Surgical management of metastatic bone disease

Comparison of reconstructive techniques for nonprimary malignancies in the proximal humerus

BACKGROUND

Endoprostheses (EPC) are often utilized for reconstruction of the proximal humerus with either hemiarthroplasty (HA) or reverse arthroplasty (RA) constructs. RA constructs have improved outcomes in patients with primary lesions, but no studies have compared techniques in metastatic disease. The aim of this study is to compare functional outcomes and complications between HA and RA constructs in patients undergoing endoprosthetic reconstruction for proximal humerus metastases.

METHODS

We retrospectively reviewed our institutional arthroplasty database to identify 66 (56% male; 38 HA and 28 RA) patients with a proximal humerus reconstruction for a non-primary malignancy. The majority (88%) presented with pathologic fracture, and the most common diagnosis was renal cell carcinoma (48%).

RESULTSS

Patients with RA reconstructions had better postoperative forward elevation (74° vs. 32°, p < 0.01) and higher functional outcome scores. HA patients had more complications (odds ratio 13, p < 0.01), with instability being the most common complication.

CONCLUSIONS

Patients with nonprimary malignancies of the proximal humerus had improved functional outcomes and fewer complications after undergoing reconstruction with a reverse EPC compared to a HA EPC. Preference for reverse EPC should be given in patients with good prognosis and ability to complete postoperative rehabilitation.

Complex Pathological Femoral Fracture in a Multiple Myeloma Patient Undergoing Intertrochanteric Fixation: A Case Report

Pathological fractures commonly occur in patients with metastatic bone diseases, particularly multiple myeloma. The current optimal management for metastatic pathological lesions affecting the proximal femur is surgical intervention. Surgical planning and appropriate use of imaging modalities are pivotal in the appropriate treatment of pathological fractures. Impending fractures create added layers of complexity in the decision-making process. The appropriateness of different surgical interventions involves a multi-disciplinary approach and the importance of holistic healthcare is paramount in these circumstances.

Psoas muscle area is an independent survival prognosticator in patients undergoing surgery for long-bone metastases

BACKGROUND

Predictive analytics is gaining popularity as an aid to treatment planning for patients with bone metastases, whose expected survival should be considered. Decreased psoas muscle area (PMA), a morphometric indicator of suboptimal nutritional status, has been associated with mortality in various cancers, but never been integrated into current survival prediction algorithms (SPA) for patients with skeletal metastases. This study investigates whether decreased PMA predicts worse survival in patients with extremity metastases and whether incorporating PMA into three modern SPAs (PATHFx, SORG-NG, and SORG-MLA) improves their performance.

METHODS

One hundred eighty-five patients surgically treated for long-bone metastases between 2014 and 2019 were divided into three PMA tertiles (small, medium, and large) based on their psoas size on CT. Kaplan-Meier, multivariable regression, and Cox proportional hazards analyses were employed to compare survival between tertiles and examine factors associated with mortality. Logistic regression analysis was used to assess whether incorporating adjusted PMA values enhanced the three SPAs' discriminatory abilities. The clinical utility of incorporating PMA into these SPAs was evaluated by decision curve analysis (DCA).

RESULTS

Patients with small PMA had worse 90-day and 1-year survival after surgery (log-rank test p < 0.001). Patients in the large PMA group had a higher chance of surviving 90 days (odds ratio, OR, 3.72, p = 0.02) and 1 year than those in the small PMA group (OR 3.28, p = 0.004). All three SPAs had increased AUC after incorporation of adjusted PMA. DCA indicated increased net benefits at threshold probabilities >0.5 after the addition of adjusted PMA to these SPAs.

CONCLUSIONS

Decreased PMA on CT is associated with worse survival in surgically treated patients with extremity metastases, even after controlling for three contemporary SPAs. Physicians should consider the additional prognostic value of PMA on survival in patients undergoing consideration for operative management due to extremity metastases.

Metastatic sarcomatoid carcinoma to bone

BACKGROUND AND OBJECTIVES

Distinguishing sarcomatoid carcinoma from primary sarcoma is clinically important. We sought to characterize metastatic sarcomatoid bone disease and its management.

METHODS

We analyzed the characteristics of all cases of sarcomatoid carcinoma to bone at a single institution from 2001 to 2021, excluding patients with nonosseous metastases. Survival was evaluated using the Kaplan-Meier method.

RESULTS

We identified 15 cases of metastatic sarcomatoid carcinoma to bone. In seven cases the primary cancer was unknown at presentation. Renal cell carcinoma was suspected or confirmed in nine cases. Nine patients presented with pathologic fracture and two with concomitant visceral metastases. All patients underwent image-guided core needle or open biopsy. Ten required surgery for discrete osseous metastases; in four cases definitive surgery was delayed (median delay, 19 days) due to inability to rule out sarcoma with frozen section. No patients required reoperation or had construct failure. Thirteen died of disease; median survival was 17.5 months (interquartile range, 6.2-25.1).

CONCLUSIONS

Metastatic sarcomatoid carcinoma is a clinically challenging entity. Multidisciplinary input and communication are key to identifying the primary carcinoma, locating osseous metastases, and defining an operative fixation that will survive the remainder of the patient's life.

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.

Surgical treatment for pelvic bone metastatic disease from renal cell carcinoma

INTRODUCTION

Pelvic bone metastases from renal cell carcinoma (RCC) are challenging due to their destructive pattern, poor response to radiotherapy and hypervascularity. The purpose of our study was to review a series of patients undergoing surgical treatment with the aim to investigate: 1) survival; 2) local disease control; and 3) complications.

METHODS

A series of 16 patients was reviewed. A curettage procedure was performed on 12 patients. In eight the lesion involved the acetabulum; a cemented hip arthroplasty with cage was performed in seven; a flail hip in one. Four patients received a resection; in two cases with acetabular involvement, reconstruction was performed with a custom-made prosthesis and with an allograft and prosthesis.

RESULTS

Disease-specific survival accounted for 70% at 3 years and 41% at 5 years. Only one local tumor progression after curettage occurred. Revision surgery (flail hip) was necessary for deep infection of the custom-made prosthesis.

CONCLUSION

A prolonged survival in patients affected by bone metastatic disease from RCC can justify also major surgical procedures. Due to a low local progression rate after intralesional procedures, curettage, cement and a total hip arthroplasty with cage, when feasible, should be considered as an alternative to more demanding surgeries like resections and reconstructions.

LEVEL OF EVIDENCE (OXFORD)

Level 4.

Is the association of electrochemotherapy and bone fixation rational in patients with bone metastasis?

BACKGROUND

Bone metastases are frequent in patients with cancer. Electrochemotherapy (ECT) is a minimally invasive treatment based on a high-voltage electric pulse combined with an anticancer drug. Preclinical and clinical studies supported the use of ECT in patients with metastatic bone disease, demonstrating that it does not damage the mineral structure of the bone and its regenerative capacity, and that is feasible and efficient for the treatment of bone metastases. Year 2014 saw the start of a registry of patients with bone metastases treated with ECT, whose data are recorded in a shared database.

QUESTIONS/PURPOSES

(1) Among patients who underwent ECT and internal fixation for bone metastasis, how many experienced a reduction of pain? (2) How many cases showed a radiological response? (3) How many patients presented local or systemic complication after ECT and fixation?

PATIENTS AND METHODS

Patients were treated in Bologna at Rizzoli Orthopaedic Institute between March 2014 and February 2022 and recorded in the REINBONE registry (a shared database protected by security passwords): clinical and radiological information, ECT session, adverse events, response, quality of life indicators, and duration of follow-up were registered. We consider only cases treated with ECT and intramedullary nail during the same surgical session. Patients included in the analysis were 32: 15 males and 17 females, mean age 65 ± 13 years (median 66, range 38-88 years), mean time since diagnosis of primary tumor 6.2 ± 7.0 years (median 2.9, range 0-22 years). Nail was indicated in 13 cases for a pathological fracture in, 19 for an impending fracture. Follow-up was available for 29 patients, as 2 patients were lost to follow-up and 1 was unable to return to controls. Mean follow-up time was 7.7 ± 6.5 months (median 5, range 1-24), and 16 patients (50%) had a follow-up longer than 6 months.

RESULTS

A significant decrease in pain intensity was observed at the mean Visual Numeric Scale after treatment. Bone recovery was observed in 13 patients. The other 16 patients remained without changes, and one presented disease progression. One patient presented a fracture occurrence during the ECT procedure. Among all patients, bone recovery was observed in 13 patients: complete recovery in 1 patient (3%) and partial recovery in 12 patients (41%). The other 16 patients remained without changes, and one presented disease progression. One patient presented a fracture occurrence during the ECT procedure. However, healing was possible with normal fracture callus quality and healing time. No other local or systemic complications were observed.

CONCLUSION

We found that pain levels decreased after treatment in 23 of the 29 cases for a pain relief rate of 79% at final follow-up. Pain is one of the most important indicators of quality of life in patients that undergo palliative treatments. Even if conventional external body radiotherapy is considered a noninvasive treatment, it presents a dose-dependent toxicity. ECT provides a chemical necrosis preserving osteogenic activity and structural integrity of bone trabeculae; this is a crucial difference with other local treatments and allows bone healing in case of pathological fracture. The risk of local progression in our patient population was small, and 44% experienced bone recovery while 53% of the cases remained unchanged. We observe intraoperative fracture in one case. This technique, in selected patients, improves outcome in bone metastatic patients combing both the efficacy of the ECT in the local control of the disease and the mechanical stability with the bone fixation to synergize their benefits. Moreover, the risk of complication is very low. Although encouraging data, comparative studies are required to quantify the real efficacy of the technique. Level of Evidence Level I, therapeutic study.

Management of Proximal Humeral Oncologic Lesions

The proximal humerus is a common location for primary tumors, benign lesions, and metastatic disease. Advances in neoadjuvant and adjuvant therapy have allowed for limb-salvage surgery in most of the cases. There are numerous of options for surgical management of proximal humerus lesions and the decision to pursue one over another depends on factors such as age, comorbidities, pathology, location within the proximal humerus, planned resection margins/size of defect, and bone quality. Long-term outcomes for these techniques tend to be retrospective comparative studies, with recent studies highlighting the improved outcomes of reverse total shoulders.

Bone Metastasis of Breast Cancer: Molecular Mechanisms and Therapeutic Strategies

Bone metastasis is a common complication of many types of advanced cancer, including breast cancer. Bone metastasis may cause severe pain, fractures, and hypercalcemia, rendering clinical management challenging and substantially reducing the quality of life and overall survival (OS) time of breast cancer patients. Studies have revealed that bone metastasis is related to interactions between tumor cells and the bone microenvironment, and involves complex molecular biological mechanisms, including colonization, osteolytic destruction, and an immunosuppressive bone microenvironment. Agents inhibiting bone metastasis (such as bisphosphate and denosumab) alleviate bone destruction and improve the quality of life of breast cancer patients with bone metastasis. However, the prognosis of these patients remains poor, and the specific biological mechanism of bone metastasis is incompletely understood. Additional basic and clinical studies are urgently needed, to further explore the mechanism of bone metastasis and develop new therapeutic drugs. This review presents a summary of the molecular mechanisms and therapeutic strategies of bone metastasis of breast cancer, aiming to improve the quality of life and prognosis of breast cancer patients and provide a reference for future research directions.

Management of Long Bones Metastatic Disease: Concepts That We All Know but Not Always Remember

Bones are the third most common site of metastatic disease. Treatment is rarely curative; rather, it seeks to control disease progression and palliate symptoms. Imaging evaluation of a patient with symptoms of metastatic bone disease should begin with plain X-rays. Further imaging consists of a combination of (PET)-CT scan and bone scintigraphy. We recommend performing a biopsy after imaging workup has been conducted. Metastatic bone disease is managed with a combination of systemic treatment, radiotherapy (RT), and surgery. External beam RT (EBRT) is used for pain control and postoperatively after fracture stabilization. Single-fraction and multiple-fractions schemes are equally effective achieving pain control. Adequate assessment of fracture risk should guide the decision to stabilize an impending fracture. Despite low specificity, plain X-rays are the first tool to determine risk of impending fractures. CT scan offers a higher positive predictive value and can add diagnostic value. Surgical management depends on the patient's characteristics, tumor type, and location of fracture/bone stock. Fixation options include plate and screw fixation, intramedullary (IM) nailing, and endoprostheses. Despite widespread use, the need for prophylactic stabilization of the entire femur should be individually analyzed in each patient due to higher complication rates of long stems.

Periprosthetic Metastatic Lung Carcinoma About a Total Knee Arthroplasty: A Case Report

CASE

A 64-year-old man presented with unrelenting left knee pain and an unremarkable radiograph 4 months after revision total knee arthroplasty (TKA). Pain persisted, despite conservative management, and repeat imaging demonstrated significant lysis of the left medial tibial condyle. A biopsy demonstrated metastatic squamous cell carcinoma of the lung. Management with excision and curettage of the tibial lesion was followed by palliative radiotherapy and chemotherapy until the patient died 7 months later.

CONCLUSION

This case highlights metastasis as an etiology for persistent TKA pain in a patient with significant risk factors.

Outcomes and prognostic factors after surgery for bone metastases in the extremities and pelvis: A retrospective analysis of 140 patients

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Pathological fracture, visceral metastasis and lung cancer were negative prognostic factors for patients with bone metastases in the extremities and pelvis.

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Complications occurred in every fourth patient within the first 30 postoperative days.

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No significant differences in short- and long-term outcomes were observed between endoprosthetic replacement and internal fixation.

Background

Methods

Results

Conclusions

Electrochemotherapy Is Effective in the Treatment of Bone Metastases

Bone metastases induce pain, risk of fracture, and neural compression, and reduced mobility and quality of life. Electrochemotherapy (ECT) is a minimally invasive local treatment based on a high-voltage electric pulse combined with an anticancer drug. Preclinical and clinical studies have supported the use of ECT in patients with metastatic bone disease, demonstrating that it does not damage the mineral structure of the bone and its regenerative capacity, and that is feasible and efficient for the treatment of bone metastases. Since 2009, 88 patients with bone metastasis have received ECT at the Rizzoli Institute. 2014 saw the start of a registry of patients with bone metastases treated with ECT, whose data are recorded in a shared database. We share the Rizzoli Institute experience of 38 patients treated with ECT for a bone metastasis, excluding patients not included in the registry (before 2014) and those treated with bone fixation. Mean follow-up was 2 months (1–52). Response to treatment using RECIST criteria was 29% objective responses, 59% stable disease, and 16% progressive disease. Using PERCIST, the response was 36% OR, 14% SD, and 50% PD with no significant differences between the two criteria. A significant decrease in pain and better quality of life was observed at FU.

A Tailored Approach for Appendicular Impending and Pathologic Fractures in Solid Cancer Metastases

Simple Summary

Patients with bone metastases often suffer with complications, such as bone fractures, which have a substantial negative impact on clinical outcomes. To optimize clinical results, a tailored approach should be defined for managing impending or pathologic fractures in each individual case. The ability to control systemic disease, the extent, location and nature of bone metastases, and the biology of the underlying tumor, are the main factors that will define the strategy to follow.

Abstract

Advances in medical and surgical treatment have played a major role in increasing the survival rates of cancer patients with metastatic bone disease. The clinical course of patients with bone metastases is often impaired by bone complications, such as bone fractures, which have a substantial negative impact on clinical outcomes. To optimize clinical results and prevent a detrimental impact on patients’ health, a tailored approach should be defined for any given patient. The optimal management of impending or pathologic fractures is unknown and relies on a multidisciplinary approach to tailor clinical decisions to each individual patient. The ability to control systemic disease, the extent, location and nature of bone metastases, and the biology of the underlying tumor, are the main factors that will define the strategy to follow. The present review covers the most recent data regarding impending and pathologic fractures in patients with bone metastases, and discusses the medical and surgical management of patients presenting with metastatic bone disease in different clinical settings.

Surgical management of renal cancer metastasis in the humerus: novel use of a trabecular metal spacer

Humeral metastases from renal cell carcinoma are not uncommon. Current surgical practice centres around adequate tumour resection, but often at the expense of functional outcome. The use of trabecular metal (TM) implants is well described in spine and joint surgery. However, their use as a reconstruction device in osseous tumour surgery has yet to be reported. We present our experience in using a TM vertebral body replacement device (VBR) in treating a patient with painful bilateral diaphyseal humeral metastases. Resection of the tumour resulted in defects which the TM-VBR was able to fill. The defect was then bridged with a locking plate and cables. At 2-year clinical and radiographic review, bony integration and a return to pain free, near-normal function was achieved.

International Validation of the SORG Machine-learning Algorithm for Predicting the Survival of Patients with Extremity Metastases Undergoing Surgical Treatment

BACKGROUND

The Skeletal Oncology Research Group machine-learning algorithms (SORG-MLAs) estimate 90-day and 1-year survival in patients with long-bone metastases undergoing surgical treatment and have demonstrated good discriminatory ability on internal validation. However, the performance of a prediction model could potentially vary by race or region, and the SORG-MLA must be externally validated in an Asian cohort. Furthermore, the authors of the original developmental study did not consider the Eastern Cooperative Oncology Group (ECOG) performance status, a survival prognosticator repeatedly validated in other studies, in their algorithms because of missing data.

QUESTIONS/PURPOSES

(1) Is the SORG-MLA generalizable to Taiwanese patients for predicting 90-day and 1-year mortality? (2) Is the ECOG score an independent factor associated with 90-day and 1-year mortality while controlling for SORG-MLA predictions?

METHODS

All 356 patients who underwent surgery for long-bone metastases between 2014 and 2019 at one tertiary care center in Taiwan were included. Ninety-eight percent (349 of 356) of patients were of Han Chinese descent. The median (range) patient age was 61 years (25 to 95), 52% (184 of 356) were women, and the median BMI was 23 kg/m2 (13 to 39 kg/m2). The most common primary tumors were lung cancer (33% [116 of 356]) and breast cancer (16% [58 of 356]). Fifty-five percent (195 of 356) of patients presented with a complete pathologic fracture. Intramedullary nailing was the most commonly performed type of surgery (59% [210 of 356]), followed by plate screw fixation (23% [81 of 356]) and endoprosthetic reconstruction (18% [65 of 356]). Six patients were lost to follow-up within 90 days; 30 were lost to follow-up within 1 year. Eighty-five percent (301 of 356) of patients were followed until death or for at least 2 years. Survival was 82% (287 of 350) at 90 days and 49% (159 of 326) at 1 year. The model's performance metrics included discrimination (concordance index [c-index]), calibration (intercept and slope), and Brier score. In general, a c-index of 0.5 indicates random guess and a c-index of 0.8 denotes excellent discrimination. Calibration refers to the agreement between the predicted outcomes and the actual outcomes, with a perfect calibration having an intercept of 0 and a slope of 1. The Brier score of a prediction model must be compared with and ideally should be smaller than the score of the null model. A decision curve analysis was then performed for the 90-day and 1-year prediction models to evaluate their net benefit across a range of different threshold probabilities. A multivariate logistic regression analysis was used to evaluate whether the ECOG score was an independent prognosticator while controlling for the SORG-MLA's predictions. We did not perform retraining/recalibration because we were not trying to update the SORG-MLA algorithm in this study.

RESULTS

The SORG-MLA had good discriminatory ability at both timepoints, with a c-index of 0.80 (95% confidence interval 0.74 to 0.86) for 90-day survival prediction and a c-index of 0.84 (95% CI 0.80 to 0.89) for 1-year survival prediction. However, the calibration analysis showed that the SORG-MLAs tended to underestimate Taiwanese patients' survival (90-day survival prediction: calibration intercept 0.78 [95% CI 0.46 to 1.10], calibration slope 0.74 [95% CI 0.53 to 0.96]; 1-year survival prediction: calibration intercept 0.75 [95% CI 0.49 to 1.00], calibration slope 1.22 [95% CI 0.95 to 1.49]). The Brier score of the 90-day and 1-year SORG-MLA prediction models was lower than their respective null model (0.12 versus 0.16 for 90-day prediction; 0.16 versus 0.25 for 1-year prediction), indicating good overall performance of SORG-MLAs at these two timepoints. Decision curve analysis showed SORG-MLAs provided net benefits when threshold probabilities ranged from 0.40 to 0.95 for 90-day survival prediction and from 0.15 to 1.0 for 1-year prediction. The ECOG score was an independent factor associated with 90-day mortality (odds ratio 1.94 [95% CI 1.01 to 3.73]) but not 1-year mortality (OR 1.07 [95% CI 0.53 to 2.17]) after controlling for SORG-MLA predictions for 90-day and 1-year survival, respectively.

CONCLUSION

SORG-MLAs retained good discriminatory ability in Taiwanese patients with long-bone metastases, although their actual survival time was slightly underestimated. More international validation and incremental value studies that address factors such as the ECOG score are warranted to refine the algorithms, which can be freely accessed online at https://sorg-apps.shinyapps.io/extremitymetssurvival/.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Follicular thyroid carcinoma with an iliac wing metastasis - Rare case report at Bugando Medical Centre in Tanzania

Thyroid carcinoma is uncommon in our geographical setting. When it occurs the leading histological type is papillary thyroid carcinoma followed by follicular thyroid carcinoma which are differentiated thyroid carcinomas. Differentiated thyroid carcinomas usually have a good prognosis as compared to undifferentiated thyroid carcinomas. Follicular Thyroid Carcinoma usually presents with a solitary thyroid nodule with or without cervical lymphadenopathy. We present a 57 year old female with history of anterior neck swelling for 5 years and inability to walk using the left lower limb for 2 years. Total thyroidectomy and modified neck dissection was done. Histopathology results revealed follicular thyroid carcinoma. Patient was received radiochemotherapy treatment post-surgery. Follicular thyroid carcinoma may present with a symptomatic distant metastatic bony lesion as presented. It is important for clinicians to be aware this and carry out confirmatory relative investigations.

All bone metastases are not created equal: Revisiting treatment resistance in renal cell carcinoma

Renal cell carcinoma (RCC) is the most common malignancy of the kidney, representing 80-90% of renal neoplasms, and is associated with a five-year overall survival rate of approximately 74%. The second most common site of metastasis is bone. As patients are living longer due to new RCC targeting agents and immunotherapy, RCC bone metastases (RCCBM) treatment failure is more prevalent. Bone metastasis formation in RCC is indicative of a more aggressive disease and worse prognosis. Osteolysis is a prominent feature and causes SRE, including pathologic fractures. Bone metastasis from other tumors such as lung, breast, and prostate cancer, are more effectively treated with bisphosphonates and denosumab, thereby decreasing the need for palliative surgical intervention. Resistance to these antiresportives in RCCBM reflects unique cellular and molecular mechanisms in the bone microenvironment that promote progression via inhibition of the anabolic reparative response. Identification of critical mechanisms underlying RCCBM induced anabolic impairment could provide needed insight into how to improve treatment outcomes for patients with RCCBM, with the goals of minimizing progression that necessitates palliative surgery and improving survival.

Can a Novel Scoring System Improve on the Mirels Score in Predicting the Fracture Risk in Patients with Multiple Myeloma?

BACKGROUND

Stratification of the fracture risk is an important treatment component for patients with multiple myeloma, which is associated with up to an 80% risk of pathologic fracture. The Mirels score, which is commonly used to estimate the fracture risk for patients with osseous lesions, was evaluated in a cohort in which fewer than 15% of lesions were caused by multiple myeloma. The behavior of multiple myeloma lesions often differs from that of lesions caused by metastatic disease, and accurate risk stratification is critical for effective care. To our knowledge, the Mirels score has not been validated specifically for multiple myeloma.

QUESTIONS/PURPOSES

Our purpose was: (1) To develop a novel scoring system for the prediction of pathologic fracture in patients with long-bone lesions from multiple myeloma; and (2) to compare the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver operating characteristic (ROC) area under curve (AUC) between the novel scoring system and the Mirels system.

METHODS

Between 2003 and 2017, 763 patients at one center with the diagnosis of multiple myeloma were reviewed, of whom 174 presented with long-bone disease involvement. Of those, 5% (nine of 174) were missing data or radiographs at a minimum of 1 year and had not reached an endpoint (fracture or surgery) before that time and were therefore excluded. Many patients have more than one lesion; consequently, we used the largest lesion in each patient, resulting in 163 lesions in as many patients. Ten percent (16 of 163) of these patients eventually developed a fracture and 4% (six of 163) underwent prophylactic stabilization (excluded from analysis because of outcome uncertainty). During the study period, prophylactic stabilization was performed at the discretion of the orthopaedic oncologist. Fifty-one percent (83 of 163) of patients were female, and the mean (± SD) age was 60 ± 10 years at radiographic lesion identification. All lesions were characterized before determining whether the patient underwent pathologic fracture. We identified variables associated with pathologic fracture on univariate analysis. Variables independently significant on logistic regression analysis were used to generate scoring algorithms at varying weights and scoring cutoffs for comparison via ROC curves. We then selected a novel score based on ROC performance, and compared the sensitivity, specificity, PPV, and NPV of that scoring system to that of Mirels score. ROC AUCs were compared after bootstrapping 100,000 iterations. Alpha was set at 0.05.

RESULTS

After controlling for potential confounders, such as age, sex, and duration of myeloma diagnosis, we found the following factors were independently associated with the occurrence of pathologic fracture: larger lesion size (area, cm2) (log odds 0.17; p = 0.03), longer lesion latency (years from diagnosis to lesion identification) (log odds 0.25; p = 0.03), presence of pain (relative risk [RR] 2.9; p = 0.04), and metaphyseal location (RR 3.2, compared with epiphyseal or diaphyseal; p = 0.003). These variables were used to formulate a novel scoring system. Compared with the Mirels system, the novel system was more sensitive (69% [95% CI 61 to 76] versus 38% [95% CI 30 to 46]; p < 0.05) but not different in terms of specificity (87% [95% CI 80 to 91] versus 87% [95% CI 81 to 92]; p > 0.05), PPV (37% [95% CI 29 to 45] versus 25% [95% CI 19 to 33]; p > 0.05), NPV (96% [95% CI 91 to 99] versus 92% [95% CI 87 to 96]; p > 0.05), or AUC (0.85 [95% CI 0.74 to 0.92] versus 0.67 [95% CI 0.51 to 0.81]; p > 0.05).

CONCLUSION

The novel scoring system was found to be more sensitive than the Mirels system for predicting pathologic fracture in our retrospective cohort of patients with multiple myeloma-related bone disease. Specificity, PPV, NPV, and ROC AUC were not different with the numbers available. Thus, the novel scoring system may serve as a more effective screening tool to determine which patients with multiple myeloma would benefit from further radiologic or orthopaedic evaluation based on a skeletal survey.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Surgical outcomes of metastatic bone tumors in the extremities (Surgical outcomes of bone metastases)

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Prognostic factors: primary tumor, visceral metastases, and surgical procedure.

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PS, BI, EQ-5D, and NRS improved at 3 months after surgery.

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The improvements of PS, BI, EQ-5D, and NRS were maintained for 6 M after surgery.

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The management of bone metastases must be decided by a multidisciplinary team.

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The proper management of bone metastasis will reduce postoperative complications.

Background

Skeletal related events due to metastatic bone tumors markedly affect the activities of daily living (ADL) and quality of life (QOL) in cancer patients. We focused on multidisciplinary therapy for metastatic bone tumors. This study aimed to evaluate the outcomes of surgical treatment for metastatic bone tumors in the extremities.

Methods

We retrospectively reviewed 114 patients who underwent surgical treatment for metastatic bone tumors of the extremities between 2008 and 2019 and 69 patients were reassessed for more than 6 months after surgery. The most common primary tumor was renal, followed by lung, thyroid, and breast cancers. We assessed 69 patients’ performance status (PS), Barthel Index (BI) for ADL, EuroQol 5 Dimensions (EQ-5D) for QOL, and numerical rating scale (NRS) for pain and analyzed these postoperative values relative to preoperative values using Friedman’s test. The postoperative overall survival and the prognostic factors were evaluated using the Kaplan-Meier method, the log-rank test and Cox proportional hazards analysis.

Results

The 1-year overall survival rate was 59%, and the median survival time after surgery was 20 months. Primary tumor, visceral metastasis, and surgical procedure were risk factors correlated with overall survival. PS, BI, EQ-5D, and NRS improved at 3 months after surgery and these improvements were maintained for 6 months after surgery regardless of the surgical procedure.

Conclusions

The significant factors affecting survival after surgical treatment for bone metastases included the primary tumor, presence of visceral metastases, and internal fixation without tumor resection or curettage. Surgical treatment for metastatic bone tumors effectively reduced pain and improved PS, ADL, and QOL postoperatively after 3 months.

Retrospective, multicenter, observational study of 112 surgically treated cases of humerus metastasis

INTRODUCTION

The humerus is the second most common site for metastasis in the peripheral skeleton. These humeral metastases (HM) occur in the midshaft in 42% to 61% of cases and theproximal humerus in 32% to 45% of cases. They are often secondary to primary breast (17-31%), kidney (13-15%) or lung (11-24%) cancer. The optimal surgical treatment between intramedullary (IM) procedures, fixation or arthroplasty is still being debated.

HYPOTHESIS

We hypothesized that fixation and/or arthroplasty are safe and effective options for controlling pain and improving the patients' function.

MATERIALS AND METHODS

Between 2004 and 2016, 11 French hospitals included 112 continuous cases of HM in 54 men (49%) and 57 women (51%). The average age was 63.7±13.4 years (30-94). The HM occurred in the context of primary breast (30%), lung (23%) or kidney (21%) cancers. The HM was proximal in 35% of cases, midshaft in 59% and distal in 7% of cases. Surgery was required in 69% of patients because of a pathological fracture. The surgical procedure consisted of bundle pinning, plate fixation, arthroplasty or locked IM nailing in 6%, 11%, 14% and 69% of patients, respectively.

RESULTS

Seven patients (6%) had to be reoperated due to surgical site complications including two infections and four fractures (periprosthetic or away from implant). Twelve patients (11%) experienced a general complication. The overall survival was 16.7 months, which was negatively and significantly impacted by the occurrence of a fracture, a diaphyseal location and the type of primary cancer. At the final assessment, 75% had normal or subnormal function and more than 90% were pain-free or had less pain. The final function was not related to the occurrence of a fracture or etiology of the metastasis. In epiphyseal and metaphyseal HM, there was a trend to better function after shoulder arthroplasty than after plate fixation or IM nailing.

CONCLUSIONS

Our initial hypothesis was confirmed. Our findings were consistent with those of other published studies. Based on our findings, we recommend using static locked IM nailing with cementoplasty for mid-shaft lesions and modular arthroplasty for destructive epiphyseal or metaphyso-epiphyseal lesions. The criteria for assessing humeral fracture risk should be updated to allow the introduction of a preventative procedure, which contributes to better survival.

LEVEL OF EVIDENCE

IV, retrospective study.

Clinical and functional comparison of dynamic hip screws and intramedullary nails for treating proximal femur metastases in older individuals

Objective

To compare the outcomes of dynamic hip screws (DHS) and intramedullary nailing (IMN) in the treatment of extra-capsular metastatic carcinoma of the proximal femur.

Methods

A retrospective case analysis method was used to examine data of patients with proximal metastatic cancer of the femur who were treated with internal fixation in Department of Orthopaedics, Beijing Friendship Hospital, from January 2007 to December 2018. Blood loss, postoperative pain, functional score, length of stay, and survival rates were compared, and postoperative complications were assessed.

Results

Complete follow-up data were available for 33 patients. The mean follow-up period was 12.2±3.6 (range: 9−32) months and the average age was 72.3±4.7 (range: 59−83) years old. There were 20 females and 13 males. Twenty-three patients had undergone IMN and 10 DHS, according to bone defects and the patient’s overall condition. The median survival time was 10 months in the IMN group and 11 months in the DHS group. Duration of surgery (t=−7.366, P<0.001) and length of hospital stay (t=−3.509, P<0.001) differed significantly between the two groups. There was one case of breakage of internal fixation in the IMN group.

Conclusions

There was no significant difference between DHS and IMN in terms of surgical efficacy. IMN and DHS were different in terms of surgical time and hospital stay. However, due to the limited number of cases in this study, multi-factor analysis has not been performed and needs to be further verified in future analysis. When developing a surgical plan, it is recommended to consider the patient’s condition and the surgeon’s experience.

The Incidence and Management Trends of Metastatic Spinal Tumors in South Korea: A Nationwide Population-based Study

STUDY DESIGN

Population-based study. From 2008 to 2017, data from the national database of the Korean Health Insurance Review & Assessment Service were analyzed. The national insurance system and all medical expense bill data of the entire population are included in the database.

OBJECTIVE

The aim of this study was to elucidate the incidence and management trends of metastatic spinal tumors in South Korea.

SUMMARY OF BACKGROUND DATA

The spine is the most common location of bone metastases. However, population-based studies in this topic are limited.

METHODS

The International Classification of Disease, 10th revision, medical behavior, and examination codes were used to identify the incidence and management trends of metastatic spinal tumors. The Cochran-Armitage trend test was used in statistical analysis.

RESULTS

Overall, 38,007 patients (average age, 61 years) diagnosed with metastatic spinal tumors were analyzed. Metastatic tumors were most common in patients in their 60s (25.7%). The 10-year incidence of spinal metastases in South Korea was 6.68 cases per 100,000 population. The age-adjusted incidence per 100,000 population decreased from 8.16 cases in 2008 to 6.18 in 2017 (P = 0.03). Sex-adjusted incidence rates in men increased from 8.60 per 100,000 persons in 2008 to 8.70 in 2017 (P < 0.001); those of women decreased from 8.20 per 100,000 persons in 2008 to 4.15 in 2017 (P < 0.05). The most common primary tumor site was the lung (26.9%), followed by the breast (16.9%), prostate (10.8%), and liver (8.1%). Radiation therapy was constant at about 3500 cases per annum (P = 0.62); surgical treatment increased from 1158 to 1382 cases (P < 0.001). Resection and instrumentation surgeries increased significantly (P < 0.001), whereas cementation decreased continuously. Total healthcare costs increased significantly from $19,925,296 in 2008 to $30,268,217 in 2017 (P < 0.001).

CONCLUSION

The incidence of metastatic spinal tumors decreased in South Korea. Resection and instrumentation procedures increased, and total healthcare costs increased rapidly.

LEVEL OF EVIDENCE

3.

Current surgical management of metastatic pathological fractures of the femur: A multicentre snapshot audit

AIMS

We aimed to find out: the typical workload for metastatic bone disease, the conventional treatment for femoral metastases and whether there is a trend for arthroplasty and endoprosthetic reconstruction.

MATERIALS AND METHODS

All sequential patients undergoing surgery for femoral metastatic lesions (both pathological fracture and impending pathological fracture) of any age patient were included in the multicenter snapshot audit. Data on demographics, institutions and operative procedures were recorded.

RESULTS

24 UK Institutions were enrolled, including 7 Major Trauma Centres (MTCs). It was a 2 month audit from 1^stMarch 2018. 95 cases were recorded. The mean age was 71 and 65% were female. 66 patients had a fracture at presentation and 23 an impending fracture. Breast carcinoma was the primary tumour at 23%. The mean Mirel's score is 9. The commonest fixation was with a long cephalomedullary nail (38%). Endoprostheses accounted for 24%. None of the endoprostheses were implanted at MTCs.

CONCLUSION

This audit revealed large numbers of cases of femoral metastases. Although the use of endoprostheses may be increasing in Trauma Units, intramedullary nailing still predominates. Future pathways may benefit from directing resources to allow greater arthroplasty.

When and where do patients with bone metastases actually break their femurs?

AIMS

Accurate estimations of the risk of fracture due to metastatic bone disease in the femur is essential in order to avoid both under-treatment and over-treatment of patients with an impending pathological fracture. The purpose of the current retrospective in vivo study was to use CT-based finite element analyses (CTFEA) to identify a clear quantitative differentiating factor between patients who are at imminent risk of fracturing their femur and those who are not, and to identify the exact location of maximal weakness where the fracture is most likely to occur.

METHODS

Data were collected on 82 patients with femoral metastatic bone disease, 41 of whom did not undergo prophylactic fixation. A total of 15 had a pathological fracture within six months following the CT scan, and 26 were fracture-free during the five months following the scan. The Mirels score and strain fold ratio (SFR) based on CTFEA was computed for all patients. A SFR value of 1.48 was used as the threshold for a pathological fracture. The sensitivity, specificity, positive, and negative predicted values for Mirels score and SFR predictions were computed for nine patients who fractured and 24 who did not, as well as a comparison of areas under the receiver operating characteristic curves (AUC of the ROC curves).

RESULTS

The sensitivity of SFR was 100% compared with 88% for the Mirels score, and the specificity of SFR was 67% compared with 38% for the Mirels score. The AUC was 0.905 for SFR compared with 0.578 for the Mirels score (p = 0.008).

CONCLUSION

All the patients who sustained a pathological fracture of the femur had an SFR of > 1.48. CTFEA was far better at predicting the risk of fracture and its location accurately compared with the Mirels score. CTFEA is quick and automated and can be incorporated into the protocol of CT scanners. Cite this article: Bone Joint J 2020;102-B(5):638-645.

Impact of body fat distribution and sarcopenia on the overall survival in patients with spinal metastases receiving radiotherapy treatment: a prospective cohort study

Introduction: An increasing number of patients is diagnosed with spinal metastases due to elevated cancer incidence and improved overall survival. Patients with symptomatic spinal bone metastases often receive radiotherapy with or without surgical stabilisation. Patients with a life expectancy of less than 3 months are generally deemed unfit for surgery, therefore adequate pre-treatment assessment of life expectancy is necessary. The aim of this study was to assess new factors associated with overall survival for this category of patients.Patients and methods: Patients who received radiotherapy for thoracic or lumbar spinal metastases from June 2013 to December 2016 were included in this study. The pre-treatment planning CT for radiotherapy treatment was used to assess the patient's visceral fat area, subcutaneous fat area, total muscle area and skeletal muscle density on a single transverse slice at the L3 level. The total muscle area was used to assess sarcopenia. Furthermore, data were collected on age, sex, primary tumour, Karnofsky performance score, medical history, number of bone metastases, non-bone metastases and neurological symptoms. Univariable and multivariable cox regressions were performed to determine the association between our variables of interest and the survival at 90 and 365 days.Results: A total of 310 patients was included. The median age was 67 years. Overall survival rates for 90 and 365 days were 71% and 36% respectively. For 90- and 365-day survival, the Karnofsky performance score, muscle density and primary tumour were independently significantly associated. The visceral or subcutaneous fat area and their ratio and sarcopenia were not independently associated with overall survival.Conclusions: Of the body morphology, only muscle density was statistically significant associated with overall survival after 90 and 365 days in patients with spinal bone metastases. Body fat distribution was not significantly associated with overall survival.

Functional outcome of operative treatment for pelvic metastatic bone disease from primary thyroid cancer: A case series

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70 % of all malignant bone tumors are metastatic in origin.

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Functional outcome of MBD surgical management rarely described in literature.

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SF-36 and MSTS can be used to measure the functional outcome of MBD surgery.

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Surgery remains a good choice of therapy for MBD of pelvic.

Background

Metastatic bone disease (MBD) is the most common malignancy of bone. It is estimated that 70 % of all malignant bone tumors are due to metastasis. The functional outcome from pelvic MBD surgical management has been rarely described in the literature contrary to that of the long bones.

Method

We reported three patients that underwent pelvic resection surgery due to pelvic MBD. All of the primary tumors were thyroid cancer. We measure the functional outcome using SF-36 and MSTS (musculoskeletal tumor society) scores after a one-year follow-up.

Result

The SF-36 scoring result was that all of the patients had a remarkable improvement in terms of pain (77.5 %, 100 %, and 100 %). All of the patients also still had proper social functioning (75 %, 100 %, and 100 %) and good emotional well-being (72 %, 92 %, and 88 %). According to the MSTS, the second and third case had an excellent functional outcome; however the first case had poor functional outcome

Conclusion

Surgery remains the choice of therapy for pelvic MBD that results in alleviation of pain and quality of life improvement.

Use of endoprostheses for proximal femur metastases results in a rapid rehabilitation and low risk of implant failure. A prospective population-based study

Background and objectives

Endoprosthesis is considered a durable implant for treating metastatic bone disease of the proximal femur (MBDf).

Objectives

  • What is the revision risk after surgery for MBDf using endoprosthesis versus internal fixation?• When do patients with MBDf treated with endoprosthesis restore quality of life (QoL) and how long time does it take to rehabilitate functional outcome?

Methods

A prospective, population-based, multicentre study of 110 patients. Patients were followed for a minimum of two years after surgery. No patients were lost to implant failure nor survival follow-up.

Results

Forty-four patients were treated with internal fixation and 66 patients received endoprostheses. Two-year implant failure risk for internal fixation was 7% (95CI: 0-14%) versus 2% (95CI: 0-5%) for endoprostheses (p = 0.058).Eq-5D improved to the same level as one month prior to surgery six-weeks after surgery, and the score improved further six months after surgery (median score from 0.603 to 0.694, p = 0.007). MSTS score increased from 12 points after surgery to 23 points six-months after surgery (p<0.001).

Conclusions

Endoprosthesis for treatment of MBDf results in low implant failure rate. Patients are satisfied with the functional outcome. QoL is restored six-weeks after surgery. Authors advocate for caution using internal fixation for MBDf due to findings of a possible high early postoperative revision risk.

The Established Nuclear Medicine Modalities for Imaging of Bone Metastases

Background:

The skeleton is one of the frequent site of metastases in advanced cancer. Prostate, breast and renal cancers mostly metastasize to bone.

Discussion:

Malignant tumors lead to significant morbidity and mortality. Identification of bone lesions is a crucial step in diagnosis of disease at early stage, monitoring of disease progression and evaluation of therapy. Diagnosis of cancer metastases is based on uptake of bone-targeted radioactive tracer at different bone remodeling sites.

Conclusion:

This manuscript summarizes already established and evolving nuclear medicine modalities (e.g. bone scan, SPECT, SPECT/CT, PET, PET/CT) for imaging of bone metastases.

Prophylactic Versus Postfracture Stabilization for Metastatic Lesions of the Long Bones: A Comparison of 30-day Postoperative Outcomes

INTRODUCTION

The goals of orthopaedic treatment for most patients with osseous metastases are to control pain, maintain function, and maximize quality of life and time at home. The aim of this study was to determine differences in 30-day postoperative morbidity and mortality between patients who underwent prophylactic versus postfracture stabilization for metastatic lesions of long bones.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent prophylactic fixation (n = 461) or postfracture stabilization (n = 856) for pathologic fractures because of metastatic lesions of long bones from 2006 to 2016. The groups were compared with respect to several potential confounders using Student t, Kruskal-Wallis, and χ tests. Logistic and Poisson regression models (inclusion threshold of P < 0.1) were used to assess the associations of functional status with outcomes. The alpha level was set at 0.05.

RESULTS

Prophylactic fixation was associated with a lower risk of major medical complications (odds ratio = 0.64; 95% confidence interval [CI], 0.45 to 0.93; P = 0.02), discharge to a care facility rather than home (odds ratio = 0.48; 95% CI, 0.36 to 0.63; P < 0.01), and lower risk of a longer hospital stay (incidence risk ratio = 0.86; 95% CI, 0.74 to 0.96; P = 0.01) compared with postfracture stabilization. No significant difference was found in the risk of unplanned revision surgery or 30-day postoperative mortality between the two groups.

CONCLUSION

Although prevention of pathologic fractures caused by metastatic disease may not always be possible, patients who underwent prophylactic stabilization had a lower risk of major complications within 30 days postoperatively and shorter hospital stays compared with patients who underwent postfracture stabilization.

LEVEL OF EVIDENCE

Level IV, retrospective cohort.

Percutaneous restoration of bone continuity with screws and PMMA cement in an extensive destruction of the pelvis

We report a case of combined percutaneous screw placement and cementoplasty guided by CT and fluoroscopy in a 66-year-old man with extensive osteolytic destruction of the right iliac bone and sacral wing due to metastasic infiltrative vesical carcinoma. The medical condition was responsible for very limited and painful walking. Two perpendicular screws were inserted into the iliac bone and sacroiliac joint, and bone cement injection was used to anchor the screws and restore the mechanical continuity of the pelvis ring. This minimally invasive procedure allowed for significant and rapid resumption of painless walking.

Revision rate of reconstructions in surgically treated diaphyseal metastases of bone

INTRODUCTION

Skeletal metastases can weaken the bone, necessitating surgery, and surgical treatment options vary. The aim of this study was to investigate the revision rate of reconstructions in surgically treated diaphyseal skeletal metastases.

MATERIALS AND METHODS

Between 2000 and 2018 at Helsinki and Tampere university hospitals in Finland, a total of 164 cases with diaphyseal skeletal metastases were identified from a prospectively maintained database. Tumor location was humerus, femur, and tibia in 106 (65%), 53 (32%), and 5 (3.0%) cases, respectively. A total of 82 (50%) cases were treated with intramedullary nailing (IMN), 73 (45%) with IMN and cementation, and 9 (5%) with another technique.

RESULTS

In the upper extremity, implant survival (IS) was 96.4% at 1, 2, and 5 years; in the lower extremity, it was 83.8%, 69.1%, and 57.6% at 1, 2, and 5 years, respectively. Lower extremity IS for impending lesions was 100% at 1, 2, and 5 years, and in cases operated for true pathologic fracture, it was 71.6%, 42.9%, and 21.5% at 1, 2, and 5 years, respectively. In IMN cases without cement, the complication rate was 16% (13/82) when compared to 6% (4/73) in IMN cases with cementation.

DISCUSSION

We would advocate for early intervention in patients with metastatic bone disease affecting the femur rather that watchful waiting with the risk for fracture and the need for urgent intervention. However, this choice must be balanced against the underlying risk of surgical intervention in a potentially fragile population with often limited prognoses.

Treatment of Pathological Humerus-Shaft Tumoral Fractures with Rigid Static Interlocking Intramedullary Nail-22 Years of Experience

Objective  This was a retrospective observational study in patients submitted to intramedullary nail fixation after established or impeding pathological humerus-shaft tumoral fracture in the context of disseminated tumoral disease along 22 years of experience at the same institution. Methods  Sample with 82 patients and 86 humeral fixations with unreamed rigid interlocking static intramedullary nail by the antegrade or retrograde approaches. Results  The most prevalent primary tumors were breast carcinoma (30.49%), multiple myeloma (24.39%), lung adenocarcinoma (8.54%), and renal cell carcinoma (6.10%). The average surgical time was 90.16 ± 42.98 minutes (40-135 minutes). All of the patients reported improvement in arm pain and the mean Musculoskeletal Tumor Society (MSTS) score rose from 26% in the preoperative period to 72.6% in the evaluation performed in patients still alive 3 months after the surgery. The overall survival was 69.50% 3 months after the surgery, 56.10% at 6 months, 26.70% at 1 year, and 11.90% at 2 years. No death was related to the surgery or its complications. There were only 4 surgery-related complications, 1 intraoperative and 3 late, corresponding to a 4.65% complication risk. Conclusion  Closed unreamed static interlocking intramedullary nailing (both in the antegrade or retrograde approaches) of the humerus is a fast, safe, effective, and low morbidity procedure to treat pathological fractures of the humerus shaft, assuring a stable arm fixation and consequently improving function and quality of life in these patients during their short life expectation.

Prediction of survival after surgical management of femoral metastatic bone disease - A comparison of prognostic models

Background

Operative fixation for femoral metastatic bone disease is based on the principles of reducing pain and restoring function. Recent literature has proposed a number of prognostic models for appendicular metastatic bone disease. The aim of this study was to compare the accuracy of proposed soring systems in the setting of femoral metastatic bone disease in order to provide surgeons with information to determine the most appropriate scoring system in this setting.

Methods

A retrospective cohort analysis of patients who underwent surgical management of femoral metastatic bone disease at a single institution were included. A pre-operative predicted survival for all 114 patients was retrospectively calculated utilising the revised Katagiri model, PathFx model, SSG score, Janssen nomogram, OPTModel and SPRING 13 nomogram. Univariate and multivariate Cox regression proportional hazard models were constructed to assess the role of prognostic variables in the patient group. Area under the receiver characteristics and Brier scores were calculated for each prognostic model from comparison of predicted survival and actual survival of patients to quantify the accuracy of each model.

Results

For the femoral metastatic bone disease patients treated with surgical fixation, multivariate analysis demonstrated a number of pre-operative factors associated with survival in femoral metastatic bone disease, consistent with established literature. The OPTIModel demonstrated the highest accuracy at predicting 12-month (Area Under the Curve [AUC] = 0.79) and 24-month (AUC = 0.77) survival after surgical management. PathFx model was the most accurate at predicting 3-month survival (AUC = 0.70) and 6-month (AUC = 0.70) survival. The PathFx model was successfully externally validated in the femoral patient dataset for all time periods.

Conclusions

Among six prognostic models assessed in the setting of femoral metastatic bone disease, the present study observed the most accurate model for 3-month, 6-month, 12-month and 24-month survival. The results of this study may be utilised by the treating surgical team to determine the most accurate model for the required time period and therefore improve decision-making in the care of patients with femoral metastatic bone disease.

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.

What Is the Adverse Event Profile After Prophylactic Treatment of Femoral Shaft or Distal Femur Metastases?

BACKGROUND

Prophylactic surgical treatment of the femur is commonly offered to patients with metastatic disease who have a high risk of impending pathologic fracture. Prophylactic fixation is associated with improved functional outcomes in appropriate patients selected based on established criteria, but the perioperative complication profile has received little attention. Given the substantial comorbidity in this population, it is important to characterize surgical risks for surgeons and patients to improve treatment decisions.

QUESTIONS/PURPOSES

(1) What is the incidence of postoperative adverse events after prophylactic surgical stabilization of metastatic lesions of the femoral shaft or distal femur? (2) How does this complication profile compare with stabilization of pathologic fractures adjusted for differences in patient demographics and comorbidity?

METHODS

We performed a retrospective study using the National Surgical Quality Improvement Program (NSQIP) database. We identified patients undergoing prophylactic treatment of the femoral shaft or distal femur by Current Procedural Terminology (CPT) codes. Patients undergoing treatment of a pathologic fracture were identified by CPT code for femur fracture fixation as well as an International Classification of Diseases code indicating neoplasm or pathologic fracture. We tracked adverse events, operative time, blood transfusion, hospital length of stay, and discharge to a facility within 30 days postoperatively. There were 332 patients included in the prophylactic treatment group and 288 patients in the pathologic fracture group. Patients in the prophylactic treatment group presented with greater body mass index (BMI), whereas the pathologic fracture group presented with a greater incidence of disseminated cancer. The odds of experiencing adverse events were initially compared between the two groups using bivariate logistic regression and then using multivariate regression controlling for age, sex, BMI, and American Society of Anesthesiologists (ASA) class and disseminated cancer causing marked physiological compromise per NSQIP guidelines.

RESULTS

With multivariate analysis controlling for age, sex, BMI, and ASA class, patients with pathologic fracture were more likely to experience any adverse event (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.03-2.29; p = 0.036), major adverse events (OR, 1.61; 95% CI, 1.01-2.55; p = 0.043), death (OR, 1.90; 95% CI, 1.07-3.38; p = 0.030), blood transfusion (OR, 1.57; 95% CI, 1.08-2.27; p = 0.017), and hospital stay ≥ 9 days (OR, 1.51; 95% CI, 1.05-2.19; p = 0.028) compared with patients undergoing prophylactic treatment. However, when additionally controlling for disseminated cancer, the only difference was that patients with pathologic fractures were more likely to receive a blood transfusion than were patients undergoing prophylactic fixation (OR, 1.61; 95% CI, 1.12-2.36; p = 0.011).

CONCLUSIONS

After controlling for differences in patient characteristics, prophylactic treatment of femoral metastases was associated with a decreased likelihood of blood transfusion and no differences in terms of the frequency of other adverse events. In the context of prior studies supporting the mechanical and functional outcomes of prophylactic treatment, the findings of this cohort suggest that the current guidelines have achieved a reasonable balance of morbidity in patients with femoral lesions and further support the current role of prophylactic treatment of impending femur fractures in appropriately selected patients.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Surgical management of metastatic lesions of proximal femur and the hip

Metastatic bony lesions involving proximal femur and hip joint pose a challenge to orthopedic surgeons. Lesions in this important weight-bearing zone of the femur weaken its ability to sustain load causing pain and impending pathologic fracture. These Patients warrant multidisciplinary approach including orthopedic surgeons, oncologist and medical specialties. Management of these lesions has evolved over the last 60 years from benign neglect to internal fixation and recently to prosthetic reconstruction for optimum function. Decision for surgical approach requires consideration for location of the lesion, presence of a fracture, tumor type, cortical destruction, patient's life expectancy, patient preferences and the expected outcome. We aim to present a narrative review of the options and results of surgical management of these lesions in the light of literature.

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Surgical management of hip metastasis.

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Metastatic lesions of the proximal femur.

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Endoprosthetic reconstruction of hip metastasis.

External Beam Irradiation Preferentially Inhibits the Endochondral Pathway of Fracture Healing: A Rat Model

BACKGROUND

External beam irradiation is an accepted treatment for skeletal malignancies. Radiation acts on both cancerous and normal cells and, depending on the balance of these effects, may promote or impair bone healing after pathologic fracture. Previous studies suggest an adverse effect of radiation on endochondral ossification, but the existence of differential effects of radiation on the two distinct bone healing pathways is unknown.

QUESTIONS/PURPOSES

The purpose of this study was to investigate the differential effects of external beam irradiation on endochondral compared with intramembranous ossification with intramedullary nail and plate fixation of fractures inducing the two respective osseous healing pathways through assessment of (1) bone biology by histomorphometric analysis of cartilage area and micro-CT volumetric assessment of the calcified callus; and (2) mechanical properties of the healing fracture by four-point bending failure analysis of bending stiffness and strength.

METHODS

Thirty-six male Sprague-Dawley rats underwent bilateral iatrogenic femur fracture: one side was repaired with an intramedullary nail and the other with compression plating. Three days postoperatively, half (n = 18) received 8-Gray external beam irradiation to each fracture. Rodents were euthanized at 1, 2, and 4 weeks postoperatively (n = 3/group) for quantitative histomorphometry of cartilage area and micro-CT assessment of callus volume. The remaining rodents were euthanized at 3 months (n = 9/group) and subjected to four-point bending tests to assess stiffness and maximum strength.

RESULTS

Nailed femurs that were irradiated exhibited a reduction in cartilage area at both 2 weeks (1.08 ± 1.13 mm versus 37.32 ± 19.88 mm; 95% confidence interval [CI] of the difference, 4.32-68.16 mm; p = 0.034) and 4 weeks (4.60 ± 3.97 mm versus 39.10 ± 16.28 mm; 95% CI of the difference, 7.64-61.36 mm; p = 0.023) compared with nonirradiated fractures. There was also a decrease in the volume ratio of calcified callus at 4 weeks (0.35 ± 0.08 versus 0.51 ± 0.05; 95% CI of the difference, 0.01-0.31; p = 0.042) compared with nonirradiated fractures. By contrast, there was no difference in cartilage area or calcified callus between irradiated and nonirradiated plated femurs. The stiffness (128.84 ± 76.60 N/mm versus 26.99 ± 26.07 N/mm; 95% CI of the difference, 44.67-159.03 N/mm; p = 0.012) and maximum strength (41.44 ± 22.06 N versus 23.75 ± 11.00 N; 95% CI of the difference, 0.27-35.11 N; p = 0.047) of irradiated plated femurs was greater than the irradiated nailed femurs. However, for nonirradiated femurs, the maximum strength of nailed fractures (36.05 ± 17.34 N versus 15.63 ± 5.19 N; 95% CI of the difference, 3.96-36.88 N; p = 0.022) was greater than plated fractures, and there was no difference in stiffness between the nailed and plated fractures.

CONCLUSIONS

In this model, external beam irradiation was found to preferentially inhibit endochondral over intramembranous ossification with the greatest impairment in healing of radiated fractures repaired with intramedullary nails compared with those fixed with plates. Future work with larger sample sizes might focus on further elucidating the observed differences in mechanical properties.

CLINICAL RELEVANCE

This work suggests that there may be a rationale for compression plating rather than intramedullary nailing of long bone fractures in select circumstances where bony union is desirable, adjunctive radiation treatment is required, and bone stock is sufficient for plate and screw fixation.

Treatment Modalities for Pathologic Fractures of the Proximal Femur Pertrochanteric Region: A Systematic Review and Meta-Analysis of Reoperation Rates

BACKGROUND

The proximal femur represents the most common site of metastatic bone disease in the appendicular skeleton, and associated pathologic pertrochanteric femur fractures contribute to cancer-related morbidity and mortality. Controversy exists as to whether these injuries are best managed with intramedullary nailing (IMN) or with arthroplasty.

METHODS

A systematic review of the literature was performed using a PubMed search following PRISMA guidelines to identify studies performed within the last 20 years regarding treatment of proximal femur metastatic lesions with either nailing or arthroplasty with a reported reoperation rate. Sixteen studies were selected for inclusion containing 1414 patients. Pooled estimates and 95% confidence intervals (CIs) for reoperation rates associated with IMN and endoprosthetic reconstruction (EPR) were separately calculated.

RESULTS

The pooled estimate for reoperation for IMN was a median of 9% (95% CI, 5%-14%) and the pooled estimate for reoperation for EPR was a median of 7% (95% CI, 5%-11%). Significant heterogeneity was present in studies reporting on both treatment modalities: for IMN, I² = 55%, and for EPR, I² = 51%.

CONCLUSION

This systematic literature review identified 16 eligible, nonrandomized, retrospective studies that reported on the results of surgical treatment for proximal femur metastatic disease. The pooled estimate of reoperation was similar between patients treated with IMN and EPR. Inconsistencies among follow-up and the study designs used limited evidence-based conclusions. As the oncologic care of patients with metastatic disease continues to evolve and improve, patient-specific needs must be carefully considered when selecting an optimal treatment strategy.

LEVEL OF EVIDENCE

Level III.

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

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

Is Total Femur Replacement a Reliable Treatment Option for Patients With Metastatic Carcinoma of the Femur?

BACKGROUND

The majority of metastatic bone lesions to the femoral bone can be treated without surgery or with minimally invasive intramedullary nailing. In rare patients with extensive metastatic disease to the femur, total femur replacement may be the only surgical alternative to amputation; however, little is known about this approach.

QUESTIONS/PURPOSES

In a highly selected small group of patients with metastatic carcinoma of the femur, we asked: (1) What was the patient survivorship after this treatment? (2) What was the implant survivorship free from all-cause revision and amputation, and what complications were associated with this treatment? (3) What functional outcomes were achieved by patients after total femur replacement for this indication?

METHODS

Eleven patients (three men, eight women) with a mean age of 64 years (range, 41-78 years) received total femur replacements between 1986 and 2016; none were lost to followup. The most common primary disease was breast cancer. In general, during this period, our indications for this procedure were extensive metastatic disease precluding internal fixation or isolated proximal or distal femur replacement, and an anticipated lifespan exceeding 6 months. Our contraindication for this procedure during this time was expected lifespan less than 6 months. Patient survival was assessed by Kaplan-Meier analysis; implant survival free from revision surgery and amputation were assessed by competing risk analysis. Function was determined preoperatively and 6 to 12 weeks postoperatively with the Musculoskeletal Tumor Society (MSTS) score normalized to a 100-point scale, with higher scores representing better function from a longitudinally maintained institutional database.

RESULTS

Eleven patients died at a median of 5 months (range, 1-31 months) after surgery. One-year revision-free and limb survival were 82% (95% CI, 51%-98%) and 91% (95% CI, 61%-99%), respectively. Reasons for reoperation were hip dislocation, infection and local recurrence in one patient each. The latter two complications resulted in amputation in two patients. The median MSTS score was 32 (range, 13-57).

CONCLUSIONS

Despite attempts to select patients who might have anticipated greater life expectancy, eight of 11 patients died by 6 months after surgery, and an additional two patients had undergone an amputation at 8 and at 17 months postoperatively. Most patients undergoing total femur replacement in this series did not recover from the procedure by the time they died, despite our best attempts to perform the procedure in patients whom we thought would live at least 6 months. Based on this, we believe that most patients with extensive metastatic disease to the femur should be offered palliative care, rather than major reconstruction.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Surgical treatment in bone metastases in the appendicular skeleton

INTRODUCTION

Metastatic bone disease is the most common neoplastic process that affects the skeletal system. Eighty percent of bone metastases come from carcinomas of the breast, lung, kidney, thyroid and prostate. The Katagiri scale enables an estimation of the survival of patients based on the presence or absence of visceral metastases, multiple bone metastases and functional status according to the ECOG scale.

MATERIAL AND METHODS

A retrospective, descriptive and observational study conducted between March 1, 2013 and June 30, 2015. Thirty-two patients were studied with a diagnosis of metastatic bone disease and who had undergone some type of orthopaedic surgical treatment for pathological fracture or impending fracture.

RESULTS

28 cases (87.5%) presented pathological fracture and 4 cases (12.5%) impending fracture according to the Mirels score. Fifteen cases (46.875%) were treated by placing a central medullary nail + spacer in the long bone diaphysis, 15 cases (46.875%) with modular arthroplasties and 2 patients (6.25%) with forequarter amputation. Eleven patients (34.375%) died during the course of this study, all with a Katagiri greater than or equal to 4.

DISCUSSION

The presence of a fracture in previously damaged territory is a catastrophic complication for most cancer patients. A clear understanding of the life expectancy of patients with bone metastases is of great help to prevent errors and failures in treatment.

An Easy-to-Use Prognostic Model for Survival Estimation for Patients with Symptomatic Long Bone Metastases

BACKGROUND

A survival estimation for patients with symptomatic long bone metastases (LBM) is crucial to prevent overtreatment and undertreatment. This study analyzed prognostic factors for overall survival and developed a simple, easy-to-use prognostic model.

METHODS

A multicenter retrospective study of 1,520 patients treated for symptomatic LBM between 2000 and 2013 at the radiation therapy and/or orthopaedic departments was performed. Primary tumors were categorized into 3 clinical profiles (favorable, moderate, or unfavorable) according to an existing classification system. Associations between prognostic variables and overall survival were investigated using the Kaplan-Meier method and multivariate Cox regression models. The discriminatory ability of the developed model was assessed with the Harrell C-statistic. The observed and expected survival for each survival category were compared on the basis of an external cohort.

RESULTS

Median overall survival was 7.4 months (95% confidence interval [CI], 6.7 to 8.1 months). On the basis of the independent prognostic factors, namely the clinical profile, Karnofsky Performance Score, and presence of visceral and/or brain metastases, 12 prognostic categories were created. The Harrell C-statistic was 0.70. A flowchart was developed to easily stratify patients. Using cutoff points for clinical decision-making, the 12 categories were narrowed down to 4 categories with clinical consequences. Median survival was 21.9 months (95% CI, 18.7 to 25.1 months), 10.5 months (95% CI, 7.9 to 13.1 months), 4.6 months (95% CI, 3.9 to 5.3 months), and 2.2 months (95% CI, 1.8 to 2.6 months) for the 4 categories.

CONCLUSIONS

This study presents a model to easily stratify patients with symptomatic LBM according to their expected survival. The simplicity and clarity of the model facilitate and encourage its use in the routine care of patients with LBM, to provide the most appropriate treatment for each individual patient.

LEVEL OF EVIDENCE

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

Management of metastatic humeral fractures: Variations according to orthopedic subspecialty, tumor characteristics

HYPOTHESIS

This study assessed, if there was a difference in surgical decision making for metastatic humeral lesions based on; orthopaedic subspecialty, tumor characteristics.

STUDY TYPE

Cross sectional survey study.

MATERIALS AND METHODS

Twenty-four case scenarios were created by combining: tumor type, life expectancy, fracture type, and anatomical location. Participants were asked for every case: what treatment would you recommend? Participants were 78 (48%) orthopaedic oncologists and 83 (52%) orthopaedic surgeons that were not regularly involved in the treatment of bone tumors.

RESULTS

There was a difference between orthopaedic oncologists and other subspecialty surgeons in recommendation for specific treatments: intramedullary nailing was less often recommended by orthopaedic oncologists (53%, 95%CI: 47-59) compared to other surgeons (62%, 95%CI: 57-67) (p=0.023); while endoprosthetic reconstruction (orthopaedic oncologists: 8.8% [95%CI: 6.6-11], other surgeons: 3.6%[95%CI: 2.3-4.8], p<0.001) and plate-screw fixation (orthopaedic oncologists: 19%[95%CI: 14-25], other surgeons: 9.5%[95%CI: 5.9-13], p=0.003) were more often recommended by orthopaedic oncologists. There was no difference in recommendation for nonoperative management. There were differences in recommendation for specific treatments based on tumor type, life expectancy, and anatomical location, but not fracture type.

DISCUSSION

Subspecialty training and patient and tumor characteristics influence the decision for operative management and the decision for a specific implant in metastatic humeral fractures.

LEVEL OF EVIDENCE

Level 3.

Skeletal metastasis in renal cell carcinoma: A review

Background

Renal cell carcinoma account for 3% of all cancers, with peak incidence between 60 and 70 years of age predominantly affecting male population. Renal carcinoma is the most common malignancy of kidney constitutes for 80–90% of renal neoplasm with an overall 45% five years survival rate. Majority are diagnosed incidentally during investigation for other disease process of abdomen. Classical triad of gross hematuria, pain and palpable mass in abdomen is rare accounting to only 6–10%. Treatment of early stages of disease i.e. localized disease is partial or radical nephrectomy. Most common metastasis in RCC occurs to lung, followed by bone involvement in 20–35%, lymph nodes, liver, adrenal gland and brain. In metastatic disease median survival rate of patient is about eight months with 50% mortality rate within first year of life, five years survival rate is 10%. Skeletal metastasis are very destructive in patients with renal cell carcinoma compromising bone integrity leading to skeletal related events including pains, impending fractures, nerve compressions, hypercalcemia and even pathological fractures which may require surgical interventions and other therapy. In addition to skeletal complications, presence of bone metastases in RCC has negative impact on progression free survival and overall survival of patients treated with systemic therapies.

Objective

In this review we discuss pathophysiology of tumor metastasis, diagnosis, management and Case examples of metastatic renal cell carcinoma.

Conclusion

Incidence of metastatic renal carcinoma is increasing. Overall prognosis of patient with advanced RCC is poor, emphasizing the importance of early detection and prompt treatment of primary lesion in its early stage. Advancement in targeted therapy in recent decades had made some improvement in treatment of SREs and has helped in improving patent's quality of life but still we are in need of further improvement in treatment modalities to cure disease thereby decreasing morbidity and mortality.

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Renal cell carcinoma account for 3% of all cancers.

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It is a very destructive that may compromise bone integrity.

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Most common metastasis in renal cell carcinoma occurs to lung, followed by bone , lymph nodes, liver, adrenal gland and brain.

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Most common metastasis in renal cell carcinoma occurs to lung, followed by bone involvement in 20–35%, lymph nodes, liver, adrenal gland and brain.

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In metastatic disease median survival rate of patient is about eight months with 50% mortality rate within first year of life, five years survival rate is 10.

Efficacy of 8 Gy Single Fraction Palliative Radiation Therapy in Painful Bone Metastases: A Single Institution Experience

Introduction Bone metastasis (BM) is a major complication of many solid tumors like breast, prostate, lung and renal cancers. BM leads to serious sequelae of pain, fractures, spinal cord compression and hypercalcemia. Radiotherapy has an established role in relieving pain caused by BM. Worldwide different radiotherapy schedules are being used for BM. The aim of this study is to determine the efficacy of single fraction palliative radiotherapy for painful bone metastases. Methods Between April 2014 and April 2017, single fraction radiotherapy was used to treat 73 patients in our institution. They had pathologically proven breast, prostate, lung or renal cancer with radiological evidence of bone metastases. There were 39 males (53%) and 34 females (47%). The median age was 58 years (range 33-87 years). 39% patients (n = 28) had breast cancer, 35% had prostate cancer (n = 26), 23% had lung cancer (n = 17), and 3% had renal cancer (n = 2). On presentation, all the patients had a pain score of more than five on Brief Pain Inventory (BPI). Results Response assessment to pain after three months from single fraction radiotherapy was found to be complete response (CR) in 23% patients (n = 17), partial response (PR) in 38% patients (n = 28), stable disease (SD) in 26% patients (n = 19) and progressive disease (PD) in 12% patients (n = 9). The overall efficacy of treatment was 62%, with CR 23% and PR 38%. Pre-treatment mean pain score was 8.15 compared to 4.68 post-treatment (p < 0.001). Conclusions Single fraction palliative radiotherapy of 8 Gy showed significant efficacy in painful bone metastases in our setting and merits further investigation in our population.

Distal Medullary Canal Decompression in Long Stem Hip Replacement in Long Bone Metastasis: Does it Reduce Cardiopulmonary Complications?

BACKGROUND

The femur is the most common long bone affected by metastatic bone disease, with 25% involving the proximal third of the femur. Long stem cemented hip replacement (LHR) is an important option for cases of impending fracture. Pulmonary embolism is a critical complication that can occur. This study evaluates the effectiveness of distal femoral canal decompression in reducing the risk of cardiopulmonary events.

MATERIALS AND METHODS

Thirty two patients with metastatic bone disease of the proximal femur undergoing LHR were recruited and randomized. Conventional technique was used in 16 cases and distal decompression of the medullary canal was carried out for the other 16 patients. The decompression was carried out through a trocar inserted into the distal medullary canal, connected to a vacuum suction. Quantity of emboli was detected through A4 chambers transesophageal echocardiography; the blood pressure and oxygen saturation readings were also recorded.

RESULTS

The decompression group experienced significantly lower Grade 2 and Grade 3 embolic events compared to the conventional group (11 vs. 26), and the duration of the embolic phenomena was shorter. Insertion of the stem and relocating the hip gave the highest amount embolic events. There was a significant drop in systolic blood pressure (SBP) in 12 out of 16 patients (75.0%) in the conventional group and 5 out of 16 patients in the decompression group (31.3%). This is statically significant (P = 0.0124). The average drop in SBP for the conventional group is 45.8 mmHg and the decompression group was 32.9 mmHg. Oxygen saturation remained at above 96% in the decompression group. However, in the conventional group, 25% of the patients had their oxygen saturation drop to below 96% during the insertion of stem and relocation of hip joint.

CONCLUSION

Distal femoral canal decompression is an effective method in reducing the risk of cardiopulmonary embolic events associated with LHR.

The role of postoperative radiation and coordination of care in patients with metastatic bone disease of the appendicular skeleton

Metastatic bone disease affects approximately 300,000 people in the United States, and the burden is rising. These patients experience significant morbidity and decreased survival. The management of these patients requires coordinated care among a multidisciplinary team of physicians, including orthopaedic surgeons. This article reviews the role of radiation therapy after orthopaedic stabilization of impending or realized pathologic extremity fractures. Orthopaedic surgeons have an opportunity to benefit patients with metastatic bone disease by referring them for consideration of post-operative radiation therapy. Further research into rates of referral and the effect on clinical outcomes in this population is needed.