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      The role of postoperative radiation and coordination of care in patients with metastatic bone disease of the appendicular skeleton

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          Abstract

          Metastatic bone disease affects approximately 300,000 people in the United States, and the burden is rising. These patients experience significant morbidity and decreased survival. The management of these patients requires coordinated care among a multidisciplinary team of physicians, including orthopaedic surgeons. This article reviews the role of radiation therapy after orthopaedic stabilization of impending or realized pathologic extremity fractures. Orthopaedic surgeons have an opportunity to benefit patients with metastatic bone disease by referring them for consideration of post-operative radiation therapy. Further research into rates of referral and the effect on clinical outcomes in this population is needed.

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          Most cited references24

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          Palliative radiation therapy for bone metastases: Update of an ASTRO Evidence-Based Guideline.

          The purpose is to provide an update the Bone Metastases Guideline published in 2011 based on evidence complemented by expert opinion. The update will discuss new high-quality literature for the 8 key questions from the original guideline and implications for practice.
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            Surgical management of metastatic bone disease.

            Metastatic bone disease is a major contributor to the deterioration of the quality of life of patients with cancer; it causes pain, impending and actual pathological fractures, and loss of function and may also be associated with considerable metabolic alterations. Operative treatment may be required for an impending or existing fracture and intractable pain. The goals of surgery are to provide local tumor control and allow immediate weight-bearing and function. Radiation therapy is often indicated postoperatively. Detailed preoperative evaluation is required to assess the local extent of bone destruction and soft-tissue involvement, involvement of other skeletal sites, and the overall medical and oncological status.
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              Metastatic Disease of the Femur: Surgical Treatment

              The senior author's 12-year consecutive series of surgery for metastatic disease of the femur was reviewed. Treatment of 97 impending pathologic fractures yielded better results than treatment of 85 completed pathologic fractures with less average blood loss (438 cc versus 636 cc), shorter hospital stay (7 days versus 11 days), greater likelihood of discharge to home as opposed to an extended care facility (79% versus 56%) and greater likelihood of resuming support-free ambulation (35% versus 12%). Internal stabilization with a reconstruction-type intramedullary nail provided satisfactory pain relief and functional preservation for most patients with impending pathologic femur fractures (69 of 97, 71%), although alternate forms of internal fixation (21 of 97, 22%) or cemented arthroplasty (seven of 97, 7%) were used successfully. Completed pathologic fractures were more likely to require some form of arthroplasty (47 of 85, 55%), although reconstruction-type nails (20 of 85, 24%), and other internal fixation techniques (18 of 85, 21%) also were used. Modular oncology-type arthroplasty systems offered a viable salvage option in both groups. In the absence of conflicting goals or contraindications, internal stabilization of impending pathologic fractures before the completion of the fracture seems to be reasonable and appropriate.
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                Author and article information

                Journal
                Orthop Rev (Pavia)
                OR
                Orthopedic Reviews
                PAGEPress Publications, Pavia, Italy
                2035-8237
                2035-8164
                16 February 2018
                14 December 2017
                : 9
                : 4
                : 7261
                Affiliations
                [1 ]Department of Orthopaedics & Rehabilitation, Oregon Health & Science University , Portland, OR
                [2 ]Operative Care Division, Portland Veterans Administration Medical Center , Portland, OR, USA
                Author notes
                Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, Oregon 97239-3098, OR, USA. +1-505.494.6400. gundle@ 123456ohsu.edu

                Contributions: all authors contributed to the production of this manuscript and deserve authorship in accordance with ICMJE recommendations.

                Conflict of interest: the authors declare no potential conflict of interest.

                Article
                10.4081/or.2017.7261
                5850070
                29564074
                f8ba5d96-9119-4355-8aa9-3367dccd9607
                ©Copyright A.R. Summers et al., 2017

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 14 June 2017
                : 30 September 2017
                Page count
                Figures: 0, Tables: 1, Equations: 0, References: 44, Pages: 5
                Categories
                Review

                Orthopedics
                multidisciplinary care,radiation therapy,metastatic bone disease,pathologic fracture,cancer

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