SURGICAL TREATMENT OF FRACTURES THROUGH METASTASES

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1 SURGCAL TREATMENT OF FRACTURES THROUGH METASTASES N THE PROXMAL FEMUR JOHANNES POGENFURST,* VENNA, AUSTRA, RALPH C. MARCOVEt and THEODORE R. MLLER4 NEW YORK, UNTED STATES OF AMERCA From the Bone Service of the Department of Surgerv, Memorial Hospitalfor Cancer and Allied Diseases, Memorial Sloaiz-Kettering Cancer Center, and the James Ewing Hospital of the City of New York One-sixth of all fractures through skeletal metastases are in the proximal fourth of the femur (Clam 1965). Closed treatment in general leads to union in only 5 per cent of fractures through metastases (Clam!oc. cit.), and in the hip region Francis, Higinbotham, Carroll, Jacobs and Graham (1962) have never found union. The period of survival after fracture averages eight months, and functional rehabilitation rather mere palliation should, therefore, be attempted. The possibility of bilateral involvement makes it even more desirable to maintain stability of at least one hip. A comparison was therefore made of the efficiency of internal fixation, resection of the head and prosthetic replacement in the treatment of fractures of the and of the intertrochanteric region caused by skeletal metastases. MATERAL During the eleven years from 1956 to 1966 surgeons of the Bone Service at Memorial Hospital, New York City, performed 121 operations on 1 12 patients for fractures through histologically proven metastases in the or intertrochanteric region. Of these, 10 operations on 101 patients were analysed. Eleven patients were excluded because either records or radiographs were not available. Essential details were coded (Table ) and statistically evaluated (Snedecor 1956). Operation numbers quoted correspond to those in Table. OBSERVATONS Distribution ofsex and age-seventy-three of the patients were women and twenty-eight men. Their ages at the time of operation ranged from thirteen to eighty-four years. The mean age for women was sixty-two years and for men fifty-seven years (Table l). Neck Head Type ofprimary tumour-mammary carcinoma was the most common type (fifty-five patients). The next most frequent groups were renal carcinoma (five patients), carcinoma of the lung (five patients) and carcinoma of the thyroid gland (four patients). Among the remaining thirty-two patients, twenty-one had carcinoma of various origins, eight had sarcoma and three had multiple myeloma. Type offracture and radiographic extent of bone involvenient-n fifty-two patients the fracture was in the ntertrochanteric region and in fifty-eight in the intertrochanteric FG. 1 region. All fractures showed metastases in the Diagram showing radiologically visible metastatic involvement of the proximal. n thirty-two these changes were restricted to femur in 110 fractures. * Formerly Orthopaedic Fellow, the Hospital for Special Surgery, affiliated with the New York Hospital-Cornell University Medical College, New York. t Assistant Attending, Bone Service, Department of Surgery, Memorial Hospital for Cancer and Allied Diseases. Chief of Bone Tumor Service, Memorial-Sloan-Kettering Cancer Center. VOL. 50 B, NO. 4, NOVEMBER

2 744 J. POGENFURST, R. C. MARCOVE AND T. R. MLLER TABLE CLNCAL CHARACTERiSTCS N 1 10 OPERATONS FOR FRACTURES THROUGH METASTASES in NECK AND NTERTROCHANTERC PART OF THE FEMUR Metastases Complications Function Survival Sex (years) Age of fracture Site Bone involved acetabulum present in difficulties (technical (ability time or infection) to walk) Resection 1 Female 43 Neck Femoral only 2 Female 62 Neck Femoral only 3 Female 42 Neck Femoral only 4 Female 62 Neck Femoral only 5 Male 65 Neck Femoral only 6 Female 64 Neck 7 Male 55 Neck - 16 months months months - Still alive - 8 months months months 8 Female 29 Neck - 16 months 9 Female 69 Neck - 64 months 10 Female 44 Neck - 16 months 11 Male 35 Neck - 4 months 12 Female 57 ntertrochanteric Femoral only 13 Female 43 ntertrochanteric Femoral only months - 16 months 14 Female 76 ntertrochanteric months 15 Female 54 ntertrochanteric - - l6months 16 Female 41 ntertrochanteric months 17 Female 44 ntertrochanteric months 18 Female 38 ntertrochanteric - 4 months 19* Female 65 ntertrochanteric - 16 months 20 Female 64 ntertrochanteric - 8 months * Second operation in patients who underwent operation on both sides. THE JOURNAL OF BONE AND JONT SURGERY

3 SURGCAL TREATMENT OF FRACTURES THROUGH METASTASES N THE PROXMAL FEMUR 745 TABLE -co,ztiizued CLNCAL CHARACTERSTCS N 10 OPERATONS FOR FRACTURES THROUGH METASTASES N NECK AND NTERTROCHANTERC PART OF THE FEMUR Case Sex Age Site number (years) of fracture Metastases Complications Function (technical (ability Survival Bone involved present in difficulties acetabulum or infection) to walk) time Resection-continued 21 Female 52 ntertrochanteric - Still alive 22 Male 68 ntertrochanteric 23 Male 59 Neck - 8 months 8 months 24 Female 62 Neck : 16 months 25 Male 58 Neck 32 months 26 Female 67 Neck 16 months 27 Female 54 Neck - 16 months 28 Female 72 Neck - 32 months 29 Female 72 Neck - 8 months 30 Male 66 Neck - 2 months 31 Female 64 ntertrochanteric - 4 months 32 Male 52 ntertrochanteric - 8 months 33 Male 13 ntertrochanteric - 8 months 34 Female 36 ntertrochanteric - 8 months 35 Male Neck Femoral only months 36 Female 58 Neck Femoral only months 37 Female 50 Neck Femoral only months 38 Male 84 Neck Femoral only months 39 Female 54 Neck months 40 Female 59 Neck 2 months VOL. 50 B, NO. 4, NOVEMBER 1968

4 746 J. POGENFURST, R. C. MARCOVE AND T. R. MLLER TABLE -continued CLNCAL CHARACTERSTCS N 10 OPERATONS FOR FRACTURES THROUGH METASTASES N NECK AND NTERTROCHANTERC PART OF THE FEMUR number Sex (years) Age of fracture Site Metastases Complications Function Bone involved present in difficulties (technical (ability Survival or infection) to walk) time acetabulum Resection-continued 41 Female 35 Neck - 8 months 42 Female 38 ntertrochanteric Femoral only months 43 : Female 74 ntertrochanteric Femoral only months 44* Male 42 ntertrochanteric Femoral only months 45 Female 49 ntertrochanteric - - 4weeks 46 Female 72 ntertrochanteric months nternal fixation 47 Female 40 Neck Femoral only - 48 Female 44 Neck Femoral only - 49 Female 44 Neck Femoral only - 50 Female 29 Neck Femoral only - 51 Male 42 Neck Femoral only - 9* Female 71 Neck - 16 months - 16 months - 8 months - 16 months - 8 months - 64 months 19 Female 65 ntertrochanteric Femoral only - 52 Female 52 ntertrochanteric 53 Female 67 lntertrochanteric months - Still alive - 32 months 54 Female 38 ntertrochanteric months 10* Female 44 ntertrochanteric - 4 months 55 Male 74 ntertrochanteric - 8 months * Second operation in patients who underwent operation on both sides. THE JOURNAL OF BONE AND JONT SURGERY

5 SURGCAL TREATMENT OF FRACTURES THROUGH METASTASES N TilE PROXMAL FEMUR 747 TABLE -conti,zued CLNCAL CHARACTERSTCS N 10 OPERATONS FOR FRACTURES THROUGH MFTASTASES N NECK AND NTERTROCHANTERC PART OF THE FEMUR Metastases Complications Function Case Age Site Bone involved present in (technical Survival number Sex (years) of fracture acetabulum difficulties (ability time to walk) or infection) nternal fixation-continued 56 Female 43 Neck Femoral only 57 Female 52 Neck - 16 months 64 months 58 Female 48 lntertrochanteric - 32 months 59 Ma!e 65 ntertrochanteric - Still alive 60 Male 60 ntertrochanteric 61 Female 56 ntertrochanteric 62 Female 65 ntertrochanteric - 8 months 8 months 8 months 63 Male 60 lntertrochanteric 16 months 64 Female 73 Neck 65 Female 46 Neck 66 Male 70 ntertrochanteric Femoral only - 64 months - 8 months - - 2weeks 67 Male 70 ntertrochanteric months 44 Male 42 tntertrochanteric 3* Female 47 Neck Femoral only 68 Female 38 Neck Femoral only 69 Female 80 Neck Femoral only 70 Female 67 Neck 71 Female 48 Neck - 4 months lweek months weeks - - 4weeks months * Second operation in patients who underwent operation on both sides. VOL. 508, NO. 4, NOVEMBER 1968

6 748 J. POGENFURST, R. C. MARCOVE AND T. R. MLLER TABLE -contiiiued CLNCAL CHARACTERSTCS N 10 OPERATONS FOR FRACTURES THROUGH METASTASES N NECK AND NTERTROCHANTERC PART OF THE FEMUR Case Age Site Bone involved Metastases present in Complications difficulties (technical Function (ability time Survival number Sex (years) of fracture acetabulum or infection) to walk) nternal fixation-continued 72 Female 49 ntertrochanteric Femoral only months 72* Female 49 ntertrochanteric Femoral only weeks 73 Female 61 ntertrochanteric Femoral only months 74 Male 83 ntertrochanteric Femoral only months 75 Female 54 ntertrochanteric Femoral only months 76 Female 53 ntertrochanteric 2 months 77 Female 70 lntertrochanteric 2 months 78 Female 70 ntertrochanteric 8 months 79 Female 63 ntertrochanteric 1 week 80 Male 49 ntertrochanteric 2 weeks Male 30 ntertrochanteric 2 weeks Female 44 ntertrochanteric 83 Male 35 ntertrochanteric - - lweek months 84 Male 54 ntertrochanteric months Prosthesis 85 Female 82 Neck Femoral only months 86 Female 53 Neck Still alive - - * Second operation in patients who underwent operation on both sides. THE JOURNAL OF BONE AND JONT SURGERY

7 SURGCAL TREATMENT OF FRACTURES TEROUG METASTASES N TlE PROXMAL FEMUR 749 TA BLE 1-conti,iuc d CLNcAl. CHARACTERSTCS N 1 10 OPERATONS FOR FRACTURES THROUGH METASTASES N NECK AND NTERTROCHANTERC PART OF THE FEMUR Case number Sex Age (years) of Site fracture Metastases Complications Function (technical Survival Bone involved present in diffifles (ability time acetabulum or infection) to walk) Prosthesis-co,zti,zued 87 Female 48 Neck - 4 months 88 Female 41 Neck - 32 months 89 Female 55 Neck -- 8 months 89* Female 55 Neck - 8 months 90 Female 53 Neck - 16 months 91 Female 57 ntertrochanteric 16 months 91 * Female 57 ntertrochanteric 8 months 92 Female 40 lntertrochanteric 2 weeks 92* Female 40 ntertrochanteric 8 months 93 Female 65 ntertrochanteric Still alive 94 Male 61 ntertrochanteric Still alive 95 Female 67 ntertrochanteric - 4 months 96 Female 70 Neck 6 months 97 Female 37 Neck Femoral only months 98 Female 46 Neck Femoral only - 8 months 99 Male 80 Neck - week 100 Female 47 Neck - 8 months 101 Male 68 ntertrochanteric - 4 months * Second operation in patients who underwent operation on both sides. VOL. 50 B, NO. 4, NOVEMBER 1968

8 750 J. POGENFURST, R. C. MARCOVE AND T. R. MLLER the (Fig. ). Six had, in addition, signs ofdisease in the head, fortyhad metastases in the intertrochanteric region also, which often extended into the proximal shaft. n thirty-two fractures the entire proximal end of the femur was involved (Fig. 1). Forty-nine patients had additional metastatic lesions in the ilium and forty-eight had lesions in both femora. TABLE 11 DsTRBUTioN OF SEX AND AGE Sex Age (years) Operation Number Female Male Range Mean nternal fixation :: 13 Resection *14 Prosthesis * 13 Total OPERATVE PROCEDURES Three methods of operation were used (Fig. 2): 1) internal fixation of the (forty-four cases) ; 2) resection of the head (forty-six cases) ; and 3) prosthetic replacement of the head (twenty cases). n none of the three methods was any particular type of tumour preferred or excluded. Among the three procedures, distribution of male and female patients and their ages did not differ significantly (Table ), nor did the extent of bone involvement. NTERNAL FXATON n this series the first nailing with a Smith-Petersen nail for pathological fracture through a metastasis of the was in 1957 (Case 68). Three further patients were treated in this way (Cases 56, 84, 66). Because of secondary displacement of the fragments none regained the ability to walk and this method was therefore discontinued. n all the other forty operations a combination nail with plate was used. As a rule, a plate with five to twelve holes was applied: shorter plates did not provide sufficient stability. Complications and post-operative changes- n ten operations the position of the fragments underwent secondary changes such as increasing varus position or shortening of the. Five of these were further complicated by penetration of the nail into the acetabulum. n one patient the shaft fractured below the plate, and in another the screws broke and allowed the plate to FG. 2 loosen. Because of these complications, Relative frequency of use of internal fixation, resection nine re-operations were necessary, as foland prosthetic replacement for fractures of the. and the intertrochanteric region. lows : second attempt at internal fixation (Cases 58 and 19); exchange for a longer plate (Case 65); removal ofthe Smith-Petersen nail (Cases 67 and 57); resection ofthe head (Cases 64 and 59): resection of the head and replacement with a Moore THE JOURNAL OF BONE AND JONT SURGERY

9 SURGCAL TREATMENT OF FRACTURES THROUGH METASTASES N THE PROXMAL FEMUR 751 prosthesis and later removal of the prosthesis (Case 56). Three operations (Cases 47, 67, 62) were followed by wound infection. RESECTON OF THE FEMORAL HEAD AND NECK The discouraging results of internal fixation led to a preference for resection of the head and which was first carried out in 1956 (Case 32). Francis and colleagues (1962) reported the results of nineteen resections and emphasised the rapid and atraumatic nature of this operation. Our operations in Cases 3, 57 and 31 were reported individually in their paper. Complications and post-operative changes-n nine cases the proximal end of the femur underwent secondary changes after operation : separation of the greater trochanter (Cases 19, 16, 1 3, 32) or lysis of the greater trochanter (Cases 29, 25, 17, 23, 22). t seems that separation is the first step to lysis and that both are caused by progressive disease. Resection through the shaft, as necessary for intertrochanteric fractures, also appears to increase resorption, probably because of remaining tumour. The changes described were independent of irradiation or weight-bearing. Eight patients had wound infections with persistent drainage. PROSTHETC REPLACEMENT OF FEMORAL HEAD Since 1960 the self-locking Moore prosthesis has been used in six patients, for the first time in Case 97. Since 1965 the long stem intramedullary prosthesis has been preferred and by the end of 1966 had been used for fourteen fractures. Complications and post-operative changes-a well known disadvantage of the short stem prosthesis, even in normal bone, is that the stem does not always lock sufficiently without use of acrylic cement. instability was noted in one patient (Case 97), who was unable to walk. n Case 56, included in the group of internal fixation, the short stem prosthesis which replaced the Smith-Petersen nail had to be removed later for instability, so that finally a condition resulted as after resection. The problem of instability can be overcome with a long stem prosthesis which fits tightly into the medullary cavity (Matchett 1965). The insertion ofthe long stem prosthesis is, however, slightly more difficult. During two operations the greater trochanter broke, and twice the distal end of the stem perforated the anterior cortex of the shaft. Propagation of tumour into the distal part ofthe shaft was seen after one operation only (Case 100). Two long stem prostheses migrated into the diseased acetabulum. Two operations were followed by wound infection. TME OF SURVVAL AFTER SURGERY Only five out of 101 patients are still alive. Two of them are in generally good condition. The other three are in hospital because of progressive disease. Two patients could not be followed owing to change of address, but it is known that in 1966 both were still alive. All the other ninety-three patients died within five years of their operations for fracture. The average survival time was eight and a half months. Six patients died within two weeks after internal fixation and one after prosthetic replacement. FUNCTON AFTER OPERATON The success of operation was assessed by the patient s ability to walk. it was postulated for a successful result that the patient should be able to walk sufficiently to take care of himself. Temporary or permanent use of a stick or crutches was not considered to imply failure. Restriction to a few steps between bed and wheelchair was not regarded as ability to walk, even if the patient was free from pain. Sixty patients regained ability to walk according to our definition. Eleven patients died within a month after operation without starting to walk, and in thirty-nine fractures operation failed to restore function. VOL. 50 B, NO. 4, NOVEMBER 1968

10 752 J. POGENFURST, R. C. MARCOVE AND T. R. MLLER FG. 7 Case 91. Figure 3-March 1966: intertrochanteric fracture through right femur. Figures 4 and 5-Treatment by insertion of long stem prosthesis into right femur and of medullary nail into left femur. Figure 6-June Fracture through of left femur. Figure 7-nsertion of long stem prosthesis into left femur. THE JOURNAL OF BONE AND JONT SURGERY

11 SURGCAL TREATMENT OF FRACTURES THROUGH METASTASES N THE PROXMAL FEMUR 753 CASE REPORTS Case 91-A woman of fifty-six underwent nephrectomy for carcinoma in n March 1966 there was an intertrochanteric fracture of the right femur through a metastasis (Fig. 3). The pelvis was not involved. There was also secondary deposit in the shaft of the left femur. The right head was removed and a long stem prosthesis was inserted. A nail was inserted down the medullary cavity of the left femur (Figs. 4 and 5). n June 1966 the left broke (Fig. 6). The medullary nail and the head were removed and a long stem prosthesis was inserted (Fig. 7). The patient was able to walk after both operations. She died from widespread metastases six months after the second operation. Case 96-A woman of seventy suffering from an infiltrating duct carcinoma of the breast refused mastectomy but later, in December 1965, underwent hypophysectomy because of skeletal metastasis. n April 1966 the right broke through a metastasis. A long stem prosthesis was inserted (Fig. 8). The patient was able to walk without support in spite of multiple metastases. She died from pulmonary embolism a little over one year after operation. FG. 8 Case 96-April Extensive metastatic involvement of pelvis and fernora. Long stem prosthesis inserted for fracture of right. Case 98-A woman of forty-six began in 1966 to get pain in the right hip. Radiographs showed diffuse metastases in the pelvis and both femora. There was evidence of impending fracture through the of the right femur. The primary tumour was a breast cancer. n November 1966 the right broke, and four weeks later a long stem prosthesis was inserted (Figs. 9 and 10). The patient could not walk. n March 1967 the prosthesis was seen to be migrating centrally, and three months later it penetrated the floor ofthe acetabulum (Figs. 1 1 and 12). The patient died seven months after operation. COMPARATVE RESULTS The success of each operative procedure was judged according to ) post-operative complications, and 2) ability to walk. Post-operative complications-the number of post-operative com plications such as instability of nail and plate, resorption of the proximal end of the femur, migration or instability of a prosthesis, or wound infection, were equally distributed among the surgical procedures, probably because these complications are attributable to the basic disease or to general surgical risks. We could not demonstrate any correlation between local or general treatment and infection. Ability to ira/k-of ninety-nine patients who survived the operation long enough to start walking, sixty actually regained walking ability. Their distribution related to the three VOL. 50 B, NO. 4, NOVEMBER 1968

12 754 J. PO1GENFURST, R. C. MARCOVE AND T. R. MLLER types ofoperation is shown in Table ll. The type ofoperation and the results in nine patients with bilateral fractures are shown in Table V. DSCUSSON The functional results after internal fixation, resection and prosthetic replacement for 1 10 fractures through metastases in the proximal end ofthe femur correspond with the findings of Francis and colleagues (1962) in so far that internal fixation does not represent a reliable treatment (sixteen failures out of thirty-six surviving patients). Recent experience did not show any superiority for resection (nineteen failures out of forty-four), but testified in favour of prosthetic replacement (four failures out of twenty). FG. 11. Case 98. Figures 9 and 10-November Fracture through right treated by insertion of long stem prosthesis. Note the metastatic involvement of femur and pelvis. Figure 11-Three months later: the prosthesis is migrating centrally. Figure 12-Six months later: the prosthesis has penetrated the acetabular floor. The obvious advantages of this method are maintenance of stability and early restoration of function. This is particularly beneficial in bilateral fractures. The possibility of stabilisation of the shaft at the same time gives an additional reason for the use of the long stem prosthesis. t is of further interest that in spite of fracture of the trochanter in two operations, resorption after resection did not occur and the fractures healed. Analysis of the four failures after prosthetic replacement reveals the following causes: infection (one case), instability of short stem prosthesis (one case), and migration of the THE JOURNAL OF BONE AND JONT SURGERY

13 SURGCAL TREATMENT OF FRACTURES THROUGH METASTASES N THE PROXMAL FEMUR 755 prosthesis into the pelvis (two cases). Because the last two were the only patients in this group with diffuse metastatic disease of the ilium and radiographic disappearance of the cortex, this seems to add the further advantage of predictability. f the ilium is not involved, migration TABLE ABLTY TO WALK RELATED TO TYPE OF OPERATON Type of operation Number of operations Number surviving 28 days or more Wa&ing Not walking nternal fixation Resection Prosthesis S 4 Total TABLE BLATERAL FRACTURES AND TYPE OF OPERATON RELATED TO WALKNG ABLrry V Number of Walking after Type of operation operations first operation Walking after second operation Bilateral internal fixation First side internal fixation. Second side resection First side resection. Second side internal fixation Bilaterallong stem prosthesis TABLE THE CHANGE N THE TYPE OF PROCEDURE USED V Number of operations Period Prostheses Total nternal Resections - fixations Short Long l Total : 14 does not occur, because of the short life span. Even multiple nodular lesions with lytic centres do not seem to impair the ability of the acetabulum to bear weight. Neither for internal fixation nor for resection was it possible to correlate the radiographic appearance of metastases to the clinical result in a similar way. VOL. 50 B, NO. 4, NOVEMBER 1968 E

14 756 J. POGENFURST, R. C. MARCOVE AND T. R. MLLER The distribution of each procedure in the eleven years from 1956 shows that the use of prostheses in 1966 has practically replaced resection of the head whereas internal fixations were still performed in 1965 to 1966 (Table V). For further improvement of results it would be advisable to use prostheses on an even larger scale and to discontinue internal fixation. SUMMARY AND CONCLUSONS The results of 1 10 operations for the treatment of fractures through metastases in the and intertrochanteric region have been studied. Of these, forty-four fractures were treated by internal fixation, forty-six by resection of the head and, and t xenty by prosthetic replacement. The following conclusions were reached.. Prosthetic replacement of the head is a reliable procedure. 2. The long stem type of prosthesis has the advantages of greater stability and simultaneous fixation of the shaft. 3. Patients with diffuse metastatic disease of the ilium are not suitable for prosthetic replacement. These patients should be treated by resection of the head and. 4. Resection is a less traumatic procedure and therefore useful in the palliative treatment of patients in poor general condition. 5. nternal fixation leads more often to complications and unfavourable results do the other methods. This work was supported in part by Public Health Service General Support Grant FR of the Division of Research Faclities and Resources, and the Evelyn Sharp Fund. REFERENCES CLAiN, A. (1965): Secondary Malignant Disease of Bone. British Journal of Cancer, 19, 15. FRANCS, K. C., HGNBOTHAM, N. L., CARROLL, R. E., JACOBS, B., and GRAHAM, W. D. (1962): The Treatment of Pathological Fractures of the Femoral Neck by Resection. Journal of Trauma, 2, 465. MATCHETT, F. (1965): A New Long-stem ntramedullary Vitallium Hip Prosthesis. Journal of Bone and Joint Surgery, 47-A, 43. SNEDECOR, G. W. (1956): Statistical Methods Applied to Experiments in Agriculture and Biology. Fifth edition. Ames, owa: owa State Coleg Press. THE JOURNAL OF BONE AND JONT SURGERY