Comparative analysis of risk factors for pathological fracture with femoral metastases

J Bone Joint Surg Br. 2004 May;86(4):566-73.


A number of risk factors based upon mostly retrospective surgical data, have been formulated in order to identify impending pathological fractures of the femur from low-risk metastases. We have followed up patients taking part in a randomised trial of radiotherapy, prospectively, in order to determine if these factors were effective in predicting fractures. In 102 patients with 110 femoral lesions, 14 fractures occurred during follow-up. The risk factors studied were increasing pain, the size of the lesion, radiographic appearance, localisation, transverse/axial/circumferential involvement of the cortex and the scoring system of Mirels. Only axial cortical involvement >30 mm (p = 0.01), and circumferential cortical involvement >50% (p = 0.03) were predictive of fracture. Mirels' scoring system was insufficiently specific to predict a fracture (p = 0.36). Our results indicate that most conventional risk factors overestimate the actual occurrence of pathological fractures of the femur. The risk factor of axial cortical involvement provides a simple, objective tool in order to decide which treatment is appropriate.

Publication types

  • Review

MeSH terms

  • Female
  • Femoral Fractures / etiology*
  • Femoral Neoplasms / complications*
  • Femoral Neoplasms / radiotherapy
  • Femoral Neoplasms / secondary*
  • Fractures, Spontaneous / etiology*
  • Humans
  • Male
  • Middle Aged
  • Pain / etiology
  • Pain Measurement
  • Prognosis
  • Prospective Studies
  • Randomized Controlled Trials as Topic
  • Risk Factors
  • Severity of Illness Index