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Griggers JI, Alcantar S, Gonzalez MR, Lozano-Calderon SA. Postoperative Complications of Intramedullary Nailing for Impending and Pathologic Fractures of the Humerus Due to Bone Metastases-A Systematic Review of the Literature. J Surg Oncol 2025; 131:932-941. [PMID: 39508337 DOI: 10.1002/jso.27975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 09/06/2024] [Accepted: 10/12/2024] [Indexed: 11/15/2024]
Abstract
Intramedullary nailing (IMN) is a common option for managing impending or pathologic fractures of the humerus secondary to metastatic disease. We sought to assess the (1) early complications, (2) failure rates and mechanisms, and (3) functional outcomes. A systematic review using the PubMed, Embase, and Cochrane databases was performed. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. The study was registered on PROSERO (CRD42023406905). The Strengthening the Reporting of Observational Studies in Epidemiology checklist was used for quality assessment. Studies describing postoperative outcomes of patients with impending or pathologic fractures of the humerus treated with IMN were included. Implant failure was classified into mechanical and nonmechanical causes. Functional outcomes were assessed via the Musculoskeletal Tumor Society (MSTS) score. Overall, 41 studies comprising 1431 patients were included. Early complications occurred in 5.5% of patients, with 2.8% of patients having systemic complications. The overall implant failure rate was 4.9%, and the mean MSTS score at the last follow-up was 79.9%. IMN was associated with good postoperative functional outcomes and low implant failure rates. Systemic complications were the most common type of early complication, and tumor progression was the main cause of implant failure. LEVEL OF EVIDENCE: III.
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Affiliation(s)
| | | | - Marcos R Gonzalez
- Department of Orthopaedic Surgery, Division of Orthopaedic Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Santiago A Lozano-Calderon
- Department of Orthopaedic Surgery, Division of Orthopaedic Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Hashimoto K, Nishimura S, Ito T, Kakinoki R, Goto K. Efficacy of Surgical Intervention in Treating Pathological Fractures of the Upper Extremity: A Retrospective Case Series. Cureus 2024; 16:e71273. [PMID: 39525158 PMCID: PMC11550891 DOI: 10.7759/cureus.71273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2024] [Indexed: 11/16/2024] Open
Abstract
BACKGROUND We conduct a retrospective analysis of patients with pathological fractures resulting from upper extremity malignancies, focusing on the evaluation of treatment strategies employed. MATERIALS AND METHODS We retrospectively studied 10 patients with metastatic bone tumors of the upper extremities. The study variables included tumor site, primary pathology, duration from the first diagnosis of the primary lesion to the occurrence of the pathological fracture, use of bone-modifying drugs, surgical technique, adjuvant therapy, postoperative functional assessment, Katagiri's score, American Society of Anesthesiologists physical status (ASA-PS), outcome, and correlations between the Eastern Cooperative Oncology Group Performance Status (ECOG-PS) and Musculoskeletal Tumor Society (MSTS) score. RESULTS The sites involved were the humerus and radius in eight and two patients, respectively. Primary pathologies were liver cancer in three patients, lung cancer and renal cancer in two patients each, and one patient each with multiple myeloma, plasmacytoma, and Hodgkin's lymphoma. Nine patients experienced pathological fractures, and one had an impending fracture. The median time from primary tumor diagnosis to fracture was 12.5 months. Bone-modifying drugs were administered in all cases. Surgical procedures included intramedullary nails in seven patients and plate fixation in two. Chemotherapy served as adjuvant therapy in nine cases. The mean MSTS score was 26.5, and Katagiri's score averaged 6. The median ASA-PS stood at 2. Outcomes showed seven patients alive with disease and three dead from disease. A significant association between the ECOG-PS and MSTS score was not observed. CONCLUSION Pathological fractures caused by malignant bone tumors of the upper extremity should be treated proactively with surgery regardless of prognosis.
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Affiliation(s)
| | - Shunji Nishimura
- Orthopedic Surgery, Kindai University Hospital, Osakasayama, JPN
| | - Tomohiko Ito
- Orthopedic Surgery, Kindai University Hospital, Osakasayama, JPN
| | - Ryosuke Kakinoki
- Orthopedic Surgery, Kindai University Hospital, Osakasayama, JPN
| | - Koji Goto
- Orthopedic Surgery, Kindai University Hospital, Osakasayama, JPN
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West W, Moore A, Gerhardt C, Webb P, Binitie O, Lazarides A, Letson D, Joyce D. Dual plating in the metastatic distal humerus: Benefits may outweigh the risks. J Orthop 2024; 51:103-108. [PMID: 38361983 PMCID: PMC10864758 DOI: 10.1016/j.jor.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/17/2024] Open
Abstract
Background Impending and complete pathologic fractures of the distal humerus are rare complications of metastatic cancer. Surgical treatment aims to quickly restore function and minimize pain. Plate and screw fixation (PSF) is a common method for addressing these lesions, but unlike in orthopaedic trauma, there are no clear guidelines for best management. While dual PSF theoretically provides better support and reduces the chance of reoperation due to tumor progression, single PSF is currently the more common choice. Materials and methods Between March 2008 and September 2021, 35 consecutive patients who underwent PSF for distal humerus metastasis or multiple myeloma were retrospectively reviewed. The proportion of patients who developed various postoperative complications, including infection, nonunion, deep vein thrombosis, tumor progression, and radial nerve palsy, as well as those requiring reoperation, was calculated. Mann-Whitney U test, Pearson's chi-squared, and Fisher's exact test were used to investigate differences between the single and dual PSF groups with statistical significance defined as p ≤ 0.05. Results There was no significant difference (p = 0.259) in revision rate, although 3 of 21 (14.3 %) single PSF patients required reoperation compared to 0 of 14 (0.0 %) dual PSF patients. The revisions were performed in one patient due to refracture and in two patients due to tumor progression. Although not statistically significant, a larger percentage of single PSF patients developed a postoperative complication compared to dual PSF patients [odds ratio 0.42 (95 % confidence interval 0.071 to 2.5); p = 0.431]. Single PSF did lead to shorter operative time compared to dual PSF [p < 0.001]. Conclusion Dual PSF is non-inferior to single PSF and potentially results in fewer reoperations and postoperative complications in distal humerus pathologic lesions, although it leads to longer operative time. The current study is limited by small sample size due to the rarity of distal humerus metastatic lesions.
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Affiliation(s)
- William West
- University of South Florida Morsani College of Medicine, USA
| | | | | | - Paul Webb
- University of South Florida Morsani College of Medicine, USA
| | | | | | | | - David Joyce
- Sarcoma Department, Moffitt Cancer Center, USA
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Chen BK, Tai TH, Lin SH, Chen KH, Huang YM, Chen CY. Intramedullary Nail vs. Plate Fixation for Pathological Humeral Shaft Fracture: An Updated Narrative Review and Meta-Analysis of Surgery-Related Factors. J Clin Med 2024; 13:755. [PMID: 38337449 PMCID: PMC10856436 DOI: 10.3390/jcm13030755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: Pathological humeral shaft fracture (PHSF) is a frequently observed clinical manifestation in the later stages of tumor metastasis. Surgical interventions are typically recommended to alleviate pain and restore functionality. Intramedullary nail fixation (INF) or plate fixation (PF) is currently recommended for the treatment of PHSF. However, there is still no standard for optimal surgical treatment. Thus, we conducted a meta-analysis comparing the clinical outcomes of INF with PF for PHSF treatment. (2) Methods: We conducted searches in databases, such as Scopus, EMBASE, and PubMed, for studies published prior to May 2023. In total, nine studies with 485 patients were reviewed. (3) Results: There were no significant differences noted in the incidence of fixation failure, local recurrence, wound complication or overall complication. However, the INF group demonstrated a significantly lower incidence of postoperative radial nerve palsy than the PF group (OR, 5.246; 95% CI, 1.548-17.774; p = 0.008). A subgroup analysis indicated that there were no statistically significant differences in fixation failure or local recurrence among subgroups categorized by the design of intramedullary nail. (4) Conclusions: Considering the short life expectancy of end-stage patients, the choice of surgical method depends on the patient's individual condition, fracture and lesion patterns, the surgeon's experience, and comprehensive discussion between the surgeon and patient.
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Affiliation(s)
- Bing-Kuan Chen
- School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (B.-K.C.); (T.-H.T.); (S.-H.L.)
- Division of General Medicine, Department of Medical Education, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
| | - Ting-Han Tai
- School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (B.-K.C.); (T.-H.T.); (S.-H.L.)
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-H.C.); (Y.-M.H.)
| | - Shu-Hsuan Lin
- School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (B.-K.C.); (T.-H.T.); (S.-H.L.)
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-H.C.); (Y.-M.H.)
| | - Kuan-Hao Chen
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-H.C.); (Y.-M.H.)
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11031, Taiwan
| | - Yu-Min Huang
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-H.C.); (Y.-M.H.)
| | - Chih-Yu Chen
- School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (B.-K.C.); (T.-H.T.); (S.-H.L.)
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-H.C.); (Y.-M.H.)
- International Ph.D. Program in Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11031, Taiwan
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Pu F, Yu Y, Shao Z, Wu W, Feng J, Chen F, Zhang Z. Clinical efficacy of customized modular prosthesis in the treatment of femoral shaft metastases. Front Oncol 2023; 13:1115898. [PMID: 37091177 PMCID: PMC10117919 DOI: 10.3389/fonc.2023.1115898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 03/17/2023] [Indexed: 04/09/2023] Open
Abstract
PurposeTo examine clinical outcomes of a specialized modular prosthesis used to fill a bone deficiency following removal of femoral shaft metastases.MethodsEighteen patients with femoral shaft metastases who underwent en bloc resection and implantation of a personalized modular prosthesis between December 2014 and December 2019 were retrospectively analyzed. Pain, limb function, and quality of life were evaluated using the visual analog scale (VAS), Musculoskeletal Tumor Society (MSTS) scale, International Society of Limb Salvage (ISOLS) scoring system, Karnofsky Performance Status (KPS) scale, and Nottingham Health Profile (NHP) scale. The Kaplan–Meier technique was used to analyze patient survival.ResultsThe operation duration was 90–150 min (mean, 115 min), and the osteotomy length was 9–16 cm (mean, 11.72 cm). The patients were followed for 12–62 months (mean, 25.28 months). The VAS and NHP ratings were lower at 3, 6, and 12 months after surgery than before surgery, while the MSTS, ISOLS, and KPS scores were higher after surgery than they had been before. These differences were statistically significant (P<0.05). The survival period was between 7 and 62 months (mean, 20.89 months), and the rates of survival at 1-year and 2-year were 72.22% and 27.78%, respectively. Except for two patients with aseptic prosthesis loosening during the follow-up period, there were no problems.ConclusionEn bloc excision and implantation of a personalized modular prosthesis can reduce pain and improve the ability of patients with femoral shaft metastases to perform daily activities, thereby improving their quality of life.
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Koob S, Plöger MM, Bornemann R, Lehmann RP, Alex D, Placzek R. Intramedullary Nailing Versus Compound Plate Osteosynthesis in Pathologic Diaphyseal Humerus Fractures: A Retrospective Cohort Study. Am J Clin Oncol 2022; 45:379-380. [PMID: 35983966 DOI: 10.1097/coc.0000000000000937] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Pathologic fractures of the extremities due to carcinoma metastases require individual and patient prognosis-related stabilization procedures. Considering the anatomic features of the humerus, implant material stability is less critical than femoral fractures because of less weight-bearing stress. Therefore, operation length, blood loss, and quick recovery of function are of greater interest. In this retrospective cohort study, we evaluated and compared the outcomes of compound plate osteosynthesis and intramedullary (IM) nailing while managing diaphyseal pathologic fractures of the humerus. METHODS We retrospectively reviewed patients treated at our institution for pathologic fractures of the diaphyseal humerus between 2010 and 2021 for group differences (plate osteosynthesis vs. IM nailing) in terms of blood loss, length of operation, implant survival, and upper extremity function. RESULTS We reviewed 42 stabilization procedures due to pathologic diaphyseal humerus fractures, with a mean follow-up of 8.5±15.4 months. IM nailing (n=20) showed a significantly lower blood loss (266.7±23.7 mL) than plate osteosynthesis (n=22, 571.1±92.6 mL). We did not detect statistically significant differences in the complication rate, length of operation, or Musculoskeletal Tumor Society score. CONCLUSION Our findings suggested that diaphyseal fractures of the humerus should be stabilized using an IM nail rather than plate osteosynthesis due to lower blood loss, while complication rate, implant survival, and length of operation remain indifferent.
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Affiliation(s)
- Sebastian Koob
- Department of Orthopaedics and Trauma Surgery, University of Bonn, Bonn, Germany
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Sebghati J, Khalili P, Tsagkozis P. Surgical treatment of metastatic bone disease of the distal extremities. World J Orthop 2021; 12:743-750. [PMID: 34754830 PMCID: PMC8554352 DOI: 10.5312/wjo.v12.i10.743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/16/2021] [Accepted: 08/06/2021] [Indexed: 02/06/2023] Open
Abstract
Metastatic bone disease of the distal extremities, also known as acrometastasis, is very rare. Thus, there is very limited information regarding the clinical manifestations and methods of surgical treatment. The current available literature shows that acrometastases are often encountered in the context of advanced disease and are thus associated with poor patient survival. As metastatic bone disease is generally uncurable, the goal of surgical treatment is to provide the patient with good function with as few complications as possible. In this article, we discuss the clinical manifestation of acrometastases, the methods of surgical intervention, and the expected clinical outcome. Non-surgically managed pathological fractures generally remain ununited; therefore, conservative treatment is reserved for patients with poor general condition or dismal prognosis. The current evidence suggests that in lesions of the lower arm and leg, osteosynthesis (plate and screw fixation or intramedullary nail) is the most common method of reconstruction, whereas local excision or amputation are more commonly used in cases of more distal lesions (such as ankle, foot and hand). Following surgery most patients receive adjuvant radiotherapy, even though its role is poorly documented. Close collaboration between orthopedic surgeons and medical oncologists is necessary to improve patient care and treatment outcome. Further studies are needed in order to provide stronger clinical evidence and improve decision-making, in an effort to optimize the patients’ quality of life and avoid the need for revision surgery.
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Affiliation(s)
| | - Pendar Khalili
- Department of Orthopedics, Central Hospital in Karlstad, Karlstad 65230, Sweden
| | - Panagiotis Tsagkozis
- Department of Orthopedic Surgery, Karolinska University hospital, Solna 17176, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Solna 17176, Sweden
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Krumme J, MacConnell A, Wallace M, Aboulafia A, Jelinek J, Adams B, Henshaw R. Early Experience in Pathologic Humerus Fracture Treated With the Photodynamic Bone Stabilization System Shows Limitations Related to Patient Selection. Orthopedics 2021; 44:154-159. [PMID: 34039219 DOI: 10.3928/01477447-20210416-06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Impending and complete pathologic fractures often necessitate surgical fixation. Traditional orthopedic implants are commonly used, achieving clinically acceptable outcomes, but their metallic composition can impair radiographic evaluation and affect radiation treatments. Recognition of these concerns led to the development of radiolucent implants such as the minimally invasive Photodynamic Bone Stabilization System (PBSS; IlluminOss Medical Inc), featuring a light cured polymer contained within an inflatable balloon catheter. Two participating hospitals in one health care system reviewed cases using the PBSS implant. Twenty-five patients with 29 impending or pathologic fractures in the proximal radius or humerus from metastatic carcinoma, myeloma, lymphoma, and melanoma were identified. Clinical charts and imaging were reviewed to determine the status of the implant at final follow-up as well as complications. For analysis, a chi-square test was used for nominal variables and a t test was used for continuous variables. Eleven of the 25 patients were alive with disease at the time of analysis. Eight of 29 (27.5%) implants failed. Five of 25 (20%) patients required repeat surgery due to complications, including 3 revision open reduction and internal fixations, 1 open reduction and internal fixation for a periprosthetic fracture, and 1 screw removal. Five of the 9 cases (56%) (P=.03) with lesions in the distal humeral shaft had breakage of the implant by final follow-up, compared with 3 of 20 cases (15%) (P=.03) elsewhere in the humerus; no failures were seen in the radius. One of 4 patients (25%) also had failure in the surgical neck, although this did not reach significance. Five patients were noted to have progression of disease on follow-up radiographs, with 4 failures in patients with progression. The PBSS implants potentially allow improved surveillance of fracture healing and tumor recurrence along with decreased scattering of radiation during treatment. Unfortunately, there may be a higher rate of mechanical failures, particularly for lesions involving the distal humerus. This may be due to decreased cross-sectional area of the implant in this region as compared with the metaphyseal and proximal regions. Caution should be exercised when treating distal humeral pathologic fractures with large lytic lesions where the underlying disease process is not well controlled. [Orthopedics. 2021;44(3):154-159.].
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Zhao Z, Ye Z, Yan T, Tang X, Guo W, Yang R. Intercalary prosthetic replacement is a reliable solution for metastatic humeral shaft fractures: retrospective, observational study of a single center series. World J Surg Oncol 2021; 19:140. [PMID: 33952258 PMCID: PMC8101207 DOI: 10.1186/s12957-021-02250-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 04/21/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Treatments for metastatic fracture of the humeral shaft continue to evolve as advances are made in both oncological and operative management. The purposes of this study were to critically evaluate the effectiveness of intercalary endoprostheses in treating metastatic humeral shaft fractures and to clarify the surgical indications for this technique. METHODS Sixty-three patients treated surgically for 66 metastatic fractures of the humerus shaft were retrospectively reviewed. Intramedullary nailing (IMN) was performed in 16 lesions, plate fixation (PF) in 33 lesions, and prosthetic replacement in 17 lesions. The operative time, intraoperative blood loss, and postoperative complications were noted. The function of the upper extremities was assessed by the Musculoskeletal Tumor Society (MSTS) score and American Shoulder and Elbow Surgeons (ASES) score. All included patients were followed until reconstructive failure or death. RESULTS The operative time was relatively shorter in the prosthesis group than in either the IMN group (p = 0.169) or PF group (p = 0.002). Notably, intraoperative blood loss was significantly less in the prosthesis group than in either the IMN group (p = 0.03) or PF group (p = 0.012). The average follow-up time was 20.3 (range, 3-75) months, and the overall survival rate was 59.7% at 12 months and 46.7% at 24 months. One rotator cuff injury, 3 cases of iatrogenic radial nerve palsy, 5 cases of local tumor progression, and 1 mechanical failure occurred in the osteosynthesis group, whereas one case of aseptic loosening of the distal stem and one case of local relapse were observed in the prosthesis group. There were no significant differences in functional scores among the three groups. CONCLUSIONS Intercalary prosthetic replacement of the humeral shaft may be a reliable solution for pathologic fractures patients; it is indicated for lesions with substantial bone loss, or accompanied soft tissue mass, or for those patients with better prognosis.
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Affiliation(s)
- Zhiqing Zhao
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, 100044, China
| | - Zhipeng Ye
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, 100044, China
| | - Taiqiang Yan
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, 100044, China.
| | - Xiaodong Tang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, 100044, China
| | - Wei Guo
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, 100044, China
| | - Rongli Yang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, 100044, China
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Wang K, Wu Z, Wang G, Shi H, Xie J, Yin L, Xu T, Mao W, Peng B. Survival nomogram for patients with bone metastatic renal cell carcinoma: A population-based study. Int Braz J Urol 2021; 47:333-349. [PMID: 33284535 PMCID: PMC7857761 DOI: 10.1590/s1677-5538.ibju.2020.0195] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/22/2020] [Indexed: 12/18/2022] Open
Abstract
Purpose: Increased attention has been focused on the survival of renal cell carcinoma (RCC) patients with bone metastasis. This study proposed to establish and evaluate a nomogram for predicting the overall survival (OS) and cancer-specific survival (CSS) of RCC patients with bone metastasis. Materials and Methods: RCC patients with bone metastasis between 2010 and 2015 were captured from the surveillance, epidemiology and end results (SEER) database. Univariate and multivariate cox regressions were performed to assess the effects of clinical variables on OS and CSS. The nomogram based on the Cox hazards regression model was developed. Concordance index (C-index) and calibration curve were performed to evaluate the accuracy of nomogram models, receiver operating characteristic (ROC) curves and decision curve analysis (DCA) were conducted to assess the predict performance. Results: A total of 2.471 eligible patients were enrolled in this study. The patients were assigned to primary (n=1.672) and validation (n=799) cohorts randomly. The 1-, 2-, and 3-year OS and CSS nomogram models were constructed based on age at diagnosis, sex, marital status, pathological grade, T-stage, N-stage, brain/liver/lung metastasis, surgery, radiotherapy and chemotherapy. The c for OS and CSS prediction was 0.730 (95% confidence interval [CI]: 0.719-0.741) and 0.714 (95%CI:0.702-0.726). The calibration curves showed significant agreement between nomogram models and actual observations. ROC and DCA indicated nomograms had better predict performance. Conclusions: The nomograms for predicting prognosis provided an accurate prediction of OS and CSS in RCC patients with bone metastasis, and contributed clinicians to optimize individualized treatment plans.
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Affiliation(s)
- Keyi Wang
- Department of Urology, People's Hospital of Putuo District, School of Medicine, Tongji University, Shanghai.,Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai
| | - Zonglin Wu
- Department of Urology, People's Hospital of Putuo District, School of Medicine, Tongji University, Shanghai
| | - Guangchun Wang
- Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai
| | - Heng Shi
- Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai
| | - Jinbo Xie
- Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai
| | - Lei Yin
- Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai
| | - Tianyuan Xu
- Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai
| | - Weipu Mao
- Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
| | - Bo Peng
- Department of Urology, People's Hospital of Putuo District, School of Medicine, Tongji University, Shanghai.,Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai
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Management of Metastatic Disease of the Upper Extremity. J Am Acad Orthop Surg 2021; 29:e116-e125. [PMID: 33492015 DOI: 10.5435/jaaos-d-20-00819] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/28/2020] [Indexed: 02/01/2023] Open
Abstract
Metastatic disease is the most common pathologic cause of bone destruction, and the upper extremity is frequently involved. This location presents many surgical challenges, but there have been several recent implant and technique-related advances that have improved outcomes. Patients can be treated nonsurgically, with radiation or with surgery, depending on patient characteristics, signs/symptoms, primary diagnosis, location, and extent of bone destruction. Most locations in the upper extremity besides the humerus can be treated nonsurgically or with radiation. This is also true of the humerus, but when surgery is indicated, plate fixation is acceptable when adequate proximal and distal cortical bone is present for screw purchase. Intramedullary nailing is used frequently in metastatic humeral disease as well, especially in the diaphysis. When extensive destruction or disease progression precludes internal fixation, a resection with endoprosthetic reconstruction can be considered. Oncologic hemiarthroplasty endoprosthetics still have a role, but reverse shoulder designs are beginning to show improved function. Humeral prosthesis designs are continuing to improve, and are becoming more modular, with custom implants still playing a role in certain challenging scenarios.
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En bloc resection and intercalary prosthesis implantation for the treatment of humeral diaphyseal bone metastases. INTERNATIONAL ORTHOPAEDICS 2020; 45:281-288. [PMID: 33025082 DOI: 10.1007/s00264-020-04845-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 09/30/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE To evaluate the short-term clinical efficacy and complications of en bloc resection and intercalary prosthesis implantation for the treatment of humeral diaphyseal bone metastases. METHODS A total of 21 patients with humeral diaphyseal bone metastases treated with en bloc resection and intercalary prosthesis implantation from August 2014 to August 2019 were retrospectively analysed. The visual analogue scale (VAS), Musculoskeletal Tumour Society (MSTS) scale, International Society of Limb Salvage (ISOLS) scoring system, Karnofsky Performance Status (KPS) scale, and Nottingham Health Profile (NHP) scale were used to assess pain, limb function, and quality of life. Survival of the patients was analysed using the Kaplan-Meier method. RESULTS The patients were followed up for 12-57 months (mean: 22 months); the operative time was 68-114 minutes (mean: 76.24 min); the osteotomy length was 6.5-10 cm (mean: 8.02 cm); and the intra-operative blood loss was 95-125 ml (mean: 104.71 ml). At three, six and 12 months after surgery, the VAS and NHP scores were lower, whereas the MSTS, ISOLS, and KPS scores were higher than those before surgery, and the differences were statistically significant (P < 0.05). The survival time was four to 24 months (mean: 19.46 months). Thesix month and one year survival rates were 80.95% and 52.38%, respectively. During the follow-up period, no complications occurred except for aseptic prosthesis loosening in one patient. CONCLUSIONS En bloc resection and intercalary prosthesis implantation can reduce pain, improve limb function, prolong survival time, and improve quality of life in patients with humeral diaphyseal bone metastases.
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Retrospective, multicenter, observational study of 112 surgically treated cases of humerus metastasis. Orthop Traumatol Surg Res 2020; 106:1047-1057. [PMID: 32768275 DOI: 10.1016/j.otsr.2020.02.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/18/2020] [Accepted: 02/27/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The humerus is the second most common site for metastasis in the peripheral skeleton. These humeral metastases (HM) occur in the midshaft in 42% to 61% of cases and theproximal humerus in 32% to 45% of cases. They are often secondary to primary breast (17-31%), kidney (13-15%) or lung (11-24%) cancer. The optimal surgical treatment between intramedullary (IM) procedures, fixation or arthroplasty is still being debated. HYPOTHESIS We hypothesized that fixation and/or arthroplasty are safe and effective options for controlling pain and improving the patients' function. MATERIALS AND METHODS Between 2004 and 2016, 11 French hospitals included 112 continuous cases of HM in 54 men (49%) and 57 women (51%). The average age was 63.7±13.4 years (30-94). The HM occurred in the context of primary breast (30%), lung (23%) or kidney (21%) cancers. The HM was proximal in 35% of cases, midshaft in 59% and distal in 7% of cases. Surgery was required in 69% of patients because of a pathological fracture. The surgical procedure consisted of bundle pinning, plate fixation, arthroplasty or locked IM nailing in 6%, 11%, 14% and 69% of patients, respectively. RESULTS Seven patients (6%) had to be reoperated due to surgical site complications including two infections and four fractures (periprosthetic or away from implant). Twelve patients (11%) experienced a general complication. The overall survival was 16.7 months, which was negatively and significantly impacted by the occurrence of a fracture, a diaphyseal location and the type of primary cancer. At the final assessment, 75% had normal or subnormal function and more than 90% were pain-free or had less pain. The final function was not related to the occurrence of a fracture or etiology of the metastasis. In epiphyseal and metaphyseal HM, there was a trend to better function after shoulder arthroplasty than after plate fixation or IM nailing. CONCLUSIONS Our initial hypothesis was confirmed. Our findings were consistent with those of other published studies. Based on our findings, we recommend using static locked IM nailing with cementoplasty for mid-shaft lesions and modular arthroplasty for destructive epiphyseal or metaphyso-epiphyseal lesions. The criteria for assessing humeral fracture risk should be updated to allow the introduction of a preventative procedure, which contributes to better survival. LEVEL OF EVIDENCE IV, retrospective study.
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Functional results and survival after surgery for peripheral skeletal metastasis: A 434-case multicenter retrospective series. Orthop Traumatol Surg Res 2020; 106:997-1003. [PMID: 32273249 DOI: 10.1016/j.otsr.2019.10.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 10/23/2019] [Accepted: 10/23/2019] [Indexed: 02/03/2023]
Abstract
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.
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Crenn V, Carlier C, Gouin F, Sailhan F, Bonnevialle P. High rate of fracture in long-bone metastasis: Proposal for an improved Mirels predictive score. Orthop Traumatol Surg Res 2020; 106:1005-1011. [PMID: 32782175 DOI: 10.1016/j.otsr.2020.03.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 03/03/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Pathologic fracture is the most feared complication in long-bone metastasis. Various radiographic tools are available for identifying at-risk patients and guide preventive treatment. The Mirels score is the most frequently studied and widely used, but has been criticized, many patients not being operated on until the actual fracture stage. We therefore conducted a French national multicenter prospective study: (1) to determine the proportion of patients operated on at fracture stage versus preventively; (2) to compare Mirels score between the two; and (3) to identify factors for operation at fracture stage according to Mirels score and other epidemiological, clinical and biological criteria. HYPOTHESIS Simple discriminatory items can be identified to as to complete the Mirels score and enhance its predictive capacity. MATERIAL AND METHODS A non-controlled multicenter prospective study included 245 patients operated on for non-revelatory long-bone metastasis, comparing patients operated on for fracture versus preventively according to body-mass index (BMI), ASA score, Katagiri score items and the 4 Mirels items. RESULTS One hundred and twenty-six patients (51.4%) were operated on at fracture stage: 106 (84.1%) showed high risk on Mirels score (score>8), and 15 (11.9%) moderate risk (score=8). On multivariate analysis, 4 independent factors emerged: in increasing order, advanced age (OR=1.03; 95%CI 1.01-1.06), VAS pain score>6 (OR=1.47; 95%CI 1.02-2.11), WHO grade>2 (OR=2.74; 95%CI 1.22-6.15), and upper-limb location (OR=5.26; 95%CI 2.13-12.84). DISCUSSION The present study confirmed that more than half of patients with long-bone metastasis are operated on at actual fracture stage, in agreement with the literature. Several studies highlighted the weakness of the Mirels score as a predictive instrument. Comparison between preventive and fracture-stage surgery showed that upper-limb location, intense pain, advanced age and impaired functional status were associated with fracture-stage surgery, and should be taken into account alongside the original Mirels criteria. This improved scoring instrument remains to be validated in a prospective study. LEVEL OF EVIDENCE IV, prospective cohort study without control group.
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Affiliation(s)
- Vincent Crenn
- Clinique Chirurgicale Orthopédique et Traumatologique, CHU de Nantes, Hôtel-Dieu, Place A. Ricordeau, 44093 Nantes Cedex, France; Physos, Inserm UMR 1238, Faculté de Médecine de Nantes, Rue G. Veil, 44000 Nantes, France.
| | - Christophe Carlier
- Clinique Chirurgicale Orthopédique et Traumatologique, CHU de Nantes, Hôtel-Dieu, Place A. Ricordeau, 44093 Nantes Cedex, France
| | - François Gouin
- Clinique Chirurgicale Orthopédique et Traumatologique, CHU de Nantes, Hôtel-Dieu, Place A. Ricordeau, 44093 Nantes Cedex, France; Physos, Inserm UMR 1238, Faculté de Médecine de Nantes, Rue G. Veil, 44000 Nantes, France; Département de Chirurgie, Centre Léon Bérard, 28, Rue Laennec, 69008 Lyon, France
| | - Fréderic Sailhan
- Hôpital Cochin, 27, Rue du Faubourg-Saint-Jacques, 75014 Paris, France; Clinique Arago, Groupe Almaviva, 187a, Rue Raymond Losserand, 75014 Paris, France
| | - Paul Bonnevialle
- Département Universitaire d'Orthopédie Traumatologie de Toulouse, Hôpital P.P. Riquet, Place Baylac, 31052 Toulouse Cedex, France
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- Société Française de Chirurgie Orthopédique et de Traulatologie (So.F.C.O.T.), 56, rue Boissonnade, 75014 Paris, France
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Colello MJ, Hunter MD, Tanner SL, Porter SE. Intramedullary Nail Fixation for the Treatment of Pathologic Humeral Shaft Fractures. Orthopedics 2020; 43:e389-e398. [PMID: 32602913 DOI: 10.3928/01477447-20200619-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 06/03/2019] [Indexed: 02/03/2023]
Abstract
The goal of this study was to report the clinical outcomes of pathologic humeral shaft fractures treated with reamed or unreamed intramedullary nail fixation in an era of longer patient survival. A retrospective review was conducted of all patients who underwent intramedullary nail fixation performed by a single surgeon for pathologic humeral shaft fractures at a Level I trauma center from 2009 to 2017. Of the 25 patients who were identified, 9 were excluded. Groups were categorized according to whether they underwent reamed or unreamed fixation, and they were evaluated for evidence of union, complications, and reoperation. Of the patients, 11 underwent an unreamed procedure and 5 underwent a reamed procedure. Mean length of follow-up was 51.5 weeks. Of the patients who participated, 12 (75%) showed evidence of union and 2 patients (12.5%) showed evidence of nonunion, with no statistical difference between the groups. Five patients (31.3%) had complications. One nonunion occurred in the reamed group and did not require reoperation. In the unreamed group, complications consisted of 1 delayed union, 1 nonunion treated with revision intramedullary nail fixation, and 2 cases of disease progression that required reoperation. Intramedullary nail fixation of pathologic humeral shaft fractures achieves rates of union parallel to those seen with fixation in a healthy population. The length of follow-up in the current study was longer than the life expectancy reported by previous authors, which can be attributed to improvements in the treatment of cancer. The current authors argue that unreamed fixation is the optimal technique because it yields similar outcomes to a reamed approach and is faster and potentially safer. [Orthopedics. 2020;43(5):e389-e398.].
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Guo W, Gao X, Wang D, Wang T, Tang L, Wang Y, Liu B. Quality of life of patients with proximal humerus metastasis treated with cement spacer. Cancer Manag Res 2019; 11:8499-8506. [PMID: 31572004 PMCID: PMC6756156 DOI: 10.2147/cmar.s219178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/23/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose The goal of this study was to determine whether the surgery using cement spacer could improve the quality of life of patients with proximal humerus metastasis. Patients and methods This is a retrospective study. The study included 34 patients who had been treated for proximal humerus metastasis between January 2010 and June 2014. The patients were divided into surgical and non-surgical group depending on whether they underwent cement spacer surgery. The patient’s quality of life (QOL) assessment is scheduled at five points—at the initial diagnosis (baseline) and at 1 month, 3 months, 6 months, and 9 months of follow-up. Evaluation tool is Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire. Results A total of 34 patients, including 15 patients in the surgery group and 19 patients in the non-surgery group, were enrolled in this retrospective study. In the end, 22 patients finished all evaluations, including 11 patients in the surgical group and 11 patients in the non-surgery group. At the completion of the study, 22 patients had died, including 8 patients in the surgery group and 14 patients in the non-surgery group. After surgical using the cement spacer, the QOL scores of patients at each follow-up point were significantly higher than that of preoperative scores. These scores were also higher than those of the non-surgery group. Conclusion The current study indicated that surgical treatment using the cement spacer could upgrade and maintain quality of life for patients with proximal humerus metastasis in the 9-month assessment.
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Affiliation(s)
- Wen Guo
- Department of Orthopedics, Taizhou People's Hospital, Taizhou 225300, Jiangsu, People's Republic of China
| | - Xin Gao
- Orthopaedic Oncology Center, Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200000, People's Republic of China
| | - Dongsheng Wang
- Orthopaedic Oncology Center, Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200000, People's Republic of China
| | - Tao Wang
- Orthopaedic Oncology Center, Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200000, People's Republic of China
| | - Liang Tang
- Orthopaedic Oncology Center, Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200000, People's Republic of China
| | - Yao Wang
- Orthopaedic Oncology Center, Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200000, People's Republic of China
| | - Bin Liu
- Department of Bone and Soft Tissue Neurosurgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning 530021, Guangxi, People's Republic of China
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Megaprosthetic replacement of the distal humerus: still a challenge in limb salvage. J Shoulder Elbow Surg 2019; 28:908-914. [PMID: 30713063 DOI: 10.1016/j.jse.2018.11.050] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 11/01/2018] [Accepted: 11/09/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND The distal humerus is a rare location of bone tumors. Because of the complexity of the elbow joint, poor soft-tissue coverage, and proximity of nerves and vessels, resection and endoprosthetic reconstruction are demanding. METHODS This retrospective study evaluated the clinical results after distal humeral resection and megaprosthetic reconstruction in 12 patients with an average age of 46 years. All patient files were reviewed for clinical information, and postoperative function and patients' contentment were assessed using the Musculoskeletal Tumor Society score. RESULTS The predominant diagnoses were bone and soft-tissue sarcoma (n = 6), giant cell tumor (n = 2), and renal cell carcinoma metastasis (n = 2). Local recurrence was the reason for secondary amputation in all cases (n = 3). The prosthetic survival rate after surgery was 82% at 2 years and 64% at 5 years. Reconstruction failure was mainly caused by aseptic loosening of the humeral stem, occurring in 27% (n = 3), followed by aseptic loosening of the ulnar stem in 9% (n = 1) and periprosthetic infection in 9% (n = 1). The mean Musculoskeletal Tumor Society score was 24 points (range, 20-30 points). An extension lag of more than 10° was noted in 6 patients (55%). CONCLUSION Our results suggest that limb salvage with a distal humeral replacement can achieve good functional results in most patients, although the complication rate with special emphasis on the loosening rate of the humeral stem is high. However, limb salvage was not achieved in 27% of patients because of local recurrence.
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