This kind of pathology can be secondary to either benign lesions (such as Paget disease or giant cell tumour) or malignancies. Their management may alter prognosis and affect quality of life and survival of these patients. Managing pathological bone fractures in patients with either primary or metastatic bone tumours represents a difficult task even for the most experienced surgeons. The timing issue for hip fractures in the elderly can be even more challenging for the orthopaedic surgeon if a pathological fracture is suspected. This unavoidable delay keeps the patient in bed, increasing the risk of pulmonary, skin and urinary tract infections. In clinical practice, it is not unusual to delay surgical procedures in elderly, as many variables can interfere with early treatment: daily therapy with oral anti-coagulant or anti-platelet drugs, on course infections, comorbidities like cardiac or renal disease which often require additional preoperative treatments and tests that take time 19. Even if it is widely accepted that hip fractures in this group of patients should be treated surgically as soon as possible, there is no consensus about the effective timing of surgery 10-18. Moreover, prompt intervention is associated with a significant reduction in pressure sores 8, 9. A recent meta-analysis conducted by Moja that included over 190,000 patients reported that early surgery for hip fracture provides a survival benefit in comparison with later intervention. Early treatment aims to minimise the length of time a patient is confined to bed rest, thereby reducing the risk for associated complications, such as pressure sores, deep vein thrombosis (DVT) and urinary tract infections (UTI). Since 2008, the Italian Ministry of Health has introduced the rate of proximal femoral fracture treated within 48 hours as one of the indexes of hospital efficiency 7. This is due to patient-related factors such as pre-existing chronic comorbidities and fracture-related factors like bleeding, anaemia and exposure to proinflammatory conditions that can worsen prognosis 5, 6. This condition is associated with increased morbidity and mortality, with estimated 1-year mortality rates between 14 and 36% 1-4. The incidence is expected to increase each year due to increasing life expectancy. In fact, more than 250,000 hip fractures are estimated annually in the United States in people over 65 years old. Proximal femoral fractures in elderly patients are a widely diffused entity in orthopaedic scenery. An algorithm could help standardise procedures and provide a tool for safe management of these patients. The surgeon should not rush to treat a suspicion of a pathological fracture without having performed all necessary investigations.Ĭonclusions. Orthopaedists must doubt a pathologic fracture. While bone metastases are the expression of a systemic disease, bone sarcomas have an extremely aggressive local course and an incorrect surgical procedure could heavily affect prognosis of the patient. Results. Proper imaging is essential in the management of bone metastases, along with appropriate laboratory tests and within a multi-disciplinary setting. Evidence from the literature was merged to define a flowchart for a safe clinical-diagnostic pathway. Methods. A review of the literature on diagnostic and therapeutic tools in pathologic fractures of the hip was conducted. This paper aims to investigate the current literature and to propose an algorithm to manage patients more securely. In such patients, a pathologic fracture of the proximal femur is not an uncommon event and may be consequent to bone metastases or primary tumours. Objective. Current Italian guidelines recommend surgery within 24 hours from admission for hip fractures of the elderly.
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