A scoping review on the surgical management of metastatic bone disease of the extremities

Radiolucent Implants for Fixation of Impending and Pathologic Fractures

Radiolucent implants offer theoretical advantages of increased ability to evaluate the fracture site for healing and recurrence and potentially less effect on radiation treatment, avoiding scatter. Their clinical utility and outcomes have yet to be proven in a well-designed randomized trial or large cohort study, although studies based on other indications have shown relative safety and they are approved by the US Food and Drug Administration for treatment of pathologic fractures. Further research is necessary to better understand when and how these implants should be implemented in practice. [Orthopedics. 2022;45(3):e115-e121.].

Does surgical technique influence the burden of lung metastases in patients with pathologic long bone fractures?

BACKGROUND

The aims of this study are to (1) determine whether fixation of metastatic long bone fractures with an intramedullary nail (IMN) influences the incidence of lung metastasis in comparison to arthroplasty or ORIF (Arthro/ORIF); and (2) assess this relationship in primary tumor types; and (3) to assess survival implications of lung metastasis after surgery.

METHODS

Retrospective cohort study investigating 184 patients (107 IMN, and 77 Arthro/ORIF) surgically treated for metastatic long bone fractures. Patients were required to have a single surgically treated impending or established pathologic fracture of a long bone, pre-operative lung imaging (lung radiograph or computed tomography) and post-operative lung imaging within 6 months of surgery. Primary cancer types included were breast (n = 70), lung (n = 43), prostate (n = 34), renal cell (n = 37). Statistical analyses were conducted using two-tailed Fisher's exact tests, and Kaplan-Meier survival analyses.

RESULTS

Patients treated with IMN and Arthro/ORIF developed new or progressive lung metastases following surgery at an incidence of 34 and 26%, respectively. Surgical method did not significantly influence lung metastasis (p = 0.33). Furthermore, an analysis of primary cancer subgroups did not yield any differences between IMN vs Arthro/ORIF. Median survival for the entire cohort was 11 months and 1-year overall survival was 42.7% (95% CI: 35.4-49.8). Regardless of fixation method, the presence of new or progressive lung metastatic disease at follow up imaging study was found to have a negative impact on patient survival (p < 0.001).

CONCLUSIONS

In this study, development or progression of metastatic lung disease was not affected by long bone stabilization strategy. IM manipulation of metastatic long bone fractures therefore may not result in a clinically relevant increase in metastatic lung burden. The results of this study also suggest that lung metastasis within 6 months of surgery for metastatic long bone lesions is negatively associated with patient survival.

LEVEL OF EVIDENCE

III, therapeutic study.

Longitudinal survival trends of patients with cancer with surgically managed appendicular metastatic bone disease: systematic review

BACKGROUND

Advances in systemic cancer therapies have improved survival for patients with metastatic carcinoma; however, it is unknown whether these advances have translated to improved survival for patients with appendicular metastatic bone disease (A-MBD) after orthopedic interventions. We conducted a study to evaluate the trend in overall survival for patients who underwent orthopedic surgery for A-MBD between 1968 and 2018.

METHODS

A systematic search of Embase and Medline to identify studies published since 1968 evaluating patients treated with orthopedic surgery for A-MBD was conducted for a previously published scoping review. We used a meta-regression model to assess the longitudinal trends in 1-, 2- and 5-year overall survival between 1968 and 2018. The midpoint year of patient inclusion for each study was used for analysis. We categorized primary tumour types into a tumour severity score according to prognosis for a further meta-regression analysis.

RESULTS

Of the 5747 studies identified, 103 were retained for analysis. Meta-regression analysis showed no significant effect of midpoint study year on survival across all time points. There was no effect of the weighted average of tumour severity scores for each study on 1-year survival over time.

CONCLUSION

There was no significant improvement in overall survival between 1968 and 2018 for patients with A-MBD who underwent orthopedic surgery. Orthopedic intervention remains a poor prognostic variable for patients with MBD. This finding highlights the need for improved collection of prospective data in this population to identify patients with favourable survival outcomes who may benefit from personalized oncologic surgical interventions.

[Treatment strategies for tumor-related pathological fractures of the extremities]

Pathological fractures of the extremities frequently lead to uncertainty with respect to the treatment strategy and timing. The origin of metastases is typically breast, bronchial, renal and prostate cancer and myelomas. Primary bone tumors play a subordinate role. The majority affect the femur, humerus and occasionally the tibia. Surgery is typically the first line treatment as healing under conservative treatment is unlikely. The most important goal is to relieve pain and the preservation or restoration of function. For correct assessment of indications, analysis of the fracture pattern and oncological aspects including dignity, entity, prognosis, metastatic status and the general condition of the patient need to be taken into consideration. Based on all these aspects the surgical approach can be chosen. Treatment options range from osteosynthetic stabilization and augmentation osteosynthesis up to endoprosthesis replacement. The treatment is carried out in an interdisciplinary procedure as additional measures need to be addressed in addition to the surgical treatment.

[Strategic approach to pathological fractures]

Pathological tumor-associated fractures are overall rare. They can occur in every age group and every bone. Although tumor-related fractures only form a small proportion of bone fractures, the early recognition of the cause of the fracture and treatment according to oncological guidelines are of enormous importance for affected patients. False treatment is frequently associated with far-reaching negative consequences with respect to the course of the disease. The great challenge is not the expeditious surgical treatment but much more the adequate diagnostics and the incorporation of local fracture treatment into an interdisciplinary overall oncological concept.

Early Experience in Pathologic Humerus Fracture Treated With the Photodynamic Bone Stabilization System Shows Limitations Related to Patient Selection

Impending and complete pathologic fractures often necessitate surgical fixation. Traditional orthopedic implants are commonly used, achieving clinically acceptable outcomes, but their metallic composition can impair radiographic evaluation and affect radiation treatments. Recognition of these concerns led to the development of radiolucent implants such as the minimally invasive Photodynamic Bone Stabilization System (PBSS; IlluminOss Medical Inc), featuring a light cured polymer contained within an inflatable balloon catheter. Two participating hospitals in one health care system reviewed cases using the PBSS implant. Twenty-five patients with 29 impending or pathologic fractures in the proximal radius or humerus from metastatic carcinoma, myeloma, lymphoma, and melanoma were identified. Clinical charts and imaging were reviewed to determine the status of the implant at final follow-up as well as complications. For analysis, a chi-square test was used for nominal variables and a t test was used for continuous variables. Eleven of the 25 patients were alive with disease at the time of analysis. Eight of 29 (27.5%) implants failed. Five of 25 (20%) patients required repeat surgery due to complications, including 3 revision open reduction and internal fixations, 1 open reduction and internal fixation for a periprosthetic fracture, and 1 screw removal. Five of the 9 cases (56%) (P=.03) with lesions in the distal humeral shaft had breakage of the implant by final follow-up, compared with 3 of 20 cases (15%) (P=.03) elsewhere in the humerus; no failures were seen in the radius. One of 4 patients (25%) also had failure in the surgical neck, although this did not reach significance. Five patients were noted to have progression of disease on follow-up radiographs, with 4 failures in patients with progression. The PBSS implants potentially allow improved surveillance of fracture healing and tumor recurrence along with decreased scattering of radiation during treatment. Unfortunately, there may be a higher rate of mechanical failures, particularly for lesions involving the distal humerus. This may be due to decreased cross-sectional area of the implant in this region as compared with the metaphyseal and proximal regions. Caution should be exercised when treating distal humeral pathologic fractures with large lytic lesions where the underlying disease process is not well controlled. [Orthopedics. 2021;44(3):154-159.].

Management of Metastatic Disease of the Upper Extremity

Metastatic disease is the most common pathologic cause of bone destruction, and the upper extremity is frequently involved. This location presents many surgical challenges, but there have been several recent implant and technique-related advances that have improved outcomes. Patients can be treated nonsurgically, with radiation or with surgery, depending on patient characteristics, signs/symptoms, primary diagnosis, location, and extent of bone destruction. Most locations in the upper extremity besides the humerus can be treated nonsurgically or with radiation. This is also true of the humerus, but when surgery is indicated, plate fixation is acceptable when adequate proximal and distal cortical bone is present for screw purchase. Intramedullary nailing is used frequently in metastatic humeral disease as well, especially in the diaphysis. When extensive destruction or disease progression precludes internal fixation, a resection with endoprosthetic reconstruction can be considered. Oncologic hemiarthroplasty endoprosthetics still have a role, but reverse shoulder designs are beginning to show improved function. Humeral prosthesis designs are continuing to improve, and are becoming more modular, with custom implants still playing a role in certain challenging scenarios.

Thirty-day Outcomes After Surgery for Metastatic Bone Disease of the Extremities: An Analysis of the NSQIP Database

INTRODUCTION

Metastatic bone disease of the extremities is a notable cause of morbidity and mortality. Surgical management is not curative; therefore, risks and benefits of surgery must be carefully considered. Previous studies of surgical outcomes are limited by small sample sizes because of the rare incidence of these procedures. In this study, we aim to describe the rates of complications and mortality in the first 30 days after surgical treatment of metastatic bone disease of the femur and humerus.

METHODS

A retrospective review of patients in the National Surgical Quality Improvement Program database who underwent surgery between 2005 and 2016 was performed. Demographics, comorbidities, preoperative factors, surgical parameters, and postoperative complications were extracted. The cohort was also partitioned by surgical site and surgical modality.

RESULTS

One thousand one hundred fifty-four patients were identified, 13.1 percent of patients experienced one or more complications within 30 days of surgery. The most common complications were urinary tract infection (2.9%), deep vein thrombosis (2.5%), pneumonia (2.4%), pulmonary embolism (2.0%), and surgical site infections (1.9%). In addition, intraoperative or postoperative bleeding requiring transfusion occurred in 32.9% of cases. The rates of unplanned readmission and unplanned revision surgery were 12.7% and 4.1%, respectively. The 30-day mortality rate was 7.1%. Femur and arthroplasty cases were associated with a higher risk of bleeding requiring transfusion. Prophylactic stabilization was associated with a lower risk of unplanned revision surgery (P = 0.015) and a lower overall complication rate (P < 0.0001).

CONCLUSION

Our study demonstrates a higher 30-day mortality rate than previously reported. In additon, prophylactic stabilization of impending pathologic fractures may be associated with a lower risk of complications and unplanned revision surgery. The National Surgical Quality Improvement Program or other large database reports can help surgeons counsel patients appropriately regarding the risks and benefits of surgery.

Current concepts in the surgical treatment of skeletal metastases

Symptomatic metastatic bone disease affects a large proportion of patients with malignant tumours and significantly impairs patients’ quality of life. There are still controversies regarding both surgical indications and methods, mainly because of the relatively few high-quality studies in this field. Generally, prosthetic reconstruction has been shown to result in fewer implant failures and should be preferred in patients with a good prognosis. Survival estimation tools should be used as part of preoperative planning. Adjuvant treatment, which relies on radiotherapy and inhibition of osteoclast function may also offer symptomatic relief and prevent implant failure. In this review we discuss the epidemiology, indications for surgery, preoperative planning, surgical techniques and adjuvant treatment of metastatic bone disease.

Communication in surgical decision-making while managing metastatic bone disease: matching patient expectations with surgical goals

BACKGROUND

There is a paucity of research examining how surgical decision-making for metastatic bone disease (MBD) can be optimized to improve quality of life (QOL) and functional outcomes, while accurately aligning with patient goals and expectations. The objective of this study was to survey and interview patients with MBD and support persons (PS), physicians, and allied health care providers (HCP) with the goal of identifying (1) important surgical issues related to MBD management, (2) discordance in perioperative expectations, and (3) perceived measures of success in the surgical management of MBD.

METHODS

Utilizing a custom survey developed by HCP and patients with MBD, participants were asked to (1) identify important issues related to MBD management, (2) rank perceived measures of success, and (3) answer open-ended questions pertaining to the management of MBD.

RESULTS

From the survey, increased life expectancy, minimizing disease progression, removal of local tumour, timely surgery after diagnosis, increased length of hospitalization, and physiotherapy access were all identified as significant discordant goals between PS and physicians/HCP. Conversely, there was an agreement between physicians and HCP who considered improved QOL and functional outcomes as most important goals. Structured homogenous-group workshops identified the need for (1) improved discussions of prognosis, surgical options, expectations, timelines, and resources, (2) the use of a care team "quarterback", and (3) an increased use of multi-disciplinary treatment planning.

CONCLUSIONS

We feel this data highlights the importance of improved communication and coordination in treating patients with MBD. Further research evaluating how surgical techniques influence survival and disease progression in MBD is highly relevant and important to patients.