PATHOLOGICAL FRACTURES IN THE AGED: WHEN DO YOU AVOID FIXATION?

Abstract

Although pathological fractures in the aged are usually due to metastasis, solitary lesions with undetected primary should be treated with caution. Assumption of such lesions as metastatic and their subsequent internal fixation could lead to completely inappropriate treatment if the lesion turns out to be a primary sarcoma of bone.

Referrals to our bone tumour service over a four year period were analysed. There were 62 pathological fractures of which 11(17. 8%) were primary sarcomas that were treated as a metastasis. The limb salvage was compromised and survival rates poor in these group.

Although it is believed that primary sarcomas are rare in the aged, our database confirms that 14% of primary sarcomas affect this age group. The survival figures of primary sarcomas in the aged (> 60 years) treated at our centre was a mean of 43 months with a 5-year survival of 22%. The presence of a pathological fracture did not significantly alter the long-term survival of these patients. On the other hand, metastasis had a poor survival with a mean of 19 months and a 5-year survival of 4% showing a significant difference. In addition, these patients underwent major inappropriate surgeries, which rendered limb-salvage difficult, worsened the morbidity and caused mental distress to patients.

Any pathological fracture in the aged presenting as a solitary osseous lesion with an undetected primary or even remote primary should be treated with caution. Their diagnosis needs to be established by biopsy whatever the age of the patient before any form of internal fixation is undertaken. The temptation to carry out biopsy and internal fixation at the same sitting or even a prophylactic fixation should be avoided when the diagnosis is not clear. Standard principles of musculoskeletal oncology need to be followed.