Surgical management of proximal femoral metastasis: Fixation or hip replacement? A 309 case series.

INTRODUCTION: The proximal femur is the most frequent operative site for metastasis, but there is no consensus between internal fixation and hip replacement. The present multicenter retrospective observational study sought: (1) to compare early clinical results between internal fixation and hip replacement for proximal femoral metastasis (PFM), and (2) to assess events affecting survival. HYPOTHESIS: The study hypothesis was that internal fixation and hip replacement give comparable clinical results, operative site complications rates and survival. MATERIAL AND METHODS: The series comprised 309 cases, 10 of which were bilateral, in 182 females and 117 males, with a mean age of 67.2±11.5 years and 62.5±13.2 years, respectively. Primaries were mainly breast (118; 38.2%), lung (85; 25.5%) or kidney (40; 12.9%). PFM was revelatory in 114 cases (36.9%). There was visceral involvement in 142 patients (46%), multiple peripheral bone involvement in 212 (68.6%), and spinal involvement in 134 (43.4%). There were 124 pathologic fractures (40%), 51 of which were revelatory. Metastases were cervicocephalic in 135 cases (43.7%), metaphyseal in 166 (53.7%) and both in 8 (2.6%). PFM was osteolytic in 90% of cases, managed by hip replacement in 161 cases and internal fixation in 148 (12 screwed plates, 136 nails). Seventy-seven patients had postoperative radiation therapy. RESULTS: After hip replacement (n=144), walking was normal in 35 cases (24.3%), impaired but unassisted in 53 (36.8%), with 1 forearm crutch in 24 (16.6%), 2 crutches or a frame in 26 (18%), and impossible in 6 (4.1%). After nailing (n=125), results were respectively 38 (30.4%), 47 (37.6%), 15 (12%), 18 (14.4) and 7 (5.6%). Recovery of normal walking capacity did not significantly differ according to technique (p=0.162); nor did pain or function. Recovery of normal walking capacity was better after preventive surgery (p<0.001). Perioperative complications comprised: 10 cases of severe blood loss, 7 pulmonary embolisms, 6 digestive hemorrhages, and 5 lung infections. Secondarily, there were 11 infections (7 after hip replacement, 2 after nailing, 2 after plate fixation), 7 progressive osteolyses and 5 fractures. Complications rates were significantly higher with plate fixation, with no difference between nailing and hip replacement. Survival did not significantly differ between hip replacement (12 months [95% CI: 7-19]), nailing (7 months [95% CI: 6-11]) and plate fixation (16 months [95% CI: 6-not calculable]). CONCLUSIONS: Clinical results and survival were comparable between hip replacement and nailing, confirming the study hypothesis, in agreement with the literature. Each technique has its indications. Patients with severely impaired walking capacity benefited greatly from surgery. The importance of preventive surgery was highlighted. LEVEL OF EVIDENCE: IV, retrospective study.

Functional results and survival after surgery for peripheral skeletal metastasis: A 434-case multicenter retrospective series.

INTRODUCTION: Peripheral skeletal metastasis (PSM) has a negative impact on quality of life. New treatments for the primary tumor or the osteolysis hold out hope of improved survival. The few published French series were small, and we therefore undertook a multicenter retrospective analysis of PSM surgery between 2005 and December 2016, with the aim of assessing: 1) rate and type of complications, 2) functional results, and 3) overall survival and corresponding risk factors. HYPOTHESIS: The French data for clinical results, survival and complications are in agreement with the international literature. MATERIALS AND METHOD: The series comprised 391 patients with 434 metastatic locations. There was female predominance: 247 women (63%). Two sites were treated in 46 patients (12%), and three in 5. The main etiologies were breast cancer (151/391: 39%), lung cancer (103/391: 26%) and kidney cancer (52/391: 13%). There was synchronous visceral metastasis in 166 patients (42.5%), other peripheral locations in 137 (35%) and spinal location in 142 (39%). One hundred (27%) had ASA score>3; 61 (16%) had WHO score>3. The reason for surgery was pathologic fracture (n=137: 35%). Locations were femoral (274: 70%), acetabular (58: 15%), humeral (40: 0%), tibial (12: 3%) or other (7: 2%). RESULTS: There were surgery site complications in 41 patients (9.4%), including 13 surgery site infections, and general complications in 47 patients (11%), including 11 cases of thromboembolism, 6 of blood loss, 9 pulmonary complications and 6 perioperative deaths. Overall survival, taking all etiologies and sites together, was 10 months (range, 5 days to 9 years; 95% CI, 8-13 months), and significantly better in females (14 versus 6 months; p=0.01), under-65 year-olds (p=0.001), and in preventive surgery versus fractured PSM (p=0.001). Median survival was 22 months (95% CI, 17-28 months) after breast cancer, 3 months (95% CI, 2-5 months) after lung cancer, and 17 months (95% CI, 8-58 months) after kidney cancer. Preoperatively, walking was impossible for 143 patients (38%), versus 23 (6.5%) postoperatively; 229 patients (63.5%) could walk normally or nearly normally after surgery, versus 110 (28%) before. After surgery, 3 patients (6%) were not using their operated upper limb, versus 27 (45%) before; 30 patients (54%) had normal upper limb use after surgery, versus 8 (5%) before. CONCLUSION: The study hypothesis was on the whole confirmed in terms of survival according to type of primary and whether surgery was indicated preventively or for fracture. LEVEL OF EVIDENCE: IV, retrospective study without control group.

Surgical treatment of tibial metastases: Retrospective, multicenter, observational study of 25 patients.

INTRODUCTION: Long bone metastasis to the tibia is somewhat rare and has only been studied in a few publications with a limited number of cases. This led us to carry out a large multicenter, observational, retrospective study to 1) evaluate the clinical and radiological outcomes of surgical treatment at this location and 2) highlight the specific risks associated with this condition. HYPOTHESIS: We hypothesized that the clinical outcomes and survivorship were comparable to those reported in the literature. MATERIAL AND METHODS: The case series included 15 men and 10 women with a mean age of 66±11.7 years. The most common primary cancers were kidney (10 patients) and lung (4 patients). Thirteen patients had a concurrent visceral metastasis and sixteen had metastasis in another bone. The tibial metastasis was the initial sign of cancer in seven patients. The surgical procedure was done to prevent an impending fracture in 19 patients and to treat a pathological fracture in 6 patients (initial sign of cancer in 4 patients). Osteolysis occurred in the proximal epiphysis/metaphysis in 12 patients, diaphysis in 9 patients and distal epiphysis/metaphysis in 4 patients. We performed fixation with a lateral cortex plate and cementoplasty in 14 patients, locked intramedullary nailing in 8 patients, cementoplasty only in 2 patients and knee arthroplasty in 1 patient. RESULTS: Three surgical site infections, one pulmonary embolism and one cardiac rhythm disturbance occurred. Four patients died before the 3rd month postoperative. At their best clinical status, 2 patients had not resumed walking, 10 could walk short distances with two canes or a walker, 3 had altered gait but could walk without aids and 6 could walk normally. The mean survival was 14±11.7 months (95% CI: 8.1-19.8) for all patients, 4±4 months (95% CI: 3-14) for those with a lung primary and 32±14 months (95% CI: 20-47) for those with a kidney primary. The survival was 15 months (95% CI: 4-29) after preventative treatment and 5 months (95% CI: 4-26) after fracture treatment. CONCLUSION: Our clinical outcomes are comparable overall to the three main published articles on this topic. The risk of infection and benefits of preventative fixation were apparent in our cohort. LEVEL OF EVIDENCE: IV, retrospective study.

Interprosthetic femoral fractures: Morbidity and mortality in a retrospective, multicenter study.

INTRODUCTION: Interprosthetic femoral fractures (IFF) are becoming more frequent; however they have not been the subject of many publications and the largest study on this topic includes only 30 cases. The complication rate and clinical outcomes have only been evaluated in small case series. This led us to conduct a retrospective, multicenter, observational study in IFF patients with at least 12 months' follow-up to (1) determine the mortality and morbidity (2) determine the clinical and radiological outcomes and (3) identify elements of the treatment indications. HYPOTHESIS: The morbidity and mortality rates will be comparable to those in recent studies on this topic. MATERIALS AND METHODS: The study included 51 patients (49 women, 2 men) with a mean age of 82.8±9.2 years [55-97], a mean Parker score of 4.9±2.4 and a mean Katz score of 4.4±1.4 who had suffered an IFF between 2009 and 2015. According to the SoFCOT modifications of the Vancouver classification, 30 fractures were interprosthetic in the shaft segment where there were no implants (19 double C and 11 type D (corresponding to a type C with less than two diaphysis widths between the extension stems of the hip and knee implants)) while 21 were periprosthetic, with 12 around the THA (11 B1 and 1 B3) and 9 around the TKA (8 B1 and 1 B3). One patient was treated conservatively with an external fixator but died the next day, 2 patients received a new total hip arthroplasty and 47 underwent plate fixation of their fracture (one patient was treated non-operatively because of poor medical condition). RESULTS: One patient was lost to follow-up, and nine died during the first 6 months. Six early surgical site complications occurred and 13 general ones. Within 1 year of the IFF, there were six mechanical complications, two surgical site infections and two cases of loosening. The mean follow-up was 27.6±17.2 months. The mean time to union was 19.25±8.8 weeks. The mean final Parker score was 3.37±2.6 and the mean Katz score was 2.98±1.8; both were significantly lower than the initial scores. Six patients died between months 12 and 50. The overall mortality at the final review was 31% (16/51) with a median survival of 3.45 years. DISCUSSION: Our hypothesis was not confirmed because the mortality and morbidity in our study were higher than in other published studies. In the six relevant studies identified, the surgical site infection rate was 12.3%, the major revision rate was 11.6% and the mortality rate was 6.5%. In our study, these values were 24%, 24% and 31%, respectively. These worse results may be explained by the very fragile nature of the studied population and the surgeons not following appropriate technical rules for fracture fixation. LEVEL OF EVIDENCE: IV, Retrospective study.