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Itokazu M, Higashimoto Y, Ueda M, Hanada K, Murakami S, Fukuda K. Effectiveness of Rehabilitation for Cancer Patients with Bone Metastasis. Prog Rehabil Med 2022; 7:20220027. [PMID: 35633758 PMCID: PMC9113922 DOI: 10.2490/prm.20220027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 04/11/2022] [Indexed: 11/29/2022] Open
Abstract
Objectives: Advances in cancer treatment have led to extended survival, and, as a result, the number of patients with bone metastases is increasing. Activities of daily living (ADL) decrease with bone metastasis and the need for rehabilitation is increasing. This study examined the effects of rehabilitation in patients with bone metastases. Methods: We retrospectively reviewed data of cancer patients with bone metastasis who received rehabilitation between 2016 and 2018. Efficacy of rehabilitation was evaluated in 92 patients as the change in the Functional Independence Measure (FIM) score divided by rehabilitation days (FIM change/day) and assessed by different metastatic sites. Results: Overall FIM scores significantly improved after rehabilitation. Moreover, FIM change/day improved in patients with pelvic metastases (n=44) more than in patients with other metastatic sites (n=48) (P=0.015). In FIM motor components, improvements in toilet, tub/shower, walk/wheelchair, and stairs were significantly greater in patients with pelvic metastasis than in those with other metastasis sites. Conclusions: Rehabilitation improved ADL status to a greater extent in patients with pelvic metastases than in those with other metastasis sites. Patients with pelvic metastases may fear fractures, limiting their ADL, but rehabilitation could eliminate this fear and improve FIM.
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Affiliation(s)
- Maki Itokazu
- Department of Rehabilitation Medicine, Graduate School of Medical Sciences, Kindai University, Osakasayama City, Japan
| | - Yuji Higashimoto
- Department of Rehabilitation Medicine, Graduate School of Medical Sciences, Kindai University, Osakasayama City, Japan
| | - Masami Ueda
- Department of Rehabilitation Medicine, Graduate School of Medical Sciences, Kindai University, Osakasayama City, Japan
| | - Kazushi Hanada
- Department of Rehabilitation Medicine, Graduate School of Medical Sciences, Kindai University, Osakasayama City, Japan
| | - Saori Murakami
- Department of Rehabilitation Medicine, Graduate School of Medical Sciences, Kindai University, Osakasayama City, Japan
| | - Kanji Fukuda
- Department of Rehabilitation Medicine, Graduate School of Medical Sciences, Kindai University, Osakasayama City, Japan
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Spine and Non-spine Bone Metastases - Current Controversies and Future Direction. Clin Oncol (R Coll Radiol) 2020; 32:728-744. [PMID: 32747153 DOI: 10.1016/j.clon.2020.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/21/2020] [Accepted: 07/10/2020] [Indexed: 02/06/2023]
Abstract
Bone is a common site of metastases in advanced cancers. The main symptom is pain, which increases morbidity and reduces quality of life. The treatment of bone metastases needs a multidisciplinary approach, with the main aim of relieving pain and improving quality of life. Apart from systemic anticancer therapy (hormonal therapy, chemotherapy or immunotherapy), there are several therapeutic options available to achieve palliation, including analgesics, surgery, local radiotherapy, bone-seeking radioisotopes and bone-modifying agents. Long-term use of non-steroidal analgesics and opiates is associated with significant side-effects, and tachyphylaxis. Radiotherapy is effective mainly in localised disease sites. Bone-targeting radionuclides are useful in patients with multiple metastatic lesions. Bone-modifying agents are beneficial in reducing skeletal-related events. This overview focuses on the role of surgery, including minimally invasive treatments, conventional radiotherapy in spinal and non-spinal bone metastases, bone-targeting radionuclides and bone-modifying agents in achieving palliation. We present the clinical data and their associated toxicity. Recent advances are also discussed.
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Nationwide Patterns of Pathologic Fractures Among Patients Hospitalized With Bone Metastases. Am J Clin Oncol 2020; 43:720-726. [PMID: 32694296 DOI: 10.1097/coc.0000000000000737] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Pathologic fractures from bone metastases can significantly affect quality-of-life, although it is unclear which patients may be at high risk of this outcome. We aim to determine risk factors for pathologic fracture among patients admitted with bone metastases and to evaluate the association of pathologic fracture with clinical and economic outcomes. METHODS The Healthcare Cost and Utilization Project National Inpatient Sample was queried for all patients hospitalized with bone metastases in 2016. Baseline differences between patients with and without pathologic fractures were assessed by χ and analysis of variance testing. Multivariable logistic regression was used to identify factors associated with fractures. RESULTS In 2016, 272,275 hospital admissions were associated with a diagnosis of bone metastases, of which 11,960 (4.4%) had a primary diagnosis of pathologic fracture. Patients with pathologic fractures had a longer length-of-hospital-stay (mean 7.5 vs. 6.4 d; P<0.001) and higher cost-of-hospital-stay (mean $23,611 vs. $15,942; P<0.001) compared to patients without pathologic fractures. Primary cancers associated with increased likelihood of pathologic fracture included liver and intrahepatic bile duct (odds ratio [OR] 2.34; 95% confidence interval [CI], 1.65-3.32), multiple myeloma (OR 1.94; 95% CI, 1.31-2.86), and kidney and renal pelvis cancer (OR 1.89; 95% CI, 1.50-2.37). CONCLUSIONS Nearly 5% of hospitalizations with bone metastases presented with a concomitant pathologic fracture, which was associated with longer inpatient stay and higher cost. Patients with hepatobiliary, renal cell carcinoma, or multiple myeloma, had a higher likelihood of pathologic fracture. These groups may benefit from increased outpatient monitoring, prophylactic stabilization, or early irradiation.
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Percutaneous Fixation by Internal Cemented Screws of the Sternum. Cardiovasc Intervent Radiol 2019; 43:103-109. [PMID: 31482339 DOI: 10.1007/s00270-019-02334-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/29/2019] [Indexed: 01/09/2023]
Abstract
PURPOSE To evaluate the feasibility, efficacy and safety of sternal percutaneous fixation by internal cemented screw (FICS) using fluoroscopy and/or CT needle guidance. MATERIALS AND METHODS This retrospective single-center study analyzed 9 consecutive cancer patients managed with percutaneous FICS for sternal fracture fixation or osteolytic metastasis consolidation, from May 2014 to February 2019. Eastern Cooperative Oncology Group performance status, Numeric Pain Rating Scale (NPRS) and opioid use were studied preoperatively and postoperatively. Sternal images at last follow-up appointment were also collected. RESULTS Among the 9 patients, 7 had a sternal fracture with 5 being displaced. The technical feasibility was 100%. Both NPRS score significantly decreased from 5.6/10 ± 2.8 to 1.1/10 ± 1.6, and analgesic consumption was significantly improved (p = 0.03) after intervention. No post-procedural complications requiring surgical correction or screw displacement occurred after a mean imaging follow-up that exceeded 1 year (mean follow-up duration, 401.8 days ± 305.8). CONCLUSION Image-guided sternal percutaneous FICS is feasible and safe. It reduces pain and analgesic consumption related to pathologic fracture of the sternum.
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Gupta S, Gulia A, Kurisunkal V, Parikh M, Gupta S. Principles of Management of Extremity Skeletal Metastasis. Indian J Palliat Care 2019; 25:580-586. [PMID: 31673216 PMCID: PMC6812423 DOI: 10.4103/ijpc.ijpc_90_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Understanding the epidemiology of extremity skeletal metastasis and the factors deciding the treatment decision-making are essential in developing a diagnostic and treatment strategy. This leads to optimum care and reduces disease-related burden. With the evolution of medical, radiation therapy, and surgical methods, cancer care has improved the quality of life for patients with improved survival and functional status in patients with skeletal metastasis. Based on the currently available literature, we have described a step-wise evaluation and management strategy of metastatic extremity bone disease. The present review article addresses various aspects and related controversies related to evaluation, staging, and treatment options in the management of extremity bone metastasis. This article also highlights the role of multidisciplinary involvement in management of extremity skeletal metastasis.
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Affiliation(s)
- Srinath Gupta
- Department of Bone and Soft Tissue, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Ashish Gulia
- Department of Bone and Soft Tissue, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Vineet Kurisunkal
- Department of Bone and Soft Tissue, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Mishil Parikh
- Department of Orthopaedics, DY Patil School of Medicine, Navi Mumbai, Maharashtra, India
| | - Sanjay Gupta
- Division of Orthopaedic Surgery, Glasgow Royal Infirmary, Glasgow, Scotland, UK
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Soeharno H, Povegliano L, Choong PF. Multimodal Treatment of Bone Metastasis-A Surgical Perspective. Front Endocrinol (Lausanne) 2018; 9:518. [PMID: 30245668 PMCID: PMC6137681 DOI: 10.3389/fendo.2018.00518] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 08/17/2018] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Henry Soeharno
- Department of Orthopedics, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Department of Orthopedics, Singapore General Hospital, Singapore, Singapore
| | - Lorenzo Povegliano
- Department of Orthopedics, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Clinica Orthopedica, Universita di Udine, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Peter F. Choong
- Department of Orthopedics, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
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Kimura T. Multidisciplinary Approach for Bone Metastasis: A Review. Cancers (Basel) 2018; 10:cancers10060156. [PMID: 29795015 PMCID: PMC6025143 DOI: 10.3390/cancers10060156] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/22/2018] [Accepted: 05/23/2018] [Indexed: 01/22/2023] Open
Abstract
Progress in cancer treatment has improved the survival of patients with advanced-stage cancers. Consequently, the clinical courses of patients are prolonged and often accompanied by morbidity due to bone metastases. Skeletal-related events (SREs), such as pathological fractures and spinal paralysis, cause impairment in activities of daily life and quality of life (QOL). To avoid serious SREs causing impairment in QOL and survival, early diagnosis and a prophylactic approach are required. It is necessary to initiate a bone management program concurrently with the initiation of cancer treatment to prevent complications of bone metastasis. In addition, the requirement of a multidisciplinary approach through a cancer board focusing on the management of bone metastases and involving a team of specialists in oncology, palliative care, radiotherapy, orthopedics, nuclear medicine, radiology, and physiatrists has been emphasized. In the cancer board, a strong focus is placed on the prevention of complications due to bone metastases and on reductions in the high morbidity, hospitalization rate, and overall costs associated with advanced-stage cancers. Recent reports suggest the usefulness of such approaches. The multidisciplinary approach through a cancer board would improve QOL and prognosis of patients, leading to new or continued systemic therapy for primary cancers.
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Affiliation(s)
- Takahiro Kimura
- Department of Urology, Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo 105-8461, Japan.
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Abstract
Metastatic bone pain is a complex, poorly understood process. Understanding the unique mechanisms causing cancer-induced bone pain may lead to potential therapeutic targets. This article discusses the effects of osteoclast overstimulation within the tumor microenvironment; the role of inflammatory factors at the tumor-nociceptor interface; the development of structural instability, causing mechanical nerve damage; and, ultimately, the neuroplastic changes in the setting of sustained pain. Several adjuvant therapies are available to attenuate metastatic bone pain. This article discusses the role of pharmacologic therapies, surgery, kyphoplasty, vertebroplasty, and radiofrequency ablation.
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Affiliation(s)
- Nicholas Figura
- Department of Radiation Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA.
| | - Joshua Smith
- Department of Supportive Care Medicine, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Hsiang-Hsuan Michael Yu
- Department of Radiation Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
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Seetharamaiah VB, Sunil B, Padmanabha MK, Sparsha N. Carcinoma of Unknown Primary Mimicking Multiple Myeloma. J Orthop Case Rep 2017; 7:44-47. [PMID: 28819601 PMCID: PMC5553835 DOI: 10.13107/jocr.2250-0685.744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Pathological fractures due to secondaries in the bone are common with carcinoma of lung, breast, prostate, and in multiple myeloma. Multiple pathological fractures after a trivial fall, indicating metastases warrants detailed investigations for the search of primary. Skeletal secondaries should be strongly suspected in addition to obvious diagnosis of multiple myeloma in such cases. Case Report: We report a case of pathological fractures at multiple sites: The vertebral column, proximal shaft of femur, and contralateral fracture neck of femur. This patient presented with typical features of multiple myeloma, but on complete evaluation was found to be due to extensive metastases in the bones secondary to adenocarcinoma, the primary site of which remained unknown, despite extensive search and evaluation, making it a case of carcinoma of unknown primary. Conclusion: While dealing with patients with extensive skeletal lesions and pathological fractures, secondaries due to adenocarcinoma elsewhere should be kept in mind along with other probabilities such as multiple myeloma.
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Affiliation(s)
- Vanamali B Seetharamaiah
- Department of Orthopedics, Bangalore Medical College and Research Institute, Victoria Hospital, KR Road, Bengaluru, Karnataka, India
| | - B Sunil
- Department of Orthopedics, Bangalore Medical College and Research Institute, Victoria Hospital, KR Road, Bengaluru, Karnataka, India
| | - M K Padmanabha
- Department of Orthopedics, Bangalore Medical College and Research Institute, Victoria Hospital, KR Road, Bengaluru, Karnataka, India
| | - N Sparsha
- Department of Orthopedics, Bangalore Medical College and Research Institute, Victoria Hospital, KR Road, Bengaluru, Karnataka, India
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Roqué i Figuls M, Martinez‐Zapata MJ, Scott‐Brown M, Alonso‐Coello P. WITHDRAWN: Radioisotopes for metastatic bone pain. Cochrane Database Syst Rev 2017; 3:CD003347. [PMID: 28334435 PMCID: PMC6464104 DOI: 10.1002/14651858.cd003347.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND This is an update of the review published in Issue 4, 2003. Bone metastasis cause severe pain as well as pathological fractures, hypercalcaemia and spinal cord compression. Treatment strategies currently available to relieve pain from bone metastases include analgesia, radiotherapy, surgery, chemotherapy, hormone therapy, radioisotopes and bisphosphonates. OBJECTIVES To determine efficacy and safety of radioisotopes in patients with bone metastases to improve metastatic pain, decrease number of complications due to bone metastases and improve patient survival. SEARCH METHODS We sought randomised controlled trials (RCTs) in MEDLINE, EMBASE, CENTRAL, and the PaPaS Trials Register up to October 2010. SELECTION CRITERIA Studies selected had metastatic bone pain as a major outcome after treatment with a radioisotope, compared with placebo or another radioisotope. DATA COLLECTION AND ANALYSIS We assessed the risk of bias of included studies by their sequence generation, allocation concealment, blinding of study participants, researchers and outcome assessors, and incomplete outcome data. Two review authors extracted data. We performed statistical analysis as an "available case" analysis, and calculated global estimates of effect using a random-effects model. We also performed an intention-to-treat (ITT) sensitivity analysis. MAIN RESULTS This update includes 15 studies (1146 analyzed participants): four (325 participants) already included and 11 new (821 participants). Only three studies had a low risk of bias. We observed a small benefit of radioisotopes for complete relief (risk ratio (RR) 2.10, 95% CI 1.32 to 3.35; Number needed to treat to benefit (NNT) = 5) and complete/partial relief (RR 1.72, 95% CI 1.13 to 2.63; NNT = 4) in the short and medium term (eight studies, 499 participants). There is no conclusive evidence to demonstrate that radioisotopes modify the use of analgesia with respect to placebo. Leucocytopenia and thrombocytopenia are secondary effects significantly associated with the administration of radioisotopes (RR 5.03; 95% CI 1.35 to 18.70; Number needed to treat to harm (NNH) = 13). Pain flares were not higher in the radioisotopes group (RR 0.74; 95% CI 0.27 to 2.06). There are scarce data of moderate quality when comparing Strontium-89 (89Sr) with Samarium-153 (153Sm), Rhenium-186 (186Re) and Phosphorus-32 (32P). We observed no significant differences between treatments. Similarly, we observed no differences when we compared different doses of 153Sm (0.5 versus 1.0 mCi). AUTHORS' CONCLUSIONS This update adds new evidence on efficacy of radioisotopes versus placebo, 89Sr compared with other radioisotopes, and dose-comparisons of 153Sm and 188Re. There is some evidence indicating that radioisotopes may provide complete reduction in pain over one to six months with no increase in analgesic use, but severe adverse effects (leucocytopenia and thrombocytopenia) are frequent.
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Affiliation(s)
- Marta Roqué i Figuls
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 171Edifici Casa de ConvalescènciaBarcelonaSpain08041
| | - Maria José Martinez‐Zapata
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 171Edifici Casa de ConvalescènciaBarcelonaSpain08041
| | - Martin Scott‐Brown
- Gray Institute for Radiation Oncology & BiologyRadiobiology Research InstituteChurchill HospitalOxfordUKOX3 7LJ
| | - Pablo Alonso‐Coello
- Biomedical Research Institute Sant Pau (IIB Sant Pau)Iberoamerican Cochrane CentreCIBER Epidemiología y Salud Pública (CIBERESP), SpainSant Antoni Maria Claret 171 ‐ Edifici Casa de ConvalescenciaBarcelonaSpain08041
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Byregowda S, Prabhash K, Puri A, Joshi A, Noronha V, Patil VM, Panda PK, Gulia A. Aggressive Surgery in Palliative Setting of Lung Cancer: Is it Helpful? Indian J Palliat Care 2016; 22:504-506. [PMID: 27803575 PMCID: PMC5072245 DOI: 10.4103/0973-1075.191859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
With increase in survival and progression-free survival in the advanced metastatic cancers, the expectation of quality of life (QOL) has increased dramatically. Palliative care plays a vital role in the management of these advanced cancer patients. At present scenario, palliative care in advanced cancer has seen a completely different approach. Aggressive surgical procedures have been performed to improve the QOL in the advanced cancer patients. We report a case of advanced lung cancer with pathological femur fracture, treated with extensive total femur replacement surgery to provide better QOL.
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Affiliation(s)
- Suman Byregowda
- Departments of Surgical and Medical Oncology, Orthopedic Oncology Services, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Kumar Prabhash
- Departments of Surgical and Medical Oncology, Orthopedic Oncology Services, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Ajay Puri
- Departments of Surgical and Medical Oncology, Orthopedic Oncology Services, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Amit Joshi
- Departments of Surgical and Medical Oncology, Orthopedic Oncology Services, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Vanita Noronha
- Departments of Surgical and Medical Oncology, Orthopedic Oncology Services, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Vijay M Patil
- Departments of Surgical and Medical Oncology, Orthopedic Oncology Services, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Pankaj Kumar Panda
- Departments of Surgical and Medical Oncology, Orthopedic Oncology Services, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Ashish Gulia
- Departments of Surgical and Medical Oncology, Orthopedic Oncology Services, Tata Memorial Hospital, Mumbai, Maharashtra, India
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12
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Tsuzuki S, Park SH, Eber MR, Peters CM, Shiozawa Y. Skeletal complications in cancer patients with bone metastases. Int J Urol 2016; 23:825-832. [PMID: 27488133 DOI: 10.1111/iju.13170] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 06/07/2016] [Indexed: 12/13/2022]
Abstract
As a result of significant improvements in current therapies, the life expectancy of cancer patients with bone metastases has dramatically improved. Unfortunately, these patients often experience skeletal complications that significantly impair their quality of life. The major skeletal complications associated with bone metastases include: cancer-induced bone pain, hypercalcemia, pathological bone fractures, metastatic epidural spinal cord compression and cancer cachexia. Once cancer cells invade the bone, they perturb the normal physiology of the marrow microenvironment, resulting in bone destruction, which is believed to be a direct cause of skeletal complications. However, full understanding of the mechanisms responsible for these complications remains unknown. In the present review, we discuss the complications associated with bone metastases along with matched conventional therapeutic strategies. A better understanding of this topic is crucial, as targeting skeletal complications can improve both the morbidity and mortality of patients suffering from bone metastases.
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Affiliation(s)
- Shunsuke Tsuzuki
- Department of Cancer Biology and Comprehensive Cancer Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Sun Hee Park
- Department of Cancer Biology and Comprehensive Cancer Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Matthew R Eber
- Department of Cancer Biology and Comprehensive Cancer Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Christopher M Peters
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Yusuke Shiozawa
- Department of Cancer Biology and Comprehensive Cancer Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
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14
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Abstract
Skeletal metastasis is a common cause of severe morbidity, reduction in quality of life (QOL) and often early mortality. Its prevalence is rising due to a higher rate of diagnosis, better systemic treatment, longer lives with the disease and higher disease burden rate. As people with cancer live longer and with rising sensitivity of body imaging and surveillance, the incidence of pathological fracture, metastatic epidural cord compression is rising and constitutes a challenge for the orthopedic surgeon to maintain their QOL. Metastatic disease is no longer a death sentence condemning patients to "terminal care." In the era of multidisciplinary care and effective systemic targeted and nontargeted therapy, patient expectations of QOL, even during palliative end of care period is high. We lay emphasis on proving the diagnosis of metastasis by biopsy and histopathology and discuss imaging modalities to help estimate fracture risk and map disease extent. This article discusses at length the evidence and decision-making process of various modalities to treat skeletal metastasis. The modalities range from radiation including image-guided, stereotactic and whole body radiation, systemic targeted or hormonal therapy, spinal decompression with or without stabilization, extended curettage with stabilization, resection in select cases with megaprosthetic or biological reconstruction, percutaneous procedures using radio frequency ablation, cementoplasties and discusses the role of emerging modalities like high frequency ultrasound-guided ablation, cryotherapy and whole body radionuclide therapy. The focus lies on the role of multidisciplinary care, which considers complex decisions on patient centric prognosis, comorbidities, cost, feasibility and expectations in order to maximize outcomes on QOL issues.
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Affiliation(s)
- Manish G Agarwal
- P.D. Hinduja National Hospital, Veer Savarkar Marg, Mahim, Mumbai, Maharashtra, India
| | - Prakash Nayak
- P.D. Hinduja National Hospital, Veer Savarkar Marg, Mahim, Mumbai, Maharashtra, India
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15
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Potter BK, Forsberg JA, Conway S, Morris CD, Temple HT. Pitfalls, Errors, and Unintended Consequences in Musculoskeletal Oncology: How They Occur and How They Can Be Avoided. JBJS Rev 2013; 1:01874474-201311000-00004. [PMID: 27490398 DOI: 10.2106/jbjs.rvw.m.00028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Benjamin K Potter
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Rockville Pike, America Building, 2nd Floor - Ortho, Bethesda, MD 20889
| | - Jonathan A Forsberg
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Rockville Pike, America Building, 2nd Floor - Ortho, Bethesda, MD 20889
| | - Sheila Conway
- Division of Musculoskeletal Oncology, Department of Orthopaedics, University of Miami Miller School of Medicine, 1400 NW 12th Avenue, Miami, FL 33136
| | - Carol D Morris
- Orthopaedic Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065
| | - H Thomas Temple
- Division of Musculoskeletal Oncology, Department of Orthopaedics, University of Miami Miller School of Medicine, 1400 NW 12th Avenue, Miami, FL 33136
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16
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Park DH, Jaiswal PK, Al-Hakim W, Aston WJS, Pollock RC, Skinner JA, Cannon SR, Briggs TWR. The use of massive endoprostheses for the treatment of bone metastases. Sarcoma 2011; 2007:62151. [PMID: 17671631 PMCID: PMC1920593 DOI: 10.1155/2007/62151] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2006] [Accepted: 05/18/2007] [Indexed: 11/17/2022] Open
Abstract
Purpose. We report a series of 58 patients with metastatic bone disease treated with resection and endoprosthetic reconstruction over a five-year period at our institution. Introduction. The recent advances in adjuvant and neoadjuvant therapy in cancer treatment have resulted in improved prognosis of patients with bone metastases. Most patients who have either an actual or impending pathological fracture should have operative stabilisation or reconstruction. Endoprosthetic reconstructions are indicated in patients with extensive bone loss, failed conventional reconstructions, and selected isolated metastases. Methods and Results. We identified all patients who were diagnosed with metastatic disease to bone between 1999 and 2003. One hundred and seventy-one patients were diagnosed with bone metastases. Metastatic breast and renal cancer accounted for 84 lesions (49%). Fifty-eight patients with isolated bone metastasis to the appendicular skeleton had an endoprosthetic reconstruction. There were 28 males and 30
females. Twelve patients had an endoprosthesis in the upper extremity and 46 patients had an endoprosthesis in the lower extremity. The mean age at presentation was 62 years (24 to 88). At the time of writing, 19 patients are still alive, 34 patients have died, and 5 have been lost to follow up. Patients were followed up and evaluated using the musculoskeletal society tumour score (MSTS) and the Toronto extremity salvage score (TESS). The mean MSTS was 73% (57% to 90%) and TESS was 71% (46% to 95%). Mean follow-up was 48.2 months (range 27 to 82 months) and patients died of disease at a mean of 22 months (2 to 51 months) from surgery. Complications included 5 superficial wound infections, 1 aseptic loosening, 4 dislocations, 1 subluxation, and 1 case, where the tibial component of a prosthesis rotated requiring open repositioning. Conclusions. We conclude that endoprosthetic replacement for the treatment of isolated bone metastases is a reliable method of limb reconstruction in selected cases. It is associated with low complication and failure rates in our series, and achieves the aims of restoring function, allowing early weight bearing and alleviating pain.
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Affiliation(s)
- D H Park
- The Royal National Orthopaedic Hospital, Stanmore, Middlesex HA7 4LP, UK
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17
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Roqué I Figuls M, Martinez-Zapata MJ, Scott-Brown M, Alonso-Coello P. Radioisotopes for metastatic bone pain. Cochrane Database Syst Rev 2011:CD003347. [PMID: 21735393 DOI: 10.1002/14651858.cd003347.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND This is an update of the review published in Issue 4, 2003. Bone metastasis cause severe pain as well as pathological fractures, hypercalcaemia and spinal cord compression. Treatment strategies currently available to relieve pain from bone metastases include analgesia, radiotherapy, surgery, chemotherapy, hormone therapy, radioisotopes and bisphosphonates. OBJECTIVES To determine efficacy and safety of radioisotopes in patients with bone metastases to improve metastatic pain, decrease number of complications due to bone metastases and improve patient survival. SEARCH STRATEGY We sought randomised controlled trials (RCTs) in MEDLINE, EMBASE, CENTRAL, and the PaPaS Trials Register up to October 2010. SELECTION CRITERIA Studies selected had metastatic bone pain as a major outcome after treatment with a radioisotope, compared with placebo or another radioisotope. DATA COLLECTION AND ANALYSIS We assessed the risk of bias of included studies by their sequence generation, allocation concealment, blinding of study participants, researchers and outcome assessors, and incomplete outcome data. Two review authors extracted data. We performed statistical analysis as an "available case" analysis, and calculated global estimates of effect using a random-effects model. We also performed an intention-to-treat (ITT) sensitivity analysis. MAIN RESULTS This update includes 15 studies (1146 analyzed participants): four (325 participants) already included and 11 new (821 participants). Only three studies had a low risk of bias. We observed a small benefit of radioisotopes for complete relief (risk ratio (RR) 2.10, 95% CI 1.32 to 3.35; Number needed to treat to benefit (NNT) = 5) and complete/partial relief (RR 1.72, 95% CI 1.13 to 2.63; NNT = 4) in the short and medium term (eight studies, 499 participants). There is no conclusive evidence to demonstrate that radioisotopes modify the use of analgesia with respect to placebo. Leucocytopenia and thrombocytopenia are secondary effects significantly associated with the administration of radioisotopes (RR 5.03; 95% CI 1.35 to 18.70; Number needed to treat to harm (NNH) = 13). Pain flares were not higher in the radioisotopes group (RR 0.74; 95% CI 0.27 to 2.06). There are scarce data of moderate quality when comparing Strontium-89 ((89)Sr) with Samarium-153 ((153)Sm), Rhenium-186 ((186)Re) and Phosphorus-32 ((32)P). We observed no significant differences between treatments. Similarly, we observed no differences when we compared different doses of (153)Sm (0.5 versus 1.0 mCi). AUTHORS' CONCLUSIONS This update adds new evidence on efficacy of radioisotopes versus placebo, (89)Sr compared with other radioisotopes, and dose-comparisons of (153)Sm and (188)Re. There is some evidence indicating that radioisotopes may provide complete reduction in pain over one to six months with no increase in analgesic use, but severe adverse effects (leucocytopenia and thrombocytopenia) are frequent.
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Affiliation(s)
- Marta Roqué I Figuls
- Iberoamerican Cochrane Centre. Institute of Biomedical Research (IIB Sant Pau), Barcelona, CIBER Epidemiología y Salud Pública (CIBERESP), Spain, Sant Antoni Maria Claret 171, Edifici Casa de Convalescència, Barcelona, Catalunya, Spain, 08041
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18
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Webber NP, Sharma S, Grossmann AH, Shaaban A, Jones KB, Layfield LJ, Randall RL. Metastatic pancreatic adenocarcinoma presenting as a large pelvic mass mimicking primary osteogenic sarcoma: a series of two patient cases. J Clin Oncol 2010; 28:e545-9. [PMID: 20713877 DOI: 10.1200/jco.2010.28.6153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Nicholas P Webber
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
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19
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Is humeral segmental defect replacement device a stronger construct than locked IM nailing? Clin Orthop Relat Res 2010; 468:252-8. [PMID: 19543862 PMCID: PMC2795839 DOI: 10.1007/s11999-009-0947-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2008] [Accepted: 06/09/2009] [Indexed: 01/31/2023]
Abstract
Intramedullary (IM) nailing is currently the most common method for treating patients with impending pathologic humeral fractures; however, this treatment is associated with known complications primarily owing to violation of the rotator cuff during insertion. A better option is needed. To determine if a humeral segmental replacement prosthesis would provide a stronger construct compared with an IM nail in this setting, we compared the mechanical properties of these two devices in a cadaver model simulating an impending pathologic fracture. In each of nine matched pairs of fresh human humeri one was randomly selected to undergo a 50% lateral middiaphyseal defect simulating an impending pathologic fracture and subsequent fixation with an IM nail and bone cement. The contralateral humerus underwent fixation using a humeral segmental defect prosthesis. We determined T-scores using DEXA. Each specimen subsequently was tested in torsion to failure. Peak torque and peak rotation at failure were greater for the prosthesis specimens whereas torsional stiffness was greater for the IM nail specimens. We found a linear relationship between peak torque and T-score for each device with the slopes of the lines suggesting the construct with the prosthesis can withstand greater forces than the IM nail and the differences between devices were greater in weaker bones.
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20
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Bibbo C, Hatfield SP, Albright JT. Treatment of metastatic prostate adenocarcinoma to the calcaneus. J Foot Ankle Surg 2009; 49:159.e15-20. [PMID: 20015665 DOI: 10.1053/j.jfas.2009.07.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Indexed: 02/03/2023]
Abstract
Metastatic skeletal adenocarcinoma is an all too common and unfortunate complication of advanced oncologic states. Mortality rates are usually elevated when bony metastasis are evident, as this signifies advanced disease. The foot and ankle are uncommon sites for metastatic deposits, but may occur. As such, the foot and ankle surgeon must be aware of the potential for such disease, and be able to proceed with an imaging and medical work-up of the patient with foot and ankle skeletal metastasis. The goal of treatment is pain relief and the preservation of functional ambulation, which may greatly enhance the quality of remaining life for patients. A team approach is mandatory to manage the patients with metastatic disease. We present a case of an elderly male with a known history of prostate cancer, who presented with unrelenting heel pain, which upon diagnostic work-up, proved to be progressive calcaneal as well as axial metastasis after a brief period of clinical remission. Operative management coupled with palliative radiation and bisphosphonate therapy provided symptomatic pain relief and maintenance of functional ambulation.
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Affiliation(s)
- Christopher Bibbo
- Foot & Ankle Section, Department of Orthopaedics, Marshfield Clinic, Marshfield, WI, USA.
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21
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Venkatesh R. Principles of surgical management of musculoskeletal conditions. Best Pract Res Clin Rheumatol 2008; 22:483-98. [DOI: 10.1016/j.berh.2008.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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22
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Abstract
Surgical management of metastases to the extremities and pelvis has benefited from advances in the technology of internal fixation, as well as the increased availability of options for large endoprostheses. Contoured periarticular plates and the screws that attach rigidly to the plates have made fixation into weakened bone more reliable and easier to provide. For massive bone loss, modular endoprostheses are now widely available. These options supplemented with bone cement (polymethylmethacrylate) give patients the ability to have most bone defects reinforced or replaced such that the patient can begin using the affected limb almost immediately.
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Affiliation(s)
- Christian M Ogilvie
- University of Pennsylvania, Department of Orthopaedic Surgery, Pennsylvania Hospital, Philadelphia, PA, USA.
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23
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Siegel HJ, Sessions W, Casillas MA. Stabilization of pathologic long bone fractures with the Fixion expandable nail. Orthopedics 2008; 31:143. [PMID: 18323258 DOI: 10.3928/01477447-20080201-31] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Herrick J Siegel
- Division of Orthopedic Surgery, University of Alabama at Birmingham, 35294, USA
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24
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Clayer MT. Clinical practice guidelines for communicating prognosis and end‐of‐life issues with adults in the advanced stages of a life‐limiting illness, and their caregivers. Med J Aust 2007; 187:478. [DOI: 10.5694/j.1326-5377.2007.tb01374.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2007] [Accepted: 08/03/2007] [Indexed: 11/17/2022]
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Robertson DD, Beck TJ, Chan BW, Scott WW, Sharma GB, Maloney WJ. Torsional strength estimates of femoral diaphyses with endosteal lytic lesions: dual-energy X-ray absorptiometry study. J Orthop Res 2007; 25:1343-50. [PMID: 17549708 DOI: 10.1002/jor.20419] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pathologic fracture is a significant problem for individuals with metastatic bone disease. Current guidelines for prophylactic internal fixation are neither reliable nor easily applied. The purpose of this study was to validate dual-energy X-ray absorptiometry (DXA) as an accurate method for estimating torsional bone strength of diaphyseal bone with endosteal lytic lesions. Endosteal lesions of varying sizes were simulated in the diaphyses of 12 adult cadaveric femurs. Unaltered contralateral femurs served as matched controls. Machined lesions ranged from 3 to 6.5 cm in length, 1 to 3 cm in width, 15 to 48 cm(2) in elliptical area, with 10% to 100% removal of the cortical thickness. Morphology and density data obtained from DXA images were used to estimate torsional strength. All femora were mechanically tested to failure in torsion. Physically measured torsional strength was not significantly correlated to lesion elliptical area (r = 0.542, p > 0.05) or percentage cortical thickness removed (r = 0.257, p > 0.05). Measured torsional strength was significantly correlated to DXA-based torsional strength estimates (r = 0.855, p < 0.01). Lesion size alone did not correlate with the strength of bones with simulated endosteal lytic lesions. In contrast, calculations based on DXA (morphology, density) did correlate with torsional strength. This is the first step in the development of a DXA-based tool for objectively estimating bone strength in the presence of endosteal lytic lesions.
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Affiliation(s)
- Douglas D Robertson
- Department of BioEngineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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26
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Abstract
Development of destructive bone lesions in a patient with a history of visceral carcinoma may be assumed to be meta-static disease. However, this assumption may lead to inappropriate treatment. We prospectively enrolled 50 patients (54 previous malignancies) from the South Australian Musculoskeletal Tumour Service with new metastases to bone after a previous diagnosis of localized visceral carcinoma. We performed biopsies on the new lesions and reviewed the patients' histories. The most common diagnosis was breast carcinoma (24 patients), followed by prostate (11 patients) carcinoma. The mean time between the first primary malignancy and the development of a bony lesion was 84 months (range, 30-83 years). The longest latency was with breast carcinoma and the shortest was with lung carcinoma. The bone abnormality was a new tumor in nine patients (15%), necrotic tissue in two patients, and normal tissue in one patient. A new tumor was most likely in patients with breast carcinoma (five patients) or prostate carcinoma (three patients). The bone lesion was always the same malignancy in patients with a history of renal or lung carcinoma. Failure to do a biopsy would have resulted in serious treatment errors in two of the three patients who had new tumors develop. We recommend performing biopsies for new bone lesions, especially if breast carcinoma was the previous primary malignancy.
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Affiliation(s)
- Mark Clayer
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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27
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Abstract
BACKGROUND The identification of a lytic bone lesion is often perceived as a harbinger of malignancy, especially in an older patient. This study reviews the results of 100 consecutive biopsies of patients who presented with either a solitary lesion or multiple lytic bone lesions in the absence of a history of malignancy. METHODS Following preoperative planning, including plain radiographs, bone scan and computed tomography scanning, an open biopsy was carried out. RESULTS The most common site affected was the pelvis (20 patients), followed by the femur (19) and tibia (15). The lesions were solitary in 88 patients and multiple in 12. The most common diagnosis was a secondary carcinoma presenting as a bone lesion, which was found in 25 patients. The carcinomas were a widely distributed group, but the most common among them were renal cell carcinoma (seven patients), breast carcinoma (five patients) and lung carcinoma (five patients). The most common primary bone tumour was a giant cell tumour (16) followed by myeloma (10). Multiple lesions were not universally an indication of a malignant process. In 14 patients the lesion was not a tumour. CONCLUSION This study emphasizes the importance of obtaining a tissue diagnosis.
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Affiliation(s)
- Mark T Clayer
- South Australian Musculo-skeletal Tumour Unit, Adelaide, South Australia, Australia.
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Shah J, Khaksar SJ, Sooriakumaran P. Management of prostate cancer. Part 3: metastatic disease. Expert Rev Anticancer Ther 2006; 6:813-21. [PMID: 16759171 DOI: 10.1586/14737140.6.5.813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite the increased detection of prostate cancer at an early stage, men are still dying of this disease. Management of advanced disease focuses on controlling the disease process, palliation of symptoms and improving quality of life. In this review, the basis for androgen deprivation in hormone-dependent disease is discussed and the role of maximum and intermittent androgen deprivation, as well as management options for hormone-refractory disease is addressed. Local radiotherapy continues to be of importance in pain control and the maintenance of quality of life. Radiopharmaceuticals and bisphosphonates also have a role to play, the latter particularly in the reduction of skeletal-related events. Chemotherapy in hormone-refractory disease is now well established following pivotal trials demonstrating a survival benefit with docetaxel. The emergence of novel agents targeting growth factors, angiogenesis and immunotherapy present exciting possibilities for future treatment.
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Affiliation(s)
- Jyoti Shah
- Department of Urology, Northwick Park Hospital, London, UK.
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29
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Randall RL, Aoki SK, Olson PR, Bott SI. Complications of cemented long-stem hip arthroplasties in metastatic bone disease. Clin Orthop Relat Res 2006; 443:287-95. [PMID: 16462453 DOI: 10.1097/01.blo.0000191270.50033.3a] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
UNLABELLED It is controversial whether a cemented long-stem femoral arthroplasty is a safe surgical option for patients with meta-static bone disease of the hip. Cemented long stems increase the risk of embolic cascades and may cause subsequent cardiopulmonary complications, particularly in patients with metastatic disease. We retrospectively reviewed results of 29 long-stem cemented femoral arthroplasties in 27 patients in which surgical techniques that minimized intramedullary debris and canal pressurization were used. The surgical techniques minimized intraoperative cement-related emboli with aggressive medullary lavage, intraoperative canal suctioning during cementation, use of early low-viscosity polymethylmethacrylate, and slow, controlled insertion of the long-stem prosthesis. Cement-associated hypotension occurred in four (14%) patients, sympathomimetics were administered in nine (31%) patients, and a worsening mental status occurred postoperatively in one (3%) patient. There were no cement-associated desaturation events, cardiac arrests, or intraoperative deaths. No patients required prolonged intubation, and there were no postoperative cardiopulmonary events. Cemented long-stem femoral arthroplasty is a safe procedure for patients with high-risk metastatic disease. Increased awareness of cement-related cardiopulmonary pathophysiology, and modifying conventional surgical techniques can minimize cement-associated complications. LEVEL OF EVIDENCE Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- R Lor Randall
- Huntsman Cancer Institute, Department of Orthopaedics, Salt Lake City, UT 84112, USA.
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30
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Affiliation(s)
- H C F Bauer
- Department of Orthopaedics, Karolinska Hospital, S-17176 Stockholm, Sweden.
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31
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Hatano H, Morita T, Kobayashi H, Ito T, Segawa H, Saito M. Pathological fracture of the femur ten years after successful radiation therapy for metastatic breast cancer. Breast Cancer 2004; 11:313-7. [PMID: 15550853 DOI: 10.1007/bf02984556] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We describe a case involving a 75-year-old woman presenting with a femur fracture 10 years after radiation therapy for metastatic breast cancer, which developed in the right femur. The lesion showed complete response with bone healing following radiation therapy; however, the patient sustained a femur fracture ten years later. Histological examination of the specimens obtained from the lesion revealed features of radiation osteonecrosis, but there was no histological evidence of tumor. To our knowledge, there has been no reported case of pathological fracture ten years after radiation therapy from radiation osteonecrosis rather than progression of the metastatic lesion. Late complications of radiation therapy should be considered with care, even when metastatic lesions demonstrate complete response to treatment.
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Affiliation(s)
- Hiroshi Hatano
- Department of Orthopedic Surgery, Niigata Cancer Center Hospital, 2-15-3, Kawagishi-Cho, Niigata City, 951-8566, Japan
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32
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Management of Metastatic Osseous Lesions of the Lower Extremity. Tech Orthop 2004. [DOI: 10.1097/00013611-200403000-00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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33
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Ciesielczyk B, Murawa DP, Dzieciuchowicz P. The evaluation of fitness and quality of life after palliative fixation of fractures caused by neoplastic metastases to the bones. Rep Pract Oncol Radiother 2004. [DOI: 10.1016/s1507-1367(04)71017-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Affiliation(s)
- Kristy L Weber
- Section of Orthopaedic Oncology, University of Texas MD Anderson Cancer Center, Box 444, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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35
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Roqué M, Martinez MJ, Alonso P, Català E, Garcia JL, Ferrandiz M. Radioisotopes for metastatic bone pain. Cochrane Database Syst Rev 2003:CD003347. [PMID: 14583970 DOI: 10.1002/14651858.cd003347] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Bone metastases manifest through pain, which can arise even before the injury is radiologically detected. Pain occurs as a result of bone destruction and, as more destruction ensues, more pain can be experienced. Radiculopathies, plexopathies and shrinkage of spinal nerves due to tumour growth and fractures are very frequent in these patients. Relief of pain from bone metastasis can be achieved by treating the cancer itself; radiotherapy; conventional analgesics; and specific drugs that work on the bone tumour-induced alteration: biphosphonates, calcitonin or radioactive agents. OBJECTIVES To determine the efficacy of radioisotopes to control metastatic pain in patients with bone metastases and complications due to bone metastases (hypercalcaemia, bone fracture and spinal cord compression) as well as its efficacy in terms of patient survival and adverse effects. SEARCH STRATEGY Randomised and controlled clinical trials related to this review were retrieved electronically using MEDLINE (1966-2003), EMBASE (1974-2003) and Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 1 2003). general strategies to identify RCTs were combined with specific commands to identify trials of radioisotopes and metastatic bone pain. SELECTION CRITERIA The inclusion criteria were: randomised trials of patients with metastatic bone pain that compared treatment with radioisotopes and placebo, and where the major outcome was either pain or complications of bone metastases (eg, hypercalcaemia, bone fracture, spinal cord compression) assessed at least four weeks after treatment. DATA COLLECTION AND ANALYSIS The quality of included studies was assessed using the Jadad scale and the Oxford Pain Validity Score. Two independent reviewers extracted the data and completed a standard form designed for that purpose. An intention-to-treat analysis was performed, and global estimates of effect were calculated using a random effects model. MAIN RESULTS Four trials (325 patients) provided data that suggest a small effect of radioisotopes on pain control both at short and medium term (one to six months). No evidence was available to assess long-term effects (12 months). Only one study provided data on analgesia use and concluded that patients given either radioisotopes or placebo showed similar levels of analgesic use when compared to baseline use. Leukocytopenia and thrombocytopenia are secondary effects associated with the administration of radioisotopes. The incidence of leukocytopenia is significantly greater in patients treated with radioisotopes (RR=4.56, 95% CI (1.22,17.08)). There were also a greater number of thrombocytopenia events in the treatment group, without reaching statistical significance. REVIEWER'S CONCLUSIONS The efficacy of radioisotopes has been assessed in clinical trials with small sample sizes and short-term evaluations of the outcomes. There is some evidence indicating that radioisotopes may give complete reduction in pain over one to six months with no increase in analgesic use, but adverse effects, specifically leukocytopenia and thrombocytopenia, have also been experienced.
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Affiliation(s)
- M Roqué
- Service of Epidemiology and Public Health. Iberoamerican Cochrane Centre, Hospital de la Santa Creu i Sant Pau, c/ Sant Antoni M. Claret 171, 4a planta 08041, Barcelona, Cataluña, Spain.
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Radford M, Gibbons CLMH. Management of skeletal metastases. HOSPITAL MEDICINE (LONDON, ENGLAND : 1998) 2002; 63:722-5. [PMID: 12512198 DOI: 10.12968/hosp.2002.63.12.1893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Bone is a frequent site of tumour metastasis and is the third most common site of metastatic carcinoma. With advances in the use of immunotherapy, hormonal manipulation, chemotherapy and radiation for the palliation of patients with metastatic bone disease, significant improvements in survival, wellbeing and overall quality of life have been achieved.
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Affiliation(s)
- M Radford
- Nuffield Orthopaedic Centre, Headington, Oxford OX3 7LD
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Bickels J, Wittig JC, Kollender Y, Henshaw RM, Kellar-Graney KL, Meller I, Malawer MM. Distal femur resection with endoprosthetic reconstruction: a long-term followup study. Clin Orthop Relat Res 2002:225-35. [PMID: 12072766 DOI: 10.1097/00003086-200207000-00028] [Citation(s) in RCA: 144] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The distal femur is a common site for primary and metastatic bone tumors and therefore, it is a frequent site in which limb-sparing surgery is done. Between 1980 and 1998, the authors treated 110 consecutive patients who had distal femur resection and endoprosthetic reconstruction. There were 61 males and 49 females who ranged in age from 10 to 80 years. Diagnoses included 99 malignant tumors of bone, nine benign-aggressive lesions, and two nonneoplastic conditions that had caused massive bone loss and articular surface destruction. Reconstruction was done with 73 modular prostheses, 27 custom-made prostheses, and 10 expandable prostheses. Twenty-six gastrocnemius flaps were used for soft tissue reconstruction. All patients were followed up for a minimum of 2 years. Function was estimated to be good or excellent in 94 patients (85.4%), moderate in nine patients (8.2%), and poor in seven patients (6.4%). Complications included six deep wound infections (5.4%), six aseptic loosenings (5.4%), six prosthetic polyethylene component failures (5.4%), and local recurrence in five of 93 patients (5.4%) who had a primary bone sarcoma. The limb salvage rate was 96%. Distal femur endoprosthetic reconstruction is a safe and reliable technique of functional limb sparing that provides good function and local tumor control in most patients.
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Affiliation(s)
- Jacob Bickels
- Department of Orthopedic Oncology, Hospital Center, Washington Cancer Institute, George Washington University, 110 Irving Street NW, Washington, DC 20010, USA
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39
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Bibbo C, Patel DV, Benevenia J. Perioperative considerations in patients with metastatic bone disease. Orthop Clin North Am 2000; 31:577-95, viii. [PMID: 11043098 DOI: 10.1016/s0030-5898(05)70177-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Preoperative assessment of patients with metastatic bone disease includes a history and physical examination, laboratory evaluation, and standard radiographs. Perioperative diagnostics include technetium bone scan, CT scans, MR imaging, positron emission tomography, and biopsy. The role of preoperative tumor embolization and vena cava filter placement is discussed in this article. Guidelines for pain control are provided. Surgical planning and instrument considerations for long bone lesions, periarticular lesions, and pelvis and acetabular lesions are addressed. The importance of rehabilitation for patients with metastatic bone disease is emphasized.
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Affiliation(s)
- C Bibbo
- Department of Orthopaedics, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, USA
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40
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Abstract
The establishment of clinically detectable skeletal metastasis is a multifactorial process. This process can be divided into three general areas of understanding. The first is that of the intrinsic characteristics and properties of the tumor cells, which allow and facilitate their migration from the site of primary neoplasia to the distant host skeleton. Second, there are anatomic considerations of the human body, which influence the distribution of metastatic seeding. Third, there are the considerations of the host organism's biology, including the immune system, the circulatory system, and the affected host skeleton, which hinder and, at times, potentiate the ability of neoplastic cells to establish skeletal lesions.
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Affiliation(s)
- A Mollabashy
- Department of Orthopaedic Surgery, Henry Ford Hospitals and Clinics, Detroit, Michigan, USA
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41
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Tadross TS, Checketts RG. Retrograde intramedullary nail for metastatic lesion of the lower tibia. Foot Ankle Int 2000; 21:683-5. [PMID: 10966368 DOI: 10.1177/107110070002100810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Two cases of distal tibial metastases are presented, and a suggestion is made for a method of treatment.
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Affiliation(s)
- T S Tadross
- Specialist registrar Trauma and Orthopaedics Gosforth, Newcastle upon Tyne, UK.
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42
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Lipton A, Theriault RL, Hortobagyi GN, Simeone J, Knight RD, Mellars K, Reitsma DJ, Heffernan M, Seaman JJ. Pamidronate prevents skeletal complications and is effective palliative treatment in women with breast carcinoma and osteolytic bone metastases: long term follow-up of two randomized, placebo-controlled trials. Cancer 2000; 88:1082-90. [PMID: 10699899 DOI: 10.1002/(sici)1097-0142(20000301)88:5<1082::aid-cncr20>3.0.co;2-z] [Citation(s) in RCA: 465] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Pamidronate therapy previously has been shown to reduce skeletal complications effectively for up to 12 months in breast carcinoma patients with bone metastases. The current study data provide further follow-up results regarding the effects of long term (up to 24 months) pamidronate treatment in women with breast carcinoma and osteolytic metastases. METHODS Follow-up results from two prospective, multicenter, randomized, double-blind, placebo-controlled intervention trials conducted at academic and community oncology centers were combined to provide a large data set with which to evaluate the long term efficacy and safety of pamidronate therapy. Seven hundred fifty-four women with Stage IV breast carcinoma and osteolytic metastases were randomized to the 2 treatment arms of the trial. Three patients were excluded from the intent-to-treat population for the analysis. A total of 751 evaluable patients were randomized to receive either a 90-mg intravenous pamidronate infusion (367 patients) or a placebo infusion (384 patients) every 3-4 weeks. The primary outcome measures were skeletal morbidity rate (events/year), proportion of patients developing a skeletal complication, and time to first skeletal complication. RESULTS Of the 367 women receiving pamidronate, 115 (31.3%) completed the trial and 81 (22.1%) discontinued the study due to adverse events. Of the 384 women who received placebo, 100 (26.0%) completed the study and 76 (19.8%) discontinued the study due to adverse events. The skeletal morbidity rate was 2.4 in the pamidronate group and 3.7 in the placebo group (P < 0.001). In the pamidronate group, 186 of the 367 patients (51%) had skeletal complications compared with 246 of the 384 patients in the placebo group (64%) (P < 0.001). The median time to first skeletal complication was 12.7 months in the pamidronate group and 7 months in the placebo group (P < 0.001). Six patients treated with pamidronate discontinued treatment due to drug-related adverse events. Pain and analgesic scores were significantly worse in the placebo group compared with those patients in the pamidronate group. CONCLUSIONS In the current study, monthly infusions of 90 mg of pamidronate as a supplement to antineoplastic therapy were found to be well tolerated and superior to antineoplastic therapy alone in preventing skeletal complications and palliating symptoms for at least 24 months in breast carcinoma patients with osteolytic bone metastases.
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Affiliation(s)
- A Lipton
- Hematology/Oncology Division, The Milton S. Hershey Medical Center, Hershey, PA 17033, USA
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Abstract
Nearly every malignant neoplasm has been described as having the capability to metastasize to bone. Of the estimated 1.2 million new cases of cancer diagnosed annually, more than 50% will eventually demonstrate skeletal metastasis. Advances in systemic and radiation therapy have led to a considerable improvement in the prognosis of patients with metastatic disease. As a result, orthopaedic surgeons are being asked with increasing frequency to evaluate and treat the manifestations of skeletal metastases. The femur is commonly the site of large impending lesions and complete pathologic fractures. Although the health status of some patients may preclude operative intervention, established pathologic fractures of the femur and metastatic lesions deemed likely to progress to imminent fracture generally should be treated surgically. A rational approach to selection of the proper treatment for these problems includes consideration of the patient's overall medical condition and the type, location, size, and extent of the tumor. Treatment principles are the same regardless of location. A construct should ideally provide enough stability to allow immediate full weight bearing with enough durability to last the patient's expected lifetime. All areas of weakened bone should be addressed at the time of surgery in anticipation of disease progression. To minimize disease progression and possible implant or internal fixation failure, postoperative external-beam irradiation should be considered.
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Affiliation(s)
- K C Swanson
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
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