surgical management of chapter 37 metastatic bone · pdf filethe femur is the most common site...

BACKGROUND■ The femur is the most common site for metastatic bone dis-ease requiring surgery. Because it is a major weight-bearingbone with minimal space for surgical errors, the operative pro-cedure must be carefully planned and meticulously executed,with the aim of achieving durable reconstruction. Detailed pre-operative clinical and imaging evaluation is essential to definethe morphologic characteristics of the lesion that validate sur-gical intervention and to distinguish between lesions that canbe managed with curettage and cemented fixation and thosethat require resection with endoprosthetic reconstruction.1,6,7

■ Unlike primary sarcomas of the femur, metastatic tumorsusually have a small soft tissue component, even in the presenceof extensive bone destruction. This feature allows the sparingof extracortical structures, such as the joint capsule, overlyingmuscles, and muscle attachments, and the possibility of apply-ing them for reconstruction and preservation of function.■ Because of distinctive differences in anatomic and surgicalconsiderations, surgeries around the proximal femur, femoraldiaphysis, and distal femur will be discussed separately (FIG 1).

ANATOMYProximal Femur■ A thick joint capsule encircles the femoral head and neckand attaches to the base of the neck.■ Key elements at the lateral aspect: The greater trochanter isthe insertion site for the gluteus medius muscle (lateral stabilizerand hip abductor) and the origin for the vastus lateralis muscle.■ Key elements at the medial aspect: The minor trochanter isthe insertion site for the psoas muscle (medial stabilizer andhip flexor).

Femoral Diaphysis■ The femoral diaphysis is encircled by two muscle layers:

■ First layer: the vastus intermedius muscle■ Second layer: The rectus femoris and vastus medialis mus-cles intersect at the anteromedial aspect, and the rectusfemoris and the vastus lateralis muscles intersect at the an-terolateral aspect.

Distal Femur■ The medial femoral condyle is positioned below the inser-tion site of the vastus medialis muscle.■ The lateral femoral condyle is positioned below the insertionsite of the vastus lateralis muscle.

INDICATIONS■ Pathologic fracture■ Impending pathologic fracture (FIG 2)

Chapter 37Jacob Bickels and Martin M. Malawer

Surgical Management ofMetastatic Bone Disease:Femoral Lesions

1

FIG 1 • Metastatic tumors at the proximal femur, femoraldiaphysis, and distal femur.

FIG 2 • Anteroposterior and lateral plain radiographs showing an im-pending fracture of the femoral diaphysis due to metastatic lesions.

A B

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■ Intractable pain associated with locally progressive diseasethat has shown inadequate response to narcotics and radiationtherapy■ Solitary bone metastasis in selected patients and tumor types(eg, those with breast cancer and renal cell carcinoma)

IMAGING AND OTHER STAGINGSTUDIES■ Plain radiographs of the entire femur are mandatory to ruleout coexisting metastases that may influence the extent andtechnique of surgery. CT of the lesion will clearly define theextents of soft-tissue component and bone destruction. Totalbody bone scintigraphy is done to detect coexisting metastases

elsewhere in the skeleton (FIG 3). The results of imagingshould provide the surgeon with answers to the followingquestions:

■ Is the lesion an impending fracture? (If not, it shouldprobably be treated nonoperatively).■ Are there additional femoral metastases? If so, can they bemanaged by nonoperative techniques or do they also requiresurgery?■ What is the appropriate surgical approach? As a rule,tumor curettage with cemented fixation is indicated for le-sions in which the remaining cortices allow containment ofthe fixation device. Otherwise, surgery consists of resectionof the affected bone segment with prosthetic reconstruction.

2 Part 4 ONCOLOGY • Section IV LOWER EXTREMITIES

FIG 3 • A. Plain radiograph showing a metastatic lesion of the proximal femur. The surrounding cortices are intact.Surgery consisted of curettage and reconstruction with a cemented intramedullary nail. B. Metastatic lesion at the samesite with extensive circumferential bone destruction. Surgery in this case entailed resection of the proximal femur andreconstruction with an endoprosthesis. Anteroposterior plain radiograph (C) and computed tomography (D) of the distalfemur showing a metastatic lesion at the left medial femoral condyle. The lateral condyle and articular cartilage are pre-served and form an anatomic continuum, which allows the fixation of a cemented reconstructive device.Anteroposterior (E) and lateral (F) plain radiographs and computed tomography (G) of the distal femur showing a largemetastasis with destruction of the entire anterior aspect of the bone and considerable thinning of the posterior cortex.Surgery included resection of the distal femur and reconstruction with an endoprosthesis.

A B C

E FG

D

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Chapter 37 SURGICAL MANAGEMENT OF METASTATIC BONE DISEASE: FEMORAL LESIONS 3

PROXIMAL FEMUR

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TECH FIG 1 • A straight longitudinal incision is made alongthe tip of the greater trochanter and femoral diaphysis.

Position and Incision■ The patient is placed supine on the operating table, with

the buttock of the affected side close to its edge. The op-erating table is positioned in a 30-degree tilt away fromthe surgeon.

■ A straight longitudinal incision is made along the tipof the greater trochanter and femoral diaphysis (TECHFIG 1). It should begin 5 cm proximal to the greatertrochanter to allow the introduction of a femoral nailand 5 cm below the lower edge of the lesion to enableadequate tumor curettage.

Exposure■ The fascia lata is divided longitudinally and retracted to

expose the lower edge of the gluteus medius muscle andits insertion site at the greater trochanter muscle, thevastus ridge, and the upper part of the vastus lateralismuscle (TECH FIG 2A,B).

■ Using electrocautery, the vastus lateralis muscle is de-tached from the vastus ridge and the lower aspect of theproximal diaphysis and reflected anteriorly to expose thediaphyseal cortex (TECH FIG 2C–E). A longitudinal corti-cal window with oval edges is made below the vastusridge (TECH FIG 2F).

Tumor Removal■ Gross tumor is removed with hand curettes (TECH FIG

3A,B). Curettage should be meticulous and should leaveonly microscopic disease in the tumor cavity. It is fol-lowed by high-speed burr drilling of walls of the tumorcavity (TECH FIG 3C,D).

TECH FIG 2 • A,B. The fascia lata is divided longitudinally and retracted to expose the lower edge of the gluteus medius mus-cle and its insertion site at the greater trochanter muscle, the vastus ridge, and the upper part of the vastus lateralis muscle.C–E. The vastus lateralis muscle is detached from the vastus ridge and femoral diaphysis. (continued)

A B

C D

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TECH FIG 2 • (continued) F. A cortical window is made below the vas-tus ridge.E

F

A B

C

TECH FIG 3 • A,B. Gross tumor is removed with hand curettes. C,D. Curettage is followed byhigh-speed burr drilling of the walls of the tumor cavity. E. The gluteus medius muscle is de-tached and reflected from its insertion site at the greater trochanter muscle. (continued)

D

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Chapter 37 SURGICAL MANAGEMENT OF METASTATIC BONE DISEASE: FEMORAL LESIONS 5TEC

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E F

TECH FIG 3 • (continued) F,G. The joint capsule is opened, the femoral head is dislocated fromthe acetabulum, its medial aspect is freed from muscle attachments, and an osteotomy is donebelow the level of the metastasis. H. Surgical specimen of an intra-articularly resected proximalfemur.

G

H

■ When a proximal femur resection is done, the gluteusmedius muscle is detached and reflected from its inser-tion site at the greater trochanter muscle (TECH FIG 3E),the joint capsule is opened and the femoral head is dislo-cated from the acetabulum, the medial aspect of theproximal femur is freed of muscle attachments, and thenan osteotomy is performed below the lower aspect ofthe tumor (TECH FIG 3F–H).

Mechanical Reconstruction■ Reconstruction begins with the introduction of an in-

tramedullary nail. After proper positioning and lengthare verified, the nail is partially withdrawn and the entiretumor cavity is filled with cement (TECH FIG 4A). Thenail is then pushed back into the medullary canal andfixed with interlocking screws (TECH FIG 4B,C).Alternatively, a side plate and a sliding screw can be sim-

TECH FIG 4 • A. After the positioning of an intramedullary nail is verified, it ispartially withdrawn and the tumor cavity is entirely filled with bone cement. B,C.After the cavity has been filled with cement, the nail is pushed back into themedullary canal and fixed with interlocking screws. D. A cemented prosthesis isused for reconstruction after resection of the proximal femur.

A B C

D

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ilarly used for reconstruction. After resection of the prox-imal femur, a cemented tumor prosthesis is used to re-construct the bone defect (TECH FIG 4D).

Soft Tissue Reconstructionand Wound Closure■ The origin of the vastus lateralis muscle is reattached to

the vastus ridge (TECH FIG 5A). If endoprosthetic re-construction had been carried out, the remaining hipcapsule is sutured tightly with a 3-mm Dacron tapearound the neck of the prosthesis, forming a noose thatprovides immediate stability. The capsule is reinforcedby rotating the external rotator muscles proximally andsuturing them to its posterolateral aspect. The remain-ing abductor tendon is attached to the lateral aspect ofthe prosthesis through a metal loop, and the psoas mus-cle is attached to the medial aspect of the prosthesis atthe level where the lesser trochanter had been (TECHFIG 5B).

■ It is important to attach these two muscles to the pros-thesis so that balanced function will be achieved. Thesurgical wound is then closed over suction drains and

the patient is placed in balanced suspension or in tibialpin traction with the hip elevated and flexed 20 de-grees. An abduction pillow can also achieve the correctpositioning.

Postoperative Care■ Continuous suction is required for 3 to 5 days, and peri-

operative intravenous antibiotics are continued until thedrainage tubes are removed. If tumor curettage hadbeen done, rehabilitation should include early ambula-tion with unrestricted weight bearing as well as passiveand active range of motion of the hip joint.

■ After wound healing, usually 3 to 4 weeks after surgery,the patient is referred for adjuvant radiation therapy.Adjuvant radiation therapy is usually not required in pa-tients who underwent proximal femur resection with en-doprosthetic reconstruction.

■ If endoprosthetic reconstruction had been done, theextremity is kept in balanced suspension for at least5 days. Postoperative mobilization with total hip replace-ment precautions with or without an abduction brace andweight bearing as tolerated are continued for 6 weeks.


the buttock of the affected side close to its edge. The op-erating table is positioned in a 30-degree tilt away fromthe surgeon.

■ A diaphyseal lesion with a lateral cortical breakthroughis approached using a longitudinal incision along the an-

terolateral aspect of the thigh at the level of the inter-face between the rectus femoris and vastus lateralismuscles, with the lesion located at the center of theincision.

■ A lesion with medial cortical destruction is similarly ap-proached using an anteromedial incision at the level ofthe interface of the rectus femoris and vastus medialis.

TECH FIG 5 • A. The origin of the vastus lateralis muscle is reattached to the vastus ridge. B. The remain-ing joint capsule is sutured around the prosthetic head to its neck. The gluteus medius and psoas musclesare reattached to the lateral and medial aspects of the prosthesis, respectively.

A B

FEMORAL DIAPHYSIS

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Exposure■ The interval between the rectus femoris and vastus later-

alis muscles is opened, and the muscles are retracted toexpose the vastus intermedius overlying the femoral dia-physis. The vastus intermedius is split longitudinally toexpose the femoral diaphysis, and retractors are placedbehind it (TECH FIG 6). This approach allows wide expo-sure of the affected bone with minimal injury to theoverlying muscles. A longitudinal cortical window withoval edges is made above the lesion.

Tumor Removal■ Gross tumor is removed with hand curettes (TECH FIG

7A,B). Curettage should be meticulous and should leaveonly microscopic disease in the tumor cavity. This is fol-lowed by high-speed burr drilling of the walls of thetumor cavity (TECH FIG 7C,D).

Mechanical Reconstruction■ Reconstruction begins with the introduction of an in-

tramedullary nail either antegrade or retrograde, de-pending on the location of the lesion along the diaph-ysis. After proper positioning and length have beenverified, the nail is partially withdrawn and the entiretumor cavity is filled with cement (TECH FIG 8). The nailis then pushed back into the medullary canal and fixedwith interlocking screws.

Soft Tissue Reconstruction andWound Closure■ A suction drain is positioned along the femoral diaphysis

muscle, and the vastus lateralis muscle is sutured to therectus femoris muscle.

TECH FIG 7 • A,B. Gross tumor is removed with hand curettes. C,D. Curettage is followed by high-speed burrdrilling of the walls of the tumor cavity.

TECH FIG 6 • The tumor is approached using the interval between the rectus femoris and vastus medialismuscles. The vastus intermedius is split to expose the underlying cortex, and an oval cortical windowis made.

A B

A B

C

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TECH FIG 8 • An intramedullary nail is introduced and adequate positioning is verified. Thenail is then partially withdrawn, the tumor cavity is entirely filled with cement, and the nail isreintroduced through the cement and secured with interlocking screws.

A B

DISTAL FEMUR


the affected knee flexed 30 degrees.■ A medial condyle lesion is approached using a longitudi-

nal incision along the anteromedial aspect of the distalthigh at the level of the interface between the rectusfemoris and vastus medialis muscles and 1 cm away fromthe medial border of the patella (TECH FIG 9).

■ A lesion of the lateral condyle is similarly approachedusing an anterolateral incision at the level of the inter-face of the rectus femoris and the vastus lateralis and lat-eral to the patella.

Exposure■ The interval between the distal aspect of the vastus medi-

alis and rectus femoris muscles is opened and the insertionof the vastus medialis to the quadriceps tendon, patella,and joint capsule is detached (TECH FIG 10A,B). Thevastus medialis muscle is retracted posteriorly, exposingthe underlying vastus intermedius muscle and the distalfemur (TECH FIG 10C,D).

■ A lesion at the lateral femoral condyle is approachedusing similar detachment and posterior reflection of thevastus lateralis muscle. This approach allows wide expo-sure of the affected bone with minimal injury to theoverlying muscles. A longitudinal cortical window withoval edges is made above the lesion.

Tumor Removal■ Curettage. Gross tumor is removed with hand curettes

(TECH FIG 11A,B). Curettage should be meticulous andshould leave only microscopic disease in the tumor cav-ity. It is followed by high-speed burr drilling of walls ofthe tumor cavity (TECH FIG 11C,D).

■ Distal femoral resection (see Chapter ON-25). TECH FIG11E,F show the release of the vastus medialis and thepopiteal exposure. TECH FIG 11G,H show the release ofall soft tissues around the distal femur and the femoralosteotomy. The cavity is reconstructed by a combinationof intramedullary and plate fixation followed by cement(PMMA). See TECH FIG 12A.

TECH FIG 9 • A medial condyle lesion is approached using a longitudinal incision along the anterome-dial aspect of the distal thigh at the level of the interface between the rectus femoris and vastus medi-alis muscles and 1 cm away from the medial border of the patella.

Incision

Tumor

A B

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Postoperative Care■ Continuous suction is required for 3 to 5 days, and peri-

operative intravenous antibiotics are continued until thedrainage tubes are removed. Rehabilitation should in-clude early ambulation with unrestricted weight bearing

as well as passive and active range of motion of the kneejoint.

■ When wound healing is complete, usually 3 to 4 weeksafter surgery, the patient is referred for adjuvant radia-tion therapy.

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A B

DC

TECH FIG 10 • A,B. The vastus medialis muscle is detached from its attachment to the rectus femoris muscle and in-serted into the quadriceps tendon, patella, and joint capsule. C,D. The vastus medialis muscle is retracted posteriorly,exposing the vastus intermedius muscle and distal femur.

A B

TECH FIG 11 • A,B. Gross tumor is removed with hand curettes. (continued)

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C D

FE

G

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TECH FIG 11 • (continued) C,D. Curettage is followed by high-speed burr drilling of the walls of the tumor cavity. E,F.The medial gastrocnemius muscle is detached and reflected, exposing the popliteal fossa. The posterior femur is iso-lated by ligation and transection of the geniculate vessels. G. The joint capsule is opened and released circumferen-tially from the femur. H. A distal femur osteotomy is done 1 to 2 cm beyond the point of proximal tumor extension.

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■ A distal femur osteotomy is carried out at the appro-priate location as determined by the preoperativeimaging studies: 1 to 2 cm beyond the point of proximaltumor extension is generally appropriate for metastatictumors (TECH FIG 11H–J). A tibial osteotomy is thendone to allow the introduction of the prosthetic tibialcomponent.

Mechanical Reconstruction■ A combination of a cemented intramedullary nail and a

condylar plate achieves optimal stability and is preferredfor reconstruction (TECH FIG 12A–C). After resection ofthe distal femur, a cemented tumor prosthesis is used forreconstruction (TECH FIG 12D–F).

Soft Tissue Reconstruction andWound Closure■ Suction drains are positioned along the femoral diaphysis,

and the vastus medialis muscle is sutured to the rectusfemoris muscle and its insertion sites along the quadricepsand patella. The medial gastrocnemius muscle is pulled upand sutured to the vastus medialis muscle (TECH FIG 13).

Postoperative Care andRehabilitation■ Continuous suction is required for 3 to 5 days, and peri-

operative intravenous antibiotics are continued untilthe drainage tubes are removed. If tumor curettagehad been done, rehabilitation should include early

A

B CD

TECH FIG 12 • A–C. A cemented intra-medullary nail and a condylar plate are usedto reconstruct metaphyseal lesions in whichthe remaining cortices allow containment ofthe fixation devices. D–F. A cemented tumorprosthesis is used for reconstruction after re-section of the distal femur.E F

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12 Part 4 ONCOLOGY • Section IV LOWER EXTREMITIESTE

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A

B C

TECH FIG 13 • The vastus medialis muscle is su-tured to the rectus femoris muscle and its inser-tion sites along the quadriceps and patella. Themedial gastrocnemius muscle is pulled up andsutured to the vastus medialis muscle.

ambulation with unrestricted weight bearing as well aspassive and active range of motion of the knee joint.

■ When the wound is healed, usually 3 to 4 weeks aftersurgery, the patient is referred for adjuvant radiationtherapy. In the case of distal femur resection, the lowerextremity is elevated for 3 days, until the first postoper-ative wound check, to prevent wound edema. Knee mo-

tion is restricted in an immobilizing brace for 2 to 3weeks to allow healing of the surgical flaps and until theextensor mechanism is again functional.

■ During that time, isometric exercises are carried out andweight bearing is allowed. Adjuvant radiation therapy isusually not required in patients who underwent distalfemur resection with endoprosthetic reconstruction.

PEARLS AND PITFALLSProximal femur ■ Adequate imaging of the entire femur: allows the surgeon to decide whether to perform tumor curettage

or resection with endoprosthetic reconstruction■ Wide exposure of the tumor cavity, using an adequately positioned and large cortical window.■ Meticulous curettage and burr drilling■ Reconstruction with hardware and cementation of the entire volume of the cavity■ Proximal femur resection: reconstruction with cemented implant, suturing of the joint capsule, and reattach-

ment of the gluteus medius and psoas muscles■ Early ambulation and range-of-motion exercises; weight bearing as tolerated

Femoral diaphysis ■ Exposure through the interval between the rectus femoris and vastus lateralis or medialis■ Wide exposure of the tumor cavity using an adequately positioned large cortical window■ Meticulous curettage and burr drilling■ Reconstruction with hardware and cementation of the entire volume of the cavity■ Early ambulation and range-of-motion exercises; weight bearing as tolerated

Distal femur■ Intraoperative ■ Exposure through the interval between the vastus medialis and lateralis and the rectus femoris

■ Wide exposure of the tumor cavity using an adequately positioned large cortical window■ Meticulous curettage and burr drilling■ Reconstruction with a cemented intramedullary nail and a condylar plate■ When distal femur resection is indicated, the gastrocnemius origin is detached to expose the popliteal fossa.■ Reconstruction is done with a cemented tumor prosthesis.

■ Postoperative ■ Early ambulation and weight bearing as tolerated

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Chapter 37 SURGICAL MANAGEMENT OF METASTATIC BONE DISEASE: FEMORAL LESIONS 13

OUTCOMES AND COMPLICATIONS■ Functional outcomes and common complications of pros-thetic replacements for metastatic bone disease are no differentfrom those with the same operations for primary sarcomas ofbone (see Chapters ON-25 and ON-26).2–5,8 Because of theshort life expectancy of most patients with metastatic bonedisease, however, the problems seen at long-term follow-up,such as aseptic loosening, the wearing down of polyethylenecomponents, and fatigue prosthetic fractures, are rarely seen.■ The real concerns in the setting of metastatic bone diseaseare local tumor recurrence and failure of reconstruction.Meticulous tumor removal, proper selection and use of fixa-tion devices, and adjuvant radiation therapy have made thesecomplications rare: local recurrence and reconstruction fail-ures are seen in less than 5% of the patients.

REFERENCES1. Aaron AD. Treatment of metastatic adenocarcinoma of the pelvis and

the extremities. J Bone Joint Surg Am 1997;79A:917–932.2. Bickels J, Meller I, Henshaw RM, et al. Reconstruction of hip joint

stability after proximal and total femur resections. Clin Orthop RelatRes 2000;375:218–230.

3. Bickels J, Wittig JC, Kollender Y, et al. Distal femur resection with en-doprosthetic reconstruction: a long-term followup study. Clin OrthopRelat Res 2002;400:225–235.

4. Capanna R, Morris HG, Campanacci D, et al. Modular uncementedprosthetic reconstruction after resection of tumours of the distalfemur. J Bone Joint Surg Br 1994;76B:178–186.

5. Dobbs HS, Scales JT, Wilson JN, et al. Endoprosthetic replacementof the proximal femur and acetabulum. J Bone Joint Surg Br 1981;63B:219–224.

6. Harrington KD. Impending pathologic fractures from metastatic ma-lignancy: evaluation and management. AAOS Instr Course Lect 1986;35:357–381.

7. Harrington KD, Sim FH, Enis JE, et al. Methylmethacrylate as an ad-junct in internal fixation of pathological fractures. J Bone Joint SurgAm 1976;58A:1047–1055.

8. Kawai A, Muschler GF, Lane JM, et al. Prosthetic knee replacementafter resection of a malignant tumor of the distal part of the femur:medium to long-term results. J Bone Joint Surg Am 1998;80A:636–647.

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surgical management of chapter 37 metastatic bone · pdf filethe femur is the most common site...

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