Pathologic fractures about the hip are an uncommon, but increasingly prevalent, clinical scenario encountered by orthopaedic surgeons. These fractures about the hip usually necessitate operative management. Life expectancy must be taken into account in management, but if survivorship is greater than 1 month, operative intervention is indicated. Determination must be made prior to operative management if the lesion is a solitary or metastatic lesion. Imaging of the entire femur is necessary to determine if there are other lesions present. Bone lesions that have a large size, permeative appearance, soft tissue mass, and rapid growth are all characteristics that suggest an aggressive lesion. Biopsy of the lesion in coordination with the operative surgeon should be conducted if the primary tumor is unknown. Metastatic disease is much more common than primary tumors in the adult population. Many metastatic fractures in the intertrochanteric region, and all fractures in the femoral neck and head are an indication for hemiarthroplasty or total hip arthroplasty. Cemented femoral implants are generally indicated. This allows immediate weight bearing in a bone with compromised bone stock, thus reducing the risk of peri-operative fractures. Additionally, patients are often treated with radiation and/or chemotherapy, which may prevent proper osseointegration of an ingrowth femoral component. Highly porous ingrowth shells have been shown to provide reliable and durable fixation even in these situations. Management of a periacetabular pathologic fracture, particularly resulting in a pelvic discontinuity is a particularly challenging situation. Use of a highly porous acetabular component combined with an acetabular cage, a custom acetabular component, a cemented Harrington technique, or a primary acetabular reconstruction cage may be utilised. Patients with neoplastic disease are often at risk for infection and thromboembolic disease both from the disease and treatment. Pre-operative evaluation of nutrition status by measuring albumin and pre-albumin will give the surgeon insight. Additionally, dehydration is commonly seen in cancer patients, and adequate pre-operative optimization of fluids and electrolytes may reduce peri-operative complications from other organ systems

Purpose. The focus of current management of soft tissue sarcoma on limb preservation often necessitates that patients undergo multimodal treatment, including both surgery and external beam radiotherapy. Pathologic fracture is a serious, late complication of radiotherapy. In patients who have also undergone wide excision of soft tissue sarcoma, nonunion rates of 80–90% persist despite optimal internal fixationMany sequelae of the treatments for soft tissue sarcoma exhibit the potential to perpetuate failure of bony union. Limb salvage surgery is associated with extensive periosteal excision, disruption of vascular supply and eradication of local osteoprogenitor cells. External beam radiotherapy leads to obliterative endarteritis, decreased osteoblast proliferation and reduction in bone matrix production. We hypothesize that the combination of radiotherapy and surgical periosteal stripping leads to greater impairment in the fracture repair process than either intervention alone will produce. Method. We developed a method for creating a reproducible, low energy, simple femoral fracture in an animal model designed to proceed to nonunion. Female Wistar, retired breeder rats were separated into four treatment groups of 18 animals each: control, radiotherapy, surgery and combination radiotherapy and surgery. Animals were then further randomized to temporal end-points of 21, 28 and 35 days post-fracture. Designated animals first underwent external beam radiotherapy, followed by surgical stripping of the periosteum three weeks later and femoral fracture with fixation after another three weeks. Animals were sacrificed at their randomly assigned end-points. Results. The fracture device was shown to produce simple, transverse or short oblique femoral fractures using x-rays obtained immediately following fracture, validating the reliability of the model. No significant differences were observed in the force required for fracture between treatment groups. Mineralized callus was observed in control animals and those undergoing periosteal stripping alone, but was absent in all animals receiving radiotherapy. Reactive bone formation was observed in animals undergoing periosteal stripping alone, but was absent when preceded by radiotherapyMicroCT analysis confirmed the results visualized on plain x-ray. No callus formation was observed in animals undergoing radiotherapy and significantly less mineralized callus was produced in animals undergoing periosteal stripping when compared to control. Preliminary studies have shown an absence of cellular activity in animals undergoing radiotherapy, suggesting that fracture in these animals will proceed to nonunion. Conclusion. Early results suggest that this pre-clinical model of combined radiation and surgical periosteal stripping prior to controlled fracture reliably results in nonunion. We expect to utilize this model to examine interventions designed to improve fracture healing in this difficult clinical situation

Introduction. Pathologic humerus fractures secondary to metastases are associated with significant pain, morbidity, loss of function, and diminished quality of life. Here we report our experience with stabilisation using intramedullary polymethylmethacrylate (PMMA) cement and non-locking plates. Methods. A retrospective review was undertaken of patients treated at a tertiary musculoskeletal oncology centre from 1989 to 2009. Patients who underwent surgery for an impending or completed pathologic humerus fracture with a diagnosis of metastatic disease or myeloma were included. All patients underwent intralesional curettage of the tumour followed by fixation with intramedullary PMMA and plating. Results. Clinical records were available for 63 patients who underwent the above procedure. There were 43 males and 20 females. In 48 (76%) there was a pathologic fracture at presentation, while in 15 (24%) it was impending. The most common histology was myeloma (22%) followed by lung and renal carcinoma which were 21% each. Complications occurred in 14 (22%) cases, and 7 (11%) required re-operation. The most common cause for re-operation was disease progression (5 of 7). At latest follow-up, 85% had no or mild pain and 80% required no or minimal assistance with activities of daily life (ADLs). Conclusion. Intralesional tumour resection and stabilisation of pathologic humerus fractures with the described technique has several attributes. It provides immediate, absolute rigidity and enables early pain relief and return of function without the need for osseous union. The patient's local disease burden is reduced, which alleviates tumour-related pain and slows disease progression. Finally, this technique is user-friendly and cost-effective as it does not require equipment or devices that are unavailable to community orthopaedic surgeons. The cemented plate technique provides a durable option for the treatment of impending and completed pathologic humerus fractures