SURGICAL MANAGEMENT OF

PATHOLOGICAL FRACTURES IN
OSTEOMALACIA
PRESENTER : DR. GIRISH.S
CHAIR PERSON : DR. JAYARAM .B. S
Factors Suggesting a Pathologic
Fracture
Spontaneous fracture
• Fracture after minor trauma
• Pain at the site before the fracture
• Multiple recent fractures
• Unusual fracture pattern
• Patient older than 45 years
• History of primary malignancy
General Considerations
The most common pathologic fracture is caused by
osteoporosis.
In most situations, these fractures should be managed
in a standard fashion as recommended
 modifications such as the addition of methyl
methacrylate or locking plate fixation may be
necessary because of the weakened bone
Patients who present with a pathologic fracture are
often medically debilitated and require
multidisciplinary care
Nutrition is of particular concern
serum prealbumin should be measured and improved if it is
low.
This may require the addition of enteral or parenteral
hyperalimentation perioperatively.
Patients may have relative bone marrow suppression and will
require adequate replacement of blood products.
Perioperative antibiotic coverage,
prophylaxis for embolic events,
Aggressive postoperative pulmonary toilet, and
early mobilization are all instituted as standard treatment.
Operative management
Surgical treatment uses the most current internal fixation
devices and prosthetic replacements.
The ideal reconstruction allows immediate weight bearing
It should be assumed that the fixation device used will be load
bearing, as only 30% to 40% of pathologic fractures unite
An intramedullary device or modular prosthesis provides more
definitive stability.
Polymethyl methacrylate (PMMA) is often used to increase the
strength of the fixation,
but it should not be used alone to replace a segment of bone.
PMMA improves the bending strength of a fixation
constructand the outcome of fixation
Proximal Humerus
Pathologic fractures involving the humeral head or neck are
treated with a proximal humeral replacement or
intramedullary fixation.
If enough bone is available in the proximal humerus, an
intramedullary locked device with multiple proximal screws
is acceptable and maintains shoulder range of motion.
PMMA may be required to supplement the fixation.
When there is extensive destruction of the proximal humerus
or a fracture leaving minimal bone for adequate fixation,
Resection of the lesion and reconstruction with a cemented
proximal humeral endoprosthesis are indicated.
Humeral Diaphysis
Humeral diaphyseal lesions of fractures can be
surgically treated with locked intramedullary fixation
Locked intramedullary humeral nails span the entire
humerus and provide mechanical and rotational
stability
there is risk of hardware failure when plate fixation is
used
Distal Humerus
Distal humeral lesions or fractures are treated with
flexible intramedullary nails, bicondylar plate fixation,
Flexible nails, inserted in a retrograde manner
through small medial and lateral incisions, offer ease
of insertion, the ability to span the entire humerus,
excellent functional recovery, and preservation of the
native elbow joint.
plate fixation when combined with PMMA, it can
provide a stable construct about the elbow.
Forearm
radius and ulna can be treated with flexible rods or
rigid plate fixation.
Pathologic fractures of the radial head can be treated
with resection.
Pelvic/Acetabular Fractures
Insufficiency fractures frequently occur in iliac wing,
superior/inferior pubic rami, or sacroiliac region locations
and are managed with protected weight bearing until the
pain diminishes
followed by assessment of bone density and appropriate
medical treatment
Periacetabular lesions or fractures; however, affect
ambulatory status and often present a difficult surgical
problemshould
be assessed with CT scans with three-dimensional
reconstruction
The trabecular metal tantalum provides new options
for acetabular fixation by allowing early bone
ingrowth.
It can be used in combination with a cemented
acetabular cage
Femoral Neck.
The procedure of choice for patients pathological
fractures to the femoral head or neck is a cemented
replacement prosthesis
The decision to use a hemiarthroplasty versus a total
hip replacement depends on the presence of
acetabular involvement.
Intertrochanteric Region
Traditional fixation of an intertrochanteric fracture
with screw and side-plate fixation has a high rate of
failure
The standard of care is intramedullary fixation or
prosthetic replacement
A cephalomedullary nail protects the femoral neck
and is used for all pathologic fractures of the femur
when an intramedullary device is indicated.
If the destruction is more extensive, a cemented
calcar-replacing prosthesis is required
Subtrochanteric Region
Using plate and screw internal fixation for
subtrochanteric fractures in patients will usually end in
failure.
This region of the femur is subjected to forces of up to
four to six times body weight.
 Statically locked intramedullary fixation with or without
PMMA will stabilize the area and provide weight-bearing
support.
A modular proximal femoral prosthesis is reserved for
cases with extensive bone destruction or used as a salvage
device for failed internal fixation
Femoral Diaphysis
Pathologic fractures of the femoral diaphysis are
treated most effectively with a statically locked
cephalomedullary nail, with or without PMMA
Plate fixation, although more rigid, will not protect a
large enough segment of bone and is prone to failure
Because the device will be load bearing if the fracture
does not unite, a nail with the largest possible
diameter should be used
Supracondylar Femur
The choice of fixation for pathologic supracondylar
femur fractures depends on the extent
Options include lateral locking plate fixation
supplemented with PMMA or a modular distal femoral
prosthesis
Tibia
Tibial diaphyseal lesions and fractures should be
managed with a locked intramedullary device
With generous use of PMMA to augment the
construct
Spinal Fractures
The goals of surgery are to maintain or restore
neurologic function and spinal stability
When surgical treatment is necessary to relieve
compression of the spinal cord, decompression and
stabilization are required.
Internal fixation is indicated to provide immediate
stability for all but the most limited decompressions
Spinal Fractures
Vertebroplasty or kyphoplasty can be used for
pathologic vertebral body fractures caused by
osteoporosis,
vertebroplasty, involves percutaneous direct injection
of PMMA through the pedicle to maintain vertebral
height.
Kyphoplasty is a way of regaining vertebral body
height by expanding the compression fracturewith a
balloon before injecting the PMMA
Complications
Because patients with pathologic fractures are often
older with multiple associated medical problems, the
chance of them developing a perioperative
complication is increased.
References
Rockwood and Greens Fractures in Adults - 2 Volume
Set [8th ed]
Thank you