Surgical treatment of pathologic hip lesions in patients with metastatic disease.

Impending and pathologic fractures about the hip due to metastatic tumors are debilitating to patients secondary to pain and loss of mobility. The results of internal fixation of impending or complete pathologic fracture about the hip in 29 patients undergoing 32 procedures were retrospectively reviewed. Operative procedures included total hip arthroplasty with protrusio cup acetabular reconstruction in 5 patients, bipolar hip replacement in 7 patients, compression screw and sideplate in 6 patients, placement of reconstruction intramedullary nail in 12 patients, proximal femoral replacement in 1 patient, and placement of pins and polymethylmethacrylate in 1 patient. Every patient in this series had relief of pain postoperatively, and all had improved ambulation. There were no operative or anesthesia related complications, no intraoperative or perioperative deaths, an no failures of fixation. A single postoperative complication occurred in a patient in whom a sacral decubitus developed that resolved with local wound care. This study shows that operative fixation of pathologic hip lesions can be performed with low morbidity and mortality in a debilitated patient population with good results postoperatively.

Role of tumor necrosis factor alpha in particulate-induced bone resorption.

The purpose of this study was to determine the role of tumor necrosis factor alpha in bone resorption secondary to mediator release from macrophages exposed to cement particles. The J774 mouse macrophage cell line was exposed to polymethylmethacrylate particles for 24 hours and the resulting conditioned medium was analyzed for prostaglandin E2, tumor necrosis factor alpha, interleukin-1 alpha and beta, and the ability to stimulate release of prostaglandin E2 and 45Ca from radiolabeled mouse calvaria. Macrophage exposure to polymethylmethacrylate particles led to a 9-fold increase in release of tumor necrosis factor alpha (p < 0.01), but did not lead to a significant increase in release of prostaglandin E2, interleukin-1 alpha, or interleukin-1 beta when compared to unexposed cells. Exposure of the macrophages to polymethylmethacrylate particles over a time course from 30 minutes to 96 hours led to an increase in the release of tumor necrosis factor alpha that was initially detected at 30 minutes and was maximum at 48 hours. Incubation of the macrophage-polymethylmethacrylate conditioned medium with rat calvaria significantly increased the release of 45Ca and prostaglandin E2 from the bone. To study the role of release of tumor necrosis factor alpha in bone resorption, the macrophage-polymethylmethacrylate conditioned medium was then preincubated with anti-tumor necrosis factor alpha antibody prior to exposure of the conditioned medium to the calvaria. This preincubation was successful in significantly inhibiting 45Ca release by calvaria (p <0.01) to levels that were not significantly different from the levels of release by unexposed calvaria. Tumor necrosis factor alpha appears to play a critical role in initiating particulate-induced bone resorption. Exposure of macrophages to polymethylmethacrylate particles leads to a significant release of tumor necrosis factor alpha in a time-dependent fashion. This macrophage-polymethylmethacrylate conditioned medium stimulated release of prostaglandin E2 and bone resorption in bone organ culture. The addition of anti-tumor necrosis factor alpha antibody to this in vitro system inhibited the bone resorption stimulated by the macrophage-polymethylmethacrylate conditioned medium and partially suppressed the production of prostaglandin E2. The sequence of events in this model for particulate-induced bone resorption appears to be initiated by the production of tumor necrosis factor alpha by the macrophage, followed by production of prostaglandin E2 by cells in bone, and then by bone resorption.