MUSCULO SKELETAL- Fatigue, Weakness, joint and bone pain, unsteady gait.
• Urinary- Nocturia, polydipsia, polyuria

26. RADIOGRAPHY
• PLAIN X RAY: Osteopenia may either be due to inadequate bone (porosis) or
inadequate mineralization (malacia)
1. OSTEOPOROSIS: Thin cortices, Loss of normal trabecular pattern
2. OSTEOMALACIA: Looser lines, calcification of small vessels, phalyngeal
periosteal reaction
OSTEOPOROSIS OSTEOMALACIA

27. • CHEST AND ABDOMINAL RADIOGRAPHY: To rule out
primaries
• USG: To distinguish cystic lesions from solid soft tissue
lesions
• 99m Tc BONE SCAN: MOST SENSITIVE indicator of skeletal
disease. Gives information about multiple lesions. Co-relates
hot areas with plain X ray and cold with hematological
malignancies.
• CT: More sensitive for lesions that destroy < 30% bone
• MRI: Useful for primary bone tumors. Shows bony extent,
marrow changes, periosteal reaction, soft tissue extension,
spinal canal compromise
• PET SCAN: Useful for metastatic lesions
• Others include GI-scopy, Endoscopy, Mammography etc

28. FLOW CYTOMETRY

29. BIOPSY
• Solitary bone lesion in a patient with or without history of
cancer should be done.
• Needle biopsy is definitive when differentiating carcinoma
from sarcoma with adequate immunohistochemistry.
• When there is pathologic fracture through the lytic lesion,
bleeding can occur due to early fracture callus.
• Thus these fractures should be stabilised first and then
biopsy undertaken.
• Biopsy should be obtained from a site near but unaffected by
fracture.

30. • Site should be as small as possible, longitudinally in line
with the extremity.
• Tissues involved in post- biopsy hematoma must be
considered as contaminated.
• Cultures for all biopsy to rule out infections that may
mimic tumors on x rays.
• If definitive diagnosis present on frozen sections intraop
then ideal to fix the fractures, otherwise wait for
permanent sections.
• Deep incision should go through a single muscle
compartment instead of intermuscular plane

31. MANAGEMENT: FRACTURE RISK
• “LOAD BEARING REQUIREMENT OF THE BONE DIVIDED BY IT’S LOAD
BEARING CAPACITY.”
• REQUIREMENT: Age, weight, activity level, ability to protect site
• CAPACITY: Amount of bone loss, modulus of remaining bone, location of
defect
VARIABLE 1 2 3
SITE UPPER EXTREMITY LOWER EXTREMITY PERITROCHANTERIC
PAIN MILD MODERATE SEVERE
LESION BLASTIC MIXED LYTIC
SIZE <1/3 DIAMETER 1/3-2/3 DIAMETER >2/3 DIAMETER
MIREL’S CRITERIA
>=8 SHOULD UNDERGO PROPHYLACTIC INTERNAL FIXATION
<8 CAN BE IRRADIATED SAFELY

32. HARRINGTON’S INDICATIONS FOR
PROPHYLACTIC FIXATION
• Cortical destruction>= 50%
• Proximal femoral lesion >=2.5cm
• Pathological avulsion of lesser trochanter
• Persistent pain following irradiation

33. ADVANTAGES OF PROPHYLACTIC FIXATION
• Shorter hospitalization
• More immediate pain relief
• Faster and less complicated surgery
• Less blood loss
• Quicker return to premorbid function
• Improved survival
• Fewer hardware complications

34. 4. EVIDENCE FOR PROPHYLACTIC FIXATION BEING
MORE ADVANTAGEOUS THAN TREATMENT
• TITLE: THE MANAGEMENT OF PATHOLOGICAL FRACTURE OF THE MAJOR
LONG BONES FROM METASTATIC CANCER
• AUTHORS: R. A. BREMNER and A. M. JELLIFFE,
• PLACE: Department of Orthopaedics and the Myerstein
Institute of Radiotherapy, the Middlesex Hospital, London
• CONCLUSION: The results of treatment of thirty-six consecutive fractures
of this type by internal fixation and radiotherapy, and of similar treatment
used “ prophylactically” on seven occasions, are reviewed. “Prophylactic”
internal fixation and radiotherapy appear to be the best method at present
available for dealing with this difficult problem.

35. MANAGEMENT CONSIDERATIONS
• Treatment of local bone lesion
• Surgical stabilisation +/- resection: large lytic lesion are at
risk of fractures/pathologic fractures.
• Radiation: Adjuvant local treatment for entire operative field.
• Functional bracing
• Bisphosphonates: inhibit osteoclast mediated bone
resorption.

36. BRACING
Indicated in:
• Limited life expectancies
• Severe comorbidities
• Small lesions
• Radiosensitive tumors
• Humerus shaft, forearm, tibia fractures
Weight bearing should be limited.

37. OPERATIVE TREATMENT
• Intramedullary device or modular prosthesis provides better
stability.
• Bone cement – Increases the strength of fixation
– Should not be used to replace segment of bone
• Goal should be to stabilize as much of the bone as possible.

38. PATHOLOGICAL FRACTURES SECONDARY TO
NEOPLASIA
ENNEKING’S QUESTIONS:
1. WHERE IS THE LESION?
2. WHAT IS THE LESION DOING TO THE BONE
3. WHAT IS THE BONE DOING TO THE LESION
OTHER IMPORTANT QUESTIONS:
4. AGE OF THE PATIENT
5. HOW IS THE MATRIX
6. IS THERE CORTICAL EROSION
7. IS SOFT TISSUE MASS EVIDENT

39. CLASSIFICATION
• BASED ON LOCATION (WHERE IS THE LESION?)
1. In the transverse plane:
a) Central – Enchondroma
b) Eccentric -GCT, osteosarcoma, chondromyxoid fibroma
c) Cortical - Non-ossifying fibroma, osteoid osteoma
d) Parosteal - Parosteal osteosarcoma, osteochondroma

40. 2. In the longitudinal plane:
a) Diaphyseal: Ewings, Osteoid Osteoma, Mets, Adamantinoma, Fibrous
Dysplasia
b) Epiphyseal: Chondroblastoma, GCT, Ganglion of Bone.
c) Metaphyseal: Everything!!!!!!
• BASED ON AGE OF THE PATIENT:
• 20>…..Osteogenic Sarcoma, Ewings. simple bone cysts and
chondroblastomas
• 40……GCT, Chondrosarcoma, MFH, Lymphoma, Mets.
• 60……Mets, Myeloma, Chondrosarcoma,

42. WHAT IS THE TUMOR DOING TO THE BONE?
Three Patterns of Bone Destruction resulting from the degree
of aggressiveness of the lesion:
• Geographic Pattern • Moth-Eaten Pattern • Permeative
Pattern
Type 1 a Geographic Lesion.

44. Type 2 Moth-eaten Appearance
• Areas of destruction with
borders
• Implies more rapid growth
• Probably a malignancy
Type 3. Permeative Pattern
• ill-defined lesion with
multiple “worm-holes”
• Spreads through marrow
space
• Wide transition zone Implies
aggressive malignancy
• Round-cell lesions Ewing sarcoma.

45. WHATIS THE BONE DOING TO THE TUMOR?
Bone reacts in two ways -- either by removing some of itself or
by creating more of itself.
If the disorder is rapidly progressive, there may only be time
for retreat (defense).
If the process is slow growing, then the bone may have time to
mount an offense and try to form a sclerotic area around the
offender.

46. PERIOSTEAL REACTION
A periosteal reaction will occur whenever the periosteum is
irritated. This may occur due to a malignant tumor, benign
tumor, infection or trauma.

47. ZONE OF TRANSITION
Most reliable indicator for benign versus malignant lesions.

48. TYPES OF MATRIX

49. BENIGN TUMORS
1. OSTEO-CHONDROMA
• Cartilage from aberrant subperiosteal nest of physeal
cartilage
• Metaphysis, adolescent, femur, humerus, tibia
• Pathognomonic: host bone flares from cortex into the lesion
• Almost never causes pathological fracture

50. 2. EN-CHONDROMA
• Intramedullary, well defined, made of hyaline cartilage,
• Metaphysis of tubular bones of hand femur humerus
• X Ray: central, well defined, lobulated with reactive sclerosis,
popcorn like opacities <6cm
• Small chondrocytes with areas of calcification
• MRI: black signal void, hot on bone scan
• Rarely cause pathological #. Surgical intervention should be
delayed till fracture heals.

51. 3. PERIOSTEAL CHONDROMA
• Cartilage neoplasm at the surface of the bone most
commonly metaphysis
• X Ray: Superficial erosion of cortex with scalloping
• # need bone grafting / PMMA
4. CHONDROBLASTOMA
• Epiphysis of long bones between 10 to 35 years
• Oval to round cystic lesion. Cortex expanded
but not breached
• Chicken wire calcification
• # treated by resection and
filling of cavity by PMMA or
graft

52. 5. OSTEIOD OSTEOMA
• small lesion formed of osteoid and woven bone surrounded by halo
of reactive bone
• Young patients, diaphysis, long bones (proximal femur)
• X Ray: dense round to oval sclerosis with small round osteolysis
surrounded by halo
• CT shows central nidus, bone scan +
• T/t: CT guided radiofrequency ablation after healing of #

53. 6. OSTEOBLASTOMA
• Tumor of osteoblasts ie osteoid and woven bone
• Children, teens, adults before 40 years
• X Ray: lytic lesion 2-5cm, central>eccentric, ring of sclerosis with
cortical thinning, sharp interface between bone and tumor
• More often in spine especially posterior arch
• Causes compression # of spine needing instrumentation

54. 7. LANGERHANS CELL HISTIOCYTOSIS
• When solitary it is called eosinophilic granuloma
• MC skull, pelvis, femur, mandible
• X ray: lytic, well demarcated with thick periosteal new bone.
• Skull shows hole within hole appearance. Onion peel reaction like
ewings and vertebra plana is common causing nerve compression.
• Pathological # allowed to heal before biopsy and intra lesional
corticosteroid injection so callus does not confuse the histological
picture

55. 8. NON OSSIFYING FIBROMA
• MC benign bone lesion, developmental defect
• Nest of fibrous tissue within bone persists before ossifying
• Metaphysis of distal and proximal tibia, distal femur
• oval radioluscent surrounded by dead bone.
• Appears central but is adjacent to or within the cortex
• If <2 cm it is called fibrous cortical defect
• Curettage and grafting is needed in case of #. If unstable, internal
fixation

56. 9. GIANT CELL TUMOR
• 5% of all bone tumors, 20-45 yrs of age
• Can occur with paget’s disease and focal dermal hyperplasia
• Metaphysis of distal femur, proximal tibia, proximal humerus, distal
radius
• X Ray: eccentric, expansile, lobulated, cystic, narrow zone of
transition
• May extend into soft tissue, abut subchondral plate
• CT: cortical involvement, MRI: heterogenicity
• If joint can be preserved, curettage with grafting or cementation is
done
• Internal fixation is necessary after # as usually extensive bone loss
and deformity occurs.

57. 10. FIBROUS DYSPLASIA
• Medullary fibro osseous affecting one or multiple bones
• MC craniofacial bones, femur
• X ray: mixed lesion, well demarcated, characteristic ground glass
matrix
• Shepherd crock deformity is characteristic in proximal femur lesion
• Fracture rarely displaced, heals well. In upper limb
and spine treated non operatively, in lower limb, by
internal fixation.
• If graft is being used, allograft
is used as autograft too
will have same genetic
abnormality

58. 11. SIMPLE BONE CYST
• Solitary, unilocular cavity lined by fibrous membrane and
filled with serous or serosanginous fluid.
• More in males, less than 20 years, in metaphysis of proximal
humerus, proximal femur, proximal tibia.
• X Ray: well outlined, lytic, central, metadiaphyseal, expansile,
abuts but does not cross physis, bone septa +,
misinterpretated as multiloculated
• Fracture stimulates healing of cyst hence not disturbed
If it does not heal, steroid injection with bone graft or
marrow aspirate recommended
• Displaced fracture needs open reduction internal
fixation with grafting

59. 12. ANEURYSMAL BONE CYST
• Expansile, blood filled cystic space, destructive.
• Children, teenagers, metaphysis of femur, tibia, humerus, posterior
spine.
• X Ray: subperiosteal, well defined, osteolytic, elevating, eroding
cortex
• MRI: cystic, multiple septations, fluid level;
• # treated with curettage, internal fixation and grafting
• Radiation is avoided as it has risk of sarcomatous changes

60. MALIGNANT BONE TUMORS
• 1. EWING’S SARCOMA
• X Ray: ill-defined osteolytic lesion with a moth-eaten or permeative type of bone
destruction, irregular cortical destruction and aggressive periostitis in the lower
extremity of a child
• MR imaging reveals the soft tissue extension.
• Treatment of Ewing sarcoma consists of neoadjuvant chemotherapy, followed by
surgical resection and adjuvant chemotherapy. The tumor also may respond to
radiation therapy.

61. 2. OSTEOSARCOMA
• Most common primary malignant bone tumor.
• Metaphyseal bone-forming lesion around the knee in a patient 10-25 years of age,
who presents with a painful mass.
• Small second peak in > 60 years
• X ray: Mixed lytic-sclerotic lesion. The matrix of the tumor is bone. MC in
metaphysis and diaphysis with possible extension to the epiphysis
• MRI: epiphyseal involvement with reactive edema. Circumferential soft tissue
extension and relationship to the neurovascular structures.

62. 3. CHONDRO-SARCOMA
• Elderly patient, Location in long bones, Size > 5 cm
• It is a malignant cartilage producing bone tumor
• X Ray: large osteolytic lesion with scalloping of the inner
cortex and rings-and-arcs or popcorn calcifications in an
elderly person with a painful swelling.
• Patients with multiple enchondromas like in Ollier's
disease and Mafucci's syndrome are at risk.
• Secundary chondrosarcoma is most common and arises
from enchondroma or osteochondroma.
• Uptake on bone scan
• Endosteal scalloping on MRI
• Cortical involvement
• Early enhancement on dynamic contrast enhanced
series
Endoste
al
scallopin
g

63. SURGICAL OPTIONS: SCAPULA/CLAVICLE
• Non operatively with shoulder immobilization, radiation,
medical management.
• Large destructive mets in inferior body or articular portion
can be resected

64. PROXIMAL HUMERUS
• Head and neck are treated with replacement or
intramedullary fixation
• If enough bone available – IMILN with multiple screws
maintains ROM
• When enough bone not available, resection and
reconstruction with cemented proximal endoprosthesis. If the
lesion is large, use long cemented stem.
• Postop radiation should be given

65. HUMERUS DIAPHYSIS
• Locked intramedullary fixation or intercalary metal spacer in
case of bone loss.
• Nail spans the entire bone and gives mechanical and
rotational stability.
• Allows unrestricted radiation to shaft without the fear of
incisional breakdown as it is inserted in closed fashion.
• Intercalary spacers are used when a large piece of bone has
been resected such as in segmental defects, failed fixation,
progressive disease.

66. DISTAL HUMERUS
• Flexible intramedullary nails, bicondylar plate, resection with
modular reconstruction.
• Flexible nails are inserted in retrograde manner which offer
ease of insertion, span full length of bone, excellent
functional recovery, preservation of the elbow joint.
• Curettage requires open reduction with PMMA
supplementation
• In case of massive bone loss, resection with modular
endoprosthetic reconstruction is the best option.

67. FOREARM AND HAND
• Unusual. MC from lung, breast, kidney
• RADIUS AND ULNA: Treated with flexible rods or rigid plate
fixation.
• Pathological fractures of radial head can be resected.
• HAND: Intralesional surgery with curettage, internal fixation,
cementation.
• If the lesion is distal or extensive, amputation may be the
best option

68. PELVIC/ACETABULAR REGION
HARRINGTON CLASSIFICATION (location and extent)
CLASS I
• Minor acetabular defects with intact lateral cortices, superior
and medial walls.
• Conventional cemented acetabular component is adequate
CLASS II
• Deficient medial wall and superior dome
• Anti-protrusion device / medial mesh is necessary

69. PELVIC/ACETABULAR REGION
CLASS III
• Massive acetabular defects with all walls deficient and no
substantial rim for fixation of metal component
• Acetabular cage with long screw fixation into remaining
pubis, ilium or ischium. Bone cement used to provide stability
and Steinmann pins to anchor the construct. A polyethylene
cup is then cemented into the acetabular cage
CLASS IV
• Pelvic discontinuity
• Treated with resection and reconstruction using saddle
prosthesis or resection arthroplasty

70. CLASS I: CLASS II CLASS III
CLASS I: CLASS II

71. CLASS III WITH
ACETABULAR
CAGE
CLASS IV WITH
SADDLE
PROSTHESIS

72. FEMORAL NECK
• Rarely heal. Treated using cemented replacement prosthesis.
• THR vs hemiarthroplasty decided based on acetabular
involvement
• All tumors should be curetted from the canal
• In case of adjacent lesions, long stemmed femoral
component is used.

73. INTERTROCHANTERIC REGION
• Intramedullary fixation or prosthetic replacement.
• Former is used if bone strength and quantity is enough in
head and neck and local control can be achieved using
radiation as the nail protects femoral neck
• If destruction is extensive, cemented calcar-replacing
prosthesis is used

74. SUBTROCHANTERIC REGION
• This region is subjected to forces 4-6 times the body weight.
• Statically locked intramedullary interlocking nail with or
without cement augmentation is the best option
• In case of extensive destruction, modular femoral prosthesis
is used.

75. FEMORAL DIAPHYSIS
• Statically locked intramedullary interlocking nail with or
without cement augmentation is the best option.
• Trochanteric or pyriformis entry is used and canal is slowly
overreamed 1 to 1.5mm to prevent high impaction forces
during rod placement.
• As the device is load bearing and fractures do not generally
heal, nail with the largest possible diameter is used.
• Field for post op radiation should encompass the entire
implant

76. SUPRACONDYLAR FEMUR
• Difficult to treat due to poor bone stock and communition.
• Lateral locking plate with cement or modular distal femur
prosthesis is used.
• For extensive destruction modular prosthesis is the optimum
choice as it allows resection en bloc.
• Retrograde nail does not stabilize neck, and causes seeding
of the knee with tumor.

77. TIBIA
• Proximal lesions: Locking plate with cement after thorough
curettage.
• For extensive destruction modular prosthesis is the optimum
choice
• Diaphyseal lesions: Locked intramedullary nail with or without
cement

78. SPINE
• Any cancer patient with back pain- consider mets.
• Any patient treated for osteoporotic compression fracture
should undergo a CT guided biopsy when not responding to
treatment or when there is excessive destruction of bone.
• X ray- Loss of pedicle on the AP view.
• MRI – Complete replacement of the vertebral segment,
Multiple vertebral body lesions, Pedicle involvement, Intact
intervertebral disc • Bone marrow biopsy.
TREATMENT OPTIONS:
• Radiation: If pain is present without neurological compromise
in lymphoma, myeloma
• Corticosteroids +/- bracing
• Kyphoplasty/ vertebroplasty

79. INDICATIONS FOR SURGERY:
• Progression of disease after radiation
• Neurologic compromise caused by bony impingement
• Radioresistant tumor within the spinal canal
• Impending fracture
• Spinal instability caused by a pathologic fracture
• Progressive deformity.
PREREQUISITES
• MRI to detect level of lesion and compression
• Angiogram with embolization of feeder vessels in vascular
tumors

80. VERTEBROPLASTY
KYPHOPLASTY

81. THANK YOU