Prophylactic Fixation of Pathological Fractures

Indications

Metastatic Tumours, pelvic radiograph showing bone metastases
Pelvic radiograph showing bone metastases. Image by Chih-Yu Chen, Yong-Te Hsueh, Tsung-Yu Lan, Wei-Hsin Lin, Karl Wu and Rong-Sen Yang, Wikimedia Commons, CC BY-SA 2.0.
  • Mirels score 9 or more
  • Over 50% cortical destruction
  • Proximal femoral lesion over 2.5 cm or avulsion of the lesser trochanter
  • Pain persisting after radiotherapy
  • Mirels score uses site, pain, lesion type and size, each scored 1 to 3
  • Life expectancy over about 6 weeks for surgery to help
  • Myeloma and lymphoma often respond to systemic treatment

Position

  • Supine on a traction table, or lateral for arthroplasty
  • Image intensifier and long implants available
  • Cell salvage is avoided with tumour

Operative Steps

  1. Biopsy a solitary lesion or unknown primary before fixation. Nailing a primary sarcoma contaminates the whole bone
  2. Embolise hypervascular renal and thyroid metastases before surgery
  3. Long cephalomedullary nail to protect the whole bone
  4. Cement augment or curette the lesion when needed
  5. Periarticular destruction, cemented long stem arthroplasty or proximal femoral replacement
  6. Vent the canal before reaming or cementing to reduce embolism
  7. Send reamings for histology

Postoperative Care

  • Weight bear as tolerated
  • Radiotherapy to the whole operated field
  • Oncology review
  • VTE prophylaxis, as cancer raises risk
  • Plan bisphosphonate or denosumab with oncology

Complications

  • Fat embolism and cardiorespiratory collapse during reaming
  • Disease progression and fixation failure
  • Bleeding
  • Implant failure if the lesion does not respond to treatment
  • Infection, higher after radiotherapy
  • Wound breakdown

Related Pages

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.