[ORT-L] femoral neck lesion - nail or not


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[ORT-L] femoral neck lesion - nail or not

Douglas.Duncan at coxhealth
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Aug 1, 2006, 3:47 PM

Post #1 of 5 (970 views)
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[ORT-L] femoral neck lesion - nail or not	Can't Post

Attached are x-ray images of a lesion in the left hip of a 71 y/o lady with numerous breast CA blastic metastases to in the spine, pelvis and many other bones. This lesion in the left femoral neck was found on a total body bone scan ordered by her oncologist to assess the extent of her metastases. She was not, and is not, symptomatic in the hip area. Her oncologist sent her to an orthopedist in town and he recommended surgery (I don't know if a hip nail or prosthesis was recommended.) Since she is fully ambulatory with full weight bearing and without pain and asymptomatic in the hip, she was reluctant to proceed with his recommendation and came to me for another opinion.
There doesn't appear to be any lytic destruction of her cortex on CT scan in all 3 planes.
The radiation oncologist wants to do radiation of the hip but not until after any recommended surgery.
I have difficulty making a case for prophylactic surgery on the basis of her x-ray findings and in light of the fact she is not having pain that can be attributed to her hip.
Any of your thoughts would be appreciated.
<<AP1.jpg>> <<CORONAL1.jpg>> <<CROSS NECK1.jpg>> <<CROSS NECK2.jpg>> <<LAT2.jpg>> <<SAGITAL1.jpg>>

Doug Duncan
Douglas.Duncan@coxhealth.com
dmdunc@mhcsi.com

Attachments:

AP1.jpg (1.24 MB)

CORONAL1.jpg (1.03 MB)

CROSS NECK1.jpg (1.03 MB)

CROSS NECK2.jpg (1.03 MB)

LAT2.jpg (875 KB)

SAGITAL1.jpg (1.03 MB)

bsangeor at u
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Aug 1, 2006, 7:14 PM

Post #2 of 5 (969 views)
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Re: [ORT-L] femoral neck lesion - nail or not [In reply to]	Can't Post

femoral neck lesion - nail or notwithout any pain and without erosion of the cortex, it would be hard to make an argument for surgery. But at the earliest sign of mechaincal stress, A recon nail before irradiation with immediate post op weightbearing saves the patient a lot of misery. after fracture and irradiation , you will not get healing. some idea of the activity level of the lesion, (bone scan etc) may provide guidance

Bruce Sangeorzan, MD
Professor Orthopedics and Sports Medicine University of Washington
Chief of Orthopedics, Harborview Medical Center

Patient Care 206 731-4830
Academic office 206 731-4631

Privileged, confidential or patient identifiable information may be contained in this message. This information is meant only for the use of the intended recipients. If you are not the intended recipient, or if the message has been addressed to you in error, do not read, disclose, reproduce, distribute, disseminate or otherwise use this transmission. Instead, please notify the sender by reply email, and then destroy all copies of the message and any attachments.

----- Original Message -----
From: Douglas Duncan
To: ORT-L@www2.aaos.org
Sent: Tuesday, August 01, 2006 3:47 PM
Subject: [ORT-L] femoral neck lesion - nail or not

Attached are x-ray images of a lesion in the left hip of a 71 y/o lady with numerous breast CA blastic metastases to in the spine, pelvis and many other bones. This lesion in the left femoral neck was found on a total body bone scan ordered by her oncologist to assess the extent of her metastases. She was not, and is not, symptomatic in the hip area. Her oncologist sent her to an orthopedist in town and he recommended surgery (I don't know if a hip nail or prosthesis was recommended.) Since she is fully ambulatory with full weight bearing and without pain and asymptomatic in the hip, she was reluctant to proceed with his recommendation and came to me for another opinion.

There doesn't appear to be any lytic destruction of her cortex on CT scan in all 3 planes.
The radiation oncologist wants to do radiation of the hip but not until after any recommended surgery.
I have difficulty making a case for prophylactic surgery on the basis of her x-ray findings and in light of the fact she is not having pain that can be attributed to her hip.

Any of your thoughts would be appreciated.
<<AP1.jpg>> <<CORONAL1.jpg>> <<CROSS NECK1.jpg>> <<CROSS NECK2.jpg>> <<LAT2.jpg>> <<SAGITAL1.jpg>>

Doug Duncan
Douglas.Duncan@coxhealth.com
dmdunc@mhcsi.com

tfinlayson at comcast
New User

Aug 1, 2006, 9:08 PM

Post #3 of 5 (969 views)
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Re: [ORT-L] femoral neck lesion - nail or not [In reply to]	Can't Post

To All:

My anecdotal contribution is my experience with a similar case (midshaft femur) in which the first sign of mechanical stress was catastrophic failure of the compromised bone while the patient was walking up the stairs one day (two days before scheduled prophylactic nailing). While the x-rays and CT cuts presented don't show any cortical erosion, they show that the pathologic lesion (blastic, but still mechanically inferior to normal bone) is contiguous with and indistinguishable from the posterior cortex.

This unfortunate woman doesn't have much time left, but I think a prophylactic recon nail (troch entry design can further limit exposure by a bit) may make what time she has left more fulfilling and predictable in terms of her mobility.

By the way, what is the indication for irradiation of the lesion if it is asymptomatic? I'm not being critical of the plan to irradiate, I just don't understand.

--
Terry I. Finlayson, MD
Alpine Orthopaedic Specialists
2310 North 400 East
Suite A
North Logan, UT 84341
(435) 787-2000 Office
(435) 787-1913 Fax
tfinlayson@alpineortho.com

-------------- Original message --------------
From: "Bruce Sangeorzan" <bsangeor@u.washington.edu>

without any pain and without erosion of the cortex, it would be hard to make an argument for surgery. But at the earliest sign of mechaincal stress, A recon nail before irradiation with immediate post op weightbearing saves the patient a lot of misery. after fracture and irradiation , you will not get healing. some idea of the activity level of the lesion, (bone scan etc) may provide guidance

Bruce Sangeorzan, MD
Professor Orthopedics and Sports Medicine University of Washington
Chief of Orthopedics, Harborview Medical Center

Patient Care 206 731-4830
Academic office 206 731-4631

Privileged, confidential or patient identifiable information may be contained in this message. This information is meant only for the use of the intended recipients. If you are not the intended recipient, or if the message has been addressed to you in error, do not read, disclose, reproduce, distribute, disseminate or otherwise use this transmission. Instead, please notify the sender by reply email, and then destroy all copies of the message and any attachments.

----- Original Message -----
From: Douglas Duncan
To: ORT-L@www2.aaos.org
Sent: Tuesday, August 01, 2006 3:47 PM
Subject: [ORT-L] femoral neck lesion - nail or not

Attached are x-ray images of a lesion in the left hip of a 71 y/o lady with numerous breast CA blastic metastases to in the spine, pelvis and many other bones. This lesion in the left femoral neck was found on a total body bone scan ordered by her oncologist to assess the extent of her metastases. She was not, and is not, symptomatic in the hip area. Her oncologist sent her to an orthopedist in town and he recommended surgery (I don't know if a hip nail or prosthesis was recommended.) Since she is fully ambulatory with full weight bearing and without pain and asymptomatic in the hip, she was reluctant to proceed with his recommendation and came to me for another opinion.
There doesn't appear to be any lytic destruction of her cortex on CT scan in all 3 planes.
The radiation oncologist wants to do radiation of the hip but not until after any recommended surgery.
I have difficulty making a case for prophylactic surgery on the basis of her x-ray findings and in light of the fact she is not having pain that can be attributed to her hip.
Any of your thoughts would be appreciated.
<<AP1.jpg>> <<CORONAL1.jpg>> <<CROSS NECK1.jpg>> <<CROSS NECK2.jpg>> <<LAT2.jpg>> <<SAGITAL1.jpg>>
Doug Duncan
Douglas.Duncan@coxhealth.com
dmdunc@mhcsi.com

FCyran at mednet
New User

Aug 2, 2006, 12:16 PM

Post #4 of 5 (969 views)
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RE: [ORT-L] femoral neck lesion - nail or not [In reply to]	Can't Post

I am an orthopaedic oncologist who still does a fir amout of trauma. Mirels
wrote a paper for a pathologic Fx scoring system. It looks at 4 risk
factors
Lesion size (<1/3 , 1/3 to 2/3, and >2/3),
Location (upper extremity, lower ext, and peri-trochanteric)
Type of lesion (blastic, mixed, lytic)
Pain ( no pain ,pain at rest, functional pain)
each gets 1,2 or 3 points
patients over a 9 have a higher risk of fracturing and probably should be
prophylactically nailed (cephalomedullary nailed)

This person looks like she scores a 1+3+1+1= 6
so I would not tend to nail her.

Note that this looked at pre-XRT patients, post XRT patient can run a
higher risk
Francis Cyran, UCLA Dept Orthopaewdic Oncology

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org]On Behalf
Of Douglas Duncan
Sent: Tuesday, August 01, 2006 3:47 PM
To: ORT-L@www2.aaos.org
Subject: [ORT-L] femoral neck lesion - nail or not

Attached are x-ray images of a lesion in the left hip of a 71 y/o lady with
numerous breast CA blastic metastases to in the spine, pelvis and many other
bones. This lesion in the left femoral neck was found on a total body bone
scan ordered by her oncologist to assess the extent of her metastases. She
was not, and is not, symptomatic in the hip area. Her oncologist sent her
to an orthopedist in town and he recommended surgery (I don't know if a hip
nail or prosthesis was recommended.) Since she is fully ambulatory with
full weight bearing and without pain and asymptomatic in the hip, she was
reluctant to proceed with his recommendation and came to me for another
opinion.

There doesn't appear to be any lytic destruction of her cortex on CT scan in
all 3 planes.
The radiation oncologist wants to do radiation of the hip but not until
after any recommended surgery.
I have difficulty making a case for prophylactic surgery on the basis of her
x-ray findings and in light of the fact she is not having pain that can be
attributed to her hip.

Any of your thoughts would be appreciated.
<<AP1.jpg>> <<CORONAL1.jpg>> <<CROSS NECK1.jpg>> <<CROSS NECK2.jpg>>
<<LAT2.jpg>> <<SAGITAL1.jpg>>

Doug Duncan
Douglas.Duncan@coxhealth.com
dmdunc@mhcsi.com

----------------------------------------------------------
IMPORTANT WARNING: This email (and any attachments) is only intended for the use of the person or entity to which it is addressed, and may contain information that is privileged and confidential. You, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Unauthorized redisclosure or failure to maintain confidentiality may subject you to federal and state penalties. If you are not the intended recipient, please immediately notify us by return email, and delete this message from your computer.
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wavedave at charter
New User

Aug 2, 2006, 2:03 PM

Post #5 of 5 (969 views)
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Re: [ORT-L] femoral neck lesion - nail or not [In reply to]	Can't Post

femoral neck lesion - nail or notIf she's a 9, I would definitely nail her.
----- Original Message -----
From: Cyran, Francis M.D.
To: 'ORT-L@www2.aaos.org'
Sent: Wednesday, August 02, 2006 12:16 PM
Subject: RE: [ORT-L] femoral neck lesion - nail or not

I am an orthopaedic oncologist who still does a fir amout of trauma. Mirels wrote a paper for a pathologic Fx scoring system. It looks at 4 risk factors
Lesion size (<1/3 , 1/3 to 2/3, and >2/3),
Location (upper extremity, lower ext, and peri-trochanteric)
Type of lesion (blastic, mixed, lytic)
Pain ( no pain ,pain at rest, functional pain)
each gets 1,2 or 3 points
patients over a 9 have a higher risk of fracturing and probably should be prophylactically nailed (cephalomedullary nailed)

This person looks like she scores a 1+3+1+1= 6
so I would not tend to nail her.

Note that this looked at pre-XRT patients, post XRT patient can run a higher risk
Francis Cyran, UCLA Dept Orthopaewdic Oncology
-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org]On Behalf Of Douglas Duncan
Sent: Tuesday, August 01, 2006 3:47 PM
To: ORT-L@www2.aaos.org
Subject: [ORT-L] femoral neck lesion - nail or not

Attached are x-ray images of a lesion in the left hip of a 71 y/o lady with numerous breast CA blastic metastases to in the spine, pelvis and many other bones. This lesion in the left femoral neck was found on a total body bone scan ordered by her oncologist to assess the extent of her metastases. She was not, and is not, symptomatic in the hip area. Her oncologist sent her to an orthopedist in town and he recommended surgery (I don't know if a hip nail or prosthesis was recommended.) Since she is fully ambulatory with full weight bearing and without pain and asymptomatic in the hip, she was reluctant to proceed with his recommendation and came to me for another opinion.

There doesn't appear to be any lytic destruction of her cortex on CT scan in all 3 planes.
The radiation oncologist wants to do radiation of the hip but not until after any recommended surgery.
I have difficulty making a case for prophylactic surgery on the basis of her x-ray findings and in light of the fact she is not having pain that can be attributed to her hip.

Any of your thoughts would be appreciated.
<<AP1.jpg>> <<CORONAL1.jpg>> <<CROSS NECK1.jpg>> <<CROSS NECK2.jpg>> <<LAT2.jpg>> <<SAGITAL1.jpg>>

Doug Duncan
Douglas.Duncan@coxhealth.com
dmdunc@mhcsi.com

----------------------------------------------------------
IMPORTANT WARNING: This email (and any attachments) is only intended for the use of the person or entity to which it is addressed, and may contain information that is privileged and confidential. You, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Unauthorized redisclosure or failure to maintain confidentiality may subject you to federal and state penalties. If you are not the intended recipient, please immediately notify us by return email, and delete this message from your computer.
----------------------------------------------------------

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