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The Use of Massive Endoprostheses for the Treatment of Bone Metastases

The Use of Massive Endoprostheses for the Treatment of Bone Metastases Hindawi Publishing Corporation Sarcoma Volume 2007, Article ID 62151, 5 pages doi:10.1155/2007/62151 Clinical Study The Use of Massive Endoprostheses for the Treatment of Bone Metastases D. H. Park, P. K. Jaiswal, W. Al-Hakim, W. J. S. Aston, R. C. Pollock, J. A. Skinner, S. R. Cannon, and T. W. R. Briggs The Royal National Orthopaedic Hospital, Stanmore, Middlesex HA7 4LP, UK Received 4 June 2006; Accepted 18 May 2007 Recommended by Adesegun Abudu Purpose. We report a series of 58 patients with metastatic bone disease treated with resection and endoprosthetic reconstruc- tion 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 im- pending 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 endo- prosthetic 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. Copyright © 2007 D. H. Park et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1. INTRODUCTION what can be achieved in the management of metastatic bone diseases [2, 3]. Skeletal complications can have a marked ef- fect on the patient’s quality of life, with bone pain being Bony metastases are the most common neoplasms of bone and the skeleton is the third most common site for metastatic the most frequent clinical symptom. An actual or impending diseases, after the lung and liver [1]. Advances in adjuvant pathological fracture impacts on the patient’s function and and neoadjuvant therapies, especially in the fields of hor- mobility. In principle, the aims of treatment should be to monal therapy and chemotherapy, have improved the prog- relieve pain and restore function by stabilising pathological nosis of patients with cancer. This has subsequently led to fractures [2, 4–6]. Stabilising impending of actual patholog- an increase in the incidence of bony metastases and resultant ical fractures allows early resumption of ambulation, which significantly improves patients’ quality of life [7]. In addi- pathological fractures of the long bones. The management of the patient with a pathological fracture presents a chal- tion to stabilisation, orthopaedic constructs should allow im- mediate weight bearing and be designed to last the expected lenge to the orthopaedic surgeon and necessitates a multidis- ciplinary approach. A consensus statement by the British Or- lifetime of the patient [2, 8]. Fracture healing is often poor in diseased or irradiated bone and the surgeon must take thopaedic Association and the British Orthopaedic Oncol- ogy Society has highlighted the fact that there remains a low into account the fact that these fractures may not unite [9]. Metastatic lesions with extensive bone loss or pathological level of awareness in the hospital and primary-care settings of 2 Sarcoma Table 1: Mirels’ Scoring System. fractures affecting adjacent joints may be treated with resec- tion and an endoprosthetic reconstruction. The load-bearing Variable Score characteristics of endoprosthesis offer immediate postopera- 12 3 tive stability, and facilitate rapid rehabilitation [10, 11]. Over Site Upper limb Lower limb Peritrochanter the last 20 years, the availability and improvement of modu- lar endoprosthesis have improved the treatment of metastatic Pain Mild Moderate Functional bone disease, particularly in the treatment of isolated bone Lesion Blastic Mixed Lytic metastasis, failed conventional reconstructions and lesions Size <1/3 1/3-2/3 >2/3 with extensive bone loss [12]. In selected cases, isolated le- As seen on plain X-ray, minimum destruction of cortex in any view. sions such as a metastasis from renal cell cancer are treated Maximum possible score is 12. If lesion scores 8 or above, then with complete excision and endoprosthetic reconstruction prophylactic fixation is recommended prior to surgery. with the intent to cure [4, 13]. The purpose of this paper is to review our experience of patients with metastatic bone disease from carcinoma that above-mentioned prostheses are modular, off-the-shelf en- had resection and an endoprosthetic reconstruction at our doprosthetic reconstruction systems. For other tumour loca- hospital over a five-year period. tions and before these dates, surgery required the manufac- ture of custom-made implants (Stanmore Implants World- wide Ltd). 2. METHODS In patients requiring proximal femoral replacement and whose disease spared the greater trochanter, this structure We performed a retrospective review of all patients with bone was osteotomised and reattached to the endoprostheses us- metastases referred to our regional musculoskeletal tumour ing a trochanteric reattachment plate and screws. The prox- centre from January 1999 to December 2003. Patients were imal femoral endoprostheses contain a spiked, hydroxyap- identified from the tumour database. We determined the pa- atite coated shoulder with two screw holes for this specific tient demographics, indications for treatment and the com- purpose. This enables gluteus medius and minimus to be plications in patients who had resection of metastatic bone reattached thereby preserving abductor function. Postopera- lesions and endoprosthetic reconstruction. The following in- tive radiotherapy was offered to all patients with pathological clusion criteria are applied for the sample collection: (1) a fractures and those whose resection margins were positive. known metastatic lesion in the appendicular skeleton on the We did not routinely offer radiotherapy to patients who had basis of histological diagnosis; and (2) no previous resec- a successful wide excision. tion and endoprosthetic reconstruction. Other information, Functional outcome was assessed using the system namely, age, gender, primary lesion if known, site of lesion, adopted by the musculoskeletal tumour Society (MSTS) for and duration of follow-up period, were also noted. All pa- the functional evaluation of reconstructive procedures after tients referred to our institution are discussed in a multidis- skeletal resection [15], and a patient-reported measure of ciplinary team setting, attended by oncologists, radiologists, disability, the Toronto extremity salvage score (TESS) [16]. orthopaedic surgeons, and other allied health professionals. The MSTS score is a clinician scored system assessing pain, Decisions regarding prophylactic surgery for patients with function, and emotional acceptance in patients for upper and impending pathological fractures are made based on Mirels lower extremities. Patients with lower extremity reconstruc- [14] scoring system (Table 1), with a score of >8 necessitating tions were also evaluated with regard to walking ability, gait, operative stabilisation. and the use of walking aids. Patients with upper extremity The indications for endoprosthetic reconstruction were reconstructions were evaluated for manual dexterity, hand isolated single metastases in the long bones, lesions involv- positioning, and lifting ability. The TESS was developed as ing adjacent joints, and large lesions with extensive bone loss. a disease-specific measure for patients undergoing limb sal- In principle, these metastatic lesions were excised in a simi- vage surgery for tumours of the extremity. It evaluates phys- lar manner to primary bone tumours. Where possible, wide ical disability based on the patients’ report of their function soft tissue margins were obtained and the shaft of the long using a self-administered questionnaire, which rates the dif- bone was transected at least 2 cm away from the extent of the ficulty experienced in performing certain activities. Both the disease. In view of the fact that this is palliative surgery, im- MSTS and TESS scores are represented as a percentage, with portant neurovascular structures were usually preserved at a higher percentage indicating better functional outcome. the expense of wide margins in order to maximise functional outcome. In patients with intraarticular spread of tumour, we performed conventional joint replacement surgery and 3. RESULTS did not attempt extraarticular resections. In the case of prox- imal femoral, distal femoral and proximal tibial reconstruc- Between January 1999 and December 2003, 171 patients tion modular endoprosthetic tumour system (METS, Stan- were diagnosed with metastatic bone tumours from carci- more Implants Worldwide Ltd, Stanmore, Middlesex, UK) noma. Fifty-eight of which underwent an endoprosthetic re- were used as it became available. For the proximal femoral construction. There were 28 males and 30 females with a replacements, this was in 2001 and for the distal femoral mean age at diagnosis of 62 years (range 24 to 88). The most and proximal tibial replacements, this was in 2003. These common underlying diagnosis was renal cell carcinoma in D. H. Park et al. 3 Table 2: Primary diagnosis of patients undergoing endoprosthetic humeral replacements had MSTS scores and TESS of 72% reconstruction. and 70%, and 73% and 71%, respectively. One patient with a distal humeral replacement had an MSTS score of 76% and a Primary diagnosis Number (%) TESS of 77%. Renal carcinoma 27 (46.6) No patients had local recurrence or required subsequent Breast carcinoma 10 (17.2) amputation and there was one revision of the humeral dia- Unknown primary 8 (13.8) physeal replacement as described above. Lung carcinoma 4 (6.9) Squamous cell carcinoma 2 (3.4) 4. DISCUSSION Prostate carcinoma 2 (3.4) Thyroid carcinoma 1 (1.7) Endoprosthetic reconstruction has a role in the management of metastatic lesions with extensive bone loss, failure of con- Oesophageal carcinoma 1 (1.7) ventional reconstruction, and large isolated lesions with the Phaeochromocytoma 1 (1.7) aim being curative. Although the conventional treatment of Ovarian carcinoma 1 (1.7) metastatic bone lesions with plates and intramedullary de- Bladder carcinoma 1 (1.7) vices supplemented with methylmethacrylate is well estab- lished [7], lesions that involve adjacent joints often require resection and reconstruction to allow early and full weight 27 (46.6%) of patients, followed by breast carcinoma in 10 bearing. The purpose of this study was to review our expe- (17.2%), unknown primary carcinoma in 8 (13.7%), lung rience with endoprosthetic replacements and to objectively carcinoma in 4, squamous cell carcinoma in 2, prostate carci- assess patient outcome using both a clinician-reported and noma in 2, thyroid, oesophageal, ovarian, and bladder carci- a patient-reported score. The majority of the endoprosthetic noma in 1 patient each and a phaeochromocytoma (Table 2). reconstructions in our series were proximal femoral replace- Forty-six patients had lower extremity lesions, which were ments, a finding reflected in other series of endoprosthetic treated with 31 proximal femoral replacements, 11 distal replacements for bone metastases [5, 12], with the proxi- femoral replacements, and 4 proximal tibial replacements. mal femur being the most common site of long-bone in- Twelve had upper extremity lesions, treated with 7 proximal volvement by metastatic disease [8, 17, 18]. The hip joint humeral replacements, 4 distal humeral replacements, and 1 must bear as much as six times body weight and this ne- humeral diaphyseal replacement. cessitates that reconstruction must provide immediate sta- Therewere5superficial woundinfections(8.6%), allof bility and prolonged durability. This strongly favours the use which resolved with oral antibiotics. Four dislocations oc- of an endoprosthetic replacement rather than internal fixa- curred in the proximal femoral replacements group (12.9%). tion [8]. Conventional fixation of pathological fractures or Three were reduced closed and one required an open re- large lytic lesions especially around the hip or proximal fe- duction without requiring component repositioning and this mur has a high failure rate when compared to a standard or patient was subsequently managed in an abduction brace tumour prosthetic replacement [5, 19, 20]. It is therefore our for 8 weeks. There was one case of aseptic loosening in the preferred method of treatment to carry out a resection and humeral diaphyseal replacement, which required revision, endoprosthetic replacement for large lesions of the proximal one subluxation in a proximal humeral replacement, and one femur. The extent of tumour in the proximal femur dictated case of component malposition. The tibial component of a the method of abductor repair and if the trochanter could be distal femoral replacement was found to be rotated 180 de- spared with an adequate margin of bone between the tumour grees requiring open exploration and repositioning. and a trochanteric osteotomy, then the trochanter was reat- Thirty-four patients had died at a mean of 22 months tached in the manner described previously. Tumour involv- (range 2 to 51 months) from surgery and 5 were lost to follow ing the trochanter resulted in resection of the proximal femur up. The remaining 19 had a mean follow-up of 48.2 months including the trochanter and a soft tissue abductor repair was (range 27 to 82 months). They were functionally evaluated done. In our series of 11 patients, only one patient was suit- with the MSTS and the TESS scores (Table 3). For the group able for a trochanteric osteotomy and reattachment to the as a whole, the mean MSTS score was 73% (range from 57 to prosthesis. This patient subsequently had a dislocation on 90%) and TESS was 71% (range 46 to 95%). Looking specifi- her first postoperative day and underwent a closed reduction. cally at lower limb reconstruction, the mean MSTS score was At 31 months follow-up, her MSTS score was 57% and her 77.9% (range 57 to 90%) and the mean TESS was 75.6% TESS was 46%. Due to the small numbers we are unable to (range 46 to 95%). The group with proximal femoral re- comment on whether trochanteric reattachment significantly placements (11 patients) had a mean MSTS score of 72.4% affects functional outcome or hip abductor function. Of the (range 57 to 83) and a mean TESS of 68.4% (range 46 to 11 patients with proximal femoral lesions, seven presented 84). The group with distal femoral replacements (4 patients) with a pathological fracture. Patients who had a pathological had a mean MSTS score of 75% (range 60 to 90) and a mean fracture on presentation had a mean MSTS score of 69.1% TESS of 77.5% (range 63 to 95). One patient with a proximal (range 57 to 80%) and a mean TESS of 65.9% (46 to 82%). tibial replacement had an MSTS score of 73% and a TESS Patients who presented without a pathological fracture had score of 72%. In the upper limb, two patients with proximal a mean MSTS score of 78% (range 70 to 83%) and a mean 4 Sarcoma Table 3: Functional outcomes of the 19 patients (out of 58) surviving 2 years or more. Patient Primary Age Operation TESS MSTS Follow-up (months) 1 Phaeochromocytoma 24 PFR 82 80 39 2 Thyroid carcinoma 42 PFR 72 74 41 3 Oesophageal carcinoma 42 PFR 69 63 35 4 Ovarian carcinoma 45 PFR 65 77 33 5 Breast carcinoma 49 PFR 46 57 31 6 Renal carcinoma 67 PFR 56 63 31 7 Unknown primary 77 PFR 71 70 44 8 Unknown primary 58 PFR 74 78 44 9 Breast carcinoma 68 PFR 53 70 27 10 Breast carcinoma 42 PFR 84 83 58 11 Renal carcinoma 36 PFR 80 81 46 12 Squamous cell carcinoma 49 PTR 72 73 28 13 Renal carcinoma 46 DFR 72 71 82 14 Breast carcinoma 50 DFR 95 90 35 15 Renal carcinoma 56 DFR 80 79 66 16 Renal carcinoma 61 DFR 63 60 73 17 Renal carcinoma 52 PHR 71 73 73 18 Renal carcinoma 54 PHR 70 72 60 19 Unknown primary 59 DHR 77 76 60 PFR = proximal femoral replacement, PHR = proximal humeral replacement, PTR = proximal tibial replacement, DFR = distal femoral replacement, DHR = distal humeral replacement. TESS of 72.8% (range 53 to 84%). The difference in scores are than 2 years and in the latest follow-up, they were mobilising not statistically significant and larger studies will be required with one walking stick. Functionally their MSTS scores and to determine if patients who present with pathological frac- TESS were 57% and 46%, and 70% and 53%, respectively. tures have poorer functional outcome scores compared to The mean time to death of the 58 patients was 22 months patients who do not. With regard to overall functional out- (range 2 to 51 months). This wide range highlights the need come, patients with proximal femoral replacements had a for a stable reconstruction that allows early weight bearing, mean MSTS score of 72.3% (range 57 to 83%) and a mean has a low incidence of failure, and outlasts the expected life- TESS score of 68.4% (range 46 to 84%). These scores com- time of the patient. pare to those reported in other series of proximal femoral Our series was associated with relatively few, easily man- endoprosthetic replacements using modular endoprostheses ageable complications and there were no implant failures. [21, 22]. Massive endoprostheses were originally developed for Table 3 shows the functional outcomes of all the patients the treatment of primary malignant bone tumours. They who survived 2 years or more who were treated with an en- have traditionally been custom-designed and hence there doprosthetic replacement. The functional outcomes for pa- was a time delay to manufacture the implant. The grad- tients with upper and lower limb reconstructions are com- ual introduction of modular endoprostheses has provided parable; however, the number of patients followed up with greater flexibility making these reconstructions possible, and upper limb reconstructions (three) is too small for any fur- in shorter time frames, therefore aiding the overall manage- ther significant conclusions. ment of metastatic bone disease. According to British Or- There were five cases of superficial infection which re- thopaedic Association guidelines [2], patients should un- solved with oral antibiotics alone, but no cases of deep in- dergo a single procedure that allows early full weight bearing fection. In 58 endoprosthetic replacements, only one patient and lasts the expected lifespan of the patient. In our experi- required a revision for aseptic loosening of a humeral diaphy- ence the use of an endoprostheses allows these criteria to be seal replacement. There were four dislocations in the group met. of patients who had proximal femoral replacements (31 pa- Appropriate and prompt surgical management of tients). All dislocations occurred within the first 3 weeks of metastatic bone lesions may be more cost-effective in terms surgery. Three were reduced closed and one required an open of the overall management of cancer patients. This is re- reduction without the need for component repositioning. flected in earlier mobilisation and therefore potentially less They were all rehabilitated postreduction in an abduction time spent in hospital. Other studies are needed to assess the brace for 8 to 10 weeks. None of these patients experienced impact of these cost savings on hospital, nursing, and com- any further dislocations. Two of these patients survived more munity cancer services. Patients who had an endoprosthetic D. H. Park et al. 5 reconstruction in our series were able to return to a good [16] A. M. Davis, J. G. Wright, J. I. Williams, C. Bombardier, A. Griffin, and R. S. Bell, “Development of a measure of physi- level of function.Careful patient selection is crucial and the cal function for patients with bone and soft tissue sarcoma,” surgeon must take into consideration the patient’s progno- Quality of Life Research, vol. 5, no. 5, pp. 508–516, 1996. sis, comorbidities, and their ability to participate in postop- [17] A. D. Aaron, “Treatment of metastatic adenocarcinoma of the erative rehabilitation. pelvis and the extremities,” Journal of Bone and Joint Surgery, vol. 79, no. 6, pp. 917–932, 1997. REFERENCES [18] J. Manabe, N. Kawaguchi, S. Matsumoto, and T. Tanizawa, “Surgical treatment of bone metastasis: indications and out- [1] F. H. Sim, “Pathogenesis and prognosis,” in Diagnosis and comes,” International Journal of Clinical Oncology, vol. 10, no. 2, pp. 103–111, 2005. Management of Metastatic Bone Disease: A Multidisciplinary Approach, F. H. Sim, Ed., pp. 1–6, Raven Press, New York, NY, [19] E. T. Habermann, R. Sachs, R. E. Stern, D. M. Hirsh, and W. J. Anderson Jr., “The pathology and treatment of metastatic dis- USA, 1998. ease of the femur,” Clinical Orthopaedics and Related Research, [2] British Orthopaedic Association and the British Orthopaedic Oncology Society. Metastatic Bone Disease: A Guide to Good no. 169, pp. 70–82, 1982. [20] R. Wedin, H. C. F. Bauer, and P. Wersal ¨ l, “Failures after op- Practice. 2001. [3] C. S. B. Galasko, H. E. Norris, and S. Crank, “Spinal instabil- eration for skeletal metastatic lesions of long bones,” Clinical Orthopaedics and Related Research, no. 358, pp. 128–139, 1999. ity secondary to metastatic cancer,” Journal of Bone and Joint Surgery, vol. 82, no. 4, pp. 570–594, 2000. [21] C. M. Ogilvie, J. S. Wunder, P. C. Ferguson, A. M. Griffin, and R. S. Bell, “Functional outcome of endoprosthetic proximal [4] R. Capanna and D. A. Campanacci, “The treatment of metas- tases in the appendicular skeleton,” Journal of Bone and Joint femoral replacement,” Clinical Orthopaedics and Related Re- search, no. 426, pp. 44–48, 2004. Surgery, vol. 83, no. 4B, pp. 471–481, 2001. [5] D.Chan, S. R. Carter,R.J.Grimer, andR.S.Sneath, “En- [22] M. Malo, A. M. Davis, J. Wunder, et al., “Functional evalu- ation in distal femoral endoprosthetic replacement for bone doprosthetic replacement for bony metastases,” Annals of the Royal College of Surgeons of England, vol. 74, no. 1, pp. 13–18, sarcoma,” Clinical Orthopaedics and Related Research, no. 389, pp. 173–180, 2001. [6] R. M. Tillman, “The role of the orthopaedic surgeon in metastatic disease of the appendicular skeleton. Working Party on Metastatic Bone Disease in Breast Cancer in the UK,” Jour- nal of Bone and Joint Surgery, vol. 81B, no. 1, pp. 1–2, 1999. [7] K. D. Harrington, “Orthopedic surgical management of skele- tal complications of malignancy,” Cancer, vol. 80, no. 8, sup- plement, pp. 1614–1627, 1997. [8] T. A. Damron and F. H. Sim, “Surgical treatment for metastatic disease of the pelvis and the proximal end of the femur,” In- structional Course Lectures, vol. 49, pp. 461–470, 2000. [9] B. J. Gainor and P. Buchert, “Fracture healing in metastatic bone disease,” Clinical Orthopaedics and Related Research, no. 178, pp. 297–302, 1983. [10] D. J. Jacofsky, P. J. Papagelopoulos, and F. H. Sim, “Advances and challenges in the surgical treatment of metastatic bone disease,” Clinical Orthopaedics and Related Research, no. 415, supplement, pp. S14–S18, 2003. [11] J. T. Torbert, E. J. Fox, H. S. Hosalkar, C. M. Ogilvie, and R. D. Lackman, “Endoprosthetic reconstructions: results of long- term followup of 139 patients,” Clinical Orthopaedics and Re- lated Research, no. 438, pp. 51–59, 2005. [12] J. J. Eckardt, J. M. Kabo,C.M.Kelly,W.G.WardSr.,and C. P. Cannon, “Endoprosthetic reconstructions for bone metas- tases,” Clinical Orthopaedics and Related Research, no. 415, supplement, pp. S254–S262, 2003. [13] K. G. Baloch, R. J. Grimer, S. R. Carter, and R. M. Tillman, “Radical surgery for the solitary bony metastasis from renal- cell carcinoma,” Journal of Bone and Joint Surgery, vol. 82, no. 1, pp. 62–67, 2000. [14] H. Mirels, “Metastatic disease in long bones. A proposed scor- ing system for diagnosing impending pathologic fractures,” Clinical Orthopaedics and Related Research, no. 249, pp. 256– 264, 1989. [15] W. F. Enneking, W. Dunham, M. C. Gebhardt, M. Malawar, and D. J. Pritchard, “A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system,” Clinical Orthopaedics and Re- lated Research, no. 286, pp. 241–246, 1993. 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The Use of Massive Endoprostheses for the Treatment of Bone Metastases

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Copyright © 2007 D. H. Park et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract

Hindawi Publishing Corporation Sarcoma Volume 2007, Article ID 62151, 5 pages doi:10.1155/2007/62151 Clinical Study The Use of Massive Endoprostheses for the Treatment of Bone Metastases D. H. Park, P. K. Jaiswal, W. Al-Hakim, W. J. S. Aston, R. C. Pollock, J. A. Skinner, S. R. Cannon, and T. W. R. Briggs The Royal National Orthopaedic Hospital, Stanmore, Middlesex HA7 4LP, UK Received 4 June 2006; Accepted 18 May 2007 Recommended by Adesegun Abudu Purpose. We report a series of 58 patients with metastatic bone disease treated with resection and endoprosthetic reconstruc- tion 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 im- pending 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 endo- prosthetic 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. Copyright © 2007 D. H. Park et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1. INTRODUCTION what can be achieved in the management of metastatic bone diseases [2, 3]. Skeletal complications can have a marked ef- fect on the patient’s quality of life, with bone pain being Bony metastases are the most common neoplasms of bone and the skeleton is the third most common site for metastatic the most frequent clinical symptom. An actual or impending diseases, after the lung and liver [1]. Advances in adjuvant pathological fracture impacts on the patient’s function and and neoadjuvant therapies, especially in the fields of hor- mobility. In principle, the aims of treatment should be to monal therapy and chemotherapy, have improved the prog- relieve pain and restore function by stabilising pathological nosis of patients with cancer. This has subsequently led to fractures [2, 4–6]. Stabilising impending of actual patholog- an increase in the incidence of bony metastases and resultant ical fractures allows early resumption of ambulation, which significantly improves patients’ quality of life [7]. In addi- pathological fractures of the long bones. The management of the patient with a pathological fracture presents a chal- tion to stabilisation, orthopaedic constructs should allow im- mediate weight bearing and be designed to last the expected lenge to the orthopaedic surgeon and necessitates a multidis- ciplinary approach. A consensus statement by the British Or- lifetime of the patient [2, 8]. Fracture healing is often poor in diseased or irradiated bone and the surgeon must take thopaedic Association and the British Orthopaedic Oncol- ogy Society has highlighted the fact that there remains a low into account the fact that these fractures may not unite [9]. Metastatic lesions with extensive bone loss or pathological level of awareness in the hospital and primary-care settings of 2 Sarcoma Table 1: Mirels’ Scoring System. fractures affecting adjacent joints may be treated with resec- tion and an endoprosthetic reconstruction. The load-bearing Variable Score characteristics of endoprosthesis offer immediate postopera- 12 3 tive stability, and facilitate rapid rehabilitation [10, 11]. Over Site Upper limb Lower limb Peritrochanter the last 20 years, the availability and improvement of modu- lar endoprosthesis have improved the treatment of metastatic Pain Mild Moderate Functional bone disease, particularly in the treatment of isolated bone Lesion Blastic Mixed Lytic metastasis, failed conventional reconstructions and lesions Size <1/3 1/3-2/3 >2/3 with extensive bone loss [12]. In selected cases, isolated le- As seen on plain X-ray, minimum destruction of cortex in any view. sions such as a metastasis from renal cell cancer are treated Maximum possible score is 12. If lesion scores 8 or above, then with complete excision and endoprosthetic reconstruction prophylactic fixation is recommended prior to surgery. with the intent to cure [4, 13]. The purpose of this paper is to review our experience of patients with metastatic bone disease from carcinoma that above-mentioned prostheses are modular, off-the-shelf en- had resection and an endoprosthetic reconstruction at our doprosthetic reconstruction systems. For other tumour loca- hospital over a five-year period. tions and before these dates, surgery required the manufac- ture of custom-made implants (Stanmore Implants World- wide Ltd). 2. METHODS In patients requiring proximal femoral replacement and whose disease spared the greater trochanter, this structure We performed a retrospective review of all patients with bone was osteotomised and reattached to the endoprostheses us- metastases referred to our regional musculoskeletal tumour ing a trochanteric reattachment plate and screws. The prox- centre from January 1999 to December 2003. Patients were imal femoral endoprostheses contain a spiked, hydroxyap- identified from the tumour database. We determined the pa- atite coated shoulder with two screw holes for this specific tient demographics, indications for treatment and the com- purpose. This enables gluteus medius and minimus to be plications in patients who had resection of metastatic bone reattached thereby preserving abductor function. Postopera- lesions and endoprosthetic reconstruction. The following in- tive radiotherapy was offered to all patients with pathological clusion criteria are applied for the sample collection: (1) a fractures and those whose resection margins were positive. known metastatic lesion in the appendicular skeleton on the We did not routinely offer radiotherapy to patients who had basis of histological diagnosis; and (2) no previous resec- a successful wide excision. tion and endoprosthetic reconstruction. Other information, Functional outcome was assessed using the system namely, age, gender, primary lesion if known, site of lesion, adopted by the musculoskeletal tumour Society (MSTS) for and duration of follow-up period, were also noted. All pa- the functional evaluation of reconstructive procedures after tients referred to our institution are discussed in a multidis- skeletal resection [15], and a patient-reported measure of ciplinary team setting, attended by oncologists, radiologists, disability, the Toronto extremity salvage score (TESS) [16]. orthopaedic surgeons, and other allied health professionals. The MSTS score is a clinician scored system assessing pain, Decisions regarding prophylactic surgery for patients with function, and emotional acceptance in patients for upper and impending pathological fractures are made based on Mirels lower extremities. Patients with lower extremity reconstruc- [14] scoring system (Table 1), with a score of >8 necessitating tions were also evaluated with regard to walking ability, gait, operative stabilisation. and the use of walking aids. Patients with upper extremity The indications for endoprosthetic reconstruction were reconstructions were evaluated for manual dexterity, hand isolated single metastases in the long bones, lesions involv- positioning, and lifting ability. The TESS was developed as ing adjacent joints, and large lesions with extensive bone loss. a disease-specific measure for patients undergoing limb sal- In principle, these metastatic lesions were excised in a simi- vage surgery for tumours of the extremity. It evaluates phys- lar manner to primary bone tumours. Where possible, wide ical disability based on the patients’ report of their function soft tissue margins were obtained and the shaft of the long using a self-administered questionnaire, which rates the dif- bone was transected at least 2 cm away from the extent of the ficulty experienced in performing certain activities. Both the disease. In view of the fact that this is palliative surgery, im- MSTS and TESS scores are represented as a percentage, with portant neurovascular structures were usually preserved at a higher percentage indicating better functional outcome. the expense of wide margins in order to maximise functional outcome. In patients with intraarticular spread of tumour, we performed conventional joint replacement surgery and 3. RESULTS did not attempt extraarticular resections. In the case of prox- imal femoral, distal femoral and proximal tibial reconstruc- Between January 1999 and December 2003, 171 patients tion modular endoprosthetic tumour system (METS, Stan- were diagnosed with metastatic bone tumours from carci- more Implants Worldwide Ltd, Stanmore, Middlesex, UK) noma. Fifty-eight of which underwent an endoprosthetic re- were used as it became available. For the proximal femoral construction. There were 28 males and 30 females with a replacements, this was in 2001 and for the distal femoral mean age at diagnosis of 62 years (range 24 to 88). The most and proximal tibial replacements, this was in 2003. These common underlying diagnosis was renal cell carcinoma in D. H. Park et al. 3 Table 2: Primary diagnosis of patients undergoing endoprosthetic humeral replacements had MSTS scores and TESS of 72% reconstruction. and 70%, and 73% and 71%, respectively. One patient with a distal humeral replacement had an MSTS score of 76% and a Primary diagnosis Number (%) TESS of 77%. Renal carcinoma 27 (46.6) No patients had local recurrence or required subsequent Breast carcinoma 10 (17.2) amputation and there was one revision of the humeral dia- Unknown primary 8 (13.8) physeal replacement as described above. Lung carcinoma 4 (6.9) Squamous cell carcinoma 2 (3.4) 4. DISCUSSION Prostate carcinoma 2 (3.4) Thyroid carcinoma 1 (1.7) Endoprosthetic reconstruction has a role in the management of metastatic lesions with extensive bone loss, failure of con- Oesophageal carcinoma 1 (1.7) ventional reconstruction, and large isolated lesions with the Phaeochromocytoma 1 (1.7) aim being curative. Although the conventional treatment of Ovarian carcinoma 1 (1.7) metastatic bone lesions with plates and intramedullary de- Bladder carcinoma 1 (1.7) vices supplemented with methylmethacrylate is well estab- lished [7], lesions that involve adjacent joints often require resection and reconstruction to allow early and full weight 27 (46.6%) of patients, followed by breast carcinoma in 10 bearing. The purpose of this study was to review our expe- (17.2%), unknown primary carcinoma in 8 (13.7%), lung rience with endoprosthetic replacements and to objectively carcinoma in 4, squamous cell carcinoma in 2, prostate carci- assess patient outcome using both a clinician-reported and noma in 2, thyroid, oesophageal, ovarian, and bladder carci- a patient-reported score. The majority of the endoprosthetic noma in 1 patient each and a phaeochromocytoma (Table 2). reconstructions in our series were proximal femoral replace- Forty-six patients had lower extremity lesions, which were ments, a finding reflected in other series of endoprosthetic treated with 31 proximal femoral replacements, 11 distal replacements for bone metastases [5, 12], with the proxi- femoral replacements, and 4 proximal tibial replacements. mal femur being the most common site of long-bone in- Twelve had upper extremity lesions, treated with 7 proximal volvement by metastatic disease [8, 17, 18]. The hip joint humeral replacements, 4 distal humeral replacements, and 1 must bear as much as six times body weight and this ne- humeral diaphyseal replacement. cessitates that reconstruction must provide immediate sta- Therewere5superficial woundinfections(8.6%), allof bility and prolonged durability. This strongly favours the use which resolved with oral antibiotics. Four dislocations oc- of an endoprosthetic replacement rather than internal fixa- curred in the proximal femoral replacements group (12.9%). tion [8]. Conventional fixation of pathological fractures or Three were reduced closed and one required an open re- large lytic lesions especially around the hip or proximal fe- duction without requiring component repositioning and this mur has a high failure rate when compared to a standard or patient was subsequently managed in an abduction brace tumour prosthetic replacement [5, 19, 20]. It is therefore our for 8 weeks. There was one case of aseptic loosening in the preferred method of treatment to carry out a resection and humeral diaphyseal replacement, which required revision, endoprosthetic replacement for large lesions of the proximal one subluxation in a proximal humeral replacement, and one femur. The extent of tumour in the proximal femur dictated case of component malposition. The tibial component of a the method of abductor repair and if the trochanter could be distal femoral replacement was found to be rotated 180 de- spared with an adequate margin of bone between the tumour grees requiring open exploration and repositioning. and a trochanteric osteotomy, then the trochanter was reat- Thirty-four patients had died at a mean of 22 months tached in the manner described previously. Tumour involv- (range 2 to 51 months) from surgery and 5 were lost to follow ing the trochanter resulted in resection of the proximal femur up. The remaining 19 had a mean follow-up of 48.2 months including the trochanter and a soft tissue abductor repair was (range 27 to 82 months). They were functionally evaluated done. In our series of 11 patients, only one patient was suit- with the MSTS and the TESS scores (Table 3). For the group able for a trochanteric osteotomy and reattachment to the as a whole, the mean MSTS score was 73% (range from 57 to prosthesis. This patient subsequently had a dislocation on 90%) and TESS was 71% (range 46 to 95%). Looking specifi- her first postoperative day and underwent a closed reduction. cally at lower limb reconstruction, the mean MSTS score was At 31 months follow-up, her MSTS score was 57% and her 77.9% (range 57 to 90%) and the mean TESS was 75.6% TESS was 46%. Due to the small numbers we are unable to (range 46 to 95%). The group with proximal femoral re- comment on whether trochanteric reattachment significantly placements (11 patients) had a mean MSTS score of 72.4% affects functional outcome or hip abductor function. Of the (range 57 to 83) and a mean TESS of 68.4% (range 46 to 11 patients with proximal femoral lesions, seven presented 84). The group with distal femoral replacements (4 patients) with a pathological fracture. Patients who had a pathological had a mean MSTS score of 75% (range 60 to 90) and a mean fracture on presentation had a mean MSTS score of 69.1% TESS of 77.5% (range 63 to 95). One patient with a proximal (range 57 to 80%) and a mean TESS of 65.9% (46 to 82%). tibial replacement had an MSTS score of 73% and a TESS Patients who presented without a pathological fracture had score of 72%. In the upper limb, two patients with proximal a mean MSTS score of 78% (range 70 to 83%) and a mean 4 Sarcoma Table 3: Functional outcomes of the 19 patients (out of 58) surviving 2 years or more. Patient Primary Age Operation TESS MSTS Follow-up (months) 1 Phaeochromocytoma 24 PFR 82 80 39 2 Thyroid carcinoma 42 PFR 72 74 41 3 Oesophageal carcinoma 42 PFR 69 63 35 4 Ovarian carcinoma 45 PFR 65 77 33 5 Breast carcinoma 49 PFR 46 57 31 6 Renal carcinoma 67 PFR 56 63 31 7 Unknown primary 77 PFR 71 70 44 8 Unknown primary 58 PFR 74 78 44 9 Breast carcinoma 68 PFR 53 70 27 10 Breast carcinoma 42 PFR 84 83 58 11 Renal carcinoma 36 PFR 80 81 46 12 Squamous cell carcinoma 49 PTR 72 73 28 13 Renal carcinoma 46 DFR 72 71 82 14 Breast carcinoma 50 DFR 95 90 35 15 Renal carcinoma 56 DFR 80 79 66 16 Renal carcinoma 61 DFR 63 60 73 17 Renal carcinoma 52 PHR 71 73 73 18 Renal carcinoma 54 PHR 70 72 60 19 Unknown primary 59 DHR 77 76 60 PFR = proximal femoral replacement, PHR = proximal humeral replacement, PTR = proximal tibial replacement, DFR = distal femoral replacement, DHR = distal humeral replacement. TESS of 72.8% (range 53 to 84%). The difference in scores are than 2 years and in the latest follow-up, they were mobilising not statistically significant and larger studies will be required with one walking stick. Functionally their MSTS scores and to determine if patients who present with pathological frac- TESS were 57% and 46%, and 70% and 53%, respectively. tures have poorer functional outcome scores compared to The mean time to death of the 58 patients was 22 months patients who do not. With regard to overall functional out- (range 2 to 51 months). This wide range highlights the need come, patients with proximal femoral replacements had a for a stable reconstruction that allows early weight bearing, mean MSTS score of 72.3% (range 57 to 83%) and a mean has a low incidence of failure, and outlasts the expected life- TESS score of 68.4% (range 46 to 84%). These scores com- time of the patient. pare to those reported in other series of proximal femoral Our series was associated with relatively few, easily man- endoprosthetic replacements using modular endoprostheses ageable complications and there were no implant failures. [21, 22]. Massive endoprostheses were originally developed for Table 3 shows the functional outcomes of all the patients the treatment of primary malignant bone tumours. They who survived 2 years or more who were treated with an en- have traditionally been custom-designed and hence there doprosthetic replacement. The functional outcomes for pa- was a time delay to manufacture the implant. The grad- tients with upper and lower limb reconstructions are com- ual introduction of modular endoprostheses has provided parable; however, the number of patients followed up with greater flexibility making these reconstructions possible, and upper limb reconstructions (three) is too small for any fur- in shorter time frames, therefore aiding the overall manage- ther significant conclusions. ment of metastatic bone disease. According to British Or- There were five cases of superficial infection which re- thopaedic Association guidelines [2], patients should un- solved with oral antibiotics alone, but no cases of deep in- dergo a single procedure that allows early full weight bearing fection. In 58 endoprosthetic replacements, only one patient and lasts the expected lifespan of the patient. In our experi- required a revision for aseptic loosening of a humeral diaphy- ence the use of an endoprostheses allows these criteria to be seal replacement. There were four dislocations in the group met. of patients who had proximal femoral replacements (31 pa- Appropriate and prompt surgical management of tients). All dislocations occurred within the first 3 weeks of metastatic bone lesions may be more cost-effective in terms surgery. Three were reduced closed and one required an open of the overall management of cancer patients. This is re- reduction without the need for component repositioning. flected in earlier mobilisation and therefore potentially less They were all rehabilitated postreduction in an abduction time spent in hospital. Other studies are needed to assess the brace for 8 to 10 weeks. None of these patients experienced impact of these cost savings on hospital, nursing, and com- any further dislocations. Two of these patients survived more munity cancer services. Patients who had an endoprosthetic D. H. Park et al. 5 reconstruction in our series were able to return to a good [16] A. M. Davis, J. G. Wright, J. I. 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