Article

Prosthetic Hip Replacement for Pathologic or Impending Pathologic Fractures in Myeloma

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Abstract

The authors retrospectively reviewed 53 hip replacements performed in 50 patients (mean age, 65 years) for plasmacytoma (four lesions) or multiple myeloma (49 lesions) of the hip region. Perioperatively, 49 patients received chemotherapy. Twenty-four hip lesions had radiation therapy. Within a mean followup period of 32.6 months, 15 (28%) complications occurred. Late deep infection, dislocation, and aseptic loosening with medial migration of the acetabular component occurred in one patient each. Three patients died during the first postoperatively month. All of the remaining patients postoperatively regained their previous ambulatory status; hip pain relief was achieved in 98% of patients. At the time of the latest followup evaluation, 84% of the patients had died (median survival time, 18 months) and 16% were still alive (median survival time, 76 months). Patients with plasmacytoma had longer survival than did patients with multiple myeloma (median survival, 6.3 years versus 18 months, respectively). No significant association was found between patient survival and the stage of disease at diagnosis, age, gender, type or location of the myeloma lesion, or the type of implant used. Because of the relatively long survival time, prosthetic replacement is indicated for extensive hip lesions in patients with plasmacytoma or multiple myeloma.

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... Multiple myeloma is a malignancy of monoclonal plasma cells, and it is the second most prevalent blood malignancy [1]. Bony involvement is common, and bony lesions due to MM tend to be more diffuse and more extensive than those from metastatic carcinoma [2]. The incidence of pelvic and periacetabular bony involvement in MM is reported to be around 6% [3]. ...
... In case series focusing on periacetabular MM lesions, the indications for surgery are either pathologic fracture or impending fracture [2,5]. Here, we report a rare case of a 69-year-old female with right groin pain due to progression of dysplastic osteoarthritis of the hip. ...
... Multiple myeloma is the second most prevalent blood malignancy, and pelvis and periacetabular lesions in MM are reported to be around 6% [1,3]. Pathologic fracture or impending fracture is the indication for surgery in case series focusing on periacetabular MM lesions [2,5]. This is a case of progressive dysplastic hip osteoarthritis complicated by periacetabular bone loss due to MM. ...
Article
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Total hip arthroplasty (THA) for pathologic and impending fracture due to periacetabular multiple myeloma (MM) lesions has been reported. We report a case of radiographic progression of dysplastic osteoarthritis, complicated by periacetabular MM lesions, treated by THA. A 69-year-old female with a 13-year history of MM presented with right hip pain. Plain radiographs and CT showed that dysplastic osteoarthritis had progressed, while the periacetabular MM lesions remained unchanged. Pathologic fracture was not observed on MRI. THA with a cementless acetabular component and impaction bone grafting was done. Bone graft incorporation was confirmed on CT at 1 year after surgery. There were no signs of bone absorption or implant loosening at last follow-up 3 years after surgery. Due to the advances in the treatment of MM and antiresorptive drugs, cementless acetabular component and impaction bone grafting may be an option for dysplastic osteoarthritis complicated by acetabular bone loss due to MM.
... [1][2][3] However, with rising health care costs and transparent outcome reporting, there is a critical need to analyze risks, outcomes, and survivorship of primary TKA procedures in these cohorts. [1][2][3][4][5][6][7][8][9][10][11][12] Patients who have undergone hematopoietic stem cell transplantation for the treatment of underlying bone marrow pathology represent a specific high-risk population. These patients often have a compromised immune system secondary to chemotherapeutic or immunosuppressive treatments, multiple medical comorbidities, and low levels of circulating hematopoietic cell lines, which theoretically may increase the risk of perioperative complications and poorer outcomes compared with the general arthroplasty population. ...
... These patients often have a compromised immune system secondary to chemotherapeutic or immunosuppressive treatments, multiple medical comorbidities, and low levels of circulating hematopoietic cell lines, which theoretically may increase the risk of perioperative complications and poorer outcomes compared with the general arthroplasty population. [4][5][6][7][8][9][10][11][12] Studies have established the effect of various solid organ transplants and the associated increased complication rate and lower implant survivorship after total joint arthroplasty. [6][7][8][9] Although little information is available on outcomes among patients undergoing non-solid organ transplantation, a recent report showed a high rate of perioperative complications, modest abstract Patients who have undergone hematopoietic stem cell transplantation to treat underlying bone marrow pathology represent a unique and potentially high-risk patient population for total knee arthroplasty (TKA). ...
... Theoretically, these patients may be at risk for increased perioperative complications and poorer implant survivorship, especially given their immunocompromised state, low levels of circulating hematopoietic stem cell lines, and associated complex medical comorbidities. [4][5][6][7][8][9][10][11][12] To the authors' knowledge, the current study is the first to report patient Patient survivorship after hematopoietic stem cell transplantation can be as high as 75% at 3 years and 50% at 5 years for patients with underlying multiple myeloma and 78% at 3 years and 70% at 5 years for patients with chemosensitive follicular lymphoma. 4 The current study, although limited by a smaller number of patients, found survival rates of 91% at 2 years and 55% at 5 years after TKA. ...
Article
Patients who have undergone hematopoietic stem cell transplantation to treat underlying bone marrow pathology represent a unique and potentially high-risk patient population for total knee arthroplasty (TKA). This study retrospectively reviewed 15 TKA procedures performed on 11 patients with a history of hematopoietic stem cell transplantation. The authors analyzed patient survivorship; clinical outcomes, including complications; and implant survivorship. Mean follow-up was 5 years (range, 2-10 years). Patient survivorship free from mortality was 91% (95% confidence interval, 76%-100%) and 55% (95% confidence interval, 25%-85%) at 2 and 5 years, respectively. Patients who underwent hematopoietic stem cell transplantation for multiple myeloma had a significantly higher 5-year mortality rate (100%) compared with patients who had an underlying diagnosis of non-Hodgkin's lymphoma (0%) (P=.008). Mean Knee Society Score improved to 83 postoperatively (P<.001). Two patients (13%) had postoperative wound healing complications that did not lead to periprosthetic joint infection; however, an additional patient (7%) underwent revision surgery at 5 years for periprosthetic joint infection. Estimated implant survivorship without revision was 80% (95% confidence interval, 60%-100%) at 5 years. Elective primary TKA does not appear to affect survivorship in patients with a history of hematopoietic stem cell transplantation. These patients have modest clinical outcomes, higher complication rates as a result of delayed wound healing, and poorer implant survivorship compared with historical control subjects. [Orthopedics. 201x; xx(x):exx-exx.].
... All rights reserved. pathological fractures of the neck of the femur 1,2,8,9,12 but to our knowledge, no such study was done in the past to identify the risk of serious pathology in suspected pathological fractures of the neck of the femur. ...
... 2,5,6 The principles of management of metastatic hip fractures is different to osteoporotic hip fractures. 1,2,8,9,12,17 Identification of the primary site and treating the whole disease are necessary. It often involves multi-disciplinary teams. ...
... 3 When destruction is limited to the femoral neck or head, a cemented hemiarthroplasty or total joint replacement is recommended as a primary procedure. 1,2,8,9,12 Devices such as the dynamic hip screw are rarely indicated as they have a high rate of failure. Radiographs of the entire femur must be obtained before operation to exclude more distal disease. ...
Article
Between 1997 and 2003, a total of 2223 patients presented to our hospital with the neck of femur fracture. This retrospective study examines the histological results of 90 patients (4%) suspected of having a fracture associated with serious underlying pathology. The mean age at the time of fracture was 80 years (44–97). The patients were divided into four groups. Group I: 34 patients with fracture without history of fall or trauma. Group II: 21 patients with suspicious lesions on the standard pelvic radiograph taken on admission. Group III: 27 patients with past history of malignancy without known bone metastases. Group IV: 8 patients with past history of malignancy and known bone metastases. None of the patients in groups I and II had significant abnormalities other than osteoporosis. Four patients (15%) in group III and six patients (75%) in group IV had metastases on histological examination. It is concluded that only groups III and IV are likely to have fractures due to metastatic disease.
... Considering the improved survival achieved with medical treatments, orthopaedic intervention to restore skeletal function and maintain ambulation is of increasing importance for patients with haematologic neoplasms affecting bone (3,15,20,23,29,39). However, the role of surgery for these patients has been restricted to biopsies and management of (15,23,27), and most of the principles for pathological fractures fixation have been similar to those for metastatic bone disease (29). ...
... Considering the improved survival achieved with medical treatments, orthopaedic intervention to restore skeletal function and maintain ambulation is of increasing importance for patients with haematologic neoplasms affecting bone (3,15,20,23,29,39). However, the role of surgery for these patients has been restricted to biopsies and management of (15,23,27), and most of the principles for pathological fractures fixation have been similar to those for metastatic bone disease (29). Moreover, large series with long-term follow-up are required since most patients will invariably relapse, and most patients with plasmacytoma will progress to myeloma (25,27). ...
... Although all patients had adjuvant treatments, our results showed improved survival to death with wide resection only in patients with primary bone lymphoma and plasmacytoma. This may be explained by the pathophysiology of myeloma (29,39) and the solitary lesions of primary bone lymphoma and plasmacytoma. surgical treatment and adjuvants did not improve survival to local recurrence, even with wide resection. ...
Article
Full-text available
We report on 205 patients with haematologic neoplasms of bone treated from 1985 to 2009. There were 77 patients with primary bone lymphoma, 77 with myeloma and 51 with plasmacytoma. All patients had medical treatments; 43 patients had wide and 162 intralesional surgery. Mean follow-up was 5 years (median, 3.5 years); 11 patients were lost to followup. At the latest examination, 99 patients were alive without disease, 20 were alive with disease and 75 were dead of disease; 13 patients (6.7%) had local recurrence; 12 patients (24%) with plasmacytoma developed myeloma. Survival to death was significantly higher after wide resection for lymphoma and plasmacytoma, but not for myeloma. Survival to local recurrence was not statistically different between wide and intralesional surgery for any haematologic neoplasm. Surgical complications including aseptic loosening, infection, neurological deficits and breakage of implants occurred in 21 patients (11%).
... The benefits of surgical treatment for pathological fractures of long limb bones include pain relief, restoration of bone continuity and limb function and improved quality of life. Appropriate surgical procedures include resection or curettage of bone lesions, filling of defects with bone cement and internal fixation as indicated with screws, titanium plates, intramedullary nails or interlocking intramedullary nails and so on 34 . ...
... The choice of fixation system and surgical procedure depends on the patient's general condition and life expectancy, previous response to chemotherapy, fracture site (e.g., femoral neck, sub-trochanteric, inter-trochanteric), number, size and location of lesions and the extent of bone invasion 34 (Table 2). The relationships between lesion location, potential fracture risk and recommended measures are shown in Table 3. ...
Article
Myeloma bone disease (MBD), the skeletal lesions caused by multiple myeloma, is also known as skeletal related events and includes bone pain, osteoporosis, pathological fractures, osteolytic bone lesions, spinal instability, spinal cord and nerve root compression and extramedullary plasmacytoma. It is now generally accepted that patients with these complications usually require surgical management and that such treatment is safe and effective. The aims of surgical interventions are to alleviate pain, improve quality of life, treat potential or existing pathological fractures, decompress the spinal cord and nerve roots, and reestablish bone continuity. Thus far, there have not been uniform standards for surgical treatment of MBD. The Surgeon's Committee of the Chinese Myeloma Working Group has therefore achieved a consensus with the aim of providing guidance for clinicians and benefitting patients with MBD. This consensus focuses on the treatment of MBD, including its clinical definition and characteristics, diagnosis and surgical management. This expert consensus document was compiled after discussion and revision by experts from several relevant institutions in China. However, it is only an interim guide that cannot be enforced legally. It will be updated with development of new techniques of treatment.
... In patients who were discharged from the hospital, pain and mobility scores improved in both groups receiving allografts and in patients who had reconstruction with reinforcement rings and threaded pins. 3 Papagelopoulos et al. 37 retrospectively reviewed 53 hip replacements performed in 50 patients (mean age, 65 years) for plasmacytoma (four lesions) or multiple myeloma (49 lesions) of the hip region. Perioperatively, 49 patients received chemotherapy. ...
... The authors concluded that prosthetic replacement is indicated for extensive hip lesions in patients with plasmacytoma or multiple myeloma. 37 Alternative reconstructive options for periacetabular lesions Harrington 18 reported on 10 patients treated with hemipelvic allograft reconstruction. Functional results were good or excellent. ...
Article
Advances in systemic treatment of cancer have improved patients' survival and increased the number of patients presenting with metastases of the pelvic ring. Pelvic metastatic lesions may cause severe pain and functional disability. A multidisciplinary approach is fundamental for the management of these lesions. Lesions of the pelvis not directly involving the hip joint such as the ischium, pubis or sacroiliac area can generally be treated non-operatively with radiation alone or using minimally invasive procedures of radiofrequency ablation, cryosurgery and percutaneous osteoplasty. Periacetabular destructive lesions may require total hip replacement with reconstruction of the acetabulum dependent on the extent of the defect. Operative treatment should restore the mechanical stability of the hip joint, and preserve the mobility, independence and comfort of these patients.
... With multiple medical comorbidities, immunosuppressive therapy regimens, and frequently diminished levels of erythrocytes, leukocytes, and platelets, patients receiving hematopoietic stem cell transplantation can be at increased risk of perioperative medical and surgical complications, including deep periprosthetic joint infection [11,12]. Historical studies have shown a high risk of complications and infections in such patients undergoing surgical reconstruction of proximal femoral pathologic fractures [2,4,9,12]. Although some studies have analyzed the perioperative outcomes, patient mortality, and implant survivorship in recipients of solid organ transplants undergoing THAs and/or TKAs [3,[5][6][7][8], there is a paucity of studies regarding elective THA outcomes in recipients of hematopoietic stem cell transplants [1,12]. ...
Article
IntroductionAs patients who receive hematopoietic stem cell transplantation are at increased risk of avascular necrosis (AVN) and subsequent degenerative arthritis, THA may be considered in some of these patients, particularly as overall patient survival improves for patients undergoing stem-cell transplants. Patients receiving hematopoietic stem cell transplantation theoretically are at increased risk of experiencing complications, infection, and poorer implant survivorship owing to the high prevalence of comorbid conditions, immunosuppressive therapy regimens including corticosteroids, and often low circulating hematopoietic cell lines; however, there is a paucity of studies elucidating these risks. Questions/PurposesWe asked: (1) What is the overall mortality of patients with hematopoietic stem cell transplantation who have undergone THA? (2) What is the complication rate for these patients? (3) What are the revision and reoperation rates and implant survivorship for these patients? Patients and Methods Between 1999 and 2013, we performed 42 THAs in 36 patients who underwent stem-cell transplants. Other than those who died, all were available for followup at a minimum of 2 years; of the patients whose procedures were done more than 10 years ago and who are not known to have died, two (5%) had not been seen in the last 5 years and so are considered lost to followup. All patients underwent thorough evaluation by the transplant team before arthroplasty; general contraindications included active medical comorbidities or evidence of unstable end-organ damage, active rejection, and critically low circulating hematopoietic cell lines. Underlying primary diseases leading to hematopoietic stem cell transplantation included lymphoma (14/42; 33%), plasma cell disorders (10/42; 24%), leukemia (9/42; 21%), and amyloidosis (3/42; 7%). Complications, reoperations, revisions, and implant and patient survivorship, were recorded from chart review and data from the institutional total joint registry. Mean followup was 5 years (range, 2–15 years). ResultsPatient survivorship free of mortality was 91% (95% CI, 81%–100%) and 82% (95% CI, 68%–96%) at 2 and 5 years, respectively. Complications occurred in four of 42 THAs (10%); these complications included an intraoperative fracture and a venous thromboembolism. Revisions occurred in two of 42 (5%) THAs; there were no reoperations. Implant survivorship free of component revision for any reason or implant removal accounting for death as a competing risk was 93% (95% CI, 83%–100%) at 5 years. Conclusion With appropriate medical evaluation and comanagement by transplant specialists, carefully selected patients with hematopoietic stem cell transplants may undergo elective primary THA, although complications do occur in this relatively fragile patient population. Although implant survivorship was modest at 93% at 5 years, there was not a high risk of revision for infection. Improved outcomes for these patients may be expected as their medical management advances and additional comparative studies may clarify other important patient factors. Level of EvidenceLevel IV, therapeutic study.
... 16 Kadar bolezenski proces zajame glavico ali metafizarni del stegnenice ali nadlahtnice, prizadeti del kosti odstranimo in ga nadomestimo z endoprotezo. 17,18 Pri kompresijskih zlomih vretenc so dobri rezultati s kifo in/ali vertebroplastiko. [19][20][21][22] Perkutano pod rentgensko kontrolo se v posedeno vretence vbrizga viskozni kostni cement. ...
Article
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Background: Multiple myeloma (MM) is a malignant haematological disease which is characterized by proliferation of plasma cell clone in the bone marrow. Among other symptoms of the disease, the important one is bone destruction with pain, pathological fractures and hypercalcemia. Methods: Retrospectively, we collected data on patients with MM treated in the period from 1 January 2007 until 31 December 2011. Diagnosis was confirmed de novo in 19 patients. We treated 15 patients (89 %), 3 patients (16 %) died soon after being diagnosed, without starting the therapy; 1 patient (5 %) continued treatment at the Institute of Oncology and at the Department of Haematology in Ljubljana. All patients received bisphosphonates. Bone disease was diagnosed by x- ray, and in case of pathology, an additional CT scan was performed. At the beginning we found skeletal impairment in 17 / 19 patients (89 %), 5 patients had pathological fractures of the spine and 1 patient destruction of the pelvis. 4 / 19 patients (21 %) had hypercalcemia. All patients were treated with chemotherapy and supporting therapy with bisphosphonates, and despite of that, 6/15 experienced extra fractures. Two patients were operated on, all of them were locally irradiated, immobilized and received analgesics. Conclusions: Supportive therapy with bisphosphonates is an important part of specific treatment for MM. With the availability of additional imaging by MRI or PET CT scan we can diagnose more bone impairments.
... Harrington in 1986 and later Mirel proposed scoring systems for decision making in impending pathologic fractures [77] [78]. Hip and periacetabular lesions, impending or pathological fractures of the acetabulum and long-bone fractures or any extensive skeletal destruction that may cause decreased quality of life, with increased pain and limitations in function and mobility, should be considered for surgical procedure [79] [80]- [82]. Prosthetic replacement is suggested for extensive hip lesions, pre operative radiation and total hip arthroplasty with acetabular reconstruction with or without reinforcement, depending on the extend of lesion, are suggested too ( Figure 5); intramedullary devices over plates for lesions in the sub-trochanteric region [77]. ...
Article
Full-text available
MM is frequently associated with the development of osteolytic bone lesions, osteoporosis and pathological fractures. Bone destruction in MM is caused by osteoclasts recruited in areas adjacent to myeloma plasma cells; their contact triggers both cell types to secrete soluble factors sustaining one each other’s activation and proliferation. Osteoclasts differentiate and maturate upon binding of the receptor activator of NF-kappaB ligand (RANKL), secreted by bone marrow microenvironmental cells, to its receptor (RANK) on osteoclast progenitors, while osteoprotegerin (OPG), a natural decoy receptor, can block the aforementioned ligation. At the same time osteoblasts are inactivated by the Wnt/β-catenin signaling pathway inhibitor, Dickkopf-1 protein (DKK-1), secreted by malignant plasma cells. Furthermore, DKK-1 deregulates the OPG/RANKL equilibrium, promoting osteoclastogenesis. Myeloma bone disease (MBD) can be treated with myeloma-directed chemotherapy and agents inhibiting bone resorption such as aminobisphosphonates, although new promising biology driven monoclonal antibodies targeting osteoclastogenesis mechanisms are emerging. Palliative MBD treatment includes analgesics, orthotics, radiation therapy, vertebroplasty and kyphoplasty. In case of spinal cord compression, radiation therapy or surgical decompression, should be instantly performed, along with steroid administration. Surgery may also be an option especially in case of weight-bearing bone fractures. MBD is a morbid complication and should be carefully managed because it deteriorates patients’ quality of life and worsens disease outcome.
... Only few studies are reported, mostly case series, with retrospective design report on the clinical course of small groups of surgically treated MM patients [35,36,37]. The high benefits of surgery in symptomatic MM patients with spinal involvement seems to be the lower surgical complication rate (8%) [43] Than the one observed in patients with metastatic spinal disease (19%) [44]. ...
Article
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Study Design: A prospective study Objective: To present the functional outcome and the survival of 21 consecutive selected Multiple Myeloma (MM) patients who underwent 25 surgeries for symptomatic vertebral body osteolysis. Summary of Background Data: Percutaneous augmentation with polymethyl methacrylate in patients with osteoporotic vertebral body fractures safely reduces the vertebral body deformity and pain. There are few shortterm studies reporting functional outcome and survival, following surgery for osteolytic vertebral body lesions in MM patients, with or without neurological impairment. Methods: Between December 2004 and May 2012, 25 wide spectrum surgeries including percutaneous augmentation, hybrid fixation and circumferential decompression were performed for symptomatic vertebral body osteolysis in 21 selected patients with MM. Tomita osteolysis classification, Karnofsky disability scale; ASIA neurological impairment scale and VAS pain scale were used. Survival analysis was performed. Results: All patients were followed for a minimum of 6 months postoperatively. Karnofsky Index improved from 66%±20% preoperatively to 81.3%±15%, one month and 83%±10% one year postoperatively. VAS score significantly reduced in all patients from 7.08±2 preoperatively to 3.35±1.5 at the latest evaluation. One patient with ASIA grades D and 2 with ASIA grades C improved postoperatively to ASIA E. The one-year survival from index diagnosis was 85.2% (95% CI, 60.6% - 96.0%), while it dropped to 55.4% (29.4% - 75.1%) five-year postoperatively. Τhe one-year survival rate from index surgery was 65.9% (95% CI, 38.8% - 83.2%), and dropped to 33.5% (95% CI, 11.1% - 58.0%) five-year post operation. Conclusions: There are several modalities of surgery for symptomatic osteolytic vertebral body lesions in MM patients. Surgery was proved a safe procedure with few complications it reduced pain and improved quality of life. Together with hematological and radiation therapy it may increase the survival of MM patients.
... THA for metastatic disease has been previously described and is well accepted as a treatment modality [1, 4, 5,121314. Metastases involving the acetabulum are a problem for which treatment options and outcomes have rarely been reported [1, 4, 5, 8]. A new implant that provides a greater surface area for fixation is commercially available. ...
Article
Full-text available
Metastatic disease commonly affects the proximal femur and occasionally the acetabulum. Surgical options include the use of a protrusio cage with a THA. However, the complications and survivorship of these cages for this indication is unknown. The purpose was to report the restoration of function, complications and implant survival. The medical records of 29 patients undergoing insertion of a protrusio cage for metastatic pelvic disease were reviewed. Complications were recorded. The most common diagnosis was metastatic breast cancer. During the review process, all but 10 of the 29 patients died 1-73 months after surgery. The median length of survival was 12 months (range, 3 days-100 months) after the procedure; 11 patients were alive at last followup at a median of 16 months (range, 1-100 months). One patient had loss of fixation owing to disease progression. Five patients had dislocations, four of which were treated. There were three deep infections (two that led to dislocation, which proceeded to revision surgery). Ten patients of the 29 patients became household ambulators, 17 became community ambulators, two remained chair-bound, and one bed-bound. The protrusio cage allowed most patients to return to walking with only one mechanical failure.
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The treatment of metastatic disease remains challenging. The number of patients who will be diagnosed with metastatic bone disease will continue to increase as survival from the primary cancer diagnosis continues to improve. Although it often is impossible to cure these patients, the task of maximizing their quality of life must be met with valiant efforts. Although a large number of medical and technological advances have occurred, perhaps the recognition of the importance of a well-qualified multidisciplinary team approach to treatment of these complex patients has done more to improve the field than any other single achievement. As basic science continues to further unravel potential treatment options, we must not forget this integrated approach and we must embrace "the bench" at the bedside.
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Current methods of treating advanced patients with metastatic periacetabular disease are complex and result in high complication rates. The purpose of this study was to show whether the implantation of the saddle prosthesis would serve as an additional tool to help treat metastatic disease in these patients. From 1991 to 2003, 20 patients with advanced metastatic periacetabular lesions (Harrington Class III) were treated using the saddle prosthesis. Goals of surgery were a decrease in pain, functional restoration, and ambulation. The mean age was 61 years. Average length of followup was 20 months. Postoperatively, ambulation was achieved in 16 of 20 patients. There were four postoperative complications (20%) in three patients. Surgical goals were met in 18 of 20 patients. The MSTS-ISOLS emotional score was 2.9 of 5. The average total MSTS-ISOLS score was 16.6 of 30 (55%). Using the Allan scoring system consisting of analgesia, independence and ambulation, and mobility, all scores had significant improvements postoperatively. Careful surgical indications and technique should result in a stable, functional reconstruction allowing patients the ability to ambulate outside the house with a cane. Patients can expect to be emotionally satisfied with the procedure while using nonnarcotic analgesia and can expect an improved quality of life despite bone metastasis.
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We present a rare case of bilateral subcapital hip fracture as a first sign of multiple myeloma in a young man. Right femoral neck fracture was treated by three Asnis screws and the left one by hemiarthroplasty. In order to avoid implant failure, we used zoledronic acid, a bisphosphonate compound, instead of methacrylate cement. After an 18-month follow-up, there was no evidence of avascular necrosis, no implant failure and no periprothetic fracture.
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Pathologic fractures from metastatic cancer pose formidable challenges to the orthopaedic surgeon technically and in terms of surgical decision making with regards to patient quality of life. We present the case of a 47-year-old woman with simultaneous bilateral pathologic femoral neck and acetabulum fractures and severe pulmonary shunt, who was treated successfully with cementless femoral and acetabular implants.
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Bone destruction is a hallmark of myeloma, with 70% to 80% of patients manifesting bone involvement. Destruction is mediated through normal osteoclasts (OCLs), which respond to local osteoclast-activating factors (OAFs) produced by myeloma cells or by other cells in the local microenvironment. OAFs implicated in myeloma bone disease include tumor necrosis factor-beta (TNFbeta), RANK ligand (RANKL), interleukin-1 (IL-1), parathyroid hormone-related protein (PTHrP), hepatocyte growth factor (HGH), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNFalpha), and macrophage inflammatory protein-1-alpha (MIP-1alpha). To date, the leading candidates for OAFs are MIP-1alpha and RANKL. Adhesive interactions between marrow stromal cells and myeloma cells induce marrow stromal cells to secrete IL-6, a potent myeloma growth/survival factor that may contribute to the bone disease. Evaluation of myeloma bone disease includes plain radiographs, and newer methods, such as magnetic resonance imaging (MRI), positron emission tomography (PET) scans, technetium-99m-sestamibi (Mibi) scanning, and dual-energy x-ray absorptiometry (DEXA) scanning, may provide more complete information. In addition, biochemical markers of bone resorption are being evaluated, although the limited availability of these assays and lack of extensive testing in patients make their routine use premature. Treatment of myeloma bone disease includes radiation therapy, vertebroplasty, surgery, and bisphosphonates. New developments on the pathogenesis and treatment of myeloma bone disease present great opportunities to combat bone disease.
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More than one half of cancer patients are likely to develop bone metastasis; thus, most orthopaedic surgeons will be presented with an adult patient with a destructive bone lesion. Proper management requires comprehensive patient evaluation, including history, physical examination, laboratory studies, and radiographic staging. Biopsy should be done in the patient with a possible malignant or metastatic tumor. The differential diagnosis of destructive bone lesions in patients aged >40 years includes metastatic bone disease, multiple myeloma, lymphoma, and, less commonly, primary bone tumors. Inaccurate diagnosis and improper treatment may adversely affect limb or life. Adherence to oncologic principles during the evaluation process aids in minimizing a negative outcome.
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La fractura del extremo proximal del fémur es la lesión más frecuentemente observada en el ámbito de la traumatología. Se produce sobre todo en ancianos osteoporóticos como consecuencia de un traumatismo menor. En cerca del 75 % de los casos se trata de mujeres. A pesar de los diversos programas de prevención, la incidencia de estas fracturas se encuentra en franca progresión. El objetivo del tratamiento consiste en restituir a los pacientes, a menudo de edad avanzada, la función y autonomía previas a la fractura con el menor grado de agresión posible, y ello en el plazo más breve y con el menor coste. Este capítulo trata la epidemiología, los aspectos socioeconómicos y las diferentes clasificaciones de las fracturas de cadera, así como las opciones terapéuticas según el tipo de fractura y el estado de los pacientes. Por otra parte, existen fracturas del extremo superior del fémur que quedan fuera del contexto de la clásica fractura del anciano. Se trata de las fracturas simultáneas de cadera y diáfisis femoral, que tienen lugar principalmente en jóvenes, las fracturas aisladas del trocánter mayor o menor, las fracturas patológicas y las fracturas de estrés. Tanto el diagnóstico como el tratamiento de estas lesiones, menos comunes, se presentan igualmente en este artículo.
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Metastatic bone tumor is a clinical challenge to most orthopaedic surgeons, and physicians. The bone lesions present pain, can progress to pathologic fractures, and cause neurologic deficits. The adequate treatment for the lesions can mean the difference between good and poor quality of life during their remaining time. The goals of the treatment are relief of pain, preservation of function, and maintenance of independence. In orthopaedic field, the goals include prophylactic fixation of metastatic deposits when there is a risk of fracture, stabilization or reconstruction after pathological fracture, and decompression the spinal cord and nerve roots and/or stabilization the spine. To achieve the goals, we should understand the evaluation methods, a pathogenesis of metastasis and the characters of the specific metastatic site. Finally we should have a knowledge about the treatment strategy and understand what the indications of operative treatment are and which conservative managements is correct for the metastatic bone lesions. It is important to consider the type of primary cancer, location of metastasis, extent of disease, expected patient life span, comorbidities, and level of pain when making treatment recommendations. New discoveries and modifications of existing treatments such as percutaneous stabilization of spinal compression fractures and the use of bisphosphonates may decrease the need for invasive surgical management of metastatic bone lesions in the future. Metastatic bone disease should be approached systematically by multidisciplinary team that has various treatment options, and then quality of life of the patients can be improved during their remaining life span. All the doctors participating in the treatment should try to do their best to get an optimal goal, even though the patients should be informed clearly that the treatments may not be curative.
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The skeleton is the most commonly affected organ when cancer metastasizes, and tumors arising from the breast, prostate, thyroid, lung, and kidney have a predilection for bony spread. Breast cancer, the most prevalent maligancy, causes the greatest morbidity. Herein, we review the relevant literature and describe a 38-year-old woman with bilateral pathological subtrochanteric fractures of the femur caused by breast cancer metastases. Treatment comprising internal fixation supplemented with polymethylmethacrylate (cement) and postoperative radiotherapy successfully achieved the desired palliative management goals.
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Hundreds of thousands of Americans are affected every year by skeletal complications of oncologic disease. Recent developments in medical oncology, radiation oncology and radiology, particularly with respect to the use of bisphosphonate medication and radiofrequency techniques, have served to greatly lessen the morbidity associated with metastatic skeletal disease. Similarly, there has been significant advancement in the field of orthopaedic oncology in the areas of internal fixation, endoprosthetic implant design, and minimally invasive kyphoplasty technology. Given the palliative intent of intervention in this patient population, the goal of treatment of skeletal metastases must be optimization of limb function and ultimately, quality of life.
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The presenting clinical features of 71 patients with multiple myeloma were correlated with myeloma cell mass (myeloma cells × 10¹²/m² of body surface area) determined from measurements of monoclonal immunoglobulin (M-component) synthesis and metabolism. Bivariate correlation and multivariate regression analyses showed that myeloma cell mass could be accurately predicted from A) extent of bone lesions, B) hemoglobin level, C) serum calcium level, and D) M-component levels in serum and urine. Analyses of response to chemotherapy and survival indicated significant correlation with measured myeloma cell burden. The results were synthesized to produce a very reliable and useful clinical staging system with three tumor cell mass levels (Table 7). For clinical research purposes, multivariate regression equations were developed to predict optimally the exact myeloma cell mass. Thus, initial staging can be quantitatively related to followup using tumor cell mass changes calculated from changes in M-component production. Use of the clinical staging system should provide better initial assessment and followup of individual patients, and should lead to improved study design and analysis in large clinical trials of therapy for multiple myeloma.
Article
In 323 patients with 375 pathological fractures or impending fractures, local tumor resection and internal fixation supplemented by intramedullary methylmethacrylate proved highly successful. One hundred and thirty-nine patients had metastases from breast carcinoma; 142, metastases from other tumors; and forty-two, myeloma or lymphoma. The mean survival for the 210 patients who had undergone operation two years or more before final evaluation was 15.4 months. Ninety-four per cent of the patients who were ambulatory before fracture regained the ability to walk. Eighty-five per cent had excellent or good pain relief and in only five was pain relief rated poor. There were four failures of fixation and six functionally poor results. Twenty patients died within four weeks of operation, but the remaining patients benefited from the procedure in terms of pain relief, improved mobility, and ease of nursing care.
Article
Metastatic involvement of the femur is a common clinical problem and accounts for the third highest incidence after the spine and pelvis. These patients are confronted with the possibility of losing the ability to ambulate during their remaining months. However, with improved prosthetic implants and internal fixation devices, most patients can resume their previous activities after operative treatment of their femoral fractures.
Article
Nine patients with 11 extremities involved with neoplastic metastases were treated with flexible intramedullary rods for stabilization and pain relief. Seven of the nine patients had sustained a fracture, and two patients received prophylactic flexible intramedullary rods for impending fracture. Good pain relief and satisfactory stabilization were accomplished in all but one patient. Methyl methacrylate was not used, and all lesions were treated closed, save for one patient who received good initial pain relief and satisfactory stability but ultimately had tumor recurrence, infection, and loss of fixation. We feel this technique is especially valuable in treating the very ill and terminal patient who might otherwise not tolerate prolonged anesthesia or extensive operative procedures.
Article
Two patients with chondrosarcoma of the periacetabular region were treated by local resection and reconstruction of the pelvic ring and hip, implanting a Charnley-Mueller total hip replacement and reconstituting the pelvic ring with cement reinforced by Küntscher rods and heavy Kirschner wires. The first patient, in whom adequate resection was accomplished, was well five years later and was able to walk with a mild lurch and without a cane except when walking long distances on rough ground. Despite a fall causing a fracture of the ipsilateral tibial plateau at two years and a fatigue fracture of the ipsilateral ischium which healed at 4.5 years, the implant had remained intact. In the other patient, for whom hemipelvectomy was advised but who refused it, the resection was not adequate and although he was able to walk with a cane for short distances postoperatively, he died of metastases at two years. Based on these two cases, it would appear that reconstruction of the pelvic ring and hip may be feasible in a few very carefully selected cases of periacetabular tumors.
Article
Patients with asymptomatic or smoldering multiple myeloma should not be treated but should be observed closely for progression. For symptomatic myeloma, chemotherapy is indicated. Melphalan, the agent of choice, should be given with prednisone for 1 week of every 6 weeks, If melphalan brings no response, or response and then relapse, cyclophosphamide (Cytoxan) should be give intravenously every 4 weeks or orally every day. BCNU, CCNU, and doxorubicin (Adriamycin) have also shown activity in myeloma. Hypercalcemia occurs in one-third of patients and should be countered with hydration, corticosteroids, Neutra-Phos, or mithramycin. Long-term hemodialysis has achieved some success. The combination of sodium flouride and calcium carbonate produces new bone formation; it seems a useful adjunct in treatment for myelomatous bone disease. Radiation should be utilized only for severe, localized pain or for solitary lesions. Survival with multiple myeloma varies, mean durations being 2 to 3 years. Multivariate analysis indicates that serum creatinine and calcium levels are the most significant indicators regarding 2-year survival. We have found monoclonal proteinuria not significantly more frequent with renal insufficiency than with normal renal function, renal insufficiency not significantly more frequent with lambda than with kappa chains, and survival not significantly greater with IgG myeloma than with IgA.
Article
Twenty-one patients were treated with Zickel nail for neoplastic pathological fracture or impending pathological fracture: in the femoral neck in three, in the intertrochanteric region in three, and in the subtrochanteric region in fifteen. Nineteen patients were restored to bed-chain status by the third postoperative day, and twenty were able to walk. Failure of fixation did not occur and there were no infections.
Article
The Zickel intramedullary appliance was used without methylmethacrylate in forty-six patients to stabilize thirty-five fractures and eleven impending fractures associated with osseous lesions in the subtrochanteric region of the femur. Early mobilization or ambulation was possible in nearly all cases. The patients with actual fractures survived an average of 4.7 months, while those with lesions stabilized prophylactically survived an average of 13.8 months postoperatively. Fourteen of the thirty-five patients with fractures showed union after an average of 4.5 months.
Article
A randomized double-blind study was carried out in 26 patients with multiple myeloma to compare the therapeutic effect of sodium fluoride (50 mg twice daily) plus calcium carbonate (1 g four times daily) and placebo. All patients also received melphalan and prednisone for one week every six weeks. Bone biopsies for microradiography and histology, and videodensitometry as well as conventional roentgenograms, 99mTc-polyphosphate bone scans, and bone densitometry of the mid and distal radius, were done initially and one year after therapy. Microradiography and videodensitometry studies revealed significant increases in bone formation (P less than 0.01) and bone mass (P less than 0.005) in the fluoride-calcium group. Bone trabeculae appeared thickened on roentgenograms of six of 13 fluoride-calcium-treated patients (P less than 0.02). Technetium bone scans and bone densitometry determinations proved insensitive for detection of skeletal changes. Fluoride calcium should be considered a useful adjunct in the treatment for multiple myeloma.
Article
The presenting clinical features of 71 patients with multiple myeloma were correlated with myeloma cell mass (myeloma cells X 10(12)/m2 of body surface area) determined from measurements of monoclonal immunoglobulin (M-component) synthesis and metabolism. Bivariate correlation and multivariate regression analyses showed that myeloma cell mass could be accurately predicted from A) extent of bone lesions, B) hemoglobin level, C) serum calcium level, and D) M-component levels in serum and urine. Analyses of response to chemotherapy and survival indicated significant correlation with measured myeloma cell burden. The results were synthesized to produce a very reliable and useful clinical staging system with three tumor cell mass levels (Table 7). For clinical research purposes, multivariate regression equations were developed to predict optimally the exact myeloma cell mass. Thus, initial staging can be quantitatively related to followup using tumor cell mass changes calculated from changes in M-component production. Use of the clinical staging system sould provide better initial assessment and followup of individual patients, and should lead to improved study design and analysis in large clinical trials of therapy for multiple myeloma.
Article
Magnetic resonance (MR) imaging examinations of the lumbar spine and clinical and laboratory findings in 32 patients with multiple myeloma were reviewed. On T1-weighted images, signal intensity (SI) of the vertebrae approximated that of muscle in 14 cases and was intermediate (between the SIs of muscle and fat) in 18. Definite foci of decreased SI were seen in eight cases (25%), and foci of increased SI, representing fatty infiltration, were seen in 12 (38%). On T2-weighted images, SI approximated that of muscle in 17 cases and was intermediate in 15. Definite foci of increased SI were seen in 17 (53%). Of 38 vertebral compression fractures (including 18 in nine additional patients), foci of abnormal SI consistent with tumor on either T1- or T2-weighted images were seen in 19 cases (50%). There was no correlation between MR imaging findings and laboratory or bone marrow findings. Foci of presumed tumor were better or exclusively shown on T2-weighted images in 11 of 17 patients (65%) with identifiable focal disease. Other suggestions of multiple myeloma on T1-weighted images may be the absence of fatty replacement or a generalized decrease in SI.
Article
The effects of involved-field radiotherapy were assessed in patients with a solitary plasmacytoma of bone (SBP). Forty-five consecutive patients with an SBP received megavoltage irradiation of at least 3,000 cGy. The median age was 53 years, 67% of patients showed a myeloma protein, and uninvolved immunoglobulins (Igs) were preserved in 93% of patients. Permanent control of presenting disease was achieved in all but two patients, but 46% of patients developed multiple myeloma. When it occurred, progression of myeloma occurred within 3 years in two thirds of the patients, suggesting that the extent of disease was understaged at diagnosis. Myeloma protein disappeared in nine patients (30%) whose disease has not yet recurred. The median survival for all patients was 13 years and the myeloma-specific survival fraction at 10 years was 53%. In patients with an SBP, the disappearance of myeloma protein with involved-field radiotherapy predicted long-term disease-free survival and possible cure. Nonsecretory disease and persistent myeloma protein after treatment were adverse prognostic factors for which adjuvant therapy with interferon alfa should be considered.
Article
A review of 46 cases of solitary plasmacytoma of bone was undertaken in an attempt to better define the clinical features and prognostic indicators associated with this disease. Criteria for inclusion in the study included the following: (a) solitary lytic bone lesion on skeletal survey; (b) histologic confirmation of the lesion; and (c) bone marrow plasmacytosis of less than 10 percent. Patients with extramedullary plasmacytomas and osteosclerotic lesions were excluded. All patients were evaluated with serum and urine protein studies at the time of diagnosis. The median follow-up was 90 months with a minimum of 30 months. Fifty-four percent of the lesions involved the vertebral column. The thoracic spine was the single most commonly involved site (13/46 patients). The initial lesion was treated with radiotherapy in all but three patients in whom complete surgical resection was achieved. Total doses ranged from less than 20 Gy to 70 Gy with a median of 39.75 Gy. Overall, 54% developed multiple myeloma, 2% failed with new bone lesions without multiple myeloma, and 11% developed local recurrences. No patient receiving 45 Gy or more to the solitary lesion had a local failure. While the median time to progression was 18 months, 23% of the failures occurred after 60 months. The five local failures occurred at 7, 12, 18, 40, and 114 months. The overall survival was 74% at 5 years and 45% at 10 years. The 5- and 10-year disease-free survivals, however, were 43 and 25%, respectively. Evidence of abnormal serum and/or urine protein was found in 25 of 46 patients. Neither survival nor disease-free survival was significantly influenced by the presence of abnormal proteins even if they persisted after irradiation.
Article
From 1974 to 1983, forty-three femora in forty patients with metastases to the subtrochanteric area were stabilized using a Zickel subtrochanteric device. Thirty-five patients with thirty-eight stabilized femora could be evaluated at follow-up times ranging from thirty-seven days to five years and one month. In twenty-eight of the thirty-eight femora, a modified technique for insertion of the device had been used. Twenty-eight (80 per cent) of the patients were able to walk after an average of 3.8 days. No patient who had been able to walk preoperatively lost that ability. The average length of survival was 312 days postoperatively. Fifteen patients survived for at least fifteen months and five patients, with an average length of survival of 1276 days, were still alive at the time when this review was initiated. Complications included four perioperative deaths, one non-fatal pulmonary embolus, and five intraoperative technical complications--four of them occurring before the described modification of the technique was instituted. There were no infections and no failures of the device. No patient had a loss of stability after Zickel nailing. The modification of the technique allows safer introduction of the intramedullary nail into the weakened but intact femur by a closed method.
Article
Although patients who have multiple myeloma usually have straightforward clinical symptoms and corroborative radiographs, in some instances, these patients will present atypically, with symptoms suggesting active disease but radiographs that are normal or nonspecific. We reviewed the records of 32 patients who had documented multiple myeloma and had undergone CT examinations, assessing the value of those examinations. Although CT is not indicated in all patients who have multiple myeloma, it is especially useful in patients who have bone pain and normal or nonspecific radiographs. CT provided confirmatory information in all cases in which lesions were seen on radiographs. CT also frequently demonstrated a greater extent of disease than could be appreciated on the radiographs.
Article
• The use of computed tomography (CT) was evaluated in 25 patients with multiple myeloma, six with extramedullary plasmacytoma, and two with undiagnosed lesions. We found that CT was useful for (1) patients with multiple myeloma who had bone pain but normal roentgenograms, (2) patients with an M-protein, bone marrow plasmacytosis, and back pain from osteoporosis and compression fractures but an inconclusive diagnosis of multiple myeloma, (3) the determination of extent of tumor, and (4) guidance in needle biopsy. (Arch Intern Med 1985;145:1451-1452)
Article
A method to classify the degree of ectopic bone formation about the hip following total hip arthroplasty revealed that 21% of 100 consecutive patients treated by total hip arthroplasty had ectopic bone formation about the hip of various degrees when reviewed 6 mth following operation. Ectopic bone formation, however, did not seem to affect the functional result as judged by the Harris hip evaluation unless apparent bone ankylosis resulted.
Article
Neoplastic subtrochanteric fractures treated with nail plate fixation have poor functional results. Applying the Zickel device to the problem in 6 patients produced encouraging results. Union at a neoplastic fracture site was well demonstrated in 1 patient and can occur if the fracture is properly treated and patient survival time is sufficient. Use of the Zickel device without methacrylate seemed to give results comparable to the use of methacrylate and a nail plate combination without the potential disadvantages of excessive foreign material in fracture site. No mechanical failures or nonunions developed in this series.
Article
Subtrochanteric fractures are an extremely difficult orthopedic problem. A review of the biomechanics and clinical management indicates that strong fixation devices, such as the Zickel nail as well as heavy one piece Jewett nails or intramedullary rods, with or without additional fixation and grafting, are generally necessary for reliable internal fixation.
Article
The blood pressure lowering effect of intravenously injected methylmethacrylate monomer, in relation to a graded blood volume deficit, has been investigated in dogs. Correlations observed between these variables support the clinical impression and current concepts of physiopathology of hemorrhagic shock, that adequate blood volume replacement during total hip arthroplasty can minimize the possible loss of vascular tone associated with circulating monomer.
Article
Between July 1972 and July 1979, 58 patients were treated by hip replacement arthroplasty for pathological fractures and fracture-dislocations of the acetabulum secondary to metastatic malignant disease. Only 11 patients had retained sufficient periacetabular bone for total hip replacement to be performed in the conventional manner. Nineteen patients had destruction of the medial part of the acetabular wall and required fixation of the acetabular prosthetic component in a manner designed to transmit weight-bearing forces into the intact superior part of the acetabular wall. Twenty-five patients had destruction of both the medial and the superior areas of the acetabular wall and required techniques for fixation of the acetabular prosthetic component that allowed transmission of the weight-bearing forces into the intact bone of the superior part of the ilium and the sacrum. Three patients had metastatic lesions that warranted an attempt at resection for cure. The affected periacetabular bone was resected with wide margins, and a prosthetic hip arthroplasty was then performed. All patients were evaluated postoperatively for relief of pain, resumption of walking, solidity of fixation of the prosthetic components, and survival without recurrence at the operative site. Thirty-seven patients (67%) had excellent or good pain relief 6 months postoperatively and 24 (43%) were rated excellent or good 2 years postoperatively. Forty-five patients (80%) were ambulatory for 6 months postoperatively and 26 (45%) could still walk at 2 years. Five patients had loosening of the acetabular prosthetic component secondary to local tumor recurrence in spite of adequate radiotherapy. There were no other instances of prosthetic component loosening. There were 2 operative deaths. The mean survival time was 19 months, but 27 of the 58 patients still were alive at the time of writing.
Article
Total hip arthroplasty with a special segmental replacement of the proximal end of the femur which varied in length from eighty to 150 millimeters was performed in twenty-one patients who had severe non-neoplastic conditions of the proximal part of the femur that necessitated salvage. Ten patients had previously failed arthroplasties associated with loss of bone structure; seven had non-union of a proximal femoral fracture or osteotomy associated with severe hip disease; there had a failed resection arthroplasty; and one had an arthrodesis and incapacitating low-back pain. Clinical and roentgenographic data during follow-up of twenty-five to ninety-two months showed that only one patient had loosening of the acetabular component. In twenty of the twenty-one patients, total hip arthroplasty with proximal femoral replacement was effective in restoring the integrity of the bone and restoring function of the hip.
Article
In 167 consecutive pathological or impending fractures of the hip treated by endoprosthetic replacement from 1975 to 1978, there was dramatic relief of pain in all patients. Either a long-stem femoral endoprosthesis or a total prosthetic hip was used. The ambulatory status was significantly enhanced in those patients who were able to walk but it was not in the gravely ill. Cementing the prosthesis allowed stabilization of the entire femur as well as resection of diseased bone. The patients had a median survival time of 5.6 months. There were no dislocations, instances of loosening, or failures of the device, and the incidence of deep infection was 1.2 per cent. If the anticipated life of the patient exceeds one month, that constitutes an indication for prosthetic replacement for treatment of a pathological or impending fracture of the hip.
Article
• A pathological fracture increases the suffering of a patient, makes nursing care more difficult, predisposes the patient to hypostatic pneumonia and decubitus ulcers, and sometimes interferes with necessary treatment of the underlying disease. The insertion of an intramedullary nail contributes to the comfort and prolongs the life of the patient in some cases of this sort. Occasionally it is possible to anticipate a pathological fracture, as in cases of metastasis to the femur from tumors in the kidney, breast, or prostate. In one case of familial splenic anemia (lipid histocytosis of the kerasin type) intramedullary fixation was used prophylactically in each femur to control the patient's disabling pain in the thigh, and by this means pathological fracture was circumvented and the patient again made ambulatory. In two other cases of pathological fractures representing metastases of tumors elsewhere, the patients were not rendered ambulatory but their treatment was facilitated. Intramedullary fixation has its risks and limitations, but when it is applicable, it saves the patient much hospital time, confinement, and pain.