Surgical Treatment of Metastatic Disease of the Femur

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Surgical Treatment of Metastatic Disease of the
Femur

• Swanson,MD, Pritchard,MD Sim,MD
• J Am Acad Orthop Surg 2000856-65
• Presented By James M. Steinberg, DO

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Introduction

• Leading cause of death in cancer patients
• Bone is the 3rd most common site (lung liver)
• Tumors of breast, thyroid, lung, prostate,
  kidney most likely to metastasize to bone
• 1.2 million new cases of cancer diagnosed
  annually more than 50 will have bony mets

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Clinical Presentation

• Pain most common symptom
• Due to stretching of periosteum stim of nerve
  endings in endosteal bone
• Night and rest pain are cardinal features
• Pathologic Fx may be 1st sign
• Breast ca accounts for most path fxs
• Femur most common 66
• Usually proximal femur (50)
• 20 intertroch region

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Clinical Evaluation

• Thorough H P
• Wt loss, dec activity level, PAIN
• Lab evaluation
• Seldom diagnostic
• No specific single marker of bone mets
• Hypercalcemia common with mets

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Mets with No Primary Tumor Identified

• Evaluation
• HP, labs, cxr, skeletal survey, whole body
  technetium-99m bone scan and CT of the chest,
  abdomen, and pelvis
• R/O multiple myeloma
• CBC, ESR, and serum electrophoresis
• Adenocarcinoma
• Alpha-fetoprotien, beta-HCG, CEA, PSA

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Metastatic Lesions

• Blastic Lesions
• Prostate
• Lytic Lesions
• Lung, thyroid, kidney
• Mixed lytic blastic
• breast
• Most lesion arise from within the intramedullary
  canal
• Lesions in pts gt 40 yrs old more likely to be
  mets
• Lesions in pts lt 40 yrs old more likely to be
  infection and primary tumors of bone

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Patterns of Bone Destruction

• Geographic Lesions
• Solitary, well defined with sharply demarcated
  borders
• Slowly developing mets
• Moth eaten Lesions
• Multiple small lytic areas in spongy cortical
  bone
• Ill defined borders
• Permeative Lesions
• Multiple tiny lytic areas in cortical bone
• Aggressive lesions

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Treatment Strategy

• Goals
• Pain relief
• Restoration of premorbid ambulatory function
• Operative vs Nonoperative
• Tumor location, tumor type, extent of the tumor,
  overall health
• Can the pt survive a major sx?
• Life expectancy

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Impending Pathologic Fx

• Determine risk of Fx
• Type, size, extent, and location
• Lytic lesions more likely to fx than blastic
• Tumors prone to Fx
• Large lesions
• Soft tissue extension (MRI)
• Region of the lesser troch
• Subtroch region with medial involvement
• Diaphyseal lesions with 50 of the diameter or
  one cortex destroyed

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Mirels Scoring System

• 12 point scoring system
• Score of 9 or above indicates a high likelihood
  of future fx.

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Preoperative Planning

• Construct should ideally provide enough stability
  to allow immediate full wt. Bearing with enough
  durability to last the patients expected
  lifetime.
• All areas of weakened bone should be addressed at
  time of sx

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Femoral Head Neck Fractures

• Replacement arthroplasty
• High stress across proximal femur
• Limited potential for healing
• Hemi vs Total
• Dependent upon condition of acetabular cartilage
• Lesions extending into the lesser troch
• Calcar replacement stem
• Long stem prosthesis
• Multiple lesions extending into the diaphysis
• Risk of distal lesions

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Intertrochanteric Fractures

• Controversial
• Lesions confined to intertroch region min
  medial cortical bone destruction
• Compression screw or Nail plate
• Proponents stress importance of adjunctive
  stabilization with methylmethacrylate
• High failure rates
• Lack of load sharing, prolonged survival,
  progression of disease, delayed union or nonunion

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Intertrochanteric Fractures

• Intramedullary hip screws
• Long Gamma nail
• Extensive involvement of head neck with
  extension into inter subtroch regions
• prosthesis

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Subtrochanteric Fractures

• IM Nails treatment of choice
• Third generation recon nails
• Modular proximal femoral prosthesis
• Reserved for radiation resistant lesions with
  extensive femoral head involvement

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Diaphyseal Fractures

• IM Rodding
• Curettage of lesion and augmentation with
  methylmethacrylate may prevent collapse
• Recon Nails locked both proximally distally
• Prevents telescoping

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Distal Femur Fractures

• Supracondylar condylar mets
• Unusual
• Difficult to treat
• Sufficient bone stock
• Conventional internal fixation with
  methylmethacrylate
• Modular type distal femoral knee arthroplasty
• Allows for immediate full wt bearing

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Summary

• Preoperative planning is essential
• Complete work up with appropriate studies
• Skeletal survey
• CT chest, abdomen and pelvis
• MRI if concerned with soft tissue involvement
• Bone scan
• Careful selection of implant type will improve
  quality of life