Predicting Fracture Risk in Patients with Metastatic Bone Disease of the Femur: A Pictorial Review Using Three Different Techniques

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Abstract

One of the key roles of an orthopedic surgeon treating metastatic bone disease (MBD) is fracture risk prediction. Current widely used impending fracture risk tools such as Mirels scoring lack specificity. Two newer methods of fracture risk prediction, CT-based structural rigidity analysis (CTRA) and finite element analysis (FEA), have each been shown to be more accurate than Mirels. This case series illustrates comparative Mirels, CTRA, and FEA for 8 femurs in 7 subjects. These cases were selected from a much larger data set to portray examples of true positives, true negatives, false positives, and false negatives as defined by CTRA relative to the fracture outcome. Case illustrations demonstrate comparative Mirels and FEA. This series illustrates the use, efficacy, and limitations of these tools. As all current tools have limitations, further work is needed in refining and developing fracture risk prediction.

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Bone Metastases: An Overview

Filipa Macedo, Kátia Ladeira, Filipa Pinho … (2017)

Bone is a frequent site of metastases and typically indicates a short-term prognosis in cancer patients. Once cancer has spread to the bones it can rarely be cured, but often it can still be treated to slow its growth. The majority of skeletal metastases are due to breast and prostate cancer. Bone metastasis is actually much more common than primary bone cancers, especially in adults. The diagnosis is based on signs, symptoms and imaging. New classes of drugs and new interventions are given a better quality of life to these patients and improved the expectancy of life. It is necessary a multidisciplinary approach to treat patients with bone metastasis. In this paper we review the types, clinical approach and treatment of bone metastases.

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Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures.

H Mirels (1989)

A weighted scoring system is proposed to quantify the risk of sustaining a pathologic fracture through a metastatic lesion in a long bone. This system objectively analyzes and combines four roentgenographic and clinical risk factors into a single score. Retrospective analysis of metastatic long bone lesions was completed in 78 lesions that had been irradiated without prophylactic surgical fixation. Clinical data and roentgenograms were scored prior to irradiation by independent observers. The outcome identified 51 lesions that did not fracture during the subsequent six months and 27 lesions that fractured within six months. A mean score of 7 was found in the nonfracture group, whereas the fracture group had a mean score of 10. The percentage risk of a lesion sustaining a pathologic fracture could be predicted for any given score. As the score increased above 7, so did the percentage risk of fracture. It is suggested that all metastatic lesions in long bones be evaluated prior to irradiation. Lesions with scores of 7 or lower can be safely irradiated without risk of fracture, while lesions with scores of 8 or higher require prophylactic internal fixation prior to irradiation.