Metastatic Bone Disease With Pathologic or Impending Pathologic Fractures: Resolve, Refer, or Collaborate

It is inevitable that every orthopaedic surgeon will need to treat patients with pathologic or impending pathologic fractures secondary to metastatic disease. Although the input of an orthopaedic oncologist is usually helpful and prudent, transferring care to an orthopaedic oncologist may not be feasible at all institutions in a prompt time frame. To avoid potentially detrimental delays to the patient, many cases can be appropriately managed or resolved by a nononcologic orthopaedic surgeon. It is therefore imperative for all orthopaedic surgeons to be familiar with the appropriate clinical and surgical principles of treating patients presenting with pathologic fractures. This starts with establishing that the pathologic fracture is indeed secondary to metastatic disease rather than a primary bone sarcoma, deciding which patients need surgery rather than nonsurgical modalities such as medicine and radiation, and understanding the unique surgical challenges that pathologic fractures present such as excess intraoperative bleeding, poor potential for bone healing, high chance of concomitant other destructive bone lesions in the same bone, and a high risk of postsurgical complications such as thromboembolic events. Although certain patient presentations and fracture patterns are certainly suitable for a nononcologic orthopaedic surgeon to aptly treat, certain complex clinical presentations or fracture patterns requiring complex surgical reconstructions may best be suited for referral to an orthopaedic oncologist or even a collaborative approach between an orthopaedic oncologist and another orthopaedic subspecialist. It is important to highlight some of these facets of pathologic fracture management, review general principles for the orthopaedic surgeon from both an orthopaedic oncologist perspective and a nononcologist perspective, discuss anatomic areas that have subtleties and controversies in their treatment such as the pelvis and acetabulum, and examine advances in management of pathologic fractures of the upper extremity and shoulder, which have benefitted from the interdisciplinary collaboration of orthopaedic oncologists and shoulder arthroplasty surgeons.