Outcomes of an anatomically based approach to metastatic disease of the acetabulum

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.

Harrington rods for periacetabular pathological lesion: is it an option?

Advancement in cancer treatment has prolonged the survival of cancer patients; as a result, there are an increased number of patients with bone metastases and pathological fractures referred to orthopaedic surgeons for surgical intervention for a better quality of life. Metastasis around the hip joint can be painful and intervene with patients' daily activity, and reconstruction of the hip joint with periacetabular metastasis is complex and challenging especially longer cancer survivals might out-live their fixation. Several acetabular reconstruction techniques and implants have been described to overcome this problem; acetabular reconstruction and total hip arthroplasty still remains the standard surgical treatment, to relief pain and to improve function and quality of life. Harrington reconstruction of periacetabular metastatic disease combined with hip arthroplasty is one of the options that can address this clinical scenario safely; it is reproducible and cost-effective. In this review, we present case series of patients treated in our institution using Harrington rod technique for acetabular pathological lesions with good outcome.

Surgical treatment of peri-acetabular metastatic disease: Retrospective, multicentre study of 91 THA cases

INTRODUCTION

The occurrence of peri-acetabular metastasis (PAM) is a turning point in the progression of cancer because the disabling pain prevents the patient from walking or makes it difficult. Recent progress in controlling cancers that spread to the bone and controlling local bone destruction justify this national study. Since the data in France is incomplete or based on small studies, we analysed a multicentre retrospective cohort of patients with PAM who underwent total hip arthroplasty (THA) to evaluate 1) the clinical and radiological outcomes and 2) the factors impacting patient survival.

HYPOTHESIS

The clinical outcomes, complication rate and survivorship are comparable to that of recent published studies.

METHODS

Ninety-one patients (27 men, 64 women) with a mean age of 62.7±10.5 years (extremes 38 and 88) with PAM secondary to breast cancer [42 patients (46%)] or lung cancer [20 patients (22%)] underwent THA. The metastasis was the first sign of cancer in 33 cases (36%). Concurrent visceral metastases were present in 30 patients (33%), multiple peripheral bone metastasis in 48 patients (53%) and synchronous spine metastasis in 39 patients (43%). The most common construct was a cemented stem with metal reinforcement cage and cemented dual mobility cup [71 times (78%), while 85/91 had a dual mobility cup (93%)].

RESULTS

Elimination or reduction of pain was reported in 81 patients (91%). Overall walking ability was deemed normal or acceptable in 74 patients (83%). Six patients died (7%) before the end of the 3rd month. There were seven general complications (8%) including five thromboembolic events. There were 22 complications related to the surgical procedure in 20 patients (22%) that required surgical revision, including 10 surgical site infections (11%) and 3 dislocations (3%) (one concerning a dual mobility cup and 2 after single mobility cup). The median survivorship all causes combined was 19.5 months; it was 23.7 months for patients with breast cancer and 8.9 months for those with lung cancer.

CONCLUSION

Despite different endpoints being used, the clinical outcomes in our study are like those in other published studies, as were the incidence of surgery-related complications and the survivorship. The recommended surgical technique is the implantation of an acetabular reinforcement cage, curettage with cement filling of osteolytic areas, dual mobility cup and cemented stem followed by radiation therapy. The role of THA versus interventional radiology procedures must still be determined.

LEVEL OF EVIDENCE

IV, retrospective study without control group.

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.

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

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

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.

3-Dimensional micropillar drug screening identifies FGFR2-IIIC overexpression as a potential target in metastatic giant cell tumor

We established two patient derived tumor cells (PDCs) from right and left pulmonary metastatic lesions respectively of a patient with giant cell tumor. At that time, patient-derived tumor cells from right and left surgical specimens were collected and cultured. High-throughput screening (HTS) for 24 drugs was conducted with a micropillar/microwell chip platform using giant cell tumor PDCs. Using 6 doses per drug in 6 replicates for giant cell tumor PDCs, the dose response curves and corresponding IC50 values were calculated from the scanned images using the S+ Chip Analyzer. A sensitive response was more significantly achieved for AZD4547 (FGFR2 inhibitor) in giant cell tumor PDCs originated from the right pulmonary nodule under the micropillar/microwell chip platform using 3D culture. This sensitivity was consistent with the target expression patterns of giant cell tumor PDCs (FGFR2-IIIC mRNA expression in giant cell tumor PDCs originated from the right pulmonary nodule was increased significantly as compared to those originated from left). However, in a conventional 2D cultured MTT assay, there was no difference for IC50 values of AZD4547 between giant cell tumor PDCs originated from right and left pulmonary nodules. An HTS platform based on 3D culture on micropillar/microwell chips and PDC models could be applied as a useful preclinical tool to evaluate the intrapatient tumor/response heterogeneity. This platform based on 3D culture might reflect far better the relation between the tumor-biology and the matched targeted agent as compared to a conventional 2D cultured MTT assay.

Reconstruction of the hip after resection of periacetabular oncological lesions: a systematic review

Aims

Reconstruction of the acetabulum after resection of a periacetabular malignancy is technically challenging and many different techniques have been used with varying success. Our aim was to prepare a systematic review of the literature dealing with these techniques in order to clarify the management, the rate of complications and the outcomes.

Patients and Methods

A search of PubMed and MEDLINE was conducted for English language articles published between January 1990 and February 2017 with combinations of key search terms to identify studies dealing with periacetabular resection with reconstruction in patients with a malignancy. Studies in English that reported radiographic or clinical outcomes were included. Data collected from each study included: the number and type of reconstructions, the pathological diagnosis of the lesions, the mean age and follow-up, gender distribution, implant survivorship, complications, functional outcome, and mortality. The results from individual studies were combined for the general analysis, and then grouped according to the type of reconstruction.

Results

A total of 57 studies met the inclusion criteria and included 1700 patients. Most lesions were metastatic (41%), followed by chondrosarcoma (29%), osteosarcoma (10%), Ewing’s sarcoma (7%), and multiple myeloma (2%). The techniques of reconstruction were divided into seven types for analysis: those involving a Harrington reconstruction, a saddle prosthesis, an allograft and allograft prosthesis composite, a pasteurised autograft, a porous tantalum implant, a custom-made prosthesis and a modular hemipelvic reconstruction. The rate of complications was 50%, with infection (14%) and instability (8%) being the most common. Mortality data were available for 1427 patients (84%); 50% had died of disease progression, 23% were alive with disease, and 27% had no evidence of disease at a mean follow-up of 3.4 years (0 to 34).

Conclusion

Both the rate of complications and mortality are high following resection of oncological periacetabular lesions and reconstruction. Many types of reconstruction have been used with unique challenges and complications for each technique. Newer prostheses, including custom-made prostheses and porous tantalum implants and augments, have shown promising early functional and radiographic outcomes.

Cite this article: Bone Joint J 2018;100-B(1 Supple A):22–30.

Metastatic bone disease: A review of survival, prognostic factors and outcomes following surgical treatment of the appendicular skeleton

Survival data and prognostic factors may help to provide insight when deciding on the appropriate orthopaedic treatment for patients presenting with metastatic bone disease. This review was conducted to look at the outcomes following orthopaedic surgery for metastatic lesions in the extremities. The literature was identified through the Medline and Embase database and further refined via a set of inclusion and exclusion criteria. Overall, patients presenting with metastatic bone disease from renal cell cancer or breast cancer had the longest survival rate. Important factors found to predict prognosis was the presence of visceral metastasis, multiple metastases, pathological fracture and the type of primary tumour involved. These prognostic factors may help to direct future inquiry into metastatic bone disease and help determine the type of surgery to use in a metastatic setting in order to avoid complications and unnecessary revisions as well as provide durability.

Functional outcome and complications following reconstruction for Harrington class II and III periacetabular metastasis

BACKGROUND

Metastatic bone disease involving the acetabulum is a debilitating condition causing significant pain and disability for patients. Many methods of reconstruction have been described for treating Harrington class II and III lesions with different results and complications. Our objectives were to report functional results, implant survival and complications following reconstruction for Harrington class II and III periacetabular metastases by using anti-protusio cages, screws and joint replacement.

METHODS

We reviewed 22 patients undergoing acetabular reconstruction for metastatic disease. There were 5 Harrington class II and 17 class III lesions. Intralesional curettage, multiple screws and cemented total hip replacement were performed in all patients. Anti-protusio cages were used in 19 hips. No Steinmann pins were used. Sixteen patients died at a median survival time of 12 months (range, 4 to 28 months) after surgery. Six patients were alive at last follow-up at a median of 8 months (range, 3 to 15 months).

RESULTS

Postoperatively, the average ECOG score was improved from 3.1 to 1.7 and Visual Analog Scale was improved from 8.4 to 2.2. One patient developed hip dislocation and one patient developed superficial infection. The mean Musculoskeletal Tumor Society (MSTS) functional score was 70 (range, 27 to 87). There was no prosthetic loosening or revision. Twenty patients were able to walk. Eight patients became community ambulators, twelve became household ambulators and two were bed-bound.

CONCLUSIONS

Good functional outcome and better ambulation could be expected following class II and III periacetabular reconstruction using anti-protusio cages, screws and cemented hip replacement. Few complications were noted and manageable. Although most of these patients with metastatic disease had limited life expectancies, their quality of life would be improved with appropriate patient selection and surgical reconstruction.

Distal Femoral Subchondral Metastasis Mistaken for an Insufficiency Fracture and Treated with Total Knee Arthroplasty: A Case Report

CASE

A seventy-three-year-old woman who had been given the tentative diagnosis of spontaneous osteonecrosis presented to our clinic for a second opinion. Additional imaging and evaluation revealed the lesion to be a subchondral metastasis consistent with breast cancer. She received proper oncologic treatment and subsequent total knee arthroplasty.

CONCLUSION

Orthopaedic surgeons should be aware of the possibility of metastatic disease manifesting itself in the form of an isolated subchondral lesion about the knee. For patients with such lesions, treatment in the form of total knee arthroplasty is a viable option that can provide excellent pain relief and function.

The modified Harrington procedure for metastatic peri-acetabular bone destruction

PURPOSE

We describe the outcome in a series of patients treated for metastatic peri-actetabular and iliac bone destruction using a modified technique of Harrington's procedure.

METHODS

Between 2006 and 2012, nine patients with a mean age of 62.2 years (42-75 years) were treated using a modified Harrington technique. Thereby, total hip replacement implants augmented by two to three threaded pins and cement were used to restore bony continuity of the pelvis and to achieve a stable construction allowing immediate full-weight bearing mobilisation.

RESULTS

Acetabular destruction was graded according to Harrington's classification of peri-acetabular metastatic destruction, as class IV in one case, class III in six, and class II in two cases. The pre-operative ASA score ranged from II-IV. There were no intra-operative deaths or major complications such as excessive haemorrhage, deep infections, lesions of the femoral nerve, loss of fixation, or dislocations at final follow-up. Eight patients achieved an improvement of their functional status postoperatively. One reconstruction required revision and four patients died due to their underlying disease ten to 36 months after surgery.

CONCLUSION

We found this technique an effective, reproducible, and long-lasting method to relieve pain and improve or restore function in patients with destructive metastatic lesions of the peri-acetabular bone and the iliac wing. Although we performed surgery even in severely ill patients with extended, generalised metastatic disease we had no intra- or postoperative death and observed no major complications.

Expressional Analysis of GFP-Tagged Cells in an In Vivo Mouse Model of Giant Cell Tumor of Bone

Giant cell tumor of bone in a neoplastic stromal cell which survives for multiple passages in primary cell culture with a stable phenotype. In the pathological environment of GCT, the neoplastic nature of the mesenchymal stromal component drives local hematopoietic precursors to undergo fusion and form multinucleated osteoclast like giant cells. There is currently very limited knowledge about the pathogenesis of GCT due to the lack of suitable in vivo models for this tumor. Here we report stable gene transfer of Green fluorescence protein (GFP) in GCT stromal cells. In the present study, we have used GCT stromal cells that stably express enhanced green fluorescence protein (GFP) that are used in a new in vivo culture model. Our results show the utility of the GFP tagged cell lines that stably express GFP signals up to 52 weeks of continuous growth. The in vivo model described herein can serve as an excellent system for in vivo therapeutic and mechanistic evaluation of existing and novel targets for GCT.

Investigation of FGFR2-IIIC signaling via FGF-2 ligand for advancing GCT stromal cell differentiation

Giant cell tumor of bone (GCT) is an aggressive bone tumor consisting of multinucleated osteoclast-like giant cells and proliferating osteoblast-like stromal cells. The signaling mechanism involved in GCT stromal cell osteoblastic differentiation is not fully understood. Previous work in our lab reported that GCT stromal cells express high levels of TWIST1, a master transcription factor in skeletal development, which in turn down-regulates Runx2 expression and prevents terminal osteoblastic differentiation in these cells. The purpose of this study was to determine the upstream regulation of TWIST1 in GCT cells. Using GCT stromal cells obtained from patient specimens, we demonstrated that fibroblast growth factor receptor (FGFR)-2 signaling plays an essential role in bone development and promotes differentiation of immature osteoblastic cells. Fibroblast growth factor (FGF)-2 stimulates FGFR-2 expression, resulting in decreased TWIST1 expression and increased Runx2, alkaline phosphastase (ALP) and osteopontin (OPN) expression. Inhibition of FGFR-2 through siRNA decreased the expression of ALP, Runx2 and OPN in GCT stromal cells. Our study also confirmed that FGF-2 ligand activates downstream ERK1/2 signaling and pharmacological inhibition of the ERK1/2 signaling pathway suppresses FGF-2 stimulated osteogenic differentiation in these cells. Our results indicate a significant role of FGFR-2 signaling in osteoblastic differentiation in GCT stromal cells.

Encountering cancer or its sequelae at the hip

The orthopedist may need act as an adjunct to the medical oncologist in the management of the cancer patient with hip disease. While management of the cancer patient with routine hip pathology is relatively straightforward, the surgeon should be aware that the cancer patient may be on treatment protocols that affect wound healing, the immune system, and the risk of deep venous thrombosis. An additional factor that may complicate management of patients who have completed treatment of peripelvic cancer may be local radiation therapy, which can lead to necrosis of the acetabular bone stock. Operating on these patients must include consultation with previous radiation therapy providers to estimate the dose sustained by the local tissues under consideration. Greater than 500 cGy has been associated with high fixation failure rates in several series. Increased rates of infection and wound healing have also been noted secondary to long-term lymphatic obliteration caused by radiation. These concerns also affect the surgeon who must manage patients with acute metastatic disease. The principles of managing metastatic disease include recognizing the presence of lesions in bone about the hip, the occasional need for biopsy, the use of radiation in sensitive tumors, surgical stabilization of impending fracture, or joint replacement when needed. The amount of tumor, as well as the effect of chemotherapy and radiation on the healing process, potentially complicates these treatment modalities.