Metastatic Pathological Fractures Research Articles

Clinical trial of the treatment using superelastic shape-memory Ti-Ni alloy intramedullary nails for metastatic pathologic fractures

Clinical trial of the treatment using superelastic shape-memory Ti-Ni alloy intramedullary nails for metastatic pathologic fractures

Proximal femoral replacements for metastatic bone disease: financial implications for sarcoma units

Metastatic pathological fractures of the proximal femur are increasingly treated by endoprosthetic proximal femoral replacement. We report the results and the costs incurred performing these procedures at our supra-regional sarcoma unit. Sixty-two patients underwent 63 proximal femoral replacements for metastatic bone disease over a seven-year period. Breast cancer was the most common primary pathology. One patient underwent a revision procedure for infection. Twenty-two patients suffered dislocations, most commonly those undergoing a conventional arthroplasty articulation. The estimated cost of a proximal femoral replacement is 18,002 pounds at our centre. Less than half of this is reimbursed under Payment by Results. Endoprosthetic replacement of the proximal femur is an effective treatment of metastases, but is poorly reimbursed under current funding arrangements.

Increased galectin-3 expression and intra-epithelial neutrophils in small airways in severe COPD

Galectins-1 and -3 regulate epithelial proliferation/apoptosis and neutrophil activation, and are implicated in lung cancer and asthma. The role of galectins in chronic obstructive pulmonary disease (COPD), characterised by epithelial changes and neutrophil infiltration, remains unknown. In the present study, galectin-1 and -3 expression was assessed by immunohistology in the bronchial epithelium of lung specimens from eight severe COPD patients and compared with nine nonsmokers and six smokers without COPD. Findings were related to epithelial proliferation (Ki-67), tissue inflammation and lung function. Epithelial galectin-3 immunostaining was increased only in the small airways of COPD patients when compared with nonsmokers and smokers. In contrast, galectin-1 was only significantly increased in the small airways of the group of smokers. Ki-67+ epithelial cells and neutrophils were increased in the small airways of COPD patients when compared with smokers. Furthermore, intra-epithelial neutrophils correlated in the small airways with Ki-67+ epithelial cells and with the forced expiratory volume in one second/forced vital capacity ratio. However, no correlation was observed with galectin expression. The present study supports the hypothesis that distal airways represent an important site for detecting changes in chronic obstructive pulmonary disease. In patients with severe disease, an increased galectin-3 expression and neutrophil accumulation in the small airway epithelium was demonstrated, correlating with epithelial proliferation and airway obstruction.

Inferior vena cava filters prevent pulmonary emboli in patients with metastatic pathologic fractures of the lower extremity.

The records of 47 consecutive patients with metastatic pathologic fractures of the lower extremity were analyzed with respect to thromboembolic complications. All patients were unable to receive pharmacologic deep venous thrombosis prophylaxis, and were stratified into two groups, based on use of an inferior vena cava filter. Group I (n = 24) consisted of patients who had an inferior vena cava filter plus mechanical deep venous thrombosis prophylaxis (compression stockings and sequential compression boots); Group II (n = 23) consisted of a group of patients receiving only mechanical deep venous thrombosis prophylaxis. All patients had routine lower extremity venous duplex imaging preoperatively, postoperatively, and before hospital discharge. At final followup, patients were examined for deep venous thrombosis and reviewed for thromboembolic events. At a mean followup of 11.5 months, Group I had two detectable deep venous thromboses and no pulmonary emboli; Group II had one detectable deep venous thrombosis and five pulmonary embolisms. In Group II, 40% (two of five) of pulmonary embolisms were fatal, yielding an 8.7% (two of 23) group mortality rate. Overall, the entire group had an approximately 17% deep venous thrombosis rate. Only 6.4% (three of 47) of deep venous thromboses were detectable by standard duplex imaging. The majority of deep venous thromboses (five of eight, 62.5%) were nondetectable by duplex imaging. Overall, a 4.3% (two of 47) death rate was attributable to pulmonary embolism. In contrast, an 8.6% (four of 47) mortality rate occurred in Group II alone. All pulmonary embolisms occurred in patients who did not receive an inferior vena cava filter. The majority of venous thromboses (62.5%) were not detectable on duplex scanning, therefore were thought to arise from the pelvic venous system. Complications related to inferior vena cava filter insertion were minimal. For patients with metastatic pathologic fractures of the lower extremities who are unable to receive pharmacologic deep venous thrombosis prophylaxis, the use of inferior vena cava filters, in conjunction with standard mechanical deep venous thrombosis prophylaxis, is a procedure that has a low risk and is useful adjunct to prevent fatal pulmonary embolisms.

SURGICAL TREATMENT OF PATHOLOGIC FRACTURES FROM METASTATIC TUMORS OF LONG BONES

Surgical treatment of 74 cases of impending and established metastatic pathologic fractures were analyzed. On the basis of various reports, the incidence of bone lesions, bone-seeking primary tumors, lesion sites, diagnostic techniques and possibilities, as well as indications for and methods of surgical treatment, are surveyed. Surgical intervention is only one aspect of the different components of general treatment in bone metastases. An aggressive surgical procedure yields very satisfactory results in most cases, compared with those of conservative treatment.

Anterior Decompression and Stabilization of the Spine as a Treatment for Vertebral Collapse and Spinal Cord Compression from Metastatic Malignancy

During a ten-year period, 77 patients with spinal instability caused by metastatic pathologic fractures of one or more vertebrae were treated with anterior decompression and stabilization by replacement of the affected vertebral bodies with methylmethacrylate, polymerizing in situ, augmented by Knodt distraction rods positioned anteriorly. No postoperative external support was required, and the fixation achieved by this method was not affected adversely by subsequent irradiation at a mean of 4020 rads. Sixty-two patients had major neurologic impairments preoperatively and required spinal cord and/or nerve root decompression anteriorly prior to fixation. Of these, 26 had complete neurologic recovery postoperatively, 16 others improved significantly, 20 remained unchanged, and one patient deteriorated neurologically. Five patients suffered failures of fixation, although two were successfully restabilized after a second operation. The remaining 72 patients enjoyed good or excellent resolution of spine pain postoperatively, and, in patients surviving their underlying malignancies, stability did not deteriorate during the follow-up period ranging from 42 to 146 months. Six patients developed spinal instability from tumor lysis at a different level between five and 95 months postoperatively. All were treated with successful decompression and stabilization. There was one wound infection among the 83 anterior stabilization procedures. However, three of the six patients requiring secondary posterior stabilization suffered wound dehiscences, and three of these became infected.

Anterior cord decompression and spinal stabilization for patients with metastatic lesions of the spine.

Metastatic lesions involving the spine may cause vertebral body collapse, resulting in either spinal instability or neural compression, or both. Progressive destruction of the vertebral body by the tumor may cause increasing spinal instability, leading to a kyphotic deformity and further neural deficit. Anterior decompression allows direct excision of the tumor focus and direct neural decompression. Because of postoperative irradiation, conventional bone grafts are rarely incorporated. Over an 8-year period, 52 patients with spinal instability secondary to metastatic pathological fractures of one or more vertebrae underwent anterior decompression and stabilization by replacement of the affected vertebral bodies with methyl methacrylate, polymerizing in situ. No postoperative external support was required, and the acrylic fixation achieved by this method was not affected adversely by subsequent irradiation to a mean of 4020 rads. Forty patients had major neurological impairment preoperatively and required anterior spinal cord and/or nerve root decompression prior to fixation. Of these, 21 had complete neurological recovery postoperatively, 13 others were improved significantly, five remain unchanged, and one patient deteriorated neurologically. There were three cases with failure of fixation. Seven other patients did not benefit from the procedure because of specific complications or the advanced state of their disease. The remaining 42 patients had good relief of pain and restoration of spinal stability, which did not deteriorate during the follow-up period, ranging from 6 to 100 months postoperatively.

The use of methylmethacrylate for vertebral-body replacement and anterior stabilization of pathological fracture-dislocations of the spine due to metastatic malignant disease.

Metastatic malignant lesions involving the spine occasionally cause severe enough vertebral-body collapse to result in either spinal instability or neural compression, or both. Conventional decompressive laminectomy in such cases rarely results in neural improvement. It may, however, cause local instability of the spine, leading to a progressive kyphotic deformity and an increasing neural deficit. Anterior decompression allows excision of the focus of tumor and direct neural decompression. However, anterior stabilization by bone grafts usually does not succeed, as postoperative irradiation in dosages sufficient for tumor control may interfere with incorporation of the graft. Over a four and one-half-year period, fourteen patients with spinal instability secondary to metastatic pathological fractures of one or more vertebrae received anterior stabilization by replacement of the affected vertebral bodies with methylmethacrylate polymerized in situ. No postoperative external support was required, and the acrylic fixation achieved by this method was not affected adversely by subsequent irradiation averaging 4375 rads. There was only one soft-tissue infection, which did not involve the anterior stabilization. Twelve patients had major neural impairment preoperatively and required spinal cord or nerve-root decompression anteriorly prior to fixation. Nine had complete neural recovery postoperatively, two others were improved significantly, and one remained unchanged. None deteriorated neurologically. Five patients had undergone decompressive laminectomy before the anterior stabilization was attempted. None had improved neurologically, and all had increased spinal instability. There was one failure of fixation. The remaining thirteen patients had excellent relief of pain and restoration of spinal stability which did not deteriorate during the follow-up period, ranging from thirteen to forty-five months postoperatively.

Surgical treatment of metastatic pathological fracture of major long bones.

Surgical treatment of metastatic pathological fracture of major long bones.