Proximal femoral replacements for metastatic bone disease: financial implications for sarcoma units

Modular intercalary prosthetic reconstruction for malignant and metastatic tumours of the proximal femur

To illustrate the surgical technique and explore clinical outcomes of the reconstruction for the malignant and metastatic bone tumour of proximal femur with metallic modular intercalary prosthesis. Sixteen patients who underwent modular intercalary prosthetic reconstruction after tumour resection were included from April 2012 and October 2020. Prosthesis and screws parameters, resected bone length and residual bone length, clinical outcomes and survivorship were analyzed. All patients were followed up for an average of 19 months (range 1-74). In our series, 12 patients died of the progression of the primary disease at the final follow-up. The cumulative survivorship since the treatment of proximal femoral metastasis was 78.6% (11 patients) at 6 months and 38.5% (5 patients) at 1 year. The mean MSTS score was 22.25 ± 4.55 among all patients. There were no cases of loosening or breakage of the prostheses, plates or screws, despite the various measurements of prostheses and residual bones. Modular intercalary prosthetic reconstruction was an effective method for malignant tumour of the proximal femur, including the advantages of providing early pain relief, quickly restoring postoperative function, required a short operation time, and preserving the adjacent joints.

Prevalence and prognosis of bone metastases in common solid cancers at initial diagnosis: a population-based study

OBJECTIVE

Bone is one of the most common target sites for advanced tumours. The objective was to survey the prevalence and prognosis of bone metastases in 12 common solid malignant tumours.

DESIGN

A retrospective cohort study.

METHODS

A total of 1 425 332 patients with a primary cancer between 2010 and 2015 were identified using the Surveillance, Epidemiology, and End Results database. We computed the prevalence and prognosis of bone metastases in each cancer and compared their survival in different stages. The Kaplan-Meier method and Cox logistic regression were used to analyse survival and quantify the effect of bone metastases.

RESULTS

This study included 89 782 patients with bone metastases at diagnosis. Lung cancer had the highest prevalence (18.05%), followed by liver cancer (6.63%), nasopharyngeal carcinoma (6.33%) and renal cancer (5.45%). Breast cancer (32.1%), prostate cancer (25.9%), thyroid cancer (46.9%) and nasopharyngeal carcinoma (24.8%) with only bone metastases had a 5-year survival rate of over 20%. Compared with patients at the stage previous to metastasis, bone metastases significantly increased the risk of mortality and decreased survival, especially for those with prostate cancer (adjusted HR: 18.24). Other concomitant extraosseous metastases worsened patient survival. Bone was the most common site of metastasis for prostate cancer, while for colorectal cancer, multiorgan metastases were predominant.

CONCLUSIONS

This study provides the prevalence and prognosis of bone metastases at the initial diagnosis of common solid cancers. In addition, it demonstrates the impact of bone metastases on survival. These results can be used for early screening of metastases, clinical trial design and assessment of prognosis.

Analysis of implants for metastatic bone tumors of the proximal femur: A retrospective study

AIM

To investigate the relationship between surgical techniques used in our hospital to treat metastatic bone tumors of the proximal femur and activity level and prognosis of patients and whether the location of the tumor is considered when selecting surgical techniques.

METHODS

We retrospectively reviewed 82 patients with metastatic bone tumors of the proximal femur who underwent intramedullary nail fixation (IMN), bipolar hip arthroplasty (BHP) or modular megaprosthesis (MMP) in our hospital from 2007 to 2020. We measured the distance from the center of femoral head to the proximal (x) and distal (y) end of the of tumor, using preoperative computed tomography images to determine the location of metastasis. We also measured revised Katagiri score at the time of fracture, postoperative ISOLS/MSTS (functional outcome) scores, and overall survival.

RESULTS

The value of x was significantly different among the three groups. The value of y showed a significant difference between the IMN and BHP groups and the BHP and MMP groups. The functional outcome score was significantly lower in the IMN group. The survival rate of the patient tended to be higher in the BHP and MMP groups than in the IMN group 1 year postoperatively.

CONCLUSION

IMN was favored when the distance from the center of femoral head to the proximal end of the tumor was ≥15 mm. In the case of prosthetic replacement, BHP was chosen if the distance from the center of femoral head to the distal end of the tumor was ≤70 mm. BHP and MMP were preferred over IMN functionally.

Resection and reconstruction of the proximal femur with revision stems: a cost-effective alternative

Background

Modular oncologic megaprosthesis is the standard method for reconstruction after resection of tumors of the proximal femur. These implants have been utilized for either primary tumors or metastatic disease of bone and multiple myeloma. Fixation is based on either cemented or cementless stems, and a collar supporting the body of the prosthesis. For those patients with advanced disease and/or limited life span, a judicious approach should balance the functional expectations, prognosis, and the issue of cost of the surgical procedure and the implant that is selected.

Methods

Based on the principles of distal fixation of tapered stems, the authors have utilized implants originally designed for hip revision surgery to reconstruct the proximal femur in 19 patients, after resection because of metastases, multiple myeloma and some aggressive primary tumors. The essentials of the technique consist of distal fixation in the remaining isthmus of the femur by means of tapered stems, impacted in such a way to achieve solid primary fixation, balanced with accurate leg length restoration. Proximally, the implant remains devoid of bone coverage.

Results

In this retrospective study, proper distal fixation, leaving the proximal part of the implant uncovered with bone, has resulted in good functional results in mid-term follow-up of patients. Primary fixation has led to secondary bone ongrowth and remodeling, providing secondary fixation. Complications such as instability, loosening and infection are comparable with those associated to the traditional management with mega prosthesis.

Conclusions

The utilization of tapered stems for distal fixation after proximal femoral resections has shown reliable results after mid-term follow-up. The method might be considered as a cost-effective alternative for selected patients.

Intramedullary nailing vs modular megaprosthesis in extracapsular metastases of proximal femur: clinical outcomes and complication in a retrospective study

BACKGROUND

Extracapsular proximal femur metastasis could be treated by synthesis or resection and megaprosthesis. No universal accepted guidelines are present in the literature. The aim of our study is to analyze of patients with metastases in the trochanteric region of the femur treated by a single type of intramedullary nailing or hip megaprosthesis.

METHODS

We retrospectively reviewed all patients affected by extracapsular metastases of proximal femur. Anthropometric and anamnestic data, routine blood exams and complications were collected. VAS score and MSTS score was administered before the surgery, ad 1-6-12 months after surgery. An un-paired T test and Chi-square were used. Multiple linear regression and logistic regression was performed. Significance was set for p < 0.05.

RESULT

Twenty patients were assigned in intramedullary Group, twenty-five in megaprostheses Group. The mean operative time is shorter in intramedullary group. Differential shows a higher anemization in megaprostheses group (2 ± 2 vs 3.6 ± 1.3; p = 0.02). The patients of intramedullary group showed malnutrition (Albumin: 30.5 ± 6.5 vs 37.6 ± 6 g/L; p = 0.03) and pro-inflammatory state (NLR: 7.1 ± 6.7 vs 3.8 ± 2.4; p = 0.05) (PLR: 312 ± 203 vs 194 ± 99; p = 0.04) greater than megaprostheses group. The patients in intramedullary groups shows a higher functional performance score than megaprostheses group at 1 month follow-up (MSTS: 16.4 ± 6.3 vs 12.2 ± 3.7; p = 0.004). A multivariate analysis confirms the role of type of surgery (p = 0.001), surgery duration (p = 0.005) and NLR (p = 0.02) in affecting the MSTS. Globally eight complications were recorded, no statistical difference was noticed between the two groups (p = 0.7), no predictor was found at logistic analysis.

CONCLUSION

Intramedullary nailing guarantees a rapid functional recovery, compared to patients undergoing hip megaprosthesis who instead improve gradually over time. The selection of patients with poor prognosis allows the correct surgical indication of nailing, while in the case of a more favorable prognosis, the intervention of hip megaprosthesis is to be preferred.

Megaprosthesis for Metastatic Bone Disease—A Comparative Analysis

Background: Megaprosthetic reconstruction is sometimes indicated in advanced metastatic bone disease (MBD) of the appendicular skeleton with large degrees of bone loss or need for oncological segmental resection. Outcome after megaprosthetic reconstruction was studied in the setting of primary bone sarcoma with high levels of complications, but it is not known if this applies to MBD. Method: We performed a comparative analysis of complications and revision surgery for MBD and bone sarcoma surgery in an institutional cohort from 2005–2019. Presented are the descriptive data of the cohort, with Kaplan–Meier (K–M) rates of revision at 1, 2 and 5 years together with a competing risk analysis by indication type. Results: Rates of revision surgery are significantly lower for MBD (8% at 1 year, 12% at 2 years), in the intermediate term, compared to that of sarcoma (18% at 1 year, 24% at 2 years) (p = 0.04). At 5 years this is not significant by K–M analysis (25% for MBD, and 33% for sarcoma), but remains significant in a competing risk model (8% for MBD, and 20% for sarcoma) (p = 0.03), accounting for death as a competing event. Conclusion: Rates of revision surgery after megaprosthetic reconstruction of MBD are significantly lower than that for primary bone sarcoma in this cohort.

Long-term outcome of patients with primary or secondary tumors of the proximal femur treated by bipolar modular tumor prosthesis

PURPOSE

The proximal femur is a common area for primary and also metastatic bone tumors. The objective of this study was to assess the long-term functional and oncological outcomes of patients with malignant primary or secondary tumors of the proximal femur, who underwent proximal femoral resection then reconstruction using bipolar modular tumor prosthesis.

METHODS

Sixty patients with proximal femoral malignant tumors underwent resection and bipolar modular prosthesis between 2000 and 2016, were retrospectively reviewed. Based on diagnosis and presence or absence of pathological fracture, patients were divided into groups. The functional outcome of the patients was evaluated using the Musculoskeletal Tumor Society (MSTS) functional scoring system for the lower extremities.

RESULTS

The mean age was 38 (9-80) years at the time of primary surgery. Pathological fracture was the presentation in 28 patients. The study included 44 patients with primary bone tumor and 16 patients with a secondary bone tumor. The mean MSTS functional score of the patients was 24.3 (range, 18-30) points with no significant difference in patients with primary or secondary tumors. The rate of complications in the present series was 45%. The most frequent complication was an infection in 10 patients (16.7%), followed by aseptic loosening in 7 patients (11.7%). Local recurrence of primary bone tumors occurred in three out of 44 patients (6.8%).

CONCLUSION

Modular bipolar tumor prosthesis has a good long-term functional result in both primary and secondary tumors of the proximal femur, with no significant effect of age, presence or absence of pathological fracture or femoral resection length on the functional outcome. It was found that the only statistically significant variable regarding the risk of infection is previous surgeries.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Acetabular complications are the most common cause for revision surgery following proximal femoral endoprosthetic replacement : what is the best bearing option in the primary and revision setting?

AIMS

Proximal femoral endoprosthetic replacements (PFEPRs) are the most common reconstruction option for osseous defects following primary and metastatic tumour resection. This study aimed to compare the rate of implant failure between PFEPRs with monopolar and bipolar hemiarthroplasties and acetabular arthroplasties, and determine the optimum articulation for revision PFEPRs.

METHODS

This is a retrospective review of 233 patients who underwent PFEPR. The mean age was 54.7 years (SD 18.2), and 99 (42.5%) were male. There were 90 patients with primary bone tumours (38.6%), 122 with metastatic bone disease (52.4%), and 21 with haematological malignancy (9.0%). A total of 128 patients had monopolar (54.9%), 74 had bipolar hemiarthroplasty heads (31.8%), and 31 underwent acetabular arthroplasty (13.3%).

RESULTS

At a mean 74.4 months follow-up, the overall revision rate was 15.0%. Primary malignancy (p < 0.001) and age < 50 years (p < 0.001) were risk factors for revision. The risks of death and implant failure were similar in patients with primary disease (p = 0.872), but the risk of death was significantly greater for patients who had metastatic bone disease (p < 0.001). Acetabular-related implant failures comprised 74.3% of revisions; however, no difference between hemiarthroplasty or arthroplasty groups (p = 0.209), or between monopolar or bipolar hemiarthroplasties (p = 0.307), was observed. There was greater radiological wear in patients with longer follow-up and primary bone malignancy. Re-revision rates following a revision PFEPR was 34.3%, with dual-mobility bearings having the lowest rate of instability and re-revision (15.4%).

CONCLUSION

Hemiarthroplasty and arthroplasty PFEPRs carry the same risk of revision in the medium term, and is primarily due to acetabular complications. There is no difference in revision rates or erosion between monopolar and bipolar hemiarthroplasties. The main causes of failure were acetabular wear in the hemiarthroplasty group and instability in the arthroplasty group. These risks should be balanced and patient prognosis considered when contemplating the bearing choice. Dual-mobility, constrained bearings, or large diameter heads (> 32 mm) are recommended in all revision PFEPRs. Cite this article: Bone Joint J 2021;103-B(10):1633-1640.

Complications after intramedullary nail fixation of pathological versus non-pathological femoral shaft fractures: a retrospective cohort study in 233 patients

BACKGROUND

Postoperative adverse events after intramedullary nailing have been reported in patients with metastatic pathological and non-pathological femoral fractures. Other consequences to be considered are readmission and reoperation. Few studies have compared the risks of postoperative adverse events, reoperation, and readmission after intramedullary nailing of pathological and non-pathological femur fractures. This study was designed to test the hypothesis that patients with pathological femoral fractures had more adverse events, readmission, and reoperation following surgical fixation than non-pathological femoral fractures.

METHODS

This was a retrospective observational cohort study, conducted at an academic medical center in Thailand. The data from patients with femoral shaft fractures undergoing long intramedullary nailing, from June 1, 2006, to June 30, 2020, were included. Patients who had a pathological fracture from a primary bone tumor, metabolic bone disease, or inadequate/missing information were excluded. Patients with pathological fractures from metastatic bone disease were assigned to be the pathological group whereas those with traumatic fractures were assigned to be the non-pathological group. The primary outcome was the risk of inpatient adverse events as compared between the two groups. The secondary outcome was the risk of consequences after discharge as compared between the two groups. Outcomes were analyzed by using multivariate logistic regression analysis.

RESULTS

The total number of patients was 48 in the pathological fracture group and 185 in the non-pathological group. There were significantly higher rates of surgical and medical adverse events in patients with pathological fractures compared to patients with non-pathological fractures. After adjusting for potential confounding factors in multivariate regression analysis, patients with pathological fractures had higher odds of both adverse surgical (adjusted OR 2.43, 95 % CI 1.15-5.13) and medical adverse events (adjusted OR 2.81, 95 % CI 1.13-7.03).

CONCLUSIONS

Patients with metastatic pathological femoral shaft fractures undergoing intramedullary nailing were more likely to experience postoperative adverse events than patients with non-pathological fractures.

Predicting length of stay after proximal femoral endoprosthetic replacement for oncological conditions

BACKGROUND

Endoprosthetic replacement of the proximal femur plays a vital role in managing metastatic and primary bone tumours¹. Length of stay (LOS) has important resource implications but is driven by patient and disease factors over and above the procedure itself. The aim of this project was to identify factors that drive LOS in patients undergoing proximal femoral replacement (PFR).

METHODS

This was a retrospective analysis of clinical records from a single centre (RNOH). 144 cases were identified over a 4 year-period. These were divided into 3 diagnostic categories: primary bone tumour with chemotherapy, primary bone tumour without chemotherapy and metastatic bone disease. Several factors were considered that could influence the length of stay including age, ASA grade, gender, admission to the high dependency unit (HDU), diagnosis, saving the greater trochanter, pre-operative radiotherapy, admission with a fracture and return to theatre.

RESULTS

The median LOS for PFR was 15 days, with 79% admitted to HDU. LOS was almost doubled for patients returning to theatre (P = 0.04). Patients with ASA grades of 3 and 4 had a 75% longer LOS compared to those with grade 1. Additionally, a 10-year increase in age was associated with a 6-8% increase in LOS. Incorporating these factors produced a model which explained 27% of the variability of LOS.

CONCLUSION

Majority of the variables which were tested were significantly associated with LOS. However, factors other than those in our model drive length of stay. This analysis can support conversations with patients and service planning around LOS.

Hip Fracture Prevention in Osteoporotic Elderly and Cancer Patients: An On-Line French Survey Evaluating Current Needs

Background and objectives: Hip fracture is a major public health issue. Those fractures lead to high costs and a decrease in quality of life. A national French survey was conducted, with the objectives to firstly assess the current management of hip fracture and its prevention, both in the osteoporotic and cancer settings, and secondly to evaluate the opinions of physicians on the potential use of minimally invasive implantable devices to prevent hip fracture in alternative of surgery. Materials and methods: This national survey was conducted in France between April and July 2017. Questionnaires were sent to orthopedic surgeons, interventional radiologists, oncologists, and rheumatologists. Completed questionnaires were analyzed and compared according to two indications: orthopedics-traumatology and oncology. Factors associated with these responses were assessed using univariable analyses, based on chi-square tests or an exact Fisher test, as appropriate. Results: A total of 182 questionnaires were completed and further analyzed. Physicians have highlighted the need for a low re-fracture rate and to improve life expectancy for more than 1 year (50% for responders of the orthopedics-traumatology questionnaire and 80% for the responders interested in both indications), as well as quality of life (12.5% and 31%, respectively), but with no significant differences in the oncologic indication. Most of the experts were willing to use or prescribe implantable devices for prevention (63% in orthopedics-traumatology and 93% in oncology), although limited clinical experience (54 and 58%) and surgical risk (around 30% in each indication) were considered as limits. Conclusions: Prevention of hip fracture remains a concern for physicians. More clinical experience with implantable devices, in particular in cancer patients, is needed, but implemented in a strategy to maximize patient recovery while reducing costs.

Bipolar hemiarthroplasty versus total hip arthroplasty in allograft-prosthesis composite reconstruction of the proximal femur following primary bone tumour resection

AIMS

The consensus is that bipolar hemiarthroplasty (BHA) in allograft-prosthesis composite (APC) reconstruction of the proximal femur following primary tumour resection provides more stability than total hip arthroplasty (THA). However, no comparative study has been performed. In this study, we have compared the outcome and complication rates of these two methods.

METHODS

In a retrospective study, 57 patients who underwent APC reconstruction of proximal femur following the primary tumour resection, either using BHA (29) or THA (28), were included. Functional outcome was assessed using the Musculoskeletal Tumour Society (MSTS) scoring system and Harris Hip Score (HHS). Postoperative complications of the two techniques were also compared.

RESULTS

The mean follow-up of the patients was 8.3 years (standard deviation (SD) 5.5) in the BHA and 6.9 years (SD 4.7) in the THA group. The mean HHS was 65 (SD 16.6) in the BHA group and 88 (SD 11.9) in the THA group (p = 0.036). The mean MSTS score of the patients was 73.3% (SD 16.1%) in the BHA and 86.7% (SD 12.2%) in the THA group (p = 0.041). Limping was recorded in 19 patients (65.5%) of the BHA group and five patients (17.8%) of the THA group (p < 0.001). Dislocation occurred in three patients (10.3%) of the BHA group and two patients (7.1%) of the THA group.

CONCLUSION

While the dislocation rate was not higher in THA than with BHA, the functional outcome was significantly superior. Based on our results, we recommend THA in APC reconstruction of the proximal femur. Cite this article: Bone Joint J 2020;102-B(4):524-529.

Prevention of Pathological Fracture of the Proximal Femur: A Systematic Review of Surgical and Percutaneous Image-Guided Techniques Used in Interventional Oncology

Background and objectives: Patients suffering from bone metastasis are at high risk for pathological fractures and especially hip fractures. Osteolytic metastases can induce a high morbidity rate (i.e., pain, facture risk, mobility impairment), and operation on them can be difficult in this frail population having a reduced life expectancy. Several medical devices have been investigated for the prevention of these pathological hip fractures. Materials and Methods: To investigate these solutions, a literature review and a meta-analysis of primary studies was performed. Data sources included electronic databases (PubMed, CENTRAL and ClinicalTrials.gov) from 1990 until 1 January 2019. Titles, abstracts and full-text articles were reviewed in order to select only studies evaluating the performance of the studied solution to prevent osteoporotic and/or pathological hip fracture. The main outcomes were the occurrence of hip fracture, pain evaluation (VAS score) and adverse events occurrence (including severe adverse events and deaths). All randomised controlled trials (RCTs) and cohort studies were considered. A Bayesian cumulative meta-analysis was undertaken on the primary studies conducted in patients with bone metastasis. Results: A total of 12 primary studies were identified, all were cohort studies without a control group, and one compared two devices, and were thereafter considered separately. In those 12 samples, 255 patients were included, mean age 61.7 years. After implantation, the cumulative risk of fracture was 5.5% (95% confidence interval, 3.0% to 8.6%), and adverse event occurrence was 17.4% (95%CI, 12.6 to 22.8%), with a median follow-up of 10 months. The posterior probability of a fracture rate below 5% was 40.3%. Conclusions: The literature about medical devices evaluation for preventing hip fractures in metastatic patients is poor and mostly based on studies with a limited level of evidence. However, this systematic review shows promising results in terms of efficacy and tolerance of these devices in patients with bone metastases. This treatment strategy requires further investigations.

Evaluation of the Role and cost-effectiveness of End-Of-Life Orthopaedic Interventions in Cancer Patients with Skeletal Metastases to the Hip

This study aimed to evaluate the effect of hip reconstruction on patients with skeletal metastases to the hip. We investigated the effect of hip reconstruction on quality of life and ambulatory status, as well as cost-effectiveness of hip reconstruction in this group of patients.

Is a Cephalomedullary Nail Durable Treatment for Patients With Metastatic Peritrochanteric Disease?

BACKGROUND

Although cephalomedullary nail fixation is often used for metastatic peritrochanteric lesions of the femur, there is concern regarding the durability of the implant in comparison to endoprosthetic reconstruction. Previous studies have reported the proportion of patients who undergo reoperation for loss of stability, but the adequacy of the construct has not been critically evaluated in a competing risk analysis that incorporates death of the patient in the calculation.

QUESTIONS/PURPOSES

(1) What is the cumulative incidence of reoperation of cephalomedullary nails with death as a competing risk for metastatic lesions of the proximal femur? (2) What is the survival of patients with metastases to the proximal femur after cephalomedullary nailing? (3) What clinical factors are associated with implant stability in these patients?

METHODS

Between 1990 and 2009, 11 surgeons at one center treated 217 patients with cephalomedullary nails for metastatic proximal femoral lesions. This represented 40% (217 of 544) of the patients undergoing surgery for metastases in this location during the study period. In general, we used cephalomedullary nails when there was normal bone in the femoral head, no fracture in the neck, and a moderate-sized lesion; we favored bipolar hemiarthroplasty for femoral neck fractures and disease affecting the femoral head; finally, we used proximal femoral endoprosthetic replacement for large lesions with severe bone destruction. A retrospective study was conducted of 199 patients with cephalomedullary nails for peritrochanteric metastases from 1990 to 2009. Pathologic fracture, defined as a breach in cortex with a clear fracture line either with or without displacement, was present in 61 patients. The most common primary cancers were breast (42 of 199 patients [21%]), lung (37 of 199 patients [18%]), and renal cell (34 of 199 patients [17%]). A competing risk analysis was performed to describe the cumulative incidence of implant revision. Patient overall survival was assessed by Kaplan-Meier survivorship. A univariate analysis was performed to determine whether there was an association between revision surgery and various patient factors, including tumor histology, pathologic fracture, cementation, and radiation.

RESULTS

Loss of implant stability necessitating revision surgery occurred in 19 of 199 patients (10%). In a competing risk analysis with death of the patient as the competing event, the cumulative incidence of revision surgery was 5% (95% confidence interval [CI], 3%-9%) at 12 months and 9% (95% CI, 5%-13%) at 5 years. Using Kaplan-Meier analysis, the overall patient survival was 31% (95% CI, 25%-37%) at 12 months and 5% (95% CI, 3%-9%) at 60 months. Patients with lung cancer had the shortest overall survival of 11% (95% CI, 1%-21%) at 12 months, and patients with multiple myeloma had the longest overall survival of 71% (95% CI, 49%-94%) at 12 months (p < 0.001). Duration of patient survival beyond the median 7 months was the only factor associated with a greater likelihood of revision surgery. Factors not associated with revision included tumor histology, pathologic fracture, closed versus open nailing, cementation, gender, age, and postoperative radiation.

CONCLUSIONS

The competing risk analysis demonstrates a relatively low cumulative incidence of reoperation and suggests that cephalomedullary nailing is reasonable for patients with moderate-sized proximal femoral metastasis not affecting the femoral head. For the large majority of patients, the construct achieves the goal of stabilizing the femur for the duration of the patient's life. Longer patient survival was associated with greater risk of revision surgery, but no particular tumor histology was found to have a greater cumulative incidence of reoperation. Future work with a larger number of patients and stricter surgical indications may be needed to corroborate these findings.

LEVEL OF EVIDENCE

Level III, therapeutic study.

EVALUATION OF QUALITY OF LIFE IN PATIENTS TREATED FOR METASTATIC DISEASE OF THE PROXIMAL FEMUR

Objective:

Patients with metastatic bone lesions have a limited life expectancy. These metastatic lesions compromise the proximal femur, and fractures are quite common. The survival of these patients depends on the behavior of the primary tumor. The aim of this study was to evaluate the quality of life of patients with extensive metastatic lesion of the proximal femur with pathological or imminent fracture, treated with non-conventional endoprosthesis.

Methods:

From May 2008 to August 2012, twenty-five (25) patients with bone metastases of the proximal femur, with pathological or imminent fracture were recruited into this study. These patients had survived for at least six weeks after surgery and the TESS questionnaire (Toronto Extremity Salvage Score) was administered.

Results:

The final score of the TESS was an average of 57 points (SD 23.78 points). There was no significant difference in TESS values considering: sex, presence of fracture, or site of the bone lesion.

Conclusion:

The TESS questionnaire provides information about the function and quality of life of patients with malignant tumors of the lower limbs, from the patient's perspective. The results can be considered positive, when compared to the limited life expectancy and complexity of this group of patients. Level of evidence III, Therapeutic studies, retrospective comparative study.

Multimodal Treatment of Bone Metastasis-A Surgical Perspective

Over the past decades there has been an increase in the incidence of cancer worldwide. With the advancement in treatment, patient survival has improved in tandem with the increasing incidence. This, together with the availability of advanced modern diagnostic modalities, has resulted in more cases of metastatic bone disease being identified. Bone metastasis is an ongoing problem and has significant morbidity implications for patients affected. Multimodal treatment strategies are required in dealing with metastatic bone disease, which include both surgical and non-surgical treatment options. In the multidisciplinary team, orthopedic surgeons play an important role in improving the quality of life of cancer patients. Surgical intervention in this setting is aimed at pain relief, restoration of function and improvement in functional independence. In selected cases with resectable solitary metastasis, surgical treatment may be curative. With the advancement of surgical technique and improvement in implant design and manufacture, a vast array of surgical options are available in the modern orthopedic arena. In the majority of cases, limb salvage procedures have become the standard of care in the treatment of metastatic bone disease. Non-surgical adjuvant treatment also contributes significantly to the improvement of cancer patient care. A multidisciplinary approach in this setting is of paramount importance.

Oncological and functional results after surgical treatment of bone metastases at the proximal femur

Background

Metastatic lesions to the proximal femur occur frequently (about 10% of patients with cancer) and require surgical treatment. There are many surgical methods of treatment, however, use of the tumor modular endoprostheses seems to be particularly promising. The aim of study was to evaluate oncological and functional results of treatment in patients with proximal femur metastases. Oncological results were evaluated considering the survival of patients and the number of local recurrences. Functional results were assessed as pain intensity in VAS score and performance in Karnofsky and MSTS score.

Methods

Between 2010 and 2016, 122 patients with metastatic tumour to the proximal femur were treated in our hospital. Majority of the patients were women − 77 patients. The mean age was 67 years for women and 72 years for men. Pathological fracture was diagnosed in 98 cases. Metastatic bone tumors commonly develop from breast cancer – 48 and myeloma – 24. One hundred one patients underwent tumor resection and in 21 cases metastatic tumors was not resected. In 75 patients wide tumour resection and modular endoprosthetic replacement were prefomed. Twenty-one patients underwent standard or long stem hip endoprosthetic replacement. Intramedullary gamma nails were implanted in 20 cases and DHS plate in 6 cases. In 92 cases 3-4 weeks after surgery patients undergo external beam radiotherapy (8Gy).

Functional results were assessed as pain intensity in VAS score and performance in Karnofsky and MSTS score. Oncological results were evaluated considering the survival of patients and the number of local recurrences.

Results

The mean follow-up of patients was 27 months (min 4, max 51). Forty-five patients died before last visit in hospital. The mean survival after modular endoprosthetic replacement was 860 days and after bone fixations 360 days. We noticed 9 cases of local recurrences or progressions, 6 in patients who had no radiotherapy. Three patients after modular endoprosthesis replacement and 6 after bone fixations.

After surgery, all patients experienced improvement in the comfort of life resulting from reduction in pain. Mean VAS score before modular endoprosthetic replacement was 6.8 and after 3.4; before standard prothesoplasty 4.9 and after 2.8; and before and after bone fixation 6.9 -5.1. Mean MSTS score was respectively 6.4-19.8; 8.8-22.4 and 10.8-18.2.

In 6 patients after modular endoprosthesis replacement, delayed wound healing were observed. Infectious complications were not observed after fixation with nails and plates. In 3 cases, the fixation was failed. The systemic complications affected 12 patients.

Conclusions

Results of surgical treatment for metastases to the proximal femur are particularly good in patients after standard or modular endoprostheses replacement. The author considers this treatment method to be optimal in patients with good prognosis.

Hemiarthroplasty proximal femoral endoprostheses following tumour reconstruction: is acetabular replacement necessary?

AIMS

Dislocation rates are reportedly lower in patients requiring proximal femoral hemiarthroplasty than for patients undergoing hip arthroplasty for neoplasia. Without acetabular replacement, pain due to acetabular wear necessitating revision surgery has been described. We aimed to determine whether wear of the native acetabulum following hemiarthroplasty necessitates revision surgery with secondary replacement of the acetabulum after proximal femoral replacement (PFR) for tumour reconstruction.

PATIENTS AND METHODS

We reviewed 100 consecutive PFRs performed between January 2003 and January 2013 without acetabular resurfacing. The procedure was undertaken in 74 patients with metastases, for a primary bone tumour in 20 and for myeloma in six. There were 48 male and 52 female patients, with a mean age of 61.4 years (19 to 85) and median follow-up of two years (interquartile range (IQR) 0.5 to 3.7 years). In total, 52 patients presented with a pathological fracture and six presented with failed fixation of a previously instrumented pathological fracture.

RESULTS

All patients underwent reconstruction with either a unipolar (n = 64) or bipolar (n = 36) articulation. There were no dislocations and no acetabular resurfacings. Articular wear was graded using the criteria of Baker et al from 0 to 3, where by 0 is normal; grade 1 represents a narrowing of articular cartilage and no bone erosion; grade 2 represents acetabular bone erosion and early migration; and grade 3 represents protrusio acetabuli. Of the 49 patients with radiological follow-up greater than one year, six demonstrated grade 1 acetabular wear and two demonstrated grade 2 acetabular wear. The remainder demonstrated no radiographic evidence of wear. Median medial migration was 0.3 mm (IQR -0.2 to 0.7) and superior migration was 0.3 mm (IQR -0.2 to 0.6). No relationship between unipolar versus bipolar articulations and wear was evident.

CONCLUSION

Hemiarthroplasty PFRs for tumour reconstruction eliminate joint instability and, in the short to medium term, do not lead to native acetabular wear necessitating later acetabular resurfacing. Cite this article: Bone Joint J 2018;100B:101-8.

Hemiarthroplasty for Fractures of Metastatic Bone Disease Have Different Outcomes Compared to Fractures Without Metastasis: A Matched-Pair Analysis

INTRODUCTION

Hemiarthropalsty (HA) for proximal femur fractures (PFF) has shown good results in the elderly patient population. It has also been used to treat fractures of the proximal femur in patients with metastatic bone disease (MBD). Nonetheless, complications still occur in both patient populations and their effect on 90-day costs can be a great burden to the healthcare system. Thus, the purpose of this study was to evaluate and compare the outcomes and costs of HA for PFF in patients with bone metastasis versus those without it.

MATERIALS AND METHODS

The Medicare standard analytical files were queried through International Classification of Diseases and Related Health Problems, ninth edition (ICD-9) codes. A case-control study comparing PFF in patients with and without MBD treated with HA was performed. Medical and surgical complications, mortality, discharge disposition, and length of stay were analyzed and compared. Outcomes were tracked for the 90-day period after surgery. Statistical analysis was performed through odds ratios, unpaired t-tests, and chi-squares.

RESULTS

Patients treated with HA for fractures with MBD have higher rates of medical complications compared to fracture patients without MBD. Mortality was found to be significantly greater in the MBD cohort (8.8% vs. 2.3%), as were medical complications and length of stay. Both charges and reimbursements were also significantly greater in the MBD cohort.

CONCLUSION

Patients who undergo hip HA for MBD are at increased risks of medical complications compared to patients who undergo HA for fractures without metastasis, and surgeons should be aware of these increased risks.

Factors associated with the decision of operative procedure for proximal femoral bone metastasis: Questionnaire survey to institutions participating the Bone and Soft Tissue Tumor Study Group of the Japan Clinical Oncology Group

BACKGROUND

Pathological fracture of the proximal femur is a main cause of cancer patients losing their ability to walk. Although both osteosynthetic devices (predominantly intramedullary nails) and prosthetic replacement have been widely performed for treatment, controversies exist regarding which procedure should be used for the various conditions. In order to decide the eligibility criteria of a planned randomized prospective study about the treatment of pathological fractures of the proximal femur, we assessed the factors affecting the selection of operative procedures using questionnaires sent to the members of the Bone and Soft Tissue Tumor Study Group (BSTTSG) of the Japan Clinical Oncology Group (JCOG).

METHODS

Questionnaire surveys to evaluate (1) the priority levels of the factors, (2) the equipoise range of each factor in situations where either procedure could be applied, (3) risk and benefit of each procedure, and (4) the degree of bone destruction affecting the selection of operative procedures, were sent to 26 institutions.

RESULTS

Over 80% of the institutions answered. Orthopaedic surgeons of BSTTSG decided on the procedure according to the following factors in descending order: life expectancy, performance status before fracture, the degree of bone destruction, walking ability before fracture, general complications, the number of bone metastases in other sites, and the visceral metastasis status. With regard to bone destruction, (1) the involvement of the head, neck, calcar, and intertrochanteric region, (2) transverse destruction >1/2, and (3) soft-tissue tumor extension, were the factors that led to the choice of prosthesis treatment.

CONCLUSIONS

Using these identified factors, the inclusion criteria for the prospective randomized study of the surgical treatment of metastatic bone tumors of the proximal femur were optimized. The evaluation system about the bone destruction of metastases needs to be refined through the following prospective randomized study.

Current orthopaedic management of bony metastases in the proximal third of the femur

Patients presenting with skeletal metastatic lesions requiring surgery are increasing, this is due to an ageing population and improved oncological survival following advances in medical management. Furthermore, patients are living longer with skeletal metastatic disease. The majority of bone metastases occur in the proximal femur. Robust diagnosis (Biopsy) and treatment is required to ensure that patients can mobilise fully weight bearing immediately post-surgery and that the construct should outlive the patients expected survival. We review the changing management of metastatic disease in the proximal femur.

Outcome after fixation of metastatic proximal femoral fractures: A systematic review of 40 studies

Endoprosthetic reconstruction, intramedullary nailing, and open reduction internal fixation (ORIF) are the most commonly practiced surgical strategies for treatment of metastatic proximal femoral fractures. This review describes functional outcome, local, and systemic complications. All three surgical strategies result in reasonable function on average; however, wide ranges indicate that both poor and good functional levels are obtained. We found that the overall reoperation rate was comparable for endoprosthesis and intramedullary nailing, but was higher for ORIF. J. Surg. Oncol. 2016;114:507-519. © 2016 Wiley Periodicals, Inc.

Reconstruction of the proximal femur with a modular resection prosthesis

BACKGROUND

Various megaprostheses are currently available for reconstruction of the proximal femur after tumor resection. This study evaluates the survival and complications of a modular megaprosthesis for reconstruction of the proximal femur.

MATERIALS AND METHODS

We studied the medical files of 109 tumor patients (age range 16-86 years) who underwent proximal femoral reconstruction with the MRP(®) megaprosthesis from 2002 to 2011. There were 70 patients with metastases, 34 patients with bone sarcomas, and five patients with hematological malignancies; 82 were primary and 27 were revision reconstructions. Mean follow-up was 2.5 years; 31 patients had a minimum five-year follow-up. We evaluated the survival and function of the patients, and the survival and complications of the megaprostheses.

RESULTS

Survival was significantly higher for the patients with bone sarcomas compared to those with metastases and hematological malignancies. Mean MSTS functional score was similar between patients with bone sarcomas and those with hematological malignancies and metastases, and between patients with primary and those with revision reconstructions. Overall survival of the MRP(®) megaprostheses was 74 % at 5 and 9 years. Fourteen (13.6 %) major complications occurred at a mean period of 1.4 years (range 3 months to 4.5 years); these included infection (5.8 %), dislocation (3.9 %), local recurrence (2.9 %), and acetabular fracture (1 %).

CONCLUSION

MRP(®) megaprostheses are a valuable reconstruction option after tumor resection of the proximal femur.

Results of the treatment of bone metastases with modular prosthetic replacement--analysis of 67 patients

Background

Surgical treatment of long-bone metastases requires a comprehensive approach. The indications for surgery are based on the patient’s general condition, type and stage of cancer, and survival time expectancy. Tumor modular endoprostheses have been increasingly used. Surgery should provide pain relief and improve the quality of life.

Methods

Between 2010 and 2013, 67 patients with malignant metastases were surgically treated with resection prostheses. We performed a retrospective analysis of the indications for the surgery, its course, the type of the prostheses used, and the implantation techniques applied. We evaluated the most important clinical parameters influencing the postoperative quality of life of the patients.

Results

Breast, prostate, and lung cancers are the most common primary tumors that metastasize to bones. The most common site of the lesions is the proximal femur; sporadically, they do occur in bones distal to the knee and elbow. After the surgery, all the patients could walk, most of them without crutches. The pain, rated on a VAS scale, decreased significantly, and the Karnofsky score improved. We observed that joint mobility and the strength of the muscles in the limbs allowed for normal functioning. Postoperative complications including infections and local tumor recurrences were rarely observed.

Conclusions

The use of modular prostheses is an adequate method of treatment in patients with bone metastases. A radical resection of the tumor, which prevents local recurrences and loosening of implants, gives good outcomes. Reduced joint mobility resulting from muscle attachment cutting is well tolerated and concerns mainly patients that underwent operations on the humerus.

The investigation and management of suspected malignant pathological fractures: a review for the general orthopaedic surgeon

The management of malignant pathological fractures necessitates careful diagnostic work-up, pre-operative investigation, planning and multidisciplinary input from specialists in the fields of radiology, pathology, oncology, trauma and orthopaedics. Malignant and non-malignant conditions including metabolic disorders, benign tumours and pharmacological therapies can be implicated. The majority of patients who present with suspected pathological fractures will be managed by general orthopaedic and trauma surgeons rather than specialists in orthopaedic oncology. Skeletal metastases can result in considerable morbidity and predispose to pathological fractures. With advances in the medical management of malignancy, life expectancy in cancer patients is increasing, leading to an increasing risk of skeletal metastasis and the potential for pathological fractures. Conventional modes of trauma fixation for pathological fractures may not be appropriate. The aim of this review is to outline diagnostic and management strategies for patients who present with a long bone fracture that is potentially pathological in nature.

Modular tumor endoprostheses in surgical palliation of long-bone metastases: a reduction in tumor burden and a durable reconstruction

Background

Surgical treatment of bone metastases has become increasingly important as patients live longer with metastatic cancer and one of the main aims is a long-lasting reconstruction which survives the patient. Conventional osteosynthesis may not be able to achieve this objective in the context of modern day cancer care.

Methods

This study evaluates the oncological outcomes, treatment-related complications, and function after resection of metastases and reconstruction with modular tumor endoprostheses in 80 patients. All patients who underwent surgical treatment with modular tumor prostheses for bone metastases from 1993 to 2008 were traced by our tumor database and clinical information was recorded from patient case.

Results

Mean age was 63 years. The most common primary tumors were renal cell (47%), breast (21%), and lung (8%). The proximal femur was affected in 45%, proximal humerus in 26%, and the distal femur in 17% of cases. In 22 cases, the tumor prosthesis was implanted during a revision operation. Mean overall survival after surgery was 2.9 years. Overall survival rate was 70% at one year and 20% at five years. Implant survival was 83% after one year and 74% at five years. Overall rate of operative revision was 18%.

Conclusions

Our data collectively suggest that despite higher costs, implantation of modular tumor endoprostheses may be a suitable treatment for bone metastases with a low complication rate and rapid improvement in function in appropriately selected patients.

Clinical, economic and humanistic burdens of skeletal-related events associated with bone metastases

Despite effective skeletal-related event (SRE)-limiting therapies such as zoledronic acid and denosumab, SREs continue to place a meaningful burden on patients, providers and payers. However, studies of SRE-related effects on clinical (i.e., survival), economic (i.e., cost per event) and humanistic (i.e., quality of life) outcomes often report results in a composite manner and frequently do not differentiate the effects by SRE-type (i.e., bone radiation, bone surgery, hypercalcemia, pathological fracture and spinal cord compression). Nevertheless, understanding the differential burdens of individual SRE types, which vary in severity and duration of effect, is an important consideration - particularly in pharmacoeconomic evaluations of SRE-limiting therapies. In this review of the clinical, economic and humanistic SRE burden, it was found that SRE types can be differentiated by these outcomes, although economic outcomes are far more frequently reported than clinical or humanistic.

Metastatic bone disease: Have we improved after a decade of guidelines?

Objectives

Guidelines for the management of patients with metastatic bone disease (MBD) have been available to the orthopaedic community for more than a decade, with little improvement in service provision to this increasingly large patient group. Improvements in adjuvant and neo-adjuvant treatments have increased both the number and overall survival of patients living with MBD. As a consequence the incidence of complications of MBD presenting to surgeons has increased and is set to increase further. The British Orthopaedic Oncology Society (BOOS) are to publish more revised detailed guidelines on what represents ‘best practice’ in managing patients with MBD. This article is designed to coincide with and publicise new BOOS guidelines and once again champion the cause of patients with MBD.

Methods

A series of short cases highlight common errors frequently being made in managing patients with MBD despite the availability of guidelines.

Results

Despite guidelines for the management of patients with MBD being available for more than a decade basic errors in management continue to be made, affecting patient survival and quality of life.

Conclusions

It is hoped that by publicising the new BOOS guidelines the management of patients with MBD will improve over the next decade, significantly more than it has over the last decade.

Reducing the burden of bone metastases: current concepts and treatment options

BACKGROUND

Bone metastases occur frequently in patients with solid tumours such as those of the prostate, breast and lung, and are associated with an increased risk of skeletal-related events (SREs). This article reviews the personal, social and economic burdens of bone metastases and SREs, and approaches to treatment.

METHODS

PubMed searches were conducted using a broad range of search terms. Articles identified were refined by author review of abstracts. Additional material was identified by searching recent relevant congress abstracts.

RESULTS

Bone metastases often decrease quality of life, but quantitative data on the extent of this effect are limited. Data from the USA demonstrate a significant financial burden associated with bone metastases; similar trends are now being uncovered in Europe as the number of assessments of health economics and healthcare resource utilisation in the region increases. The bisphosphonate zoledronic acid reduces the incidence of SREs compared with placebo. Recent phase 3 studies have shown that therapy with the RANK ligand inhibitor denosumab is superior to zoledronic acid for preventing or delaying SREs in patients with bone metastases from solid tumours. Denosumab also has a comparable safety profile to bisphosphonates, with reduced risk of renal toxicity and acute phase reactions. Data from Europe suggest that denosumab is cost-effective for the prevention of SREs compared with zoledronic acid. Additionally, several new experimental bone-targeted agents show promise.

CONCLUSION

Recent progress may help to reshape evidence-based guidelines to improve patient care and reduce the economic burden of bone metastases.