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.     

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.     

Functional bracing of humeral schaft fractures in osteoporotic patients

Introduction. There are many treatment methods in use, both surgical and non-surgical, for fractures of the shaft of the humeral bone.
Material and methods. We did a prospective study of the effectiveness of functional bracing for humeral shaft fractures in 8 selected patients with osteoporosis, aged 56-78. Evaluation was based on radiographic signs of bone union, the quality of reduction, and the functioning of the ulnar and gleno-humeral joints and the upper extremity as a whole.
Results. In all the cases studied, good and fast bone union was achieved with varying degrees of residual deformation, without detectable influence of the latter on the functional result.
Conclusions. The method in use proved to be very effective, since early, good function of the injured extremity was restored and patient satisfaction was very high.     

Possibilities of surgical treatment of bone metastases to the proximal epiphysis of the femur: a review of the literature and own experience

Background. The most common complication of bone metastases to the hip is pathological fracture of the proximal epiphysis. The present study presents the indications and contraindications for surgery and the choice of particular surgical techniques, based on the literature and the authors' own experience.
Material and methods. In the period 1992-2002 we treated 25 patients with bone metastases to the proximal epiphysis of the femur. All had suffered pathological fractures. Various surgical procedures were used, depending on the indications. In two cases we used pallative treatment.
Results. There were no intraoperative or immediate post-operative deaths. In all cases but one we observed reduced pain after surgery. 23 patients recovered hip mobility. 22 patients could walk with elbow crutches after surgery. A functional evaluation performed on day 14 post-surgery produced an average score of 13.2, which on Merle d'Aubigne's scale is a "good" outcome. The survival time ranged from 6 weeks to 4 years (average 13.5 months).
Conclusions. Surgical treatment is essential, both in existing and imminent pathological fractures of the proximal epiphysis of the femur, in order to provide relief from persistent pain and enable independent movement. A patient with advanced neoplastic disease and bone metastases to the hip should be operated even before a pathological fracture occurs, which enables the use of a less invasive surgical technique and prevents immobility and worsening of the patient's physical and mental status.     

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.     

Technique and results of operative treatment of bone metastases to the knee

Background. Bone metastases in the knee are rare. The most difficult challenge in this area is to achieve a stabile fixation. The aim of the study was to evaluate results of various techniques of operative treatment of bone metastases to the knee in relation to its localisation and lesion patomorphology.
Material and methods. We assed 13 patients (5,9%) out of 220 treated operatively. The destruction area was located in femur in 12 patients and in 1 in tibia. Bone metastases were found in physis of femur in 5 patients and cross the line drawn through epicondyles. In 8, metastases were located in the epicondylar area. Pathological fractures were noted in 7 patients.
Results. Successful stabilisation was achieved in 4 patients without pathological fracture and in one patient where we resected distal part of femur and stabilised it with tibia using Küntscher nail, plate and bone cement.
In 8 patients complications were observed. One died due to pulmonary embolism on the fifth day after operation. In 3 patients we observed local recurence of tumor if the curetage alone was performed. In 2 cases where we used 2 rods introduced from the epicondylar area the stabilisation become loose. It was due to short distal femoral part. In one patient we noticed stress fracture of plate and in one the stabilisation of tibia and femur become unstabile because of local progression of metastases.     

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.
     

Complications after surgical treatment of bone metastases to proximal femur

Background. Bone metastases in proximal femur a frequently treated surgically.
Material and methods. The authors present complications in the operative treatment of bone metastases to proximal femur in 82 patients managed at the Departament of Orthopedics and Traumatology of the Lublin University of Medical Sciences between 1978 and 2002.
Results. Recidives, angulated plates fractures, endoprostheses luxations and deep infections complicated 20% of the procedures. Revision surgery restored good function of painless limbs. Poor results were noted in
3 patients with deep infections of the endoprostheses.
Conclusions. Recidives, angulated plates fractures and endoprosthesis luxations can be avoided by large resections of the tumor and reconstruction with bipolar postresection endoprosthesoplasty.     

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.     

Radiological assessment of indications for surgical treatment of spinal metastases

Background. The purpose is to assess the risk of spinal cord compression in patients with spine metastases using radiological data.
Material and methods. We evaluate 103 patients with the thoraco-lumbar vertebral body metastases - 52 with neurological symptoms of spinal cord compression and 51 symptoms free. We measured the statistical relation between spinal cord compression, pathological fracture, angle deformity of the spine and metastasis location. We divide spine into 3 columns and named pediculum as the fourth. We used statistical multiple regression analysis.
Results. The risk of spinal cord compression is depended on the location of the metastasis in vertebral body (p < 0,01). We found spinal cord compression symptoms in 25 out of 31 patients in group with pediculum involvement and in 27 out of 72 in group with other locations. It was highly statistically important (p < 0.001). In 45 out of 68 patients with vertebral fractures we found spinal cord compression symptoms (p < 0.01). We did not found statistical correlation between angle deformity and compression symptoms.
Conclusions. The risk of spinal cord compression is higher if the metastases are localised in thoraco-lumbar part of spine and if the pediculum is involved. The pathological fracture increases the risk of the compression, too.     

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.     

The impact of bisphosphonate therapy on the survival time of patients undergoing radiotherapy for bone metastases

Background. Bisphosphonates are form of medical therapy for bone metastases. Morbidity from bone metastases including hypercalcemia episodes, pain, pathological fractures and appearance of new metastases in skeletal system is decreased by bisphosphonate therapy. The aim of this article is to determine the influence of bisphosphonate therapy on survival time of patients irradiated due to bone metastases.
Material and methods. 305 patients irradiated due to bone metastases were assessed in this retrospective study. 94 of them were additional treated by bisphosphonates. Median survival time counted from the end of radiotherapy to the death of patients was assessed. Using U Mann Whitney test the influence of bisphosphonates therapy on survival time was determined. The significance level of p = 0,05 was accepted.
Results. The median survival time of patients irradiated due to bone metastases and treated by bisphosphonates was 8,1 month and 5,24 month in the group treated only by radiotherapy. Median survival time of pts with breast cancer and with unknown primary site of cancer who were treated by radiotherapy and bisphosphonates was significantly longer (respectively p = 0,001 and p = 0,016) as compared with the group with irradiated bone metastases only.
Conclusions. 1. Bisphosphonates therapy improved the median survival time in the whole group of patients irradiated due to bone metastases. 2. Statisticaly significant prolonged survival time was observed in groups of patients with breast cancer and with unknown primary site of cancer. Median survival time was prolonged in these groups about 5 months and 3,5 months respectively.     

骨质软化症中骨折的影像学鉴别诊断

目的 探讨代谢性及内分泌性骨病所致骨质软化中假骨折、真骨折和衰竭骨折的成因、诊断和鉴别诊断的意义及其临床价值.方法 收集X线平片上具有骨质软化表现的病人36例,进行骨结构及骨密度的影像学分析.对18例出现骨折的病人进行骨折分类.对6例平片发现有假骨折线的病人行局部薄层CT扫描.对1例双侧耻骨上、下支有假骨折线的病人进行了6年的随访观察.结果 所有病例均有不同程度的骨弯曲变形和骨密度异常.骨密度异常包括骨密度减低和骨密度增高.18例出现骨折线的病例中13例诊为假骨折,3例为真骨折,2例为衰竭骨折.6例有假骨折病人行局部薄层CT扫描并三维重建,显示假骨折线走行较平片更加清晰.一例双侧耻骨上、下支出现假骨折的病人经治疗6年后假骨折线消失.结论 在代谢性及内分泌性骨质软化症中出现的骨折线可以是假骨折、真骨折和衰竭骨折,归纳并提出了这三种骨折的诊断标准,薄层CT扫描和三维重建技术可以更准确地显示假骨折线.假骨折线可以作为监测病情发展情况的指标之一.     

Treatment of osteoporotic pertrochanteric fractures with use of elastic Ender nails in aged people

Introduction: Proximal femur fractures are often the first symptom of osteoporosis in old people. Proximal femur fractures in the sequence of minimal trauma are as the rule multifragmental and covers peritrochanteric part. We reviewed effectiveness of Ender technique in aged people with coexisting ostoporosis.
Material and methods: In 1995-2001 114 patients with osteoporotic peritrochanteric fractures were treated with Ender technique. In our group of patients before operation coexisted in 27 diabetes mellitus, in 52 arteriosclerosis and in 29 patient in different degree senile dementia. We evaluated 76 patient after 6, 12, 18 weeks and 12 months post operatively. We examined range of hip motion and way of walking, on x-rays we evaluated the healing of fracture and shaft-neck angel.
Results: Clinical and radiological evaluation of named group showed a very good result in 45 (60%), a good result in 20 (28%) and a poor results in 11 (12%) of operated patients. The fracture healing occurred in all named group in 84% of patient in 10-24 weeks (mean 17 weeks).
Conclusion: Elastic Ender nailing is a technique of choice in the treatment of aged people with osteoporosis and passed medical history. The best result of operative treatment were achieved in patient operated in
1 day after trauma, with high physical and mental dexterity before trauma.     

Broken bones: common pediatric lower extremity fractures--Part III

Lower extremity injuries and fractures occur frequently in young children and adolescents. Nurses are often one of the first healthcare providers to assess a child with an injury or fracture. Although basic fracture care and principles can be applied, nurses caring for these young patients must have a good understanding of normal bone growth and development as well as common mechanisms of injury and fracture patterns seen in children. Similar to many of the injuries in the upper extremity, fractures in the lower extremity in children often can be treated nonoperatively with closed reduction and casting. However, this article will also review several lower extremity fractures that frequently require surgical intervention to obtain a precise anatomical reduction. Common mechanisms of injury, fracture patterns, and current management techniques will be discussed. Teaching strategies and guidelines that will enable nurses and nurse practitioners to confidently educate parents, families, and other providers caring for these young patients will be reviewed.     

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 effectivness of strontium 89 in palliative therapy of painful prostate cancer bone metastases

Background. The aim of this study was to evaluate the effectivness of strontium 89 (Metastron) therapy in the group of prostate cancer patients with multiple bone metastases.
Material and methods. The study included 70 patients (aged 53-84) with prostate cancer and multiple bone painful metastases detected by scintigraphy and by radiogram character of metastases (osteoblastic - 55 patients, osteolytic-osteoblastic - 15 patients). Before strontium 89 therapy 34 out 70 patients have been performed local irradiation to the back bone as prevention of spinal cord compression. For assessment of therapy effectivness; pain relief (VAS scale), a reduction in analgesic requirements and motor activity (ECOG and Karnofsky scale) were evaluated.
Results. We conclude that palliative therapy using strontium 89 is effective (88% "good" and "moderate" response rate) and safe for bone pain palliation in patients with multiple prostate cancer bone metastases; it also improves the quality of life. We have observed that the analgesic requirments decreased to 50% of dose on average. The motor activity of the points evaluated according to ECOG scale and Karnofsky scale was much better (p < 0,05).     

Preliminary results of combined application of radioisotopes and biphosphonates in the management of pain associated with osteoblastic-osteolytic bone metastases of breast cancer

Background. The aim of this study was to evaluate the effectivness of connected therapy using strontium 89 or Sm153 (osteoblastic component) and bisphosphonate therapy (osteolytic component) in the group of breast cancer patients with multiple osteoblastic-osteolytic (mixt) bone metastases.
Material and methods. The study included 16 patients with breast cancer and multiple bone painful metastases detected by scintigraphy and by radiogram or CT or MRI (the type of metastases). Each patient received a standard dose of strontium 89 (Metastron) or samarium 153 (Quadramet) combined with intravenous infusion of pamidronate (Aredia) or zoledronate (Zometa). The bisphosphonate therapy was repeated every month. For assessment of therapy effectivness; pain relief (VAS scale), a reduction in analgesic requirements and motor activity (ECOG and Karnofsky scale) were evaluated. The group of 10 patients treated with bisphosphonate only in the same time was observed.
Results. We conclude that connected palliative therapy using strontium 89 and bisphosphonates is effective (66-75% "good" and "moderate" response rate) and safe for bone pain palliation in patients with multiple osteoblastic-osteolytic bone metastases from breast cancer. We have observed that the analgesic requirments decreased to 30% of dose on average. The motor activity of the points evaluated according to ECOG scale increased from 3 to 2 and from 50 to 60 to Karnofsky scale.
Conclusions. The results of treatment in the group with radioisotope and bisphosphonate were better than in the group treated with bisphosphonates or radioisotope only.     

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.