Prophylactic stabilization for bone metastases, myeloma, or lymphoma: do we need to protect the entire bone?

Abstract

Background: The current operative standard of care for disseminated malignant bone disease suggests stabilizing the entire bone to avoid the need for subsequent operative intervention but risks of doing so include complications related to embolic phenomena.

Questions/purposes: We questioned whether progression and reoperation occur with enough frequency to justify additional risks of longer intramedullary devices.

Methods: A retrospective chart review was done for 96 patients with metastases, myeloma, or lymphoma who had undergone stabilization or arthroplasty of impending or actual femoral or humeral pathologic fractures using an approach favoring intramedullary fixation devices and long-stem arthroplasty. Incidence of progressive bone disease, reoperation, and complications associated with fixation and arthroplasty devices in instrumented femurs or humeri was determined.

Results: At minimum 0 months followup (mean, 11 months; range, 0-72 months), 80% of patients had died. Eleven of 96 patients (12%) experienced local bony disease progression; eight had local progression at the original site, two had progression at originally recognized discretely separate lesions, and one had a new lesion develop in the bone that originally was surgically treated. Six subjects (6.3%) required repeat operative intervention for symptomatic failure. Twelve (12.5%) patients experienced physiologic nonfatal complications potentially attributable to embolic phenomena from long intramedullary implants.

Conclusions: Because most patients in this series were treated with the intent to protect the bone with long intramedullary implants when possible, the reoperation rate may be lower than if the entire bone had not been protected. However, the low incidence of disease progression apart from originally identified lesions (one of 96) was considerably lower than the physiologic complication rate (12 of 96) potentially attributable to long intramedullary implants.

Level of evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Fig. 1

The pie chart shows the breakdown of primary diagnoses for the reported patient population (N = 96). The “other” category includes the following primary tumors: parotid gland carcinoma, colonic adenocarcinoma, hepatocellular carcinoma, malignant melanoma, thyroid carcinoma, bladder carcinoma, cervical squamous cell carcinoma, and metastatic chondrosarcoma.

Fig. 2A–C

The most common forms of surgical instrumentation used in this series are shown here. (A) For impending proximal femoral pathologic fractures and intertrochanteric, subtrochanteric, and diaphyseal femur pathologic fractures, reconstruction intramedullary nailing was performed in most cases. A typical reconstruction intramedullary nail is shown in the right femur. (B) For femoral neck pathologic fractures, extensive periarticular destruction of the proximal femur, and selected intertrochanteric femur pathologic fractures, a long-stem cemented arthroplasty was used. A calcar-replacing long-stem cemented arthroplasty of the right femur is shown. (C) For impending humeral fractures and fractures distal to the neck region with adequate remaining proximal bone, an antegrade locked nailing of the humerus was done. A locked intramedullary nail of the humerus is shown.

Fig. 3A–B

Type 2 progression was seen in this patient who initially was treated with a long-stem cemented hemiarthroplasty for a pathologic femoral neck fracture secondary to multiple myeloma. (A) An immediate postoperative radiograph after shows small lesions in the subtrochanteric region. (B) A followup radiograph taken at the 3-month office visit shows local progression of the original lesion compared with the immediate postoperative radiograph. This Type 2 progression occurred despite perioperative irradiation and protection of the entire bone by the long-stem cemented device. In this case, the patient remained asymptomatic and did not require additional operative intervention.