Large impending lesions or actual pathologic fractures often result in forced immobilization due to severe pain and account for as many as 60% of orthopaedic proce-dures performed on pat
Trang 1Metastatic disease is the leading
cause of death in cancer patients
Bone is the third most common site
of metastatic disease, after lung and
liver Tumors of breast, thyroid,
lung, prostate, and kidney origin
are the most likely to metastasize to
bone Of the estimated 1.2 million
new cases of cancer diagnosed,
more than one half will be
osteo-philic tumors (i.e., breast, lung and
prostate cancer).1 Furthermore, by
the time of death, more than 50% of
patients with these tumors will
have had metastases to bone
Im-provements in oncologic
manage-ment of patients with metastatic
disease have resulted in increased
duration of survival As a result,
orthopaedic surgeons are being asked more frequently to evaluate and treat the skeletal manifestations
of metastatic disease
Virtually any primary malignant tumor can metastasize to bone, and any bone may be involved How-ever, metastatic lesions most typi-cally occur in the spine, pelvis, femur, ribs and skull In most cases, there are multiple sites of involve-ment Large impending lesions or actual pathologic fractures often result in forced immobilization due
to severe pain and account for as many as 60% of orthopaedic proce-dures performed on patients with metastatic disease.2 Most femoral lesions involve the proximal third
However, this review will discuss the evaluation and treatment of metastatic disease in any portion of the femur
Clinical Presentation
Pain is the most common present-ing symptom of metastatic disease (both solid tumors and hematologic malignant conditions) In a study of
87 patients with breast cancer, 32 of the 33 patients who had osseous metastases had bone pain.3 In a study of 536 patients with multiple myeloma, bone pain was reported
in more than two thirds.4 Al-though the mechanism responsible for causing bone pain remains incompletely understood, it is thought to be the result of stretch-ing of the periosteum by increasstretch-ing tumor size or stimulation of nerve endings in endosteal bone The symptoms of metastases in the lower extremity range from a dull ache to a deep-seated, intense pain
Dr Swanson is Resident, Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minn Dr Pritchard is Professor of Ortho-paedic Surgery and Consultant, Mayo Clinic, Rochester Dr Sim is Professor of Orthopaedic Surgery and Consultant, Mayo Clinic, Rochester.
Reprint requests: Dr Pritchard, Mayo Clinic,
200 First Street SW, Rochester, MN 55905 Copyright 2000 by the American Academy of Orthopaedic Surgeons.
Abstract
Nearly every malignant neoplasm has been described as having the capability to
metastasize to bone Of the estimated 1.2 million new cases of cancer diagnosed
annually, more than 50% will eventually demonstrate skeletal metastasis.
Advances in systemic and radiation therapy have led to a considerable
improve-ment in the prognosis of patients with metastatic disease As a result,
orthopaedic surgeons are being asked with increasing frequency to evaluate and
treat the manifestations of skeletal metastases The femur is commonly the site
of large impending lesions and complete pathologic fractures Although the
health status of some patients may preclude operative intervention, established
pathologic fractures of the femur and metastatic lesions deemed likely to
progress to imminent fracture generally should be treated surgically A
ratio-nal approach to selection of the proper treatment for these problems includes
consideration of the patientÕs overall medical condition and the type, location,
size, and extent of the tumor Treatment principles are the same regardless of
location A construct should ideally provide enough stability to allow
immedi-ate full weight bearing with enough durability to last the patientÕs expected
life-time All areas of weakened bone should be addressed at the time of surgery in
anticipation of disease progression To minimize disease progression and
possi-ble implant or internal fixation failure, postoperative external-beam irradiation
should be considered.
J Am Acad Orthop Surg 2000;8:56-65
Kyle C Swanson, MD, Douglas J Pritchard, MD, and Franklin H Sim, MD
Trang 2Weight bearing may precipitate
severe discomfort as a result of
microscopic buckling.5 Night pain
and pain at rest are also cardinal
features at presentation
A pathologic fracture, most
com-monly of the femur,6 may be the
first presenting sign of metastatic
disease Approximately two thirds
of all long-bone pathologic
frac-tures occur in the femur.7 Most
(50%) involve the proximal femur,
with 20% involving the
intertro-chanteric region, and the remainder
occurring in the subtrochanteric,
diaphyseal, and supracondylar
re-gions
The incidence of pathologic
frac-ture of the femur is quite variable,
depending on tumor type, location,
and histologic characteristics Breast
cancer accounts for most pathologic
fractures, but a large percentage of
renal cell carcinomas and thyroid
cancers cause pathologic fracture as
well, due to the lytic nature of the
bone involvement In one study of
180 pathologic fractures in 157
patients, 130 fractures were
sec-ondary to breast, lung, or prostate
carcinoma.8 Habermann et al9
eval-uated 283 pathologic fractures and
23 impending fractures of the
femur Metastatic disease from four
types of primary tumors accounted
for 85% of the fractures (breast, 56%;
kidney, 11%; multiple myeloma,
9.5%; lung, 8.5%).9 Only 11 (3.6%)
of the 306 pathologic and
impend-ing fractures were due to prostate
cancer Although the incidence of
prostate cancer is relatively high
and its metastatic spread is almost
universally to bone, it infrequently
causes pathologic fracture This
may be related to its blastic, rather
than lytic, nature
Clinical Evaluation
Proper evaluation of a patient with
metastatic disease begins with a
thorough history and physical
examination For patients present-ing with no prior history of malig-nancy, salient historical points include characterization of pain, weight loss, and decline in activity level Prior history of malignancy should heighten clinical suspicion
The location of the pain usually directs the physical examination, although metastases that involve joints or periarticular bone may pro-duce symptoms (referred pain) sim-ilar to those of arthritis With in-volvement of the femur in the hip and thigh region, swelling and soft-tissue masses are rarely detectable
Laboratory evaluation is seldom diagnostic in the workup of meta-static disease because there is no single specific marker of bone metastasis However, disturbances
in normal metabolic and hemato-logic variables can aid in the diag-nosis of a primary or secondary disorder associated with a patho-logic process
Hypercalcemia is a common met-abolic complication of metastatic disease In a study of 498 patients with breast cancer, hypercalcemia was noted in 86 patients (17%) on first recurrence in bone Unrecognized, it can be the source of significant mor-bidity Serum calcium levels be-tween 2.9 and 3.1 mmol/L (11.5 to
12 mg/dL) may cause unpleasant side effects related to dysfunction of the gastrointestinal tract, kidneys, and central nervous system When calcium levels exceed 3.2 mmol/L (13 mg/dL), renal insufficiency and calcification in kidneys, skin, blood vessels, lungs, heart, and stomach may occur, particularly if blood phosphate levels are normal or ele-vated due to impaired renal func-tion Severe hypercalcemia, usually defined as a calcium level of 3.7 mmol/L (15 mg/dL) or above, is a medical emergency Death may ensue as a result of cardiac arrhyth-mias and renal failure.10,11
When there is evidence of meta-static disease and no primary
tu-mor has been identified, the patient should undergo biochemical screen-ing for multiple myeloma This in-cludes a complete blood cell count, erythrocyte sedimentation rate, and serum protein electrophoresis Approximately 70% of patients with multiple myeloma are anemic, and approximately 65% have an ele-vated sedimentation rate.12 When adenocarcinoma is suspected, it may be reasonable to evaluate tu-mor markers, such as α-fetoprotein,
β-human chorionic gonadotropin, carcinoembryonic antigen (associ-ated with ovarian and breast can-cer), and prostate-specific antigen However, because of the lack of specificity, the value of these mark-ers generally resides in assessment
of response to therapy, rather than identification of the primary site, in
a patient with metastatic disease Rougraff et al13have outlined a successful diagnostic strategy aimed at identification of the pri-mary malignant tumor in patients who have skeletal metastases of unknown origin Evaluation con-sists of a history, physical examina-tion, routine laboratory analysis, plain radiography of the involved bone and the chest, whole-body technetium-99m bone scintigraphy, and computed tomography (CT) of the chest, abdomen, and pelvis In
34 of their 40 patients (85%), the primary site was identified Labo-ratory values were found to be nonspecific in all cases The history and physical examination revealed the occult primary site of the malignant tumor in 3 patients (8%) Plain radiographs of the chest were diagnostic of lung carcinoma in 17 patients (43%) An additional 6 (15%) primary lung carcinomas were identified with CT of the chest Computed tomography of the abdomen and pelvis estab-lished the diagnosis in 5 patients (13%) Although tissue biopsy alone was diagnostic in 3 patients (8%), it was not useful in
Trang 3identify-ing the primary site of malignancy
in 26 (65%) patients
Evaluation of skeletal metastases
is usually accomplished with one or
more of four clinical imaging
meth-ods: plain-film radiography,
radio-isotope scanning, CT, and magnetic
resonance (MR) imaging
Radio-graphic evaluation should involve
not only spot orthogonal views of
the affected region but also a
sur-vey with anteroposterior and lateral
radiographs of the entire femur
Care must be taken to avoid
miss-ing metachronous lesions, which
may influence the choice of
treat-ment and may ultimately
compro-mise outcome
Metastatic lesions originating
from the lung (Fig 1), kidney, and
thyroid are commonly lytic in
ap-pearance Lesions of prostatic
ori-gin are usually blastic Breast
carci-nomas are commonly mixed in
appearance Most metastatic lesions
arise from within the intramedullary
canal In rare instances, aggressive
vascular tumors are intracortical,
whereas squamous cell carcinoma of the lung may be juxtacortical Bone lesions in patients more than 40 years old are more likely to be sec-ondary to metastatic lesions and myeloma, but bone lesions in patients less than 40 years old are more likely to be related to infection and primary tumors of bone.14 Lod-wick15 described three patterns of bone destruction: geographic le-sions (solitary, well-defined lele-sions with sharply demarcated borders, seen in the most slowly developing metastases), Òmoth-eatenÓ lesions (multiple small lytic areas in spongy and cortical bone with ill-defined margins), and permeative lesions (multiple tiny lytic areas in princi-pally cortical bone, found in the most aggressive lesions)
Patients presenting for ortho-paedic evaluation of impending or pathologic fracture of the femur usually have a prior history of a malignant condition If a patient has a history of skeletal or visceral metastasis and a lesion of the
fe-mur consistent with metastatic dis-ease, rarely is a study other than high-quality orthogonal radiogra-phy of the entire femur necessary However, in the case of lesions in either of the femoral condyles, the femoral head, or the acetabulum,
CT may be necessary to assess the degree of bone destruction Fur-thermore, if there is reason to eval-uate the amount of involvement of the femur or if it is suspected that a large soft-tissue mass may be asso-ciated with a bone lesion (as may occur in renal cell carcinoma or squamous cell carcinoma), MR im-aging may be helpful
One must be cautious about plain-film radiographic evaluation
of a solitary osseous lesion consis-tent with metastatic disease in a pa-tient with a remote history of a prior malignant condition (>5 years) but without prior evidence of distant metastases The possibility of a sec-ond primary tumor or even a sar-coma of bone or soft tissue should always be considered, especially if
Figure 1 Anteroposterior (A) and lateral (B) radiographs of the knee reveal large destructive lesion of the distal femur due to metastatic disease originating in the lung C and D, Radiographs obtained after prophylactic stabilization with a dynamic compression screwÐplate
device augmented with methylmethacrylate.
Trang 4the radiologic characteristics are not
consistent with metastases from the
primary tumor Obtaining a biopsy
prior to or at the time of surgery
should be considered to confirm the
diagnosis
Further imaging is warranted if
there is a prior history of malignancy
coupled with symptoms suggestive
of metastatic disease, even when
radiographs appear normal
Edel-styn et al16demonstrated that more
than 50% of the medullary canal
must be destroyed before a
meta-static lesion is visualized on plain
films Radionuclide scanning with
technetium-99m methylene
diphos-phonate is an extremely sensitive
modality for detecting skeletal
lesions A period of 2 to 18 months
may be necessary before a lesion
initially evident on radionuclide
scanning becomes apparent on
plain-film radiography.17 The
main disadvantage of bone
scintig-raphy is its lack of specificity;
find-ings must always be correlated
with further imaging
Treatment Strategy
General Considerations
The management goals of
treat-ment of metastatic disease of the
femur are relief of pain and
resto-ration of premorbid ambulatory
function Recognition of the full
therapeutic potential for each
patient requires a multidisciplinary
team approach
The decision between operative
and nonoperative management is
determined on the basis of the
loca-tion, tumor type, and extent of the
tumor and the patientÕs general
med-ical condition (Fig 2) The initial
step in a rational approach to
im-pending or established pathologic
fractures of the femur is to carefully
examine the patient and to
deter-mine the overall health status If
there is no reasonable expectation
that the patient can survive a major
operative procedure, nonsurgical measures may be the only viable alternative for palliation If the patient can reasonably be expected
to survive the procedure but will have an extremely limited potential for survival beyond a few weeks, it may not be prudent to proceed with
an operative procedure Patients who are not expected to survive long enough to recover and truly benefit from surgical treatment may decide against committing to the time, dis-comfort, and expense of proceeding with an operation and may instead prefer palliative measures, such as analgesic medications or splinting
Although the latter approach would probably restrict the patient to bed and chair, it might be appealing to someone who is aware of his or her short life expectancy
Pathologic Fracture
If the patient is deemed to be healthy enough and the life expec-tancy is such that there will be suf-ficient benefit (e.g., pain relief, ease
of mobility, ease of care) to justify the procedure, an operative
ap-proach might be appropriate After assessment of the general health status, the next step is to evaluate local tumor factors If the patient has a pathologic fracture secondary
to metastatic disease, local factors must be addressed when planning treatment
In most cases, the surgeon should concentrate on achieving stable fixa-tion (Figs 1 and 3), with the expec-tation that local control of the metastatic disease can be obtained without resection of the tumor This
is true of most metastatic lesions, especially those due to primary tumors in the breast or prostate However, some metastatic lesions are relatively resistant to adjunctive treatments, such as radiation therapy, chemotherapy, and hormonal ma-nipulation For example, there are few chemotherapy options for hypernephromas, which are also particularly unresponsive to radia-tion therapy In instances in which there is considerable bone destruc-tion, fracture fixation and postoper-ative radiation therapy do not ade-quately control the tumor, and
Not a surgical candidate
Palliative treatment
Possible surgical candidate
Impending fracture
Low risk
of fracture
Palliative treatment
High risk
of fracture
Established fracture
General health status
Resection or fixation
± adjuvant treatment
Resection or fixation
± adjuvant treatment
Figure 2 Treatment strategy for patients with metastatic disease of the femur.
Trang 5tumor progression leads to ultimate
failure of the fixation (Fig 4)
Be-cause patients with hypernephroma
may have a relatively prolonged
survival, particularly if there is only
one site of metastatic disease, it may
be better to resect the involved area
of bone and perform a prosthetic reconstruction, rather than relying
on internal fixation and adjuvant radiation treatment In addition to dealing with the fracture, resection
of a solitary metastasis may im-prove the patientÕs chances of sur-vival This strategy is applicable to other tumors that are resistant to radiation therapy or are prone to recurrence Preoperative
Figure 3 Anteroposterior radiographs of the femur demonstrate pathologic subtrochanteric fracture (A) and impending distal femur fracture (B) C and D, Anteroposterior radiographs obtained after stabilization with an intramedullary nail.
Figure 4 A,Anteroposterior radiograph of the proximal femur 2 years after intramedullary fixation of an impending pathologic fracture due to metastatic renal cell carcinoma Despite radiation therapy, there was progression of the lesion with extensive cortical bone loss
B, Extensive vascularity of the lesion necessitated preoperative embolization C, Anteroposterior radiograph obtained after proximal
femoral replacement arthroplasty.
Trang 6tion of highly vascular lesions may
minimize the risk of massive
hem-orrhage during surgery
The size and extent of the tumor
are also important factors that must
be carefully assessed when
plan-ning an operative procedure In
ad-dition to plain radiography, MR
imaging may provide helpful
infor-mation regarding intramedullary
involvement, as well as any
soft-tissue extension of the tumor A CT
scan may reveal the extent of
corti-cal disruption Technetium
scan-ning or MR imaging may suggest
the possibility of additional lesions
in the same bone However, in the
case of highly aggressive lesions or
multiple myeloma, the Tc-99m
bone scan may not be positive
Impending Pathologic Fracture
If the patient is known to have
metastasis to the femur but there is
no actual fracture, the surgeon
needs to assess the relative risk of
fracture The type, extent, size, and
location of the tumor are all factors
in determining the risk of fracture
Lytic lesions are more likely to
frac-ture than blastic lesions Large
tumors, those that have soft-tissue
extension, and those that occur in
the region of the lesser trochanter
of the femur are particularly prone
to fracture
There have been several attempts
to provide guidelines for assessing
the risk of fracture in the presence of
metastasis.18-21 Although it must be
borne in mind that estimating the
risk of pathologic fracture is very
subjective and is dependent on
many variables (e.g., location of
lesion, quality of host bone, and
anticipated load), the Mirels scoring
system has proved useful (Table 1)
The location of the lesion, the
degree of pain, the type of bone
destruction, and the size of the
defect are the variables considered
in this 12-point scoring system A
score of 9 or above indicates a high
likelihood of subsequent fracture
In addition to the Mirels system, several general rules regarding involvement of the femur may be helpful Even small lesions in the region of the lesser trochanter are particularly at risk for fracture
Most lesions in the subtrochanteric area are also at high risk, especially when the metastasis is on the medial aspect of the bone In diaphyseal lesions, destruction of 50% of the diameter or one cortex, as evi-denced radiographically, is proba-bly a valid predictor of subsequent fracture Pain, particularly with weight bearing, in a lytic focus fol-lowing radiation therapy is a solid indication for prophylactic stabi-lization despite the radiographic appearance
Although there are guidelines and methods of systematic assess-ment, there is really no accurate way to predict the risk of fracture
Even experienced orthopaedic sur-geons will occasionally underesti-mate the risk of pathologic fracture
If there is a high risk of fracture and the patientÕs general condition warrants an operative approach, an appropriate procedure can be
select-ed and plannselect-ed Preoperatively, the patient will need to protect the femur with ambulation aids to mini-mize the chance of a fracture occur-ring before the procedure
Preoperative Planning
Metastatic lesions to the femur present unique challenges, but the treatment principles are the same
regardless of location A construct
should ideally provide enough stability to allow immediate full weight bearing with enough durability to last the patientÕs expected lifetime In addition, all areas
of weakened bone should be ad-dressed at the time of the operation
in anticipation of disease sion To minimize disease progres-sion and possible failure of the im-plant or internal fixation, radiation should be administered postopera-tively, preferably to the entire femur
Operative Procedures by Site
Femoral Head and Neck Fractures
Both impending lesions and complete pathologic fractures of the femoral head and neck should
be managed with replacement ar-throplasty (Fig 5) The high stresses across the proximal femur, com-bined with the limited potential for healing, even in low-demand pa-tients, has resulted in a high rate of failure for internal fixation devices Moreover, fractures in tumor-destroyed bone in the femoral neck
Table 1 Mirels Scoring System for Assesing Risk of Pathologic Fracture in Long Bones *
Score
Site Upper limb Lower limb Peritrochanteric
Lesion type Blastic Mixed Lytic Size (as a proportion <1/3 1/3 - 2/3 >2/3
of shaft diameter)
* Reproduced with permission from Mirels H: Metastatic disease in long bones: A
pro-posed scoring system for diagnosing impending pathologic fractures Clin Orthop
1989;249:256-264.
Trang 7(even nondisplaced fractures) will
rarely heal within the patientÕs
remaining life span
There have been several reports
of favorable results with prosthetic
replacement.22,23 Lane et al24
re-ported the results in 167 patients
treated by endoprosthetic
replace-ment for impending or complete
pathologic fractures of the hip All
patients reported dramatic relief of
pain Use of a long-stemmed
fe-moral endoprosthesis or a total
prosthetic hip resulted in significant
enhancement of the ambulatory
sta-tus in three fourths of those who
were able to walk before the
frac-ture Nonwalkers improved in their
ability to transfer The patients who
had little benefit from the procedure
were those who were bedridden,
usually with severe metastatic
in-volvement of the spine
Patients with proximal femoral
lesions may have concurrent
ace-tabular lesions Harrington25 has
classified acetabular metastatic lesions into four groups on the basis of location, extent of involve-ment, and surgical technique re-quired to accomplish acetabular reconstruction Unless tumor in-volvement is extensive, creating structural weakness in the acetabu-lum, a standard cemented bipolar hemiarthroplasty or hip replace-ment may be utilized The choice of hemiarthroplasty versus total hip arthroplasty is dependent on the condition of the acetabular cartilage and the extent of involvement
Harrington26has reported a compli-cation rate of less than 1% for endo-prosthetic migration due to weak-ened periacetabular bone
In lesions that extend distally into the region of the lesser trochanter, a calcar-replacing prosthesis may be utilized Multiple lesions in the peritrochanteric and diaphyseal regions of the femur, as well as rela-tively radiation therapyÐresistant
lesions, are often best addressed with a long-stemmed prosthesis to prophylactically reinforce the fe-mur and avoid stress risers, espe-cially in patients with potentially long survival who are prone to multiple lesions, such as myeloma Additionally, if there is thought to
be significant risk that distal lesions will develop in the patientÕs re-maining life span despite radiation therapy, use of a long-stemmed prosthesis may be indicated
Intertrochanteric Fractures
The surgical treatment of patho-logic intertrochanteric fractures remains controversial Lesions con-fined to the intertrochanteric region, with minimal medial cortical-bone destruction, have traditionally been treated with a compression screw or nail plate However, prolonged sur-vival, local disease progression, poor initial fixation, delayed union
or nonunion, and lack of load shar-ing between the implant device and residual bone have all contributed
to a high failure rate with this form
of treatment (Fig 6)
Proponents of the use of open reduction and internal fixation with a compression screw or nail-plate device stress the importance
of adjunctive stabilization with methylmethacrylate A cortical window is created in the lateral cortex, and all devitalized tumor-laden tissue is removed Whether the compression screw should be inserted before or after injection of methylmethacrylate into the bone
is controversial Some surgeons have chosen to hollow out the femoral head and neck by drilling
to the subchondral bone Cement
of liquid consistency is then placed
in the defect, and the compression screw is placed in the cement Advocates argue that the screw is thus embedded in cement rather than in bone of questionable in-tegrity The combination of screw threads and cement gives a greater
Figure 5 A,Anteroposterior radiograph of the proximal femur shows a pathologic
frac-ture of the femoral neck B, Anteroposterior radiograph obtained after bipolar
hemiarthro-plasty.
Trang 8surface area of contact for the
fixa-tion device in the femoral head and
thus reduces the risk of the screw
cutting out of the femoral head
Critics state that drilling of the
femoral head may result in
osteo-necrosis or release of microemboli
of cement into the rich vascular
plexus in the head of the femur
Adjunctive stabilization by
inject-ing methylmethacrylate distally
into the medullary canal can also
add stability to the cortical screws
along the side plate The cortical
screws are then inserted by drilling
and tapping both the bone and the
methylmethacrylate
Intramedullary hip screws have
recently been used for pathologic
intertrochanteric fractures These
devices have the biomechanical
advantage of more medial
place-ment closer to the compression side
of the femur and away from the lateral-tension side However, short intramedullary hip screws have been problematic because of fractures occurring at the tip of the nail in the diaphyseal region Long intramedullary hip screws have the advantage of protecting the entire bone, but there have been few reports on their use Another suc-cessful alternative includes the use
of an intramedullary rod with proximal fixation screws that ex-tend into the femoral neck and head, with distal interlocking
Extensive involvement of the femoral head and neck with exten-sion into the trochanteric and sub-trochanteric regions is seldom managed successfully with internal fixation devices Prosthetic
replace-ment with either calcar or proximal femoral devices is the procedure of choice for large destructive areas not amenable to internal fixation, for salvage of failed internal fixa-tion, and for lesions not amenable
to radiation therapy Ease of appli-cation and improvements in im-plant design and availability have contributed to more frequent use of these devices Potential disadvan-tages include increased rates of postoperative infection and disloca-tion With use of proximal femurÐ replacing prostheses, loss of hip flexor and abductor strength re-sults in permanent gait distur-bance Despite the high complica-tion rate, patients may be allowed immediate weight bearing with predictable relief of pain Use of the bipolar femoral component and modular design has helped reduce the incidence of complications due
to improper soft-tissue tension and dislocation
Subtrochanteric Fractures
Subtrochanteric fractures are pri-marily treated with intramedullary devices The region extending 5 cm distally from the lesser trochanter receives tremendous torque and shear stress, resulting in high rates
of failure with screw and side-plate devices The Zickel nail was previ-ously used to treat complete and impending pathologic fractures in the subtrochanteric region (Fig 7) Its design allowed stable fixation between the proximal and distal fragments Zickel and Mouradian27
reported successful results in the treatment of 35 pathologic impend-ing and complete fractures in the subtrochanteric region Early mobi-lization or ambulation was achieved
in nearly all cases
Insertional difficulty, proximal fragment fracture, femoral shorten-ing, varus migration, and rotational instability associated with the Zickel nail have been addressed by the current use of reconstruction
Figure 6 A,Anteroposterior radiograph of the proximal femur demonstrates a large
destructive lesion of the peritrochanteric region stabilized with a compression screwÐplate
device B, Anteroposterior radiograph obtained 1 year after internal fixation shows
pro-gressive collapse and failure of the internal fixation.
Trang 9intramedullary nails (Fig 3)
Se-cure fixation may be obtained with
two screws directed proximally
into the femoral head Likewise,
the nail should be statically locked
with two distal screws
Methyl-methacrylate can be used as an
adjunct to fixation, but is not
neces-sary in most cases, due to the
in-trinsic strength of the device
Recently, so-called
third-genera-tion variathird-genera-tions of the
reconstruc-tion nail have become available A
feature of these devices in common
with early reconstruction-nail
de-signs is the capability for proximal
and distal interlocking However,
these devices differ primarily in the
proximal interlocking device The
spiral-blade nail uses a single
low-profile spiral-blade device to secure
proximal fixation while conserving
bone loss in the femoral neck In
many cases, these nails have been
placed without reaming, thus
di-minishing blood loss
The use of modular proximal
femoral replacement prostheses
should be reserved for radiation
therapyÐresistant lesions with
extensive involvement of the head, neck, and peritrochanteric femur for which stable proximal screw fixation is unattainable (Fig 4) In selected patients with a solitary metastasis and overall favorable prognosis, reconstruction with an allograft-prosthetic composite may also be a consideration There is no role for condylocephalic or Ender nails because of the high rate of mechanical failure
Diaphyseal Fractures
Impending pathologic fractures
of the femoral shaft can usually be treated by conventional closed in-tramedullary rodding techniques
The use of reconstruction nails, locked proximally and distally, has served to reduce the common com-plication of progressive femoral collapse with telescoping of the fracture fragments and proximal migration of the rod With tumor progression, proximal placement of screws into the femoral head offers more secure fixation than conven-tional transverse or antegrade screw placement and may protect
the femoral head from subsequent fracture Open rodding techniques may be necessary for large defects with extensive cortical destruction Exposure of the lesion, curettage, and augmentation of the lesion with methylmethacrylate may be necessary to prevent collapse
Distal Femur Fractures
Pathologic fractures in the supra-condylar and supra-condylar regions of the femur are unusual and difficult
to treat If there is sufficient bone stock, use of conventional internal fixation devices augmented with methylmethacrylate will usually achieve stability Satisfactory pain relief and restoration of ambulatory function have been achieved with nail-plate and dynamic compression screwÐplate devices (Fig 1) Use of the Zickel supracondylar nail has reportedly been a successful treat-ment option for fractures in the supracondylar region.28 Treatment with internal fixation devices is gen-erally not recommended or possible for patients with poor bone stock or with massive destruction of the femoral condyles Modular-type distal femoral knee arthroplasty has also been successful in achieving immediate stability and full weight-bearing status
Summary
In recent years, there have been marked improvements in tech-niques for achieving secure fixation
of pathologic fractures of the femur
or prosthetic reconstruction, even
in cases of severe tumor destruc-tion Careful preoperative plan-ning is essential to determine the extent of tumor involvement and to select appropriate reconstruction and implant type Achievement of stable, durable fixation or
prosthet-ic replacement will improve the quality of life for patients with these fractures
Figure 7 A,Anteroposterior radiograph reveals a pathologic subtrochanteric fracture
sec-ondary to lung cancer B, Stabilization with a Zickel nail augmented with
methyl-methacrylate.
Trang 101 Landis SH, Murray T, Bolden S, Wingo
PA: Cancer statistics, 1998 CA Cancer
J Clin 1998;48:6-29.
2 Harrington KD, Sim FH, Enis JE,
J o h n s t o n J O , D i c k H M , G r i s t i n a
AG: Methylmethacrylate as an
ad-junct in internal fixation of
patho-logical fractures: Experience with
t h r e e h u n d r e d a n d s e v e n t y - f i v e
cases J Bone Joint Surg Am 1976;58:
1047-1055.
3 Winchester DP, Sener SF, Khandekar
JD, et al: Symptomatology as an
indi-cator of recurrent or metastatic breast
cancer Cancer 1979;43:956-960.
4 McCloskey EV, MacLennan ICM,
Drayson MT, Chapman C, Dunn J,
Kanis JA: A randomized trial of the
effect of clodronate on skeletal
mor-bidity in multiple myeloma Br J
Haematol 1998;100:317-325.
5 Twycross RG: Management of pain in
skeletal metastases Clin Orthop 1995;
312:187-196.
6 Sim FH: Metastatic bone disease of
the pelvis and femur Instr Course Lect
1992;41:317-327.
7 Harrington KD: The management of
malignant pathologic fractures Instr
Course Lect 1977;26:147-162.
8 Galasko CSB: Skeletal Metastases.
London: Butterworths, 1986, pp 125-155.
9 Habermann ET, Sachs R, Stern RE,
Hirsh DM, Anderson WJ Jr: The
path-ology and treatment of metastatic
dis-ease of the femur Clin Orthop 1982;
169:70-82.
10 Coleman RE: Skeletal complications of
malignancy Cancer 1997;80(suppl 8):
1588-1594.
11 Potts JT: Diseases of the parathyroid gland and other hyper- and hypocal-cemic disorders, in Isselbacher KJ, Braunwald E, Wilson JD, Martin JB,
Fauci AS, Kasper DL (eds): HarrisonÕs
Principles of Internal Medicine, 13th ed.
New York: McGraw-Hill, 1994, pp 2151-2171.
12 Kyle RA: Multiple myeloma: A
re-view of 869 cases Mayo Clin Proc
1975;50:29-40.
13 Rougraff BT, Kneisl JS, Simon MA:
Skeletal metastases of unknown ori-gin: A prospective study of a
diagnos-tic strategy J Bone Joint Surg Am 1993;
75:1276-1281.
14 Aaron AD: Treatment of metastatic adenocarcinoma of the pelvis and the
extremities J Bone Joint Surg Am 1997;
79:917-932.
15 Lodwick GS: A systematic approach to the roentgen diagnosis of bone tumors,
in M D Anderson Hospital and
Tu-mor Institute: TuTu-mors of Bone and Soft
Tissue: A Collection of Papers, 8th ed.
Chicago: Year Book Medical Publishers,
1965, pp 49-68.
16 Edelstyn GA, Gillespie PJ, Grebbell FS:
The radiological demonstration of os-seous metastases: Experimental
obser-vations Clin Radiol 1967;18:158-162.
17 Galasko CSB: Skeletal metastases and
mammary cancer Ann R Coll Surg Engl
1972;50:3-28.
18 Mirels H: Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic
frac-tures Clin Orthop 1989;249:256-264.
19 Beals RK, Lawton GD, Snell WE: Pro-phylactic internal fixation of the femur
in metastatic breast cancer Cancer
1971;28:1350-1354.
20 Hipp JA, Springfield DS, Hayes WC: Predicting pathologic fracture risk in the management of metastatic bone
defects Clin Orthop 1995;312:120-135.
21 Fidler M: Incidence of fracture through
metastases in long bones Acta Orthop
Scand 1981;52:623-627.
22 Algan SM, Horowitz SM: Surgical treatment of pathologic hip lesions in
patients with metastatic disease Clin
Orthop 1996;332:223-231.
23 Yazawa Y, Frassica FJ, Chao EYS, Pritchard DJ, Sim FH, Shives TC: Metastatic bone disease: A study of the surgical treatment of 166 pathologic
humeral and femoral fractures Clin
Orthop 1990;251:213-219.
24 Lane JM, Sculco TP, Zolan S: Treat-ment of pathological fractures of the
hip by endoprosthetic replacement J
Bone Joint Surg Am 1980;62:954-959.
25 Harrington KD: The management of acetabular insufficiency secondary to
metastatic malignant disease J Bone
Joint Surg Am 1981;63:653-664.
26 Harrington KD: New trends in the
m a n a g e m e n t o f l o w e r e x t r e m i t y
metastases Clin Orthop 1982;169:
53-61.
27 Zickel RE, Mouradian WH: Intramed-ullary fixation of pathological frac-tures and lesions of the
subtrochan-teric region of the femur J Bone Joint
Surg Am 1976;58:1061-1066
28 Healey JH, Lane JM: Treatment of pathologic fractures of the distal femur with the Zickel supracondylar nail.
Clin Orthop 1990;250:216-220.