The Use of Massive Endoprostheses for the Treatment of Bone Metastases

Abstract

Purpose. We report a series of 58 patients with metastatic bone disease treated with resection and endoprosthetic reconstruction over a five-year period at our institution. Introduction. The recent advances in adjuvant and neoadjuvant therapy in cancer treatment have resulted in improved prognosis of patients with bone metastases. Most patients who have either an actual or impending pathological fracture should have operative stabilisation or reconstruction. Endoprosthetic reconstructions are indicated in patients with extensive bone loss, failed conventional reconstructions, and selected isolated metastases. Methods and Results. We identified all patients who were diagnosed with metastatic disease to bone between 1999 and 2003. One hundred and seventy-one patients were diagnosed with bone metastases. Metastatic breast and renal cancer accounted for 84 lesions (49%). Fifty-eight patients with isolated bone metastasis to the appendicular skeleton had an endoprosthetic reconstruction. There were 28 males and 30 females. Twelve patients had an endoprosthesis in the upper extremity and 46 patients had an endoprosthesis in the lower extremity. The mean age at presentation was 62 years (24 to 88). At the time of writing, 19 patients are still alive, 34 patients have died, and 5 have been lost to follow up. Patients were followed up and evaluated using the musculoskeletal society tumour score (MSTS) and the Toronto extremity salvage score (TESS). The mean MSTS was 73% (57% to 90%) and TESS was 71% (46% to 95%). Mean follow-up was 48.2 months (range 27 to 82 months) and patients died of disease at a mean of 22 months (2 to 51 months) from surgery. Complications included 5 superficial wound infections, 1 aseptic loosening, 4 dislocations, 1 subluxation, and 1 case, where the tibial component of a prosthesis rotated requiring open repositioning. Conclusions. We conclude that endoprosthetic replacement for the treatment of isolated bone metastases is a reliable method of limb reconstruction in selected cases. It is associated with low complication and failure rates in our series, and achieves the aims of restoring function, allowing early weight bearing and alleviating pain.

Endoprostheses Last Longer Than Intramedullary Devices in Proximal Femur Metastases

“…A majority of the intramedullary nail complications occurred late (after 1 year) as compared with a small minority of the endoprosthesis complications, a comparison not yet noted in previous literature but which should play a role in decisionmaking. Our relatively low dislocation rate of 9% (10 of 113) is comparable to previous series of endoprostheses using bipolar heads, which demonstrate a 1% to 12% dislocation rate [4,5,10,21,23,25]. Other series in which acetabular resurfacing was also performed report a higher rate of instability of up to 30% when compared with bipolar implants [10,17].…”

“…The MSTS functional scores were similar (p = [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27], respectively.…”

“…Intramedullary devices have a lower rate of mechanical failure of 2% to 22% but death from cardiopulmonary complications ranges from 1% to 10% [6,24,26,28]. Endoprostheses have the lowest reported mechanical failure rate (under 3.7%) with a complication rate of 6% to 35% [5,21,25]. One study directly comparing the use of intramedullary devices and endoprostheses for proximal femur metastatic lesions found an increased 2-year risk of reoperation when comparing internal fixation with endoprosthetic reconstruction [28].…”

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

“…Endoprosthetic reconstruction has been shown to improve ambulatory status and decrease pain in patients with pathologic fractures of the proximal femur [1,5,6,15,18,19,23]. The procedure also enables the surgeon to remove all gross disease, minimize recurrence and hardware failure, and protect the rest of the femur against progressing disease [2].…”

“…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).…”