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

Abstract

Background: Traditional treatments for pathological fractures of the proximal femur resulting from metastatic bone disease include fixation with intramedullary nailing supplemented with polymethylmethacrylate, osteosynthesis with a plate-screw construct and polymethylmethacrylate, or endoprosthetic reconstruction. Despite the frequent practice of these treatments, treatment outcomes have not been rigorously compared. In addition, very few studies examine specific approaches to endoprosthetic reconstruction such as long stem hemiarthroplasty.

Questions/purposes: This study examines survival, functional outcomes, and complications associated with long stem hemiarthroplasty in a small group of patients treated for impending and actual pathologic fractures of the proximal femur resulting from metastatic bone disease.

Methods: Between 2012 and 2015, 21 patients were treated with long stem cemented hemiarthroplasty in 22 limbs. During that time, indications for this approach included lesions from metastases, myeloma, or lymphoma involving the proximal femur that resulted in an impending or actual pathological fracture. An impending fracture was classified as a painful lesion with at least 50% cortical erosion. During the study period, six patients with proximal femoral metastases not deemed to meet these indications were treated with other surgical approaches such as intramedullary nailing supplemented with polymethylmethacrylate and osteosynthesis with a plate-screw construct and polymethylmethacrylate. Mortality was tracked through medical records and phone calls to the patients and their families. Followup for the entire group of patients (n = 22) ranged from 1 to 27 months with a mean duration of 11 months. For patients with at least 1 year of followup (n = 11), the mean duration was 18 months (range, 12-27 months) and for patients with less than 1 year of followup (n = 11), the mean duration was 3 months (range, 1-11 months). Functional outcomes were evaluated according to the Musculoskeletal Tumor Society (MSTS) scoring system for lower extremities, the Eastern Cooperative Oncology Group (ECOG) Scale of Performance Status, and the Karnofsky Performance Scale (KPS) Index. Scores and complications were determined by direct patient examination, retrospective chart review, review of a longitudinally maintained institutional database, and followup phone calls.

Results: Ten patients died of disease within the followup period. Before surgery, the median total MSTS score for the entire group of patients (n = 22) was 4.5 (range, 0-23), the median ECOG score was 3.5 (range, 1-4), and the median KPS score was 40 (range, 30-70). Postoperatively, the median total MSTS score (measured at most recent followup) for the entire group of patients was 21 (range, 5-30), the median ECOG score was 2 (range, 0-3, 68% ≤ 2), and the median KPS score was 60 (range, 40-100). For the 11 patients with at least 1 year of followup, the median total MSTS score (measured at most recent followup) was 27 (range, 21-30), the median ECOG score was 1 (range, 0-2, 100% ≤ 2), and the median KPS score was 80 (range, 60-100). For the remaining 11 patients with less than 1 year of followup, the median total MSTS score (measured at most recent followup) was 11 (range, 5-25), the median ECOG score was 3 (range, 1-3, 36% ≤ 2), and the median KPS score was 40 (range, 40-80). Complications included one periprosthetic fracture resulting from a fall, three cases of radiation-induced edema, and two cases of sciatica that developed unrelated to the procedure.

Conclusions: Long stem cemented hemiarthroplasty results in fair levels of function in a complex population of patients whose prognosis is sometimes measured only in months and who otherwise might be disabled by their metastatic lesions. Comparative trials applying consistent indications and inclusion criteria should be performed between this approach and fixation with intramedullary nailing supplemented with polymethylmethacrylate as well as osteosynthesis with a plate-screw construct and polymethylmethacrylate.

Level of evidence: Level IV, therapeutic study.

Fig. 1A–B

A 72-year-old woman with metastatic breast adenocarcinoma was treated for a pathologic fracture with a long stem hemiarthroplasty. (A) Preoperative radiographs show an impending pathologic fracture of the left proximal femur. (B) Postoperative radiographs show fixation of the impending fracture with a long stem prosthesis in place. Cables were placed in this particular patient to stabilize the greater trochanter. A total knee prosthesis from prior surgery is also noted. Proximal and distal radiographs superimposed using photograph-editing software to appreciate the extent of the operation.

Fig. 2A–D

A 73-year-old man with multiple myeloma was treated for a pathologic fracture with a long stem hemiarthroplasty. (A) Preoperative radiographs show a pathologic fracture of the left proximal femur. (B) Postoperative radiographs show fixation of the fracture with a long stem prosthesis in place. A total knee prosthesis from prior surgery is noted. Proximal and distal radiographs are superimposed using photograph-editing software to appreciate the extent of the operation. (C) A fall 3 months postoperatively resulted in a segmental periprosthetic diaphyseal fracture. (D) The patient was treated with surgical reduction and fixation with Dall–Miles cables.