Surgical treatment of cervical spine metastatic tumours - case report

Background. Metastatic tumours to the cervical spine generate pathological fractures followed by spinal instability and are connected with significant risk of neurological defects.
The goal of this study was to asses the surgical treatment of 4 patients with metastatic tumours in the cervical spine.
Material and methods. Between 1999 and 2001 four patients underwent surgery due to metastatic tumours in cervical spine. Primary focus was following: breast - 2 patients, prostate - 1 patient, in one case primary tumor remained unknown. Spinal localization of tumors: axial dens, vertebral body and arch of C5, vertebral body of C6. Patients' age at the time of surgery ranged from 48 to 75 years. The severity of spinal cord lesion before treatment was estimated according to Frankel classification: type B - 1 patient, E - 3 patients. According to Harrington classification, we noted type IV in 3 cases and type V - in one case.
Tumour resection with anterior and posterior stabilization, with use of implants was performed at 2 cases, occipito-cervical stabilization was done at one case and tumor resection with anterior stabilization was done in one case.
Results. Patients' neurological status did not change after treatment. As a result of operative treatment, we achieved full spine stabilization in 3 cases. Destabilization of vertebral cage due to osteoporosis occurred in one case and reoperation with change of the implant was performed at the fifth day after primary surgery.
Conclusion. Performed operations enabled further specialistic oncologic and rehabilitation treatment.     

The surgical manegement of metastases to humerus-clinical evaluation

Background. The humerus is a common localisation of cancer metastases. The restoration of anatomical order and tumor resection within humerus is important for patients quality of everyday life and for their pain relief. The surgical treatment is one of the most important part of the whole oncological ways of tratment.
The study objective was a clinical assesment of tumor resection and reconstruction within humerus according to matastasis localisation and the choice of surgical technique.
Material and methods. In the years 1999-2002 19 patients underwent surgery due to pathological fracture or/and cancer metastasis within humerus. The shaft localisation of the tumor was found in 8 cases and in 11 patients the metastatic foci were found in proximnal diaphysis. In patients with proximal diaphysis localisation of the tumor the partial resection with subsequent joint exchange procedure was made. The humeral shaft metastatic cancer changes were treated by the segmental resection with subsequent surgical cement filling or auto/allogenical bone grafting combined with intramedullary nail or AO/ASIF plate stabilisation. The average follow-up period was 8,5 months.
Results. In patients after resection with shoulder joint alloplasty according to the Enneking test a very good result was found in 7 and very good in 4 cases.
In patients with femoral shaft metastatic tumor locaslisation, 6 good and 2 fair results were found. In 1 patient after 2 months rehabilitation a reoperation was needed due to the mechanical destabilisation. The best results were found in patients after intramedullary nailing.An acute soft tissue inflamation requiering surgical treatment was found in 1 patient after shoulder joint replacement.
Conclusions. After clinical analysis of the material we highly recomend the partial humeral bone resection with subsequent shoulder alloplasty in patients with proximal humeral diaphysis metastatic localisation. In cases with shaft localisation a better results were found after intramedullary nailing compared to common plate technique.     

Indications and range of surgery in the treatment of spine metastatic tumours

Background. Spine is the most common place of metastatic tumors in the skeletal system. Due to diagnostic problems and the risk of quickly increasing neurological defects, the treatment of metastatic spine tumors is a significant clinical problem. The goal of surgical treatment is decreasing pain, neurological improvement and achieving full spinal stability.
Material and methods. Material consists of 31 patients with metastases in spine, who underwent spine surgery. Tumors were placed in thoracic spine at 48% patients, at lumbar spine - 42% patients, and at cervical spine in 10% patients; one level was involved in 56% cases, two or more levels - in 44 % cases. Qualification for surgery contained: the type of primary tumor, the amount of metastases to the spine impairment of spinal biomechanics and overall patient's condition of the. Corporectomy with anterior stabilization (intervertebral cage) was performed at 13 patients, and with additional anterior implants at 2 cases. At 8 patients, with destabilization of posterior spinal column, in spite of corporectomy, posterior stabilization was done. Surgery from posterior approach was performed in 3 cases.
Results. After operation, we noted pain relief at 34% of patients, while in 14% of them transient increase of pain occurred. Neurological status worsened after surgery at 1 patient. We achieved proper spine stabilization, without the need of use of external orthoses at 30 patients. At one patients, reoperation with change of implants and the range of stabilization was necessary. The amount of complications correlated with patient's general condition at the time of surgery.
Conclusions. 1. The main condition of success in operative treatment of spinal metastatic tumors is individual patient's qualification for surgery, including the extent of disease and general patient's condition. 2. Good stabilization with use of implants is a necessary element of surgery of spinal metastases from both anterior and posterior approach.     

Surgical treatment of metastasic tumors to long bones in the material of the Unit

Background. Neoplasms of limbs are appear as primary of changes or as bone metastases.
Material and methods. In 1989-2002 due to neoplasms limbs 795 patients were hospitalised, of which 278 suffered from malignant metastases to bones. In this group, 242 patients with lesions localised within the femoral (169), humeral (55) and tibial (18) bones were identified. In 75% of patients pathological fractures were diagnosed, in the remaining ones the metastasis was manifested in the form of osteolytic lesion. In most cases early surgical treatment was performed to eliminate pain complaints, improve patient's physical mobility through restoration of limb functions and also to enable nursing care to be performed in palliative management. The choice of treatment method depended on: location of metastasis, degree of bone tissue destruction, type of primary tumour, progression of malignant process and technical resources. Within the long bones intramedullary nails (189) of different generations were implanted. In the proximal part of femoral bone various types of endoprostheses (65) were used, enabling oncological radicalism and early rehabilitation of the patients.
Results. Resection of bones with neoplasm-induced lesions, filling the lesion with bony cement and stabilisation with blocking nails permitted early rehabilitation of patients. In our material the most common malignancies inducing metastases were: breast, kidney, lung cancers and myeloma. Patients with these neoplasms constituted nearly 74% of all hospitalised subjects.
Conclusions. Necessity of systemic management and importance of early surgical treatment of metastases in specialized centres were underlined.     

A new protocol of surgical treatment of long bone metastases

Background. The choice of proper treatment way is one of the most important things in surgically treated long bones metastases.
The aim of this research was evaluation of the treatment way according to neoplasm's type and metastasis localisation and spreading.
Material and methods. The evaluation underwent 158 patients who were divided in 4 groups. The first one consists of 13 patients with single metastasis of cancer with good prognosis. In the second group were 69 patients with bone fracture. The third group included 36 patients with such bone destruction that fracture was expected. The last fourth one had 40 patients with osteoblastic metastases or osteolitic in unloaded bones.
Results and Discussion. In group I long lasting reconstructive implants are required and postoperative irradiation is recommended, in groups II and III the aggressiveness of treatment should be related to three parameters: survival expectancy, mechanical properties of the affected bone, predictive response to adjuvants. Based on the above parameters the quidelines of the protocol allow to identify the most appropriate reconstructive indication for every single case ranging from simple osteosynthesis (bad prognosis, low fracture risk, goodresponse to adjuvants) to prosthetic replacement (good prognosis, high fracture risk, bad response to adjuvants). Patients from group IV were admitted to oncology treatment ward after biopsy.     

The treatment of pathological fractures with the use of intramedullary locking nail in neoplastic disease

Background. About 1/4 patients with neoplastic disease experience of pathological fracture.
Material and methods. In the period of 1998-2002 we treated 14 patients with pathological fractures of long bones. The fractures occurred due to metastasis.
Results. By use of intramedullary locking nail, the rehabilitation could be preformed very quickly. The patients were made upright and learned to walk, two days after operation. The patients could be discharged from hospital quickly and continued the treatment for neoplastic disease. In patients, who lived longer than 8 months after operation, we observed a characteristic bone union rebuilding.
Conclusions. The treatment of pathological fractures with use of intramedullary locking nail is advantageous method.     

Clinical features and outcomes of metastatic bone tumors of the pelvis

ObjectiveThe number of patients with metastatic bone tumors of the pelvis (MBTP) has increased, and the risk of metastasis and recurrence in the pelvic bones is difficult to assess. Therefore, we investigated the clinical features and oncological outcomes of patients with MBTP.MethodsWe analyzed the clinical features and oncological outcomes of MBTP in 72 patients (42 men, 30 women; mean age, 50.5 years) from 2008 to 2017. Recurrence in the pelvic bones and survival rates were analyzed with regard to patients’ potential contributing factors.ResultsEnneking region I was the area most commonly containing MBTP (47.3%). Low- and high-grade tumors were identified in 40 and 32 patients, respectively. The most common pathological type was adenomatous carcinoma (34.7%), and the most common primary lesion was lung cancer (20.8%). The 3-year overall recurrence rate within the pelvic bones was 34.7%, and the 5-year overall survival rate was 29.2%.ConclusionPatients with MBTP have a high risk of recurrence in the pelvic bones and poor survival after multimodal treatment. Pelvic recurrence might be affected by the metastatic involvement, tumor grade, surgical margins, and type of surgery, whereas the survival rate tends to be associated with the tumor grade.     

Total hip arthroplasty for treatment of bone metastases

Background. Bone metastases are observed in many patients with neoplastic disease. Frequently, the first sign of metastasis is a pathological fracture in weight bearing regions. The proximal end of the femur is the most common site of long bone involvement by metastatic disease and pathological fracture. Treatment of metastatic disease should be multidisciplinary: both oncologic and orthopedic. The target of operative procedure is a relief of pain and regaining the ability to walk. In case of changes in proximal end of the femur, the tumor resection and total hip arthroplasty is a procedure of choice.
Material and methods. In the Orthopedic Clinic in Warsaw, 27 patients with bone metastases in proximal end of the femur had total hip arthroplasty performed in the period of 1998-2002. In 16 cases it was possible to collect data about postoperative period - these patients were analyzed. In 14 patients postresective prostheses were used and in 2 procedures - standard prostheses.
Results and Conclusions. This type of treatment reduced pain, restored weight bearing ability of the limb and improved comfort of life. Subjective estimation of treated patients was good. Only in one case the clinical result was poor. Total hip arthroplasty is an efficacious palliative treatment in patients with metastases in proximal end of the femur. Final effect of therapy depends on individual precise preoperative planning and multidisciplinary specialist postoperative care.     

Time of survival and quality of life of the patients operatively treated due to pathological fractures due to bone metastases

Background. Aims of the study: 1) evaluation of the quality of life of the patients after surgical treatment of bone metastases, 2) evaluation of survival rate of the patients after surgical treatment of bone metastases,
3) presentation of the authors' clinical score system for evaluation of the treatment results of bone metastases, 4) analysis of general complications rate after surgical treatment of bone metastases.
Material and methods. Retrospective evaluation of 62 patients with bone metastases treated operatively in our Ward during last 13 years was made. Mean age of patients was 63,6 years. There were 41 women (mean age; 62,8 years) and 21 men (mean age: 64,3). In 49 cases (79%) we were able to diagnose primary localization of the tumour: breast carcinoma - 22, ovary cancer - 6, lung cancer - 5, prostate cancer - 5, kidney cancer - 6, gastric cancer - 1, vaginal cancer - 1, hepatocellular cancer - 1, melanoma - 1 and plasmocytoma - 1. We could not reveal primary focus of the tumour in 13 cases (21%). Localizations of bone metastases are as follow: femur - 49 cases, humerus - 10, tibia - 3. After being accepted to operavite treatment, the patients had been cured as quickly as possible - sometimes during emergency service. In 2 cases with metastases in the tibia there were amputations made in femur regions. In remainq patients we made local excisions of metastatic tumours with internal osteosynthesis and bone cement application in 47 cases, with internal osteosynthesis only in 7 cases, with hip arthroplasty in 8 cases.
Results. We have poor results in 4,8%, because of the death of 3 patients. Mean time of follow-up since surgical procedure was 6 months. In 82,3% we have very good or good results - no pain, good function and independence in daily activities. Mean survival time is 17,5 months (range: 5-36 months).
Conclusions. Efficacy of the surgical procedures of pathological fracures due to bone metastases in reliving the pain, improvement of patients' mobility and activiteis of day living are very good. Mean time of survival after surgical treatment of pathological fracture due to bone metastases in study group justifies its applications in spite of higher rate of general complications.
     

Treatment procedure in spinal metastases: the orthopedic dimension

Background. The authors have presented the results of the medical treatment of patients with metastatic disease of the spine. The aim of this treatment was to improve the patients quality of life through spinal stabilisation, maintaining neurological functions and the maximum pain relief.
Material and methods. Surgical indications included progressive, neurological deficit, fracture of vertebra, spine instability and histologic diagnosis. The patients underwent anterior, posterior or combined decompression and stabilisation procedures with the use of implants. Neurological examination of the patients has been carried out by means of Frankel grade whereas the tool for measurement of vertebra destruction was Harrington classification.
The results and the treatment for spinal metastatic tumors of the 86 patients were treated from 1997 to 2002.
There were 55 men and 33 women with a median age of 56 years. The mean survival time after surgery was 7,5 months.
Results. The improvement in neurological state of 28 in 59 patients was recorded. 11 patients have died of health conditions during the medical treatment as a consequences of the metastases.
Conclusions. The full decompression and stabilisation of the spine should be carried out in order to avoid the consequences and enable the patients to continue oncological treatment. The early diagnostic and good health conditions have been stressed. The can help in patient's qualification to surgical treatment, improve the general results of the treatment while giving the full satisfaction to the surgeon and the patient, prolonging the patient's life and improving his comfort of life by pain restriction and the protection of neurological consequences.     

Fixation of pathological fractures and impending long bone fractures in the course of neoplastic disease with the use of polymethylmethacrylate with added methotrexate

Background. The authors present the results of operative treatment in 71 patients with pathological fractures and impending long bone fractures resulting from neoplastic metastases.
Materials and methods. The discussed group of patients consists of 43 women and 28 men aged 36 to 80 years, the follow-up period is 6 to 48 months. After resection the metastatic focus was filled with cement supplemented with 2g methotrexate and stabilised with AO plate or a hip endoprosthesis was set up.
Results. In 37 operated patients the pain subsided completely or markedly eased, 13 patients periodically required non-narcotic analgesics, and in 19 the pain did not subside.
The treatment applied allowed all the patients with fractures within the lower extremities to abandon the bed and to move with the aid of crutches., and in 17 with fractures of the humerus it enabled the performance of daily living and self-care activities. Within the discussed group 9 patients with multiple metastases to the lungs and to the vertebral column died after average of 12 months. The longest survival period was observed in patients with metastases of renal cancer - average of 42 months, breast cancer - 37 months and ovary cancer - 29 months. No postoperative complications were observed; in 2 patients after 8 and 10 weeks destabilisation of the fixation intervened as a result of intensive weight-bearing without the aid of crutches.
Conclusions. Filling the metastatic bone defect with methotrexate supplemented cement and stable fixation of a pathological fracture or an impending fracture enables movement, performance of daily living activities, eases or clears pain completely, improves the comfort of life, facilitates patient care and it may be an element of complex treatment of pathological and impending fractures in the course of neoplastic disease.     

Evaluation of efectiveness of palliative radiotherapy alone or combined with surgery in patients with bone metastases

Material and methods. The retrospective analysis results of palliative radiotherapy alone or combined with surgery of 200 patients with bone metastases are presented. All patient were irradiatated, 47 of them were operated before or after radiotherapy. General performance status, pain relief, movement efficiency, analgetic drugs and bisphosphonates administration, disease progress and bone reossification were assesed 1, 2, 3, 6, 12 months after the treatment and durning the last examination.
Results. The complete or partial pain relief were observed in 47% of patients 1 month, 56% two months 41% in 3, 38% 6 months after the treatment. 26% reported pain relief 1 year after irradiation and 33% at the last visit
The Kaplan Maier survival analysis shows ststistically significant longer survival for patient treated by combined treatment, women, patients with multiple bone metastases and patients with metastases located in long bones and patients without symptoms of spine compression. Spearman analysis reveals correlation beetween performance status and follow up. There are no correlations between radiation dose, bisphosphonates administration and pain relief, pathology of tumor and follow up.
Conclusions. The obtained results suggests that radiotherapy is effective method of analgetic treatment in bone metastases and that radiotherapy associated with surgery improves survival.     

The own experience in femoral bone metastases treatment

Background. The objective of this paper is an efficacy analysis of surgical treatment of femoral bone cancer metasases depending on surgical technique and tumor localisation.
Material and methods. 144 patients who underwent surgery in 1996-2002 were assesed. In 32 patients with proximal femur matastases tumor resection and angled plate stabilisation was made, 68 patients underwent THR.
In 20 patients with tumor situated in femoral shaft an intramedullary nailing was performed and the rest 14 patients were treated with plate (AO/ASIF) technique. In 10 patients with distal femoral metastases an angled condylar plate was used.The average follow-up time was 6 months.
Results. The surgery outcome was assesed by functional Enneking test. The cases with proximal femur metastases were assesed by Merle d'Aubigne classification. In cases after resection and subsequent THR very good results were found in 5 patients,good in 34, fair in 23 and bad in 6 patients according to Enneking scale. In Merle d'Aubigne classification the results were as follows:very good in 6, good in 30, fair in 26 and bad in 6 patients.
In the intramedullary nailing group the limb function was found good in 17, in 1 fair and bad in 2 patients. The limb function in patients who were operated using plate condylar or stright(AO/ASIF) plate technique was found fair.
Conclusions. The high patients satisfaction and high ratio of good and very good results in tests after modular THR(proximal femur metastases)and after intramedullary nailing(femoral shaft pathology)are methods of choice in those cases. AO plate stabilisation combined with bone cement augmentation is suitable for pathological fractures management.     

Local experience in the surgical treatment of primary malignant and metastatic bone tumors of the proximal femur

Background. The introduction of new techniques for fixation of long bones and postresectional prosthetic replacement, combined with chemotherapy and radiotherapy, have created new possibilities for the surgical treatment of primary and metastatic bone tumors. The main problem is still the time of diagnosis and the proper choice of operative treatment. Material and methods. We examined a group 67 patients operated for tumor of the proximal femur between 1985 and 2004, consisting of 48 females (average age 57) and 19 males (average age 46.8). The follow-up period ranged from 1 to 24 years (average 5.7 years). Metastatic bone tumors were found in 51 cases, as compared to 16 primary bone tumors. The clinical outcomes were evaluated by orthopedic and radiological examination, using Enneking's functional scale, depending on the treatment method applied. Results. Following surgical excision of the bone tumor, total postresectional arthroplasty was performed, or, in some patients, hip hemiarthroplasty. In some cases resection of the tumor was followed by plate fixation or the application of an intramedullary device after the resection bone defect had been filled with methylmethacrylate. Conclusions. Excellent or good postoperative outcomes were obtained by 76% of the patients. In 18% of the patients there was tumor recurrence. The most common complication was either surgical wound infection caused by lowered immunity after chemotherapy or breakage of the stabilizing plates.     

Surgical outcome in patients with spinal metastases in the period 1993-2002

Background. Authors introduced ways and results of treatment operating patients with spinal metastases, treated in Orthopaedic Clinic of Central Military Hospital in years 1993-2002.
Material and methods. In introduced period in Clinic 54 patients was treated with spinal metastases. 37(68,6%) was treated surgical and 17(31,4%) conservatively. In Clinic following indications were established to operating treatments: pathological fracture of vertebrae, growing neurological symptoms, as well as uncompromising pain in conservative treatment. Advancement of neoplasmatic disease and very bad prognosis was most important contraindication to operating treatment. Following operating method treatments: posterior stabilization by Harrington method and stabilization by transpedicular screws. Percutaneous vertebroplasty was applied.
Results. In Frankel scale following results were noted down: in front of operation E-5, D-23, C-7, B-2, A-0, after operation E-8, D-24, C-5, B-0, A-0.
Conclusions. Authors affirm, that operation treatment in choose cases is only effective way of supply patients with spinal metastases.     

Radiotherapy of skeletal metastases

Radiotherapy plays an important role in treatment of bone metastases.
The mayor problem associated with bone metastases is pain, pathological fractures and a spinal cord compression. Radiotherapy is employed as a palliative treatment, mainly to relieve pain.
1.Radiotherapy with a single dose of 5-8 Gy/T is an efficient method of pain management especially in patients with bone metastases outside the vertebral column. This treatment can be provided as a day procedure.
2.Multi-fractionated irradiation - patients receive 20 Gy/T in 5 fractions or 30 Gy/T in 10 fractions. This is advocated for patients with metastases in the vertebral column or bones of the pelvis.
3.Half- body irradiation is designed for patients with multiple bone metastases. It's a single dose treatment. The upper half of body is irradiated with a dose of 6 Gy/T, the lower part with a dose of 8 Gy/T. Patients need a special preparation beforehand (steroids, hydratation) and hospitalization afterwards.     

The efficacy analysis of partial bone resection procedure in pathological fractures treatment (own experience)

Background. The objective of this paper is efficacy assesment of partial bone resection procedure with subsequent joint exchange as a method of skeletal cancer metastases and pathological fractures surgical treatment within hip and shoulder among patients in our own experience.
Material and methods. 79 patients operated between 1997 and 2002 were assesed.Group I - 68 cases with sceletal cancer metastases and pathological fracture of proximal femur.Group II - 11 patients with sceletal cancer metastases and pathological fracture of humerus.The patients underwent primary or secondary (after complications) partial resection procedure with subsequent joint prosthesis implantation.The range of femur resection was 6-17cm.Various types of total or partial hip and shoulder joint endoprostheses according to indication were used.Additional paliative radiotherapy of mathastases,bisphosphonians and analgetics were used according to the case.The average follow-up period was 9,6 months (0-3y). The efficacy analysis was based on Enneking limb function test and Merle d'Aubigne classification and X-ray analysis in patients with partial proximal femur resection.
Results. Group I-according to Enneking test in 41 patients very good and good results,fair in 22 and bad only in 5 cases were found.According to Merle'd Aubigne classification in 37 cases very good and good outcome was found.In 25 the outcome was fair and bad in 6 patients.The machanical instability complication assesed radiologically were found in 7 patients.
Conclusions. The partial bone resection with subsequent joint exchange procedure is positively assesed in patients subjective opinion and its high rate of very good and good results let us conclude this kind of surgery as a very good method in some types of pathological fracture treatment.However a massive bone and particullary soft tissue resection may produce higher incidence of mechanical complications - especially dislocations.     

Patient-specific instrument can achieve same accuracy with less resection time than navigation assistance in periacetabular pelvic tumor surgery: a cadaveric study

Purpose

Inaccurate resection in pelvic tumors can result in compromised margins with increase local recurrence. Navigation-assisted and patient-specific instrument (PSI) techniques have recently been reported in assisting pelvic tumor surgery with the tendency of improving surgical accuracy. We examined and compared the accuracy of transferring a virtual pelvic resection plan to actual surgery using navigation-assisted or PSI technique in a cadaver study.

Methods

We performed CT scan in twelve cadaveric bodies including whole pelvic bones. Either supraacetabular or partial acetabular resection was virtually planned in a hemipelvis using engineering software. The virtual resection plan was transferred to a CT-based navigation system or was used for design and fabrication of PSI. Pelvic resections were performed using navigation assistance in six cadavers and PSI in another six. Post-resection images were co-registered with preoperative planning for comparative analysis of resection accuracy in the two techniques.

Results

The mean average deviation error from the planned resection was no different (\(p=0.19\)) for the navigation and the PSI groups: 1.9 versus 1.4 mm, respectively. The mean time required for the bone resection was greater (\(p=0.0006\)) for the navigation group than for the PSI group: 16.2 versus 1.1 min, respectively.

Conclusions

In simulated periacetabular pelvic tumor resections, PSI technique enabled surgeons to reproduce the virtual surgical plan with similar accuracy but with less bone resection time when compared with navigation assistance. Further studies are required to investigate the clinical benefits of PSI technique in pelvic tumor surgery.

     

Clinical and radiographic evaluation of mechanical sufficiency of the operative treatment of pathological fractures in bone metastases

Background. Aims: Retrospective evaluation of mechanical sufficiency of applied surgical methods of bone metastases treatment according to authors' own scoring system.
Material and methods. 60 patients with bone metastases treated operatively in our Ward during 1989-2002. Mean age of patients was 62,5 years old. There were 39 women and 21 men. In 48 cases (80%) there were possible to diagnose primary localization of the tumor. We could not reveal primary focus of the tumor in 10 cases (20%). Localizations of bone metastases are as follow: femur - 49 cases, humerus - 10 cases, tibia - 1 case.
After local excision of metastatic tumor had been done the internal osteosynthesis and bone cement application was made in 45 cases, the internal osteosynthesis only was made in 7 cases, hip arthroplasty was made in 8 cases. Mean time of follow-up since surgical procedure was 8 months. Scoring system for radiographic and clinical evaluation of mechanical efficacy of operative fixation of pathologic fractures: grade I - good mechanical fixation, grade II - minimal loss of fixation, grade III - poor mechanical fixation, grade IV - relapse of pathological fracture.
Results. We had poor results in 5%, because of the death of 3 patients. In 58 cases (97%) we had very good or good results - no pain, good function and independence in daily activities (grade I and II in scoring system of mechanical efficacy of pathologic fracture fixation). In remaining 2 patients (3%) there was loss of mechanically stabile fixation of pathological fracture.
Conclusions. 1. Mechanical efficacy of the fixation of pathological fractures is good and lasting in 97% of cases. 2. Local complications rate was 2% and was due to mechanical unstabile fixation of pathological fracture.     

Radiological and functional assessment of indications for operative treatment in patients with long bone metastases

Background. The purpose of the study is to evaluate the risk of fractures in long bones with metastases based on intact cortical bone index (ICBI) and functional assessment.
Material and methods. We evaluate radiograms of 36 (25 fractures) and 86 patients (56 fractures) with the upper and lower extremity metastases, respectively. We measured on radiograms intact cortical bone index (ICBI) using the schedule K-G/K-J x100%, where is K-shaft diameter, G-size of destruction, J-bone marrow diameter above or below the metastases. We asses the extremity function by the ability to elevate and abduct it straight.
Results. We found that fracture occurs if the ICBI is lower than 46% and 40% in upper and lower extremity, respectively. 7 (5,7%) patients develop fracture despite higher ICBI. If the metastases are located in upper part of the femur and humerus and he/she can not elevate or abduct the extremity the fracture inevitably occurs.
Conclusions. Counting the ICBI and simple functional assessment allows to predict fracture in 94,3% of patients with long bone metastases.