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Abstract
Purpose
The skeleton is commonly affected by metastatic cancer. The purpose of this study was to evaluate the results of treating metastatic pathologic fractures in lower extremities using locking plates.
Materials and Methods
Between 2004 and 2010, we evaluated 12 patients (13 cases) of metastatic pathologic fractures in lower extremities, treated with the locking plate. Mean patient age was 62.2 years (range, 50-81 years), the locations of the fractures were; proximal femur in 2 cases, femoral mid-shaft in 3, distal femur in 3, proximal tibia in 4, and distal tibia in 1 case. The interval to wheelchair ambulation, pain relief and complications were evaluated. Additionally, we assessed operation time and postoperative blood loss.
Results
Mean time from operation to wheelchair ambulation was 3.2 days (range, 1-6 days). Mean VAS scores improved from a preoperative score of 8.1 points (range, 7-9 points) to a score of 2.7 points (range, 2-4 points) at 1 week postoperatively. No early complications associated with surgery were encountered. Mean operation time was 88.4 minutes (range, 70-105 minutes), and mean postoperative blood loss was 246.5 ml (range, 130-320 ml).
Conclusion
Internal fixation of metastatic pathologic fractures using a locking plate in the lower extremity can be an effective treatment option in the meta- or diaphyseal area of long bones with massive bony destruction or poor bone stock by offering early ambulation, pain relief and low postoperative complications.
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Figure 1.
A 70-year-old man with a fracture of the distal femur secondary to metastasis of lung cancer. (A) Anteroposterior (AP) radiograph of the distal femur shows a displaced pathologic fracture. (B) The patient underwent an open reduction and internal fixation using a locking plate with cement augmentation.
Figure 2.
An 81-year-old man with thyroid cancer showing a pathologic fracture of the femoral mid-shaft. (A) Preoperative radiograph shows an osteolytic lesion of the femoral shaft. (B) Coronal plane of preoperative CT scan demonstrates a cortical discontinuity around the lesion of the femoral shaft. (C) A minimally invasive plate osteosynthesis was performed with a locking plate.
Figure 3.
A 58-year-old man with a pathologic fracture of the distal femur due to lung cancer. (A) AP radiograph shows an osteolytic lesion of the distal femur with a pathologic fracture. (B) The distal femur with a pathologic fracture was stabilized by using locking plate with cement augmentation. (C) AP and lateral radiograph obtained 3 months after internal fixation shows loss of reduction and failure of the internal fixation.
Table 1.
Demographic Data of Patients with an Impeding or Pathologic Fracture of the Lower Extremity Caused by Metastatic Cancer
| Cases | Gender | Age (year) | Primary tumor | Metastases | Pathologic fracture site | Operation name | Survival after fracture (day) | Interval from operation to ambulation (day) | Preoperative VAS (points) | Postoperative VAS (points) | Postoperative blood loss (ml) | Operation time (minute) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | M | 81 | Thyroid | Multiple (skeleton, Lymph nodes) | Femur mid-shaft | ORIF with LCP | 84 | 1 | 8 | 3 | 260 | 70 |
| 2 | M | 61 | Lung | Multiple (skeleton) | Proximal femur | ORIF with LCP | 14 | No∗ | 8 | 3 | 200 | 65 |
| 3 | M | 61 | Lung | Multiple (skeleton) | Proximal tibia | ORIF with LCP & cementing | 14 | No∗ | 8 | 2 | 315 | 80 |
| 4 | M | 70 | Stomach | Multiple (Skeleton, Brain) | Distal tibia | ORIF with LCP & cementing | 32 | 3 | 7 | 4 | 130 | 65 |
| 5 | M | 70 | Lung | Multiple (Skeleton, Lymph nodes) | Distal femur | ORIF with LCP & cementing | 44 | 2 | 9 | 3 | 320 | 85 |
| 6 | M | 58 | Lung | Multiple (Skeleton, Brain) | Distal femur | ORIF with LCP & cementing | 220 | 6 | 9 | 2 | 200 | 90 |
| 7 | M | 50 | Lung | Multiple (Skeleton, Brain) | Distal femur | ORIF with LCP & cementing | 378 | 4 | 8 | 2 | 300 | 95 |
| 8 | F | 58 | Thyroid | Multiple (Skeleton) | Proximal femur | ORIF with LCP & cementing | 38 | 4 | 7 | 4 | 225 | 105 |
| 9 | M | 60 | Lung | Multiple (Skeleton) | Mid-shaft femur | ORIF with LCP & cementing | 65 | 2 | 8 | 2 | 255 | 105 |
| 10 | F | 66 | Stomach | Multiple (Skeleton) | Proximal tibia | ORIF with LCP & cementing | 149 | 2 | 8 | 3 | 230 | 100 |
| 11 | F | 56 | Kidney | Multiple (Skeleton) | Proximal tibia | ORIF with LCP | 241 | 5 | 9 | 3 | 295 | 95 |
| 12 | M | 57 | Lung | Multiple (Skeleton, Brain) | Mid-shaft femur | ORIF with LCP & cementing | 74 | 3 | 7 | 2 | 265 | 95 |
| 13 | M | 62 | Lung | Multiple (Skeleton) | Proximal tibia | ORIF with LCP | 107 | 3 | 9 | 2 | 210 | 100 |
| ORIF, open reduction and internal fixation; LCP, locking compression plate. | ||||||||||||
Table 2.
Results Compared with Intramedullary Nailing for the Treatment of Pathologic Fractures
| Authors | Cases | Operation time (minute) | Blood loss (ml) | Ambulation (day) | Complications (numbers) |
|---|---|---|---|---|---|
| Sharma et al.26) | 21 | 140 | 900 | 3∗ | Superficial wound infection (2) |
| Pneumonia (2) | |||||
| Loss of reduction (1) | |||||
| Moholkar et al.27) | 48 | 98 | 400 | 7† | Chest infection (4) |
| Urinary track infection (2) | |||||
| Superficial wound infection (2) | |||||
| Deep wound infection (1) | |||||
| Renal failure (1) | |||||
| Death (2) | |||||
| Present study | 13 | 88.4 | 246.5 | 3.2 | Screw breakage (1) |
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