Additional imaging is of limited value in traumatic hip fractures with a history of distant malignancy and no suspicious lesion on plain radiographs

Sharrock, Martin, Mati, Wael, Koh, Shang Peng, Abdullah, Mustafa and Charalmabous, Charalambos (2022) Additional imaging is of limited value in traumatic hip fractures with a history of distant malignancy and no suspicious lesion on plain radiographs. Journal of Orthopaedic Trauma . ISSN 0890-5339

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Official URL: http://doi.org/10.1097/BOT.0000000000002410

Abstract

Objective:
To determine the value of obtaining additional pre-operative imaging in patients with a traumatic hip fracture and a history of malignancy in whom plain radiographs show no lesion suspicious for metastases.

Design:
Retrospective review.

Setting:
Teaching NHS Trust in the UK, over an 8-year period treating 4,421 hip fractures.

Patients/Participants: 367 patients with hip fracture and a history of malignancy at a site distant to the hip. 330 had a history of trauma and no lesion on the plain radiograph suspicious for metastases.

Main Outcomes Measurements:
Whether obtaining additional imaging pre-operatively (MRI, CT, bone scan) identified metastases or affected management.

Results:
32/330 patients had further pre-operative imaging, none of which demonstrated a pathological fracture secondary to malignancy. On follow up, 3/330 (0.9%) cases were found to have occult metastasis at the hip fracture site. All 3 had only plain radiographs prior to surgery. In 2 this was identified on histological examination of intra-operative samples, and in 1 radiologically as a metastatic metaphyseal lesion 18 months following a hemiarthroplasty. Only in the latter case, pre-operative identification of hip metastasis could have altered surgical management. Patients undergoing further pre-operative imaging waited significantly longer for surgery (35±26 versus 51±26 hours, P=0.0011).

Conclusions:
In the absence of a suspicious metastatic lesion on initial plain radiographs, further pre-operative imaging is unlikely to identify a lesion that will affect management and confers significant delays to surgery. Sending intra-operative histological samples may help guide post-operative oncological management but further work is needed to prove its utility.

Level of Evidence:
Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.


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