Pathological fractures of the femur: improvement of quality of life after surgical treatment

Safety and Efficacy of a Single-Stage versus Two-Stage Intramedullary Nailing for Synchronous Impending or Pathologic Fractures of Bilateral Femur for Oncologic Indications: A Systematic Review

Although intramedullary nail (IMN) fixation is the standard of care for most impending and/or complete pathologic fractures of the femur, the optimal timing/sequence of the IMN in cases of synchronous bilateral femoral disease in advanced cancer is not well established. Thus, we compared the outcomes of single-stage (SS) vs. two-stage (TS) IMN of the bilateral femur with a systematic review of the literature on this topic. Bilateral SS and TS IMN cases were identified from 14 studies extracted from four databases according to PRISMA guidelines. Safety (complications, reoperations, mortality, survival, blood loss, and transfusion) and efficacy (length of stay [LOS], time to start rehabilitation and adjuvant therapy, functional scores, and cost) were compared between the groups. A total of 156 IMNs in 78 patients (36 SS and 42 TS) were analyzed. There were one surgical (infection in TS requiring reoperation; p = 0.860) and fifteen medical complications (five in SS, ten in TS; p = 0.045), with SS being associated with lower rates of total and medical complications. Survival, intraoperative mortality, and postoperative same-admission mortality were similar. No cases of implant failure were reported. Data on LOS, rehabilitation, and adjuvant therapy were scarcely reported, although one study favored SS over TS. No study compared cost or functional scores. Our study is the largest and most comprehensive of its kind in supporting the safety and efficacy of a SS bilateral femur IMN approach in these select patients. Further investigations with higher levels of evidence are warranted to optimize treatment protocols for this clinical scenario.

Surgical Management of Metastatic Pathologic Subtrochanteric Fractures: Treatment Modalities and Associated Outcomes

BACKGROUND

Subtrochanteric pathological fractures (PFs) occur in approximately one-third of femur bone metastases. We seek to analyze surgical treatment strategies for subtrochanteric metastatic PFs and their revision rates.

METHODS

A systematic review was performed using the PubMed and Ovid databases. Reoperations as a result of complications were analyzed according to initial treatment modality, primary tumor site, and type of revision procedure.

RESULTS

We identified a total of 544 patients, 405 with PFs and 139 with impending fractures. The study population's mean age was 65.85 years with a male/female ratio of 0.9. Patients with subtrochanteric PFs who underwent an intramedullary nail (IMN) procedure (75%) presented a noninfectious revision rate of 7.2%. Patients treated with prosthesis reconstruction (21%) presented a noninfectious revision rate of 8.9% for standard endoprostheses and 2.5% for tumoral endoprostheses (p < 0.001). Revision rates because of infection were 2.2% for standard and 7.5% for tumoral endoprostheses. There were no infections within the IMN and plate/screws group (p = 0.407). Breast was the most common primary tumor site (41%) and had the highest revision rate (14.81%). Prosthetic reconstructions were the most common type of revision procedure.

CONCLUSION

No consensus exists regarding the optimal surgical approach in patients with subtrochanteric PFs. IMN is a simpler, less invasive procedure, ideal for patients with a shorter survival. Tumoral prostheses may be better suited for patients with longer life expectancies. Treatment should be tailored considering revision rates, patient's life expectancy, and surgeon's expertise.

LEVEL OF EVIDENCE

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

Neck of femur fracture: Previous history of malignancy is not an indication to send femoral head for routine histology

BACKGROUND

Neck of femur fractures is the most common fractures associated with low-velocity injury in the elderly. Some patients may require further histological examination of the femoral head due clinical suspicion of malignance as a cause of fracture.

OBJECTIVES

To review whether standard screening question(s) could be used to identify patients that require histological examinations following neck of femur fracture.

STUDY DESIGN AND METHODS

Femoral heads sent for histological examination over a period of 5 years were identified from hospital database. All patients presenting acutely with neck of femur fracture above the age of 70 were included, and their case notes were retrospectively reviewed. Reason for histopathological examination were categorised into three screening questions: (Q1) clinical suspicion based on history alone, i.e. neck of femur fracture with no clear history of fall or trauma or preceding hip pain, (Q2) radiological evidence of suspicious abnormality on admission radiographs, (Q3) previous history of malignancy or concurrent malignancy or (Q4) combination of above.

RESULTS

In total, 119 samples of femoral head were sent and 18 patients had a positive histology. The sensitivity and specificity of these questions individually showed very poor correlation to positive histology with lowest for (Q3) previous history of malignancy (0.39 and 0.51, respectively). However, combining Q1 and Q2 the sensitivity is improved to 1.0 (95% CI 1.0-1.0) and specificity to 0.35 (95% CI 0.25-0.44) with a positive predictive value of 0.21 (95% CI 0.13-0.30) and negative predictive value of 1.00 (95% CI 1.00-1.00).

CONCLUSION

History of previous malignancy poorly correlates with positive histology. Routine request based on these screening criteria is not cost-effective in patient management.

LEVEL OF EVIDENCE

Prognostic level III.

Short-term outcomes of en bloc resection of solitary bone metastases in limbs

BACKGROUND

To evaluate the pain, quality of life (QOL), and limb function of patients after en bloc resection of solitary metastatic bone cancer in the limbs.

MATERIAL/METHODS

A total of 27 patients with solitary metastatic bone cancer in the limbs were recruited. All these patients underwent limb-salvage surgery with en bloc resection of the metastatic tumor. Pain and QOL were evaluated before and after surgery. Pain was assessed with a 10-point scale before and 1 month after surgery. The QOL was evaluated with the SF-30 scale before and 3 months after surgery. Limb function was evaluated with the Musculoskeletal Tumor Society scale (MSTS) 3 months after surgery. Follow-up was performed for 6~31 months (mean: 16.15 ± 7.47 months).

RESULTS

All procedures were successfully performed. Post-operative complications were found in 6 patients, including incision infection, prosthesis dislocation, deep vein thrombosis, and pulmonary infection. The pain score before and 1 month after surgery was 6.85 ± 3.11 and 1.26 ± 0.81, respectively, indicating obvious improvement (t=9.978, P<0.001). The QOL score before and 3 months after surgery was 38.30 ± 13.05 and 65.78 ± 10.65, respectively, indicating pronounced improvement (t=-18.550, P<0.001). The mean post-operative MSTS score was 23 ± 3 (range: 17-30) (t=-1.450, P=0.016). No local recurrence was observed in any patient during the follow-up.

CONCLUSIONS

Limb salvage surgery with wide or marginal resection for solitary metastatic bone cancer may significantly improve the pain, QOL, and limb function, but there is no difference in local control between wide and marginal resection.

Pathological subtrochanteric fractures in 194 patients: a comparison of outcome after surgical treatment of pathological and non-pathological fractures

BACKGROUND

The surgical treatment of pathological subtrochanteric fractures has been associated with technical difficulties and frequent failures. We analyzed survival, risk factors for death, and outcome after surgical treatment.

METHODS

The study group consisted of 194 patients with pathological subtrochanteric femur fractures operated during 1999-2009. Cox multiple-regression analysis was performed to study risk factors and results were expressed as hazard ratios (HR). We included a control group with non-pathological subtrochanteric fractures (n = 87) for comparison.

RESULTS

The median age at surgery was 68 (29-96) years in the study group and 82 (66-101) in the controls. The 1-year survival rate after surgery was 33% (95% CI: 26-40) in the study group and 85% (79-93) in the controls. In the study group, the risk of death after surgery was increased for patients ≥65 years of age (HR 1.5, 95% CI: 1.1-2.1), with a moderate (HR 2.2, 1.5-3.4) and poor (HR 2.9, 1.6-5.2) Karnofsky score, with visceral metastases (HR 1.6, 1.1-2.3), and perioperative hemoglobin levels <100 g/L (HR 2.2, 1.3-3.7). In patients with pathological fractures, there was no statistically significant difference concerning reoperation rates comparing intramedullary nails (9%) with endoprostheses (6%; P = 0.3).

CONCLUSIONS

Surgery for pathological subtrochanteric femur fractures is a relatively safe and effective procedure.

Evidence for orthopaedic surgery in the treatment of metastatic bone disease of the extremities: a review article

BACKGROUND

The decision to offer orthopaedic surgery to patients with metastatic bone disease is often difficult and requires an understanding of the underlying disease, the patient's needs or wishes, the expected outcomes and the principles of surgery.

AIM

We aimed to look at the literature to support the role of orthopaedic surgery for skeletal metastasis in improving key outcomes such as pain, quality of life and physical functioning.

DESIGN

Review article.

DATA SOURCES

The 'Dialog Datastar' database was used to access Medline and other resources from 1951 to December 2009 using keywords 'Metasta$' AND 'Bone or Skeletal' AND 'Results Or Outcome Or Surg$ Or Management'.

RESULTS

The majority of the studies that have looked at these key outcomes are limited by their design and their use of non-validated outcome measures. This study has detailed the measures to assess outcome, predict survival, predict fracture and how to arrive at key decisions, such as when to operate and when not to operate on these patients.

CONCLUSION

Timely and appropriate surgical intervention reliably alleviates pain and improves quality of life and can be undertaken with few complications in most patients. Although most procedures can be undertaken by non-specialists, consultation with other members of the multidisciplinary team is mandatory, and in complex cases, referral to a specialist orthopaedic oncology centre can be helpful.

Compound osteosynthesis for osteolyses and pathological fractures of the proximal femur

Due to improved oncological therapeutic procedures with longer survival times, the stabilization of osteolyses and pathological fractures is gaining importance. The proximal femur is often affected by metastases. As femoral stability can be compromised by such bone lesions, stabilization as a palliative measure is indicated to restore function and relieve pain. Besides intramedullary osteosynthesis and endoprosthetic reconstruction, compound osteosynthesis is an alternative method for stabilization of the proximal femur. Between 1994 and 2004, 34 compound osteosyntheses were performed for a tumor-caused lesion compromising mechanical stability of the proximal femur. Of those cases, 22 double-plate compound osteosyntheses and 12 single-plate compound osteosyntheses were performed for 9 pathological fractures and 25 osteolyses. Both techniques provided good primary stability. The average survival time after compound osteosynthesis was 14.2 months (range, 0-72 months). Double-plate compound osteosyntheses showed a lower mechanical failure rate than single-plate compound osteosyntheses (14.3% vs 33.3%) and a higher survival probability after 5 years (76.4% vs 38.6%). No surgical revision was required due to perioperative complications in any case. We conclude that reliable stabilization of extensive osteolyses and pathological fractures of the proximal femur can be achieved with compound osteosynthesis. Our data suggest that double-plate compound osteosyntheses is a more favorable technique than single-plate compound osteosyntheses based on a lower rate of mechanical failure and higher survival probability.

Surgery for metastatic lesions of the femur: good outcome after 245 operations in 216 patients

We report our experience with surgery for femoral metastatic lesions, based on 216 patients who underwent a total of 245 operations for femoral metastatic lesions. The median age was 66 (30-94) years, and the most common diagnosis breast cancer, followed by prostate cancer. All patients had pain on weight bearing, 196 had pain at rest, 147 were unable to walk preoperatively, and 148 were confined to a health-care facility. The patients were operated with bipolar hip prosthesis (n=7), total hip replacement (THR) with Harrington reconstruction of the acetabulum (n=42), ordinary THR (n=108), intramedullary nailing (n=55), and other techniques (n=33). All patients improved as regards pain at rest, pain on weight bearing, walking ability and social independence. The median survival for the 216 patients was 6 (0-123) months. All in all, 47 operations were followed by complications of any kind, where dislocations of hip prostheses and implant breakdown were the commonest, but pulmonary embolism the most serious. Patients with femoral metastatic lesions can be operated safely and with acceptable complication rates. Furthermore, large and long-standing gains as regards pain control and mobility can be expected.

Palliative care and orthopedics: what is on the horizon?

Patient-centered palliative care involves effective and empathetic communication between the physician and patient, with the ultimate goal of providing improved quality of life for individuals who have terminal illnesses. Although several nonoperative and operative treatment options are available to improve the patient's quality of life, providing palliative care requires more than technical expertise and knowledge. Orthopedic surgeons need to be supportive facilitators who inform patients of the available treatments, risks, and benefits and incorporate these treatments into the wishes of patients and their families. Realistic expectations and outcomes of treatment need to be discussed with patients so that they can decide what risks they are willing to accept and what measures of success are meaningful to them. Advances in medical treatments and surgical techniques and principles are available to patients who have metastatic bone disease that were not available less than a decade ago. Although many orthopedic surgeons are involved in the care of patients who have metastatic disease, at times, expertise from an orthopedic oncologist may be required to optimize palliative care.

The Holland nail: a universal implant for fractures of the proximal femur and the femoral shaft

OBJECTIVE

To study the possibilities and outcomes for hip and femoral fractures treated with the universal Holland nail((R)).

DESIGN

Retrospective study from November 1998 to December 2001.

SETTING

Department of Traumatology, Erasmus Medical Centre, Rotterdam.

SUBJECTS

112 patients with 115 fractures of the proximal femur and/or the femoral shaft, due to traumatic causes or to metastatic disease.

MAIN OUTCOME MEASURES

Implant possibilities of the Holland nail((R)) and observed complications.

RESULTS

110 patients presented for primary fracture treatment. Two patients were treated secondarily. In three patients, both femora were fractured. Nineteen patients suffered a pathological (impending) fracture. During operation we dealt with 27 minor difficulties. Postoperatively, in 80% of the cases full weight-bearing was allowed. Three patients developed wound infection. In follow-up, 14 patients were lost and two died. The remaining 77 patients (80 fractures) were available for follow-up with regard to fracture healing. Overall consolidation was achieved in 89% of the patients within 12 months. Two patients developed perforation of the femoral head, necessitating removal of the hip screws, and in two patients failure of the nail was seen. Overall, 19 patients needed a non-planned secondary intervention, of which 12 were deemed a minor procedure (e.g. 'dynamisation by distal screw removal').

CONCLUSION

The Holland nail((R)) is technically easy to use for any type of hip and femoral-shaft fracture.

Prospective quality of life research in bony metastatic disease

Metastatic bone disease is a major factor contributing to the deterioration in quality of life in patients with cancer. The decision to surgically stabilize an impending or existing pathologic fracture, or to excise a metastatic deposit is difficult because of the paucity of conclusive data regarding the efficacy of surgery in achieving pain relief, improved function, and quality of life. The psychometric properties of quality of life outcomes instruments and the differences between pain, function, and quality of life are explored in an attempt to define surgical goals. The results of different quality of life instruments in existing studies of internal fixation, chemotherapy, radiation therapy, and bisphophonate treatment suggest that although the majority of patients derive benefit from their treatment, the success of such treatment is heavily dependent the quality of life instrument. Existing instruments are deficient and obstacles to the design and implementation of quality of life assessment in patients with skeletal metastasis are reviewed. Recommendations for improving our ability to assess the risk to benefit ratio of surgery include moving away from physician reported results, devising more appropriate quality of life measurement techniques, analyzing the relationship between pain relief, physical function and quality of life, and focusing attention on prospectively evaluating optimal treatments for patients as they near the end of life.

Subtrochanteric metastatic lesions treated with the long gamma nail

From 1996 to 2002, 39 consecutive intramedullary reconstructions (three bilateral) in 36 patients were performed in a group of subtrochanteric femoral metastatic bone disease using the long gamma nail (LGN). Reconstruction was performed prophylactically in 28 femurs and, for actual fractures in 11. All patients achieved good functional results with pain relief and improved mobility. No major intraoperative complication or long-term mechanical failures were observed. Minor technical, medical and implant related complications were seen in 14 patients. The LGN is a valuable intramedullary reconstruction device with good functional outcome for the treatment of subtrochanteric femoral metastatic bone disease.

The treatment of impending and existing pathological femoral fractures using the long gamma nail

The subtrochanteric region of the femur accounts for one-third of all pathological fractures requiring surgical intervention. The large forces occurring in this region and the possible non-occurrence of bony consolidation constitute a difficult problem to the trauma surgeon. The medical records and X-rays of 25 consecutive patients treated with the long gamma nail (LGN) for pathological (impending or existing) fractures of the femur were analysed retrospectively. Our results in the use of the LGN for pathological fractures of the femur have been good. We recommend an aggressive approach to the early stabilisation of impending fractures and the use of distal locking.

Metastatic lesions of the humerus treated with the isoelastic diaphysis prosthesis

Between January 1, 1987, and December 31, 1997, an isoelastic polyacetal resin prosthesis was used in 50 patients with metastatic bone disease to reconstruct pathologic or impending fractures of the humeral diaphysis. Fifty-seven operations were performed, including seven revision surgeries. The patients were assessed before and after surgery for limb function and quality of life using a modified Karnofsky scale. The mean survival time was 440 days. Ninety-one percent of the operations resulted in restoration or improvement of quality of life. Limb function was good or excellent in more than 80% of the patients after surgery. Breaking of the implant (n = 3), loosening of the implant (n = 2), periprosthetic fracture (n = 1), hematoma (n = 2), infection (n = 1), and one radial nerve paralysis were the main complications. In the cases of implant failure, the prosthesis broke at the site of a locking screw that was inserted across the prosthetic shaft in the cementless implantation technique. This kind of complication could be avoided by using bone cement for implantation or additional plate osteosynthesis between the prosthesis and humeral shaft. The isoelastic diaphyseal prosthesis offers a promising method of treating patients with metastatic lesions of the humeral shaft.

Operative management of impending pathological fractures: a critical analysis of therapy

BACKGROUND

Evident and impending pathological fractures should be stabilised operatively because patients are in serious pain and debilitated for their remaining life span.

METHODS

We evaluated survival and functional results after operative therapy. A retrospective study was conducted concerning 116 patients with 152 impending pathological fractures.

RESULTS

Of all operated patients, postoperatively 79% regained walking capacity and 60% required no or only occasional analgesic drugs. Patients operated on for impending pathological fractures showed better functional results, as well as those operated with the additional use of polymethylmethacrylate (PMMA). Prophylactic use of antibiotics reduced the number of infectious complications significantly. The median survival after operative therapy was 15 months.

CONCLUSIONS

We conclude that impending pathological fractures should be operatively stabilised, if possible, with the additional use of PMMA because of better functional results.

[Pathologic fractures: diagnostic and therapeutic considerations and results of treatment]

Compared with bone fractures caused by trauma, pathologic fractures due to diseased bone are rare events. A pathologic fracture is one that occurs without adequate trauma and is caused by a benign or malignant bone lesion. Diagnosis of the basic disease is important for the subsequent therapy. In cases of benign bone lesions the aim of treatment is total osseus healing with complete restoration of function. In malignant pathologic fractures surgery is an essential part of the overall oncologic treatment design. In most cases it is combined with adjuvant therapy. Various surgical procedures are available for fractures at different sites and depending on whether the operation is performed with curative or palliative intent. In cases of progressive neoplastic disease stabilization is necessary to attenuate pain and to maintain mobility. Between 1983 and 1993 we treated 131 patients with 143 pathologic fractures. Conservative therapy was possible in 10 cases, while 133 fractures had to be treated surgically. Most fractures were caused by skeletal metastasis (61), solitary bone cysts (19), osteoporosis (17) and plasmocytoma (16). The most frequent localizations of pathologic fractures were humerus and femur. The favoured methods of surgical stabilization were endoprosthesis and reinforced osteosynthesis. Most fractures appeared in adolescent patients up to the age of 19 and in adults between the 5th and the 7th decade, and 57.3% of the fractures were caused by a primary or secondary malignant tumour lesion. Surgical treatment was performed in all but 1 case of malignant pathologic fractures. Of 74 patients, with malignant bone lesions 6 (8.1%), are still alive. For 68 patients who died after stabilization, the average survival time was 11.6 months; individual survival time depended on the kind of the tumour present. In 55 patients with fractures in the area of benign bone lesions complete healing was achieved, in 9 cases with conservative therapy. The rate of recurrence for solitary bone cysts treated by curettage or segment resection was 23.5%. Compared with the recurrence rates published by other authors this is a very good result.

Metastatic instability at the proximal end of the femur. Comparison of endoprosthetic replacement and plate osteosynthesis

A retrospective study was performed of the surgical treatment of metastatic lesions of the proximal femur in 50 patients. In 25 consecutive cases a megaprosthesis was implanted; compound plate osteosynthesis was performed in another 25 consecutive patients. Indications for surgical treatment were pathological fractures or, for prophylactic treatment, lesions of the femoral cortex exceeding 2.5 cm in diameter or affecting half the diameter of the bone or more. In all patients capable of walking preoperatively mobility was regained. Immediate full weight-bearing stability was obtained in all patients. Group analysis showed that the functional rating of the hip joint was unchanged, i.e., good or excellent, in all patients with compound osteosynthesis, compared to only 68% in the endoprosthesis group. Pain relief was excellent or good in 84% and 88% respectively. Dislocation of the tumor prosthesis occurred in 3 patients. Closed reduction was possible in 2 cases. Local recurrence was higher in the patients undergoing plate osteosynthesis, as was the frequency of tumor-related implant failure. Postoperative survival averaged 14.7 months and 12.1 months respectively.