Management of metastatic bone disease of the acetabulum

Artificial intelligence assisted preoperative planning and 3D-printing guiding frame for percutaneous screw reconstruction in periacetabular metastatic cancer patients

Background

The percutaneous screw reconstruction technique, known as the "Tripod Technique," has demonstrated favorable clinical outcomes in the management of metastatic periacetabular lesions, as evidenced by our prior investigations and corroborated by independent studies. Nevertheless, there is a steep learning curve in handling this technique, with possible complications such as intraarticular screw placement.

Methods

Preoperative pelvic CT scans were acquired before surgery and utilized for the guiding frame design. A convolutional neural network model was trained with annotated data to identify the starting point and trajectory of each potential screw. A model boundary intersection detection technology was used to determine the optimal diameter and length of each screw. A non-rigid registration technology was matched with a prefabricated model of the body surface to design personalized anchoring skin pads. Finally, a polylactic acid-based guiding frame for intraoperative was custom-made with a 3D printer.

Results

12 patients underwent a guiding frame-assisted Tripod procedure for treatment of periacetabular metastatic lesions. An intraoperative CT scan was performed in all cases to confirm screw trajectories. Among 36 screws that were implanted, 26 screws were implanted as designed. The remaining ten screws drifted, but all remained within the intra-osseous conduit without any complications. The mean surgical time was 1.22 h with the guiding frame compared with 2.3 h without the guiding frame. Following the surgical procedure, a noteworthy enhancement in pain management, as evidenced by a reduction in scores on the visual analog scale (p < 0.01), and an improvement in functional status, as assessed through the Eastern Cooperative Oncology Group score (p < 0.01), were observed when compared to the patient's pre-operative condition.

Conclusion

This proof-of-concept investigation demonstrates that the amalgamation of AI-assisted surgical planning and additive manufacturing can improve surgical accuracy and shorten surgical duration. While access to this technology is currently constrained during its early stages of development, it is anticipated that these limitations will diminish as the potential of AI and additive manufacturing in facilitating complex orthopedic procedures becomes more evident, leading to a surge in interest and adoption of this approach.

Minimally invasive stabilization using screws and cement for acetabular metastatic tumor: a case report

BACKGROUND

The aim of this case report is to evaluate minimally invasive stabilization using screws and cement for acetabular metastatic tumor and summarize the indications and contraindications for minimally invasive stabilization of acetabular metastatic tumors with screw and cement techniques.

CASE PRESENTATION

Under imaging guidance, a patient with acetabular metastatic tumor was treated with hollow screw combined with bone cement fixation. Ischial screw, ascending branch screw, and anterior and posterior screws were inserted to firmly fix the anterior and posterior column of the acetabulum. At the same time, the third screw connected the anterior and posterior columns together, combined with bone cement into the fracture site to further increase local stability and resist bone defects caused by local tumor osteolysis. The patient was a 52-year-old Uygur male. Herein, we summarize his clinical symptoms and operation. Differences in visual analog scale and walking function (Musculoskeletal Tumor Society) before operation and at 2 months, 6 months, and 12 months after operation were compared.

RESULTS

Postoperative complications and tumor progression were recorded. The patient was followed up for 16 months, and the operative time was 60 minutes. In total, 20 ml of bone cement was injected into the acetabular posterior column and the top of the acetabulum. VIsual analog scale score was 8 before operation, 3 at 2 months, 3 at 6 months, and 2 at 12 months after operation. Musculoskeletal Tumor Society function was 13 before operation, 23 at 2 months, 25 at 6 months, and 26 at 12 months after operation. During follow-up, no cement leakage, fever, hip nerve injury, pulmonary embolism, or imaging findings of further destruction of the acetabulum and surrounding bone were noted.

CONCLUSION

This case report shows that the treatment of acetabular metastatic cancer with minimally invasive stabilization using screws and cement under the C arm can effectively relieve pain and enhance the strength of the pelvis, and is innovative and feasible.

Outcomes Following Pedestal Cup Reconstruction of (Impending) Pathological Fractures of the Acetabulum due to Metastatic Bone Disease

Management of periacetabular metastatic bone disease (MBD) is challenging, specifically if associated with bone loss or fracture. The aim of this study was to evaluate the complications and outcomes after undergoing peri-acetabular reconstruction using an 'ice-cream cone' pedestal cup endoprostheses for the most severe cases of (impending) pathological acetabular fractures. Fifty cases with severe periacetabular disease were identified. Acetabular defects were classified using the Metastatic Acetabular Classification (MAC). Pre- and post-operative mobility was assessed using the Eastern Cooperative Oncology Group (ECOG) Performance Status. Pain levels were assessed using a verbal rating scale. Surgical complications and patient survival were analysed; the Prognostic Immune Nutritional Index (PINI) was applied retrospectively to survival. There were 32 females and 18 males with a median age of 65 (41-88). Median post-operative follow-up was 16 months (IQR 5.5-28.5 months). Thirty-nine had complete, and 11, impending pathological fractures. The observed five-year survival was 19%, with a median survival of 16 months (IQR 5.8-42.5 months). Significantly worse survival was observed with PINI scores < 3.0 (p = 0.003). Excluding three perioperative deaths, 13 complications occurred in 12 patients: Implant failure in six patients (four aseptic loosening, one dislocation and one infection). At the final follow-up, mobility and pain levels were improved in 85% and 100%, respectively. Reconstruction of significant pelvic MBD with the 'ice-cream cone' reduces pain and improves mobility. Whilst the mortality rate is high, it remains a reasonable option for bed-bound, immobile patients. We advocate the use of an 'ice-cream cone' prosthesis for selected patients balancing the reported risks with the observed benefits.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-024-01917-x.

Percutaneous Screws for Column Support During Total Hip Reconstruction of Metastatic Disease of the Acetabulum

Reconstruction of the hip joint in the setting of metastatic lesions of the acetabulum is particularly challenging and can carry significant morbidity for patients who are already medically frail. Novel techniques to minimize morbidity and optimize function warrant exploration for these patients. Here, we present a 50-year-old woman was unable to walk secondary to metastatic breast cancer involving the acetabulum with articular disruption. A primary reconstruction technique was used that combined percutaneous stabilization of the acetabulum and cemented total hip arthroplasty using primary components. Existing reconstructive techniques for metastatic lesions of the acetabulum often require extensive open surgical approaches and revision components. Percutaneous acetabular stabilization combined with cemented total hip replacement may be a less-morbid and equally durable option.

[Acetabular metastatic defect reconstruction using the modular revision support cup MRS-C]

OBJECTIVE

Stabilization of metastatic acetabular defects with a bone cement-augmented revision support cup for remobilization of oncological patients in advanced cancer stages.

INDICATIONS

Metastatic acetabular defects (Metastatic Acetabular Classification, MAC 2-4) in patients with a prognostic medium or long-term survival.

CONTRAINDICATIONS

Highly limited survival due to metastatic disease (< 6 weeks). Local bone or soft tissue infection. Primary bone tumor with curative treatment option. Advanced pelvic discontinuity. Recent wound compromising systemic therapy.

SURGICAL TECHNIQUE

Standard hip approach. Curettage of the metastatic defect and careful reaming of the acetabulum before insertion of the cup. Predrilling of the dome und flange screws before application of the bone cement through the center hole of the implant and filling of the acetabular defect. Complete insertion of the screws for compound osteosynthesis. Implant of a modular inlay or dual mobility system.

POSTOPERATIVE MANAGEMENT

Full weight bearing or mobilization with two crutches according to the level of pain. Adjuvant local radiation therapy after wound consolidation. Continuation of systemic therapy according to tumor board decision.

RESULTS

Between 2012 and 2019, we treated 14 patients with metastatic acetabular defects using the modular revision support cup "MRS-TITAN® Comfort", MRS-C, Peter Brehm GmbH, Weisendorf, Germany) at our institution. Mean Harris Hip Score improvement was 23.2 with a mean patient's survival of 9.7 months due to the reduced cancer-related prognosis; 13 of the 14 implants endured the patient's prognosis. One implant had to be removed due soft tissue defect-related periprosthetic joint infection.

Does Perioperative Radiation Affect Implant Survivorship of Primary Total Hip Arthroplasty in the Setting of Metastatic Bone Disease?

Background

Metastatic bone disease (MBD) commonly affects the hip and surgical intervention including total hip arthroplasty (THA) is often indicated to treat the joint and improve function. Patients with metastatic cancer often receive radiotherapy, and orthopaedic oncologists must consider surgical risks with operating on irradiated bone and soft tissue. We evaluated surgical outcomes and implant survival (IS) of titanium acetabular components and femoral components in patients treated for MBD in the setting of perioperative radiation.

Methods

This was a retrospective review of patients who underwent THA for MBD at 3 institutions between 2017 and 2021. Outcomes included rates of reoperation, complications, IS, and overall survival.

Results

Forty-six patients who received primary THA for MBD were included in the study. Twenty patients (43.5%) received perioperative radiation for MBD. Six postoperative complications including one superficial wound infection, 2 dislocations, 2 pathologic fractures, and one aseptic acetabular component loosening led to 5 reoperations. There were no significant differences in postoperative outcomes, reoperation after THA, and IS based on radiotherapy status.

Conclusions

To our knowledge, this is the first paper evaluating primary THA outcomes and IS between patients who receive perioperative radiation for MBD to the hip and those who do not. As surgical management is a crucial part of the treatment in alleviating pain and disability in patients with MBD, we continue to recommend THA for patients who received radiation at the operative site.

Management of metastatic bone disease of the pelvis: current concepts

PURPOSE

Metastatic disease of the pelvis is frequently associated with severe pain and impaired ambulatory function. Depending on the patient's characteristics, primary tumor, and metastatic pelvic disease, the treatment choice may be varied. This study aims to report on the current management options of metastatic pelvic disease.

METHODS

We comprehensively researched multiple databases and evaluated essential studies about current concepts of managing a metastatic bone disease of the pelvis, focusing on specific indications as well as on the result of treatment.

RESULTS

Pelvic metastases not in the periacetabular region can be managed with modification of weight-bearing, analgesics, bisphosphonates, chemotherapy and/or radiotherapy. Minimally invasive approaches include radiofrequency ablation, cryoablation, embolization, percutaneous osteoplasty, and percutaneous screw placement. Pathological or impending periacetabular fracture, excessive periacetabular bone defect, radioresistant tumor, and persistent debilitating pain despite non-surgical treatment and/or minimally invasive procedures can be managed with different surgical techniques. Overall, treatment can be divided into nonoperative, minimally invasive, and operative based on specific indications, the expectations of the patient and the lesion.

CONCLUSION

Different treatment modalities exist to manage metastatic pelvic bone disease. Decision-making for the most appropriate treatment should be made with a multidisciplinary approach based on a case-by-case basis.

Functional outcomes after open reconstruction or nonoperative management of 81 pathologic acetabular fractures from metastatic bone disease

Background

Pathologic acetabular fracture secondary to skeletal metastasis may result in debilitating pain, inability to ambulate, and impaired quality of life, which may mark the first period of dependent care in cancer patients. Acetabular reconstruction may involve morbid procedures with increased complication rates. This study aimed to evaluate the evolution of pain, performance status, and ambulation following nonoperative management or open reconstruction of pathologic acetabular fractures.

Methods

A retrospective cohort of 2630 adult patients with osseous metastatic disease treated at a high-volume cancer center between 2005 and 2021 was screened for pathologic fractures of the acetabulum. The study outcomes were pain, performance status, and the ability to ambulate. We identified 78 patients (median age, 60 years; 37 female patients [46%]) with 81 fractures. Of these, treatment consisted of open reconstruction (n = 34) or nonoperative management alone (n = 47). The mean follow-up in surviving patients was 3.4 years.

Results

Open reconstruction was performed more frequently for displaced fractures (P < 0.01), Harrington class III or IV acetabula (P < 0.01), and patients with a performance status ≥3 at hospitalization (P = 0.00). Open reconstruction was associated with clinically meaningful improvements in pain (adjusted odds ratio [aOR], 8.3; 95% CI, 1.4-50.6; P = 0.02) and performance status (aOR, 10.9; 95% CI, 1.7-71.0; P = 0.01) at discharge and a restoration of ambulation (aOR, 7.5; 95% CI, 1.9-29.8; P < 0.01) at final follow-up.

Conclusions

In patients with pathologic acetabular fracture due to osseous metastatic disease, functional improvements in pain, performance status, and ambulation were observed following open acetabular reconstruction in carefully selected patients, with no impact on survival, while noninferior improvements were observed in patients receiving nonoperative management when considering their larger clinical context.

Level of evidence

Level III, therapeutic study.

Opiate use after total hip arthroplasty for metastatic bone disease

OBJECTIVES

To investigate post-operative opioid use following a total hip arthroplasty (THA) in metastatic bone disease (MBD) patients and identify factors associated with post-operative opioid use at 6 weeks and 90 days.

BACKGROUND

MBD commonly affects the hip, and surgical intervention including THA may be indicated for pain relief or to improve function. Following THA, patients are often prescribed short courses of opioids for post-operative pain relief. No study has evaluated opiate use following THA in patients for MBD.

METHODS

This was a retrospective review of patients using opioids preoperatively who underwent primary THA for MBD at two institutions between 2009 and 2022. Preoperative and post-operative opioid usages, respectively, at 6 weeks and 90 days were quantified through calculating daily morphine milligram equivalents (MMEs) and compared using the sign test. Factors associated with post-operative opioid use at 6 weeks and 90 days were compared using χ2 test or Fisher's exact test as appropriate.

RESULTS

Nineteen THA and 11 THA with complex acetabular reconstruction were included. At 6 weeks, 26 (86.7 percent) patients were utilizing opiates, and at 90 days, 23 (76.7 percent) patients were utilizing opiates. There was a statistically significant difference between median daily preoperative MME compared to daily MME at 90 days (p < 0.001). The only statistically significant association with opioid use at 90 days was opioid use at 6 weeks.

CONCLUSION

To our knowledge, this is the first paper evaluating post-operative opioid use following primary THA in MBD patients. After THA in the setting of MBD, patients exhibit decreased post-operative opioid use. Future studies with larger cohorts should be conducted to characterize post-operative opioid use following joint arthroplasty in MBD patients.

Operative management of metastatic disease of the acetabulum: review of the literature and prevailing concepts

Metastatic disease of the periacetabular region is a common problem in orthopaedic oncology, associated with severe pain, decreased mobility, and substantial decline of the quality of life. Conservative management includes optimisation of pain management, activity modification, and radiation therapy. However, patients with destructive lesions affecting the weight-bearing portion of the acetabulum often require reconstructive surgery to decrease pain and restore mobility. The goal of surgery is to provide an immediately stable and durable construct, allowing immediate postoperative weight-bearing and maintaining functional independence for the remaining lifetime of the patient. A variety of surgical techniques have been reported, most of which are based upon cemented total hip arthroplasty, but also include porous tantalum implants and percutaneous cementoplasty. This review discusses the various reconstructive concepts and options, including their respective indications and outcome. A reconstructive algorithm incorporating different techniques and strategies based upon location and quality of remaining bone is also presented.

O-arm-guided percutaneous microwave ablation and cementoplasty for the treatment of pelvic acetabulum bone metastasis

Objective

This study aims to evaluate the indications, safety, and efficacy of microwave ablation combined with cementoplasty under O-arm navigation for the treatment of painful pelvic bone metastasis.

Methods

We retrospectively collected data from 25 patients with acetabulum bone metastasis who underwent microwave ablation combined with cementoplasty. All patients underwent percutaneous microwave ablation combined with cementoplasty under O-arm navigation. The postoperative follow-up included evaluations of pain, quality of life, function, the incidence of bone cement leakage, and the presence of perioperative complications. Pain and quality of life were evaluated using the visual analog scale (VAS) and the QLQ-BM22 quality of life questionnaire for patients with bone metastases, respectively. The functional scores were calculated using the MSTS93 scoring system of the Bone and Soft Tissue Oncology Society.

Results

There were 10 males and 15 females with an average age of 52.5 ± 6.5 years, all 25 patients received percutaneous procedures, and no technical failure occurred. Major complications, including pulmonary embolism, vascular or nervous injury, hip joint cement leakage, and infection, were not observed in the current study. Pain regression was achieved in 24 of 25 patients. The mean VAS scores significantly decreased to 3.4 ± 1.0, 2.5 ± 1.2, and 1.2 ± 0.6 points at 1 week, 1 month, and 3 months after the procedure, respectively, compared with 7.0 points before the procedure (P < .05). The mean QLQ-BM22 score significantly decreased to 36.2 ± 4.9, 30 ± 5.6, and 25.4 ± 2.3 points at 1 week, 1 month, and 3 months after the procedure, respectively, compared with 55.8 points before the procedure (P < .05). The preoperative Musculoskeletal tumour society (MSTS) functional score of 25 patients was 18.5 ± 5.3 points, and MSTS score was 20.0 ± 3.0, 21.4 ± 4.9, and 22.8 ± 2.3 at 1 week, 1 month, and 3 months after the procedure, respectively (P < .05). The average bone cement injection volume was 8.8 ± 4.6 ml.

Conclusion

The use of O-arm-guided percutaneous microwave ablation combined with cementoplasty for the treatment of pelvic metastases could quickly and significantly alleviate local pain, prevent pathological fracture, and improve the quality of life of patients with reduced complications.

Trabecular metal augments in severe malignancy-associated acetabular bone loss

INTRODUCTION

Acetabular reconstruction is a challenging problem in orthopaedic oncology, especially in extended defects (Paprosky Type 3A and Type 3B). In revision total hip arthroplasty (THA), 1 option is trabecular metal (TM) augments with a porous metal acetabular component. This study evaluated the use of TM augments in periacetabular malignant bone disease.

METHODS

15 patients were identified from our institutional database from 2000 to 2020 with either Paprosky Type 3A or Type 3B acetabular bone loss due to periacetabular malignancies that underwent at least 1 complex THA reconstruction with TM augments. Postoperative complications were documented, and clinical and radiographic outcomes were analysed. Radiological loosening or revision of the acetabular component were defined as endpoints.

RESULTS

There were 7 primary and 8 metastatic cancer patients. 5 were Type 3A and 10 were Type 3B defects after tumour resection. The average follow-up time was 23.8 (range 1.5-47) months. 1 patient required revision for acetabular component loosening after 7 months from the initial implantation. An additional 4 patients required surgical intervention for infection, they had stable TM augments at latest follow-up.

CONCLUSION

TM augments with a porous metal acetabular component may be an alternative to the traditional cemented constructs.

Acetabular reconstruction after advanced acetabular metastasis resection: Modified Harrington technique with a Kerboull reinforcement device

The surgical treatment of acetabular bone metastases rests on total hip arthroplasty (THA). In the event of major bone defects, the reconstruction may prove challenging. Two complicating factors are the need to obtain a mechanically stable acetabulum and the unfeasibility of using an autograft to increase the bone stock. The technique described in 1981 by Harrington involves implanting steel rods to reinforce the pelvis before sealing the prosthetic cup. We have now been using this technique for several years, and based on our accumulated experience we introduced several substantial modifications. The most important among them is the use of a Kerboull acetabular reinforcement device (KARD) in addition to the iliac pins. This reinforcement of the acetabulum, which is widely used for THA, serves as the basis for guiding the reconstruction, while also facilitating the sealing of the prosthetic cup. Furthermore, we use centrally threaded rods to avoid secondary displacement. Finally, we routinely use a dual-mobility cemented cup to decrease the risk of dislocation. Here, we describe our acetabular reconstruction technique based on a modified Harrington technique, which is used for acetabular reconstruction in patients with advanced acetabular metastases managed at our French referral centre.

Outcomes of Hip Reconstruction for Metastatic Acetabular Lesions: A Scoping Review of the Literature

(1) Background: Management of metastatic periacetabular lesions remains a challenging area of orthopaedics. This study aims to evaluate and summarize the currently available reconstructive modalities, including their indications and outcomes. (2) Methods: A scoping review was carried out in accordance with PRISMA guidelines. Medline, EMBASE, and Cochrane were searched for relevant articles. (3) Results: A total of 18 papers met inclusion criteria encompassing 875 patients. The most common primary malignancy was breast (n = 230, 26.3%). Reconstruction modalities used were total hip arthroplasty (n = 432, 49.1%), the Harrington procedure (n = 374, 42.5%), modular hemipelvic endoprotheses (n = 63, 7.2%) and a reverse ice-cream cone prosthesis (n = 11, 1.25%). (4) Conclusions: Advances in implant design including use of dual mobility or flanged cups, tantalum implants, and modular hemipelvic endoprostheses allow for larger acetabular defects to be addressed with improved patient outcomes. This armamentarium of reconstruction options allows for tailoring of the procedure performed depending on patient factors and extent of periacetabular disease.

Percutaneous Screw Stabilization of Non-Periacetabular Pelvic Lesions Caused by Metastatic Cancer and Multiple Myeloma

BACKGROUND

The pelvis is one of the most common locations for metastatic bone disease. While many of the publications that describe surgical treatments focus on periacetabular lesions (Enneking zone II), there is a lack of investigation into lesions in the non-periacetabular areas (zones I, III, and IV). We recently described a minimally invasive percutaneous screw application for metastatic zone-II lesions with excellent results. In the present study, we aimed to extend this approach to the other pelvic areas.

METHODS

Twenty-two consecutive patients with painful non-periacetabular pelvic metastatic cancer were included based on retrospective chart review. There were 16 women and 6 men with an average age of 60 years (range, 36 to 81 years). The most common primary cancers were multiple myeloma (7 cases) and breast (5 cases). The most common locations were the sacrum and the ilium. A pathologic fracture was identified in 15 patients. Most of the lesions were treated with multiple large-diameter screws, except for the isolated zone-III lesions. All of the procedures were completed in a standard operating room without the need for special instruments. Radiation therapy was given to 19 patients; the average dose was 15 Gy. The studied outcomes were pain and functionality as assessed by a visual analog scale (VAS) score and the Eastern Cooperative Oncology Group score (ECOG), respectively.

RESULTS

There were no surgical complications and no need for blood transfusion. The average follow-up time was 7 months (range, 0.3 to 34.0 months). Two patients died within 4 weeks of surgery due to COVID-19 infection. There was significant improvement in the postoperative VAS pain score (p < 0.0001) and the ECOG score (p < 0.05) when compared with the preoperative scores. There was no implant failure or revision surgery. Local bone-healing was observed in 12 of 14 patients (86%) who survived for >3 months after surgery.

CONCLUSIONS

Percutaneous screw application is safe and effective in the treatment of metastatic non-periacetabular pelvic lesions. Given the simplicity of the technique and the instrumentation and the tolerance for concomitant treatments, this approach is worthy of broader consideration.

LEVEL OF EVIDENCE

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

Joint-sparing Reconstruction for Extensive Periacetabular Metastases: Literature Review and a Novel Minimally Invasive Surgical Technique

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Metastasis accounts for nearly half of pathologic acetabular reconstructions.

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Increasing use of combined percutaneous ablation, cementoplasty, and osteosynthesis.

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Harrington or MAC classification may lead to overtreatment of acetabular lesions.

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Know indications for joint-sparing reconstruction; consider use in select patients.

Classically, patients with advanced lytic disease of the acetabulum secondary to metastatic bone disease are treated with complex arthroplasty reconstruction techniques. Advancements in percutaneous techniques have extended the indications for safer, minimally invasive procedures for patients with periacetabular metastasis without the need for complex hip replacement and the complications that follow it. The purpose of this report is to revisit the management of this group of patients and provide indications for an alternative minimally invasive joint-sparing technique. We describe a novel technique using a combination of percutaneous cryoablation, cementoplasty and two-screw fixation. With careful consideration of indications, excellent functional and oncologic outcomes one year after surgery is possible without the need for additional procedures.

Total Hip Arthroplasty with a Cementless Acetabular Component and Impaction Bone Grafting for Dysplastic Osteoarthritis Complicated by Multiple Myeloma

Total hip arthroplasty (THA) for pathologic and impending fracture due to periacetabular multiple myeloma (MM) lesions has been reported. We report a case of radiographic progression of dysplastic osteoarthritis, complicated by periacetabular MM lesions, treated by THA. A 69-year-old female with a 13-year history of MM presented with right hip pain. Plain radiographs and CT showed that dysplastic osteoarthritis had progressed, while the periacetabular MM lesions remained unchanged. Pathologic fracture was not observed on MRI. THA with a cementless acetabular component and impaction bone grafting was done. Bone graft incorporation was confirmed on CT at 1 year after surgery. There were no signs of bone absorption or implant loosening at last follow-up 3 years after surgery. Due to the advances in the treatment of MM and antiresorptive drugs, cementless acetabular component and impaction bone grafting may be an option for dysplastic osteoarthritis complicated by acetabular bone loss due to MM.

The Harrington Plus Reconstruction for Pelvic and Acetabular Metastases

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The Harrington Plus reconstruction is a modification of the original Harrington rod technique for reconstruction of extensive periacetabular metastases. This procedure was developed in our institution.

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An intrapelvic suprapectineal plate is used, with the aim of reconstructing a disrupted anterior column and reducing the risk of failure in cases where there is extensive medial bone loss.

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This paper describes the outcomes of patients who have undergone this procedure to date.

Background

Surgical management of periacetabular bone metastases is challenging. The Harrington Plus reconstruction is a modification of the original Harrington rod technique. An intrapelvic suprapectineal plate is used, with the aim of reconstructing a disrupted anterior column and reducing the risk of failure in cases where there is extensive medial bone loss.

Methods

A retrospective review of the 13 patients who have undergone the Harrington Plus procedure to date was performed. Mobility status, EQ5D and Oxford Hip scores were assessed.

Results

There was a significant improvement in mobility status, EQ5D and Oxford Hip Scores at 6 months postoperatively (p < 0.05). Two patients returned to theatre for debridement of infection. There were no postoperative dislocations, cup medialisation or cases of loosening of the prosthesis. No patient required revision arthroplasty surgery.

Conclusion

The Harrington Plus procedure produces a reliable construct that allows patients with extensive periacetabular metastatic defects to fully weight-bear. Careful patient selection and multidisciplinary management is essential.

Reinforced reconstruction: A technique for the treatment of periacetabular metastases

Purpose

To describe a single-stage reconstruction of intraarticular periacetabular metastases that utilizes a cemented acetabular liner reinforced with percutaneous screws oriented along various osseous fixation pathways.

Methods

A retrospective evaluation of all patients with intraarticular periacetabular metastases who underwent the procedure outlined.

Results

16 procedures (1 bilateral) were included. There were no intraoperative complications or postoperative mechanical failures to date despite allowing the patients to immediately weight bear in the postoperative setting.

Discussion

Utilizing osseous fixation pathways to reinforce a cemented acetabular cup represents a safe and effective strategy to allow for immediate weightbearing in patients with periacetabular metastases.

Emerging Concepts in the Surgical Management of Peri-Acetabular Metastatic Bone Disease

The pelvis is a common site of metastatic bone disease. Peri-acetabular lesions are particularly challenging and can cause severe pain, disability and pathologic fractures. Surgical management of these lesions has historically consisted of cementoplasty for contained lesions and Harrington reconstructions for larger, more destructive lesions. Due to the limitations of these procedures, a number of novel procedures have been developed to manage this challenging problem. Percutaneous techniques—including acetabular screw fixation and cementoplasty augmented with screws—have been developed to minimize surgical morbidity. Recent literature has demonstrated a reliable reduction in pain and improvement in function in appropriately selected patients. Several adjuncts to the Harrington procedure have been utilized in recent years to reduce complication rates. The use of constrained liners and dual mobility bearings have reduced the historically high dislocation rates. Cage constructs and porous tantalum implants are becoming increasingly common in the management of large bony defects and destructive lesions. With novel and evolving surgical techniques, surgeons are presented with a variety of surgical options to manage this challenging condition. Physicians must take into account the patients’ overall health status, oncologic prognosis and anatomic location and extent of disease when developing an appropriate surgical plan.

Surgical Treatment and Proposed Modified Classification for Harrington Class III Periacetabular Metastases

Objectives

This study aims to: (i) evaluate the outcome of patients with Harrington class III lesions who were treated according to Harrington classification; (ii) propose a modified surgical classification for Harrington class III lesions; and (iii) assess the efficiency of the proposed modified classification.

Methods

This study composes two phases. During phase 1 (2006 to 2011), the clinical data of 16 patients with Harrington class III lesions who were treated by intralesional excision followed by reconstruction of antegrade/retrograde Steinmann pins/screws with cemented total hip arthroplasty (Harrington/modified Harrington procedure) were retrospectively reviewed and further analyzed synthetically to design a modified surgical classification system. In phase 2 (2013 to 2019), 62 patients with Harrington class III lesions were classified and surgically treated according to our modified classification. Functional outcome was assessed using the Musculoskeletal Tumor Society (MSTS) 93 scoring system. The outcome of local control was described using 2‐year recurrence‐free survival (RFS). Owing to the limited sample size, we considered P < 0.1 as significant.

Results

In phase 1, the mean surgical time was 273.1 (180 to 390) min and the mean intraoperative hemorrhage was 2425.0 (400.0 to 8000.0) mL, respectively. The mean follow‐up time was 18.5 (2 to 54) months. Recurrence was found in 4 patients and the 2‐year RFS rate was 62.4% (95% confidence interval [CI] 31.6% to 93.2%). The mean postoperative MSTS93 score was 56.5% (20% to 90%). Based on the periacetabular bone destruction, we categorized the lesions into two subgroups: with the bone destruction distal to or around the inferior border of the sacroiliac joint (IIIa) and the bone destruction extended proximal to inferior border of the sacroiliac joint (IIIb). Six patients with IIIb lesions had significant prolonged surgical time (313.3 vs 249.0 min, P = 0.022), massive intraoperative hemorrhage (3533.3 vs 1760.0 mL, P = 0.093), poor functional outcome (46.7% vs 62.3%, P = 0.093), and unfavorable local control (31.3% vs 80.0%, P = 0.037) compared to the 10 patients with IIIa lesions. We then modified the surgical strategy for two subgroup of class III lesions: Harrington/modified Harrington procedure for IIIa lesions and en bloc resection followed by modular hemipelvic endoprosthesis replacement for IIIb lesions. Using the proposed modified surgical classification, 62 patients in the phase 2 study demonstrated improved surgical time (245.3 min, P = 0.086), intraoperative hemorrhage (1466.0 mL, P = 0.092), postoperative MSTS 93 scores (65.3%, P = 0.067), and 2‐year RFS rate (91.3%, P = 0.002) during a mean follow‐up time of 19.9 (1 to 60) months compared to those in the phase 1 study.

Conclusion

The Harrington surgical classification is insufficient for class III lesions. We proposed modification of the classification for Harrington class III lesions by adding two subgroups and corresponding surgical strategies according to the involvement of bone destruction. Our proposed modified classification showed significant improvement in functional outcome and local control, along with acceptable surgical complexity in surgical management for Harrington class III lesions.

Total hip arthroplasty with reconstruction of acetabulum through direct anterior approach for metastatic bone disease of acetabulum combined with pathological proximal femoral neck fracture: A case report

Most surgical treatment options for metastatic acetabular lesions involve variants of total hip arthroplasty (THA). However, these are technically complex reconstructions performed in very frail patients, and previous reports indicate complications such as dislocation, deep infection, aseptic loosening, and intraoperative death. A 73-year-old man presented to the emergency department at our hospital with right hip pain following a fall. He had undergone nephrectomy for the treatment of right kidney cancer at the age of 68 years. Four years after the nephrectomy, multiple lung metastases, pelvic bone metastases, and right femoral head and neck bone metastases were found. A radiograph of the hip joint showed a pathological proximal femoral fracture with a radiolucent lesion of the acetabulum. THA with acetabular reconstruction using a Kerboull-type (KT) plate through the direct anterior approach (DAA) was performed. After removal of the femoral head, curettage of the metastatic acetabular dome lesion was carefully performed under fluoroscopic guidance. After the KT plate was placed, cementation of the metastatic acetabular dome lesion was performed, and an optimally sized polyethylene liner was fixed with cement. A cemented stem was inserted after confirming the hip joint stability. At the 14-month follow-up, he could walk steadily without any complications and his modified Harris hip score was 100. The DAA conserves soft tissue because it is an intermuscular approach. Accordingly, postoperative recovery is fast and thus associated with a low dislocation rate and effective pain reduction. The acetabulum with metastatic disease was reconstructed using a KT plate for hip joint stability. Bone with metastatic disease that appears adequate at the time of THA may become incompetent after a few years. THA with acetabular reconstruction using a KT plate through the DAA was an effective treatment for metastatic bone disease of the acetabulum combined with pathological proximal femoral neck fracture.

A graphic guide to the percutaneous tripod acetabular reconstruction for metastatic cancer

Symptomatic peri-acetabular metastatic lesions are often treated with open surgery such as modified Harrington procedures. In an effort to avoid surgical complications inherently associated with open surgical approaches, we developed and recently reported a novel Tripod percutaneous screw technique. The tripod technique is minimally invasive and was found to yield excellent outcomes regarding both pain control and functionality. The procedure is performed in a standard operative theater using fluoroscopic guided percutaneous screws. Despite the simplicity of intraoperative set-up and instrumentation, it is technically demanding. Obtaining the correct fluoroscopic views and troubleshooting intraoperative hurdles can be challenging for even an experienced orthopedic surgeon. The technique and bony conduits were previously described in the trauma literature, however, there are key points of difference in the setting of metastatic disease. Here we provide a compilation of a stepwise graphic guide for the tripod model in the setting of metastatic peri-acetabular lesions, as well as the tips and tricks based on our own experience. These encompass preoperative preparation, operating room settings, intraoperative fluoroscopic guidance, postoperative care, and subsequent conversion to a cemented total hip arthroplasty, if needed.

A Novel Tripod Percutaneous Reconstruction Technique in Periacetabular Lesions Caused by Metastatic Cancer

BACKGROUND

Metastatic lesions in the periacetabular region can cause pain and immobility. Symptomatic patients are often treated surgically with a total hip replacement using various modified Harrington methods. These open surgical procedures confer inherent risks. Prolonged recovery and potential complications may delay adjuvant radiation and systemic therapy.

METHODS

We describe a novel technique for acetabular reconstruction. Three large-bore cannulated screws are placed percutaneously under fluoroscopy in a tripod configuration to reinforce the mechanical axes of the acetabulum. Increased stability improves pain control and permits weight-bearing.

RESULTS

Twenty consecutive patients with periacetabular metastases were treated using the tripod technique. Eighteen patients (90%) had Harrington class-III lesions, and 2 patients had Harrington class-II lesions. The mean surgical time was 2.3 hours. Sixteen patients (80%) were able to get out of bed on postoperative day 1. At 3 months postoperatively, there was significant improvement in pain as documented on their visual analog scale (p < 0.01) and in functionality as measured by the Eastern Cooperative Oncology Group score (p < 0.01). The mean follow-up time was 7 months (range, 0.6 to 20 months). At the most recent follow-up, only 3 among the 16 surviving patients were using opioids chronically for pain. Total hip arthroplasty was performed in 4 patients (20%) in a staged fashion using the previously placed screws as support for a cemented cup and obviating the need for a cage device. Of the 16 patients, 15 could walk either independently (6 patients) or using an ambulatory aid (9 patients). Eight patients with the primary tripod reconstruction survived >6 months postoperatively. They were found to have either new bone formation filling the defects or healing of the pathological fractures. There has been no implant loosening or failure.

CONCLUSIONS

The tripod technique is a novel application to provide safe and effective pain relief in the context of periacetabular metastatic disease. It can be easily converted to support a cemented acetabular cup for a total hip replacement should disease progression occur. This technique provides an alternative to open surgery as currently practiced in these patients.

LEVEL OF EVIDENCE

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

Minimally Invasive Stabilization Using Screws and Cement for Pelvic Metastases: Technical Considerations for the Pelvic "Screw and Glue" Technique

Metastatic disease involving the pelvis is common, often resulting in significant pain and disability. Several percutaneous interventions for unstable pelvic metastatic disease have been described, including osteoplasty, ablation, and screw fixation, that when used alone or in combination can significantly reduce pain and disability from metastatic bone disease. While it is possible to make a significant impact in patient care with basic principles and techniques, certain advanced techniques can extend the application of percutaneous interventions while minimizing morbidity.

Percutaneous osteoplasty for the management of a pubic bone metastasis

Percutaneous osteoplasty (POP) has been proven to relieve pain due to osteolytic metastases by injecting bone cement to stabilize the pathological fracture. Nevertheless, there have been few reports about POP of metastases in the pubis. This article presents a case involving the use of POP to manage a metastasis in the pubis. After POP the patient experienced significant pain relief and improvement in the quality of life.

Rapid return to function and stability with dual mobility components cemented into an acetabular reconstructive cage for large osseous defects in the setting of periacetabular metastatic disease

BACKGROUND AND OBJECTIVES

Large acetabular defects secondary to metastatic disease frequently require extensive acetabular reconstruction. Techniques of acetabular reconstruction have been described, but no consensus for the management of these defects has been reached so far. We present our technique and patient outcomes for acetabular reconstruction by cementing a dual mobility cup into an acetabular cage.

METHODS

We reviewed 152 total hip arthroplasties and identified 19 patients with periacetabular metastatic disease and large defects who required acetabular reconstruction utilizing a dual mobility cup cemented into an acetabular reconstructive cage. The following outcomes were evaluated: pain relief, functional improvement, postoperative complications.

RESULTS

Mean follow-up was 3 years, with 13 of the 19 patients eligible for 2-year follow-up. Patients reported a significant improvement in both pain and functional outcomes. There were no dislocations or signs of loosening. Two patients developed postoperative infections. One patient required hemipelvectomy 16 months postop due to recurrence of metastatic disease.

CONCLUSIONS

Cementing a dual mobility cup into an acetabular cage provides a highly stable and durable option for patients with periacetabular metastatic disease and large defects. Patients are able to return to immediate full weight bearing with significant improvement in both function and pain at 2 years.

Total Hip Arthroplasty for Periacetabular Metastatic Disease. An Original Technique of Reconstruction According to the Harrington Classification

BACKGROUND

Periacetabular metastatic disease requires complex acetabular reconstruction. The complication rate for these frail patients is high. Various cement-rebar reinforced techniques allowing cemented total hip arthroplasty (THA) have been described. The optimal procedure has not yet been identified.

METHODS

A continuous series of 131 THAs performed in 126 patients with periacetabular metastatic disease was prospectively included in this study. After bone metastasis curettage and cementation, an original technique of acetabular reconstruction was performed using a dual mobility cup cemented into an acetabular reinforcement device (ie, Kerboull cross-plate or Burch-Schneider antiprotrusio cage) according to the Harrington classification. Functional outcome for independent ambulation in the community, pain relief, and occurrence of dislocation or mechanical failure of the acetabular reconstruction were assessed.

RESULTS

At a mean follow-up of 33 ± 17 months, the improvement in the preoperative to postoperative functional outcome and pain relief was significant (P < .001). The dislocation rate was 2%. Two of the 3 cases of dislocation occurred in acetabular reconstructions associated with a proximal femoral arthroplasty. No mechanical failure or aseptic loosening of the acetabular reconstruction was observed.

CONCLUSION

This study emphasized that our original technique combining bone metastasis curettage and cementation, acetabular reinforcement device and cemented dual mobility cup was effective to restore a painless functional independence and ensure a durable acetabular reconstruction able to face to adjuvant radiation therapy and mechanical solicitations for long survivors. In addition, dual mobility cup limited the risk of dislocation in patients undergoing THA for periacetabular metastatic disease.

Use of minimally invasive spine surgical instruments for the treatment of bone tumors

INTRODUCTION

Orthopedic oncologists often encounter patients with minor bony lesions that are difficult to access surgically and therefore require large exposures out of proportion to the severity of disease that confer significant patient morbidity. Minimally invasive surgical techniques offer the advantage of smaller incisions, shorter operative times, decreased tissue damage, and decreased costs. A variety of surgical procedures have emerged using minimally invasive technologies, particularly in the field of spine surgery. Areas covered: In this article, we describe the Minimal Exposure Tubular Retractor (METRx^TM) System which is a minimally invasive surgical device that utilizes a series of dilators to permit access to a surgical site of interest. This system was developed for use in treatment of disc herniation, spinal stenosis, posterior lumbar interbody fusion, transforaminal lumbar interbody fusion and spinal cord stimulation implantation. We also describe novel uses of this system for minimally invasive biopsy and treatment of benign and metastatic bone lesions at our institution. Expert commentary: Minimally invasive surgical techniques will continue to expand into the field of orthopedic oncology. With a greater number of studies proving the safety and effectiveness of this technique, the demand for minimally invasive treatments will grow.

Percutaneous Acetabuloplasty for Metastatic Lesions to the Pelvis

Metastatic lesions of the acetabulum can be painful and debilitating. First-line treatment is multimodal and consists of disease-specific chemotherapy, osteoclastic inhibitors, analgesics, and radiation therapy. When these therapies fail, surgical intervention usually is indicated and varies from regional defect stabilization to large periacetabular reconstructions that are demanding procedures with high rates of complications. Percutaneous cement augmentation (acetabuloplasty) of lesions in selected patients has been explored as a less invasive method of lesional control. This retrospective review included 11 patients with painful periacetabular lesions who underwent percutaneous acetabuloplasty using fluoroscopic guidance from 2007 to 2012, in addition to standard treatment with either radiation or chemotherapy, or a combination of both radiation and chemotherapy. Primary tumors included 4 multiple myeloma, 4 renal cell, and 3 breast malignancies. Mean procedure length was 58.4 minutes, and mean hospital stay was 1.4 days (range, 1-2 days). Mean blood loss was 33.4 mL, and there were no complications due to infection or cementation. Mean follow-up was 26.4 months (range, 3-36 months), with 2 patients dying from complications of underlying disease. All of the patients experienced pain relief following the procedure, with mean visual analog scale scores improving from 7.7 to 2.1 (P=.002). Postoperative Musculoskeletal Tumor Society and Oxford hip scores were obtained for 7 of 11 patients and demonstrated improvement. One patient underwent conversion to an acetabular reconstruction due to disease progression. This report demonstrates the effective use of a minimally invasive procedure to provide acute stability, pain relief, and good functional outcomes in patients with periacetabular metastatic lesions without pathologic fracture. [Orthopedics. 2017; 40(1):e170-e175.].

Reconstruction with iliac pedestal cup and proximal femur tumor prosthesis after wide resection of chondrosarcoma - 10-year follow-up results

Chondrosarcoma is a malignant cartilage-forming neoplasm. It is difficult to treat because of resistance to both chemotherapy and radiation, making wide local excision the only treatment. This report presents an active, 43 year-old man who was diagnosed with recurrent clear cell chondrosarcoma of the proximal left femur, previously reconstructed with a total hip prosthesis, extending to the weight-bearing dome of the acetabulum. Cancer staging study revealed no signs of tumor dissemination at distance. Given the excellent functional status of the patient, the authors performed a Enneking–Dunham type periacetabular pelvic resection and resected en bloc, with the total hip prosthesis including 22 cm of the femur and a portion of the hip abductor apparatus. Acetabular reconstruction was performed with a non-cemented pedestal cup prosthesis fixed at the iliac, and in-femur reconstruction utilized a cemented silver-coated proximal femur modular prosthesis. Today, after a 10-year follow-up, the patient is walking without crutches, he practices recreational cycling without assistance, and he is asymptomatic and free of tumoral disease. At present, no signs of relevant loosening, instability, infection, heterotopic ossification, or any other complications have been observed. Pelvic reconstructions are challenging and risky surgeries; however, the appearance of more functional implants, like the pedestal cup prosthesis, and its correct application and indication, may allow promising clinical and functional results with low complications rate.

Combination acetabular radiofrequency ablation and cementoplasty using a navigational radiofrequency ablation device and ultrahigh viscosity cement: technical note

BACKGROUND

Percutaneous radiofrequency ablation and cementoplasty is an alternative palliative therapy for painful metastases involving axial load-bearing bones. This technical report describes the use of a navigational radiofrequency probe to ablate acetabular metastases from an anterior approach followed by instillation of ultrahigh viscosity cement under CT-fluoroscopic guidance.

MATERIALS AND METHODS

The tumor ablation databases of two institutions were retrospectively reviewed to identify patients who underwent combination acetabular radiofrequency ablation and cementoplasty using the STAR Tumor Ablation and StabiliT Vertebral Augmentation Systems (DFINE; San Jose, CA). Pre-procedure acetabular tumor volume was measured on cross-sectional imaging. Pre- and post-procedure pain scores were measured using the Numeric Rating Scale (10-point scale) and compared. Partial pain improvement was categorically defined as ≥ 2-point pain score reduction. Patients were evaluated for evidence of immediate complications. Electronic medical records were reviewed for evidence of delayed complications.

RESULTS

During the study period, 12 patients with acetabular metastases were treated. The median tumor volume was 54.3 mL (range, 28.3-109.8 mL). Pre- and post-procedure pain scores were obtained from 92% (11/12) of the cohort. The median pre-procedure pain score was 8 (range, 3-10). Post-procedure pain scores were obtained 7 days (82%; 9/11), 11 days (9.1%; 1/11) or 21 days (9.1%; 1/11) after treatment. The median post-treatment pain score was 3 (range, 1-8), a statistically significant difference compared with pre-treatment (P = 0.002). Categorically, 73% (8/11) of patients reported partial pain relief after treatment. No immediate symptomatic complications occurred. Three patients (25%; 3/12) were discharged to hospice within 1 week of treatment. No delayed complications occurred in the remaining 75% (9/12) of patients during median clinical follow-up of 62 days (range, 14-178 days).

CONCLUSIONS

Palliative percutaneous acetabular radiofrequency ablation and cementoplasty can be feasibly performed from an anterior approach using a navigational ablation probe and ultrahigh viscosity cement instilled under CT-fluoroscopic guidance.

The best of both worlds - managing the cancer, saving the bone

In the context of breast cancer, the importance of the skeleton in the regulation of primary tumour development and as a site for subsequent metastasis is well characterized. Our understanding of the contributions made by the host bone and bone marrow cells increasingly demonstrates the extent of the interaction between tumour cells and normal host cells. As a result, the need to develop and utilize therapies that can impede the growth and/or function of tumour cells while sparing normal host bone and bone marrow cells is immense and expanding. The need for these new treatments is, however, superimposed on the orthopaedic management of patients' quality of life, where pain control and continued locomotion are paramount. Indeed, the majority of the anticancer therapies used to date often result in direct or indirect damage to bone. Thus, although the bone microenvironment regulates tumour cell growth in bone, cells within the bone marrow niche also mediate many of the orthopaedic consequences of tumour progression as well as resistance to the antitumour effects of existing therapies. In this Review, we highlight the effects of existing cancer treatments on bone and the bone marrow microenvironment as well as the mechanisms mediating these effects and the current utility of modern orthopaedic interventions.