Criteria for prophylactic fixation Several methods exist to predict the risk of pathologic fracture. These include the presence of significant functional pain > 50% destruction of cortical bone formal staging systems Harington's criteria Mirels' criteria Prophylactic fixation is preferred to fixation of actual pathological fracture due to shorter operative time decreased morbidity quicker recovery Harington's criteria Haringtons' Criteria > 50% destruction of diaphyseal cortices > 50-75% destruction of metaphysis (> 2.5 cm) Permeative destruction of the subtrochanteric femoral region Persistent pain following irradiation Mirels' criteria Mirels' classification score > 8 suggests prophylactic fixation size of lesion is expressed as a fraction of the cortical thickness. Mirels' criteria Score 1 2 3 Site Upper limb Lower limb Peritrochanteric Pain Mild Moderate Functional Lesion Blastic Mixed Lytic Size < 1/3 1/3 to 2/3 > 2/3 Treatment algorithm Obtain tissue diagnosis unless patient has a known primary neoplasm with bone biopsy proven skeletal metastasis, the treating surgeon should biopsy the lesion in question biopsy may require separate incision than the incision used for IM nailing of bone if biopsy suggests primary neoplasm of bone (like sarcoma) that may benefit from neoadjuvant chemo/radiotherapy then close wound and refer to local sarcoma center prior to surgical stabilization surgical treatment of primary sarcoma will contaminate entire bone with sarcoma and affect ability to perform limb-salvage surgery Radiation therapy indications painful lesion with Mirels' score =< 8 Surgical fixation do not proceed with fixation until primary neoplasm of bone has been ruled out with biopsy goals of fixation maximize ability for immediate mobilization and weight-bearing protect the entire bone in setting of systemic or metastatic disease optimize implant choice in the context of the patient's overall prognosis type of fixation depends on location of lesion and type of disease humerus proximal humerus lesions endoprosthesis diaphysis intramedullary nail resection and intercalary spacer plates and screws (less preferred) distal humerus lesions flexible nails elbow replacement femur peritrochanteric lesions intramedullary nail femoral neck and head lesions hemiarthroplasty Postoperative radiation following surgery refer the patient to radiation oncology for post-operative radiotherapy treatment to decrease pain slow progression treat remaining tumor burden not removed at surgery