Endoprosthetic proximal femur replacement: Metastatic versus primary tumors

148

161

Background The proximal femur is the most common site of surgery for bone metastases, and stabilization may be achieved through intramedullary fixation (IMN) or endoprosthetic reconstruction (EPR). Intramedullary devices are less expensive, less invasive, and may yield improved function over endoprostheses. However, it is unclear which, if either, has any advantages. Questions/purposes We determined whether function, complications, and survivorship differed between the two approaches. Methods We retrospectively reviewed 158 patients with 159 proximal femur metastatic lesions treated with surgical stabilization. Forty-six were stabilized with IMN and 113 were treated with EPR. The minimum followup was 0.25 months (mean, 16 months; median, 17 months; range, 0.25-86 months). Results The mean Musculoskeletal Tumor Society score was 24 of 30 (80%) after IMN and 21 of 30 (70%) after EPR. There were 12 complications (26%) in the IMN group, including 10 nonunions, six of which went on to mechanical failure. There were complications in 20 of 113 (18%) of the EPR group, which consisted of 10 dislocations (9%) and 10 infections (9%). There were no mechanical failures with EPR. Both implants remained functional for the limited lifespan of these patients in each group at all time intervals. EPRs were associated with increased implant longevity compared with IMNs (100% versus 85% 5-year survival, respectively) and a decreased rate of mechanical failure (0% versus 11%, respectively) when compared with the intramedullary devices. Conclusions Patients with metastatic disease to the proximal femur may live for long periods of time, and these patients may undergo stabilization with either IMN or EPR with comparable functional scores and the implant survivorship exceeding patient survivorship at all time intervals. Endoprostheses demonstrate a lower mechanical failure rate and a higher rate of implant survivorship without mechanical failure than IMN devices.

Section: Discussionsupporting

confidence: 89%

Section: Discussionsupporting

confidence: 80%

See 1 more Smart Citation

Endoprostheses Last Longer Than Intramedullary Devices in Proximal Femur Metastases

Harvey

Ahlmann

Allison

et al. 2012

148

161

“…Postoperatively, the median total MSTS score (measured at most recent followup) for the entire group of patients was 21 (range, , the median ECOG score was 2 (range, 0-3, 68% B 2), and the median KPS score was 60 (range, 40-100). For the 11 patients with at least 1 year of followup, the median total MSTS score (measured at most recent followup) was 27 (range, [21][22][23][24][25][26][27][28][29][30], the median ECOG score was 1 (range, 0-2, 100% B 2), and the median KPS score was 80 (range, 60-100). For the remaining 11 patients with less than 1 year of followup, the median total MSTS score (measured at most recent followup) was 11 (range, 5-25), the median ECOG score was 3 (range, 1-3, 36% B 2), and the median KPS score was 40 (range, 40-80).…”

mentioning

confidence: 99%

What Are the Functional Results and Complications With Long Stem Hemiarthroplasty in Patients With Metastases to the Proximal Femur?

Peterson

Decilveo

O'Connor

et al. 2017

Background Traditional treatments for pathological fractures of the proximal femur resulting from metastatic bone disease include fixation with intramedullary nailing supplemented with polymethylmethacrylate, osteosynthesis with a plate-screw construct and polymethylmethacrylate, or endoprosthetic reconstruction. Despite the frequent practice of these treatments, treatment outcomes have not been rigorously compared. In addition, very few studies examine specific approaches to endoprosthetic reconstruction such as long stem hemiarthroplasty.Questions/purposes This study examines survival, functional outcomes, and complications associated with long stem hemiarthroplasty in a small group of patients treated for impending and actual pathologic fractures of the proximal femur resulting from metastatic bone disease. Methods Between 2012 and 2015, 21 patients were treated with long stem cemented hemiarthroplasty in 22 limbs. During that time, indications for this approach included lesions from metastases, myeloma, or lymphoma involving the proximal femur that resulted in an impending or actual pathological fracture. An impending fracture was classified as a painful lesion with at least 50% cortical erosion. During the study period, six patients with proximal femoral metastases not deemed to meet these indications were treated with other surgical approaches such as intramedullary nailing supplemented with polymethylmethacrylate and osteosynthesis with a plate-screw construct and polymethylmethacrylate. Mortality was tracked through medical records and phone calls to the patients and their families. Followup for the entire group of patients (n = 22) ranged from 1 to 27 months with a mean duration of 11 months. For patients with at least 1 year of followup (n = 11), the mean duration was 18 months (range, 12-27 months) and for patients with less than 1 year of followup (n = 11), the mean duration was 3 months (range, 1-11 months). Functional outcomes were evaluated according to the Musculoskeletal Tumor Society (MSTS) scoring system for lower extremities, the Eastern Cooperative Oncology Group (ECOG) Scale of Performance Status, and the Karnofsky Performance Scale (KPS) Index. Scores and complications were determined by direct patient examination, retrospective chart review, review of a longitudinally maintained institutional database, and followup phone calls. Results Ten patients died of disease within the followup period. Before surgery, the median total MSTS score for the entire group of patients (n = 22) was 4.5 (range, 0-23), Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research1 editors and board members are on file with the publication and can be viewed on request. Clinical O...

“…We reviewed the peer-reviewed literature from 1980 through 2011 and found 14 articles describing outcomes for IMN, PFRR, LSCH/CH, and ORIF in patients treated for femoral metastases. Notably, few studies examined proximal femur fractures specifically, and 14 of 15 studies were retrospective, citing either a retrospective cohort (Level of Evidence IV) or retrospective comparison design (Level of Evidence III) (Table 5) [2,4,5,[7][8][9][10][11][12][13][14][15][18][19][20]. A single, prospective study (Level I) was found that showed functional improvement in patients undergoing surgery for nonspinal bone metastases [17], but outcomes specific to the proximal femur were not reported.…”

Section: Discussionmentioning

confidence: 99%

Trends in the Surgical Treatment of Pathologic Proximal Femur Fractures Among Musculoskeletal Tumor Society Members

Steensma

Healey

2013

Background Several strategies for the treatment of pathologic proximal femur fractures are practiced but treatment outcomes have not been rigorously compared. Questions/purposes Major variations in the use of intramedullary fixation, extramedullary/plate-screw fixation, and endoprosthetic reconstruction techniques for pathologic proximal femur fractures in patients with skeletal metastases are reported. The clinical and surgical variables that influence this choice differ among treating surgeons. To characterize the technique preferences and to identify areas of consensus regarding specific clinical presentations, we administered an online survey to the Musculoskeletal Tumor Society (MSTS) membership. We also tested whether responses correlated with the respondents' years in practice and asked about the indications for wide tumor resection and the role of tumor debulking and adjuvant cementation. Methods A 10-minute, web-based survey was sent via email to 244 MSTS members. The survey queried participants' musculoskeletal oncology training and experience and presented case scenarios illustrating different combinations of four variables that influence decision-making: cancer type, estimated patient survival, fracture displacement, and anatomic region of involvement. Results Forty-one percent (n = 98) of MSTS members completed the survey. Intramedullary nail fixation (IMN; 45%) and proximal femur resection and reconstruction (34%) were the most commonly recommended techniques followed by long-stem cemented hemiarthroplasty/cemented hemiarthroplasty (15%) and open reduction and internal fixation (7%). Most respondents (56%) recommended use of cementation with IMN. Differences of opinion on recommended treatment were associated with variations in cancer type, fracture displacement, and anatomic region of involvement. Conclusions Our online survey showed a trend among MSTS members for selecting IMN and arthroplasty-related techniques to treat pathologic fractures of the proximal femur, but major differences in preferred operative technique exist. Prospective studies are needed to develop consistent, evidence-based treatment recommendations.