Errors and pitfalls in the diagnosis and treatment of metastatic bone disease

1. The orthopedist must be sure of the diagnosis and not embark on treatment for the wrong diagnosis. 2. Solitary lesions in patients with a remote history of malignancy require complete investigation and biopsy. This includes blood work, bone scan, magnetic resonance imaging of the bone lesion, and CT scan of the chest and abdomen. 3. Pathologic fractures do not require immediate fixation. They require careful surgical planning and a team approach to the underlying malignancy. 4. Load-sparing devices should not be used. 5. Femoral neck fractures should be treated by endoprosthetic replacement, and consideration should be given to long-stemmed femoral components. 6. The orthopedist should assume that the fracture will never heal. 7. Immediate full and unrestricted weight bearing should be planned. 8. Future problems in the surgical site should be anticipated. Often a long-stem cemented femoral component is a better choice than a standard length. 9. The orthopedist must ensure that there are no other lesions that require stabilization in the bone being treated. 10. Methyl methacrylate can be used to augment fixation if needed. 11. If secure fixation cannot be achieved with the use of cement, the bone should be replaced with a tumor endoprosthesis. 12. The orthopedist should not hesitate to call in help. These can be difficult situations to manage and often require the assistance of a tumor surgeon and oncologic team.