Until recently, there had been few advances in the science of predicting fracture risk in the setting of metastatic cancer from the early days of orthopedic oncology. Numerous rules based on clinical and plain film radiographic criteria evolved into Mirels scoring and Carnesale’s “conventional” definition, as well as its variation, the L-cort >30 mm rule, and then nothing new appeared for many years. Within the last few years, however, much has been published regarding CT-based techniques, particularly CT-based structural rigidity analysis (CTRA). Other techniques such as finite element modeling (FEM) and fludeoxyglucose positron emission tomography/computerized tomography (FDG PET/CT) continue to evolve. In addition, techniques that combine imaging with demographic and oncologic characteristics, similar to what has been done to predict fractures in osteoporosis using the World Health Organization’s (WHO) Fracture Risk Assessment Tool (FRAX), merit consideration. At this point, albeit improved from 30 years ago, precise, practical, and widely available prediction of impending fractures in patients with metastatic lesions remains elusive and warrants further prospective evaluation. In addition, although it would seem intuitively obvious that preventing a pathologic fracture is important, literature supporting this is lacking, and evaluation of the clinical and financial benefit of such preventative testing requires more investigation.
Department of Orthopedic Surgery, Upstate Medical University, Syracuse, NY
Supported by National Institutes of Health/National Cancer Institute (NIAMS) (unrelated work). Research grant support. Musculoskeletal Tumor Society (sponsored work reported herein). Orthopaedic Research and Education Foundation (unrelated sponsored work). Carol M. Baldwin Breast Cancer Research Foundation (sponsored work reported herein). Children’s Miracle Network (unrelated work). Jim and Juli Boeheim Foundation (unrelated work). Orthovita, Inc. (Investigator-initiated prospective trial; unrelated). Stryker, Inc. (Multicenter industry sponsored trial; unrelated). Wright Medical, Inc. (Investigator-initiated prospective trial; unrelated). Royalties. Lippincott, Williams & Wilkins (Book). UpToDate (Author). eMedicine (Editor). Bone Support (US Ortho-Oncology Surgeon Advisory Board).
The author has been involved in research examining CTRA and FEM, including institutional research support, but claims no conflict of interest.
For reprint requests, or additional information and guidance on the techniques described in the article, please contact Timothy A. Damron, MD, at or by mail at Department of Orthopedics, Suite 200, Upstate Bone and Joint Center, 6620 Fly Road, East Syracuse, NY 13057. You may inquire whether the author(s) will agree to phone conferences and/or visits regarding these techniques.