Angelini Andrea, Trovarelli Giulia, Berizzi Antonio, Pala Elisa, Breda Anna, Maraldi Marco, Ruggieri Pietro
Department of Orthopedics and Orthopedic Oncology, University of Padova, Italy.
Department of Orthopedics and Orthopedic Oncology, University of Padova, Italy.
Injury. 2018 Nov;49 Suppl 3:S77-S83. doi: 10.1016/j.injury.2018.09.044.
Metastatic lesions to the proximal femur occur frequently and require special consideration due to the high risk of pathologic fractures. Type of surgery might influence patient survival considering the growing concept of oligometastases. In fact, the use of modular tumor megaprosthesis is increasing in the last decades compared to intramedullary nailing. Aim of this study was to evaluate oncological and functional results of treatment in patients with pathologic or impending fracture of the proximal femur, with patient survival being the primary, complications the secondary, and functional results the tertiary endpoint.
Between 2016 and 2017, 40 patients with pathologic fracture (29 cases) or impending fracture according to the Mirels score (11 cases) of the proximal femur, were treated in our Institute and prospectively collected. There were 29 females (72.5%) and 11 males (27.5%), with a mean age at diagnosis of the metastasis of 63.6 years (range 35 to 92 years). Patients were treated due to bone metastases (commonly develop from breast cancer) or hematologic malignancies. Considering number of lesions, 17 patients had less than three bone metastases. Surgical procedures included intramedullary nailing (7 patients), conventional endoprosthesis (4 patients) and modular endoprosthetic replacement (29 patients). Adjuvant treatments included chemotherapy (13 cases), radiation therapy (8 cases) or both (15 cases), and selective arterial embolization (6 pre-op). Oncological results were evaluated considering the survival of patients. Functional results were assessed as pain intensity in VAS score and MSTS score.
The mean follow-up of patients was 10.2 months (range 6-26.3 years). At the latest evaluation, 23 patients were alive with disease, 3 patients were alive without evidence of disease and 14 patients were dead with disease. There was a significant better survival in patients treated with PFR compared to IMN and EPR groups (p = 0.0080). No differences in term of survival were found comparing impending vs actual pathological fracture and oligo vs multiple metastases. After surgery, all patients experienced improvement in quality of life resulting from reduction in pain. Mean MSTS score was 22.4. The overall complications rate was 22.5%. The most frequent complication was dislocation followed by wound dehiscence and deep infections.
Modular tumour prosthesis for proximal femur replacement provides good functional outcome, relative low incidence of complications and higher life quality in the medium term. Oncologic results were influenced by type of surgery, biased by the correct indications for resection and nailing. Preoperative general health condition, life expectancy and ambulatory capacity may influence treatment strategy. With the numbers available, the patients with actual pathologic or impending fracture of the proximal femur treated with resection had a significantly higher survival, especially those with metastases from renal carcinoma or multiple myeloma.
股骨近端的转移瘤很常见，由于病理性骨折风险高，需要特别关注。考虑到寡转移概念的不断发展，手术方式可能会影响患者的生存率。事实上，与髓内钉固定相比，在过去几十年中模块化肿瘤假体的使用正在增加。本研究的目的是评估股骨近端病理性或即将发生骨折患者的肿瘤学和功能治疗结果，以患者生存率为主要终点，并发症为次要终点，功能结果为第三终点。
2016年至2017年期间，我院收治并前瞻性收集了40例股骨近端病理性骨折（29例）或根据Mirels评分即将发生骨折（11例）的患者。其中女性29例（72.5%），男性11例（27.5%），转移瘤诊断时的平均年龄为63.6岁（范围35至92岁）。患者因骨转移（通常由乳腺癌发展而来）或血液系统恶性肿瘤接受治疗。考虑到病变数量，17例患者的骨转移灶少于3个。手术方式包括髓内钉固定（7例）、传统假体置换（4例）和模块化假体置换（29例）。辅助治疗包括化疗（13例）、放疗（8例）或两者联合（15例），以及选择性动脉栓塞（术前6例）。根据患者生存率评估肿瘤学结果。功能结果通过视觉模拟评分法（VAS）的疼痛强度和肌肉骨骼肿瘤学会（MSTS）评分进行评估。
患者的平均随访时间为10.2个月（范围6至26.3年）。在最近一次评估时，23例患者带瘤生存，3例患者无疾病证据存活，14例患者带瘤死亡。与髓内钉固定组和传统假体置换组相比，接受假体置换重建（PFR）治疗的患者生存率显著更高（p = 0.0080）。比较即将发生骨折与实际病理性骨折以及寡转移与多发转移，在生存率方面未发现差异。手术后，所有患者因疼痛减轻生活质量均有所改善。MSTS评分的平均值为22.4。总体并发症发生率为22.5%。最常见的并发症是脱位，其次是伤口裂开和深部感染。
股骨近端置换的模块化肿瘤假体在中期提供了良好的功能结果、相对较低的并发症发生率和较高的生活质量。肿瘤学结果受手术方式影响，受正确的切除和钉固定指征影响。术前总体健康状况、预期寿命和活动能力可能影响治疗策略。就现有数据而言，接受切除治疗的股骨近端实际病理性或即将发生骨折的患者生存率显著更高，尤其是那些来自肾癌或多发性骨髓瘤转移的患者。
