Orthopedic surgical management of skeletal complications of malignancy

Coincident with improved overall cancer palliation during the past 2 decades has been an increasing incidence of clinically apparent bone metastases, and from these metastases subsequent pathologic fractures of the long bones, spine, and pelvis. Current techniques for surgical management of these fractures are extremely effective in alleviating pain and allowing patients to resume an ambulatory status, often without the need of external support. This, in turn, has significantly improved the quality of the remaining months or years of these individuals' lives. In fact, the long term survival of patients after their first long bone pathologic fracture from malignancy has more than tripled for the most common cancers (breast carcinoma, prostate carcinoma, lymphomas, and myelomas) during the past 25 years. Surgical techniques for stabilizing pathologic or impending fractures must be individualized for the area of involvement, the particular qualities of the bone involved, and the potential for involvement of adjacent soft tissue structures. Long bone fractures most commonly occur in the femur and humerus and are typically internally fixed by intramedullary devices that control impaction, distraction, and torquing stresses by the use of proximal and distal interlocking fixation. Such fixation must be able to withstand weight-bearing stresses on lower extremity long bones. Upper extremity pathologic fractures are often subjected to distractive forces inherent in lifting and pulling, but they are also subjected to heavy compressive forces, particularly in patients who require crutches or other devices to assist them in walking. Fixation of upper or lower extremity long bone fractures ordinarily may be accomplished with minimal blood loss or morbidity. In contrast, fractures or impending fractures involving the acetabulum necessitate extensive joint reconstruction, with inherent increased potential for morbidity and complications. For this reason, the anticipated prognosis for survival and mobility should be greater preoperatively for patients with acetabular fractures than for patients with fractures of either upper or lower extremity long bones. Most spinal metastases can be managed conservatively. Those requiring surgical intervention present with progressive neurologic compromise, which requires decompression, or spinal instability, which requires stabilization. Constructs for internal stabilization of the spine must not be adversely affected by local postoperative irradiation. Ninety-six percent of patients experience good or excellent relief of pain after internal fixation of pathologic malignant long bone fractures. Eighty-four percent of patients with acetabular fractures experience good or excellent relief of pain after joint reconstruction. Eighty-two percent of patients with neurologic compromise secondary to vertebral malignancy improve at least one functional grade after decompression and stabilization, and 88% experience good or excellent relief of spinal pain with restoration of walking ability. Thirty-two percent survived for more than 2 years after spinal decompression and stabilization. Patients with pathologic fractures from metastatic carcinoma of the breast had a mean survival of 24.6 months after surgical management of their fractures. There was a similarly encouraging improvement in the survival statistics for patients with other primary tumor types. Most malignant pathologic fractures of the pelvis, long bones, or spine are amenable to effective stabilization by the techniques described in this article. These techniques allow resumption of weight-bearing ambulation in all but a few patients, good or excellent relief of pain in the vast majority, and an enhanced anticipation of survival and improvement in quality of life.