Review Article Management of Metastatic Bone Disease of ...upload.orthobullets.com/journalclub/free_pdf/24187038_24187038.pdfthan CT in evaluating metastatic ac-etabular disease and

Management of Metastatic BoneDisease of the Acetabulum

Abstract

Metastatic acetabular disease can be severely painful and mayresult in loss of mobility. Initial management may consist ofdiphosphonates, narcotic analgesics, radiation therapy, protectedweight bearing, cementoplasty, and radiofrequency ablation.Patients with disease affecting large weight-bearing regions of theacetabulum and with impending failure of the hip joint are unlikelyto gain much relief from nonsurgical treatment and interventionalprocedures. The profound osteopenia of the acetabulum, limitedhealing potential of the fracture, and projected patient life span andfunction necessitate surgical techniques that provide immediatestable fixation to reduce pain and restore ambulatory function.Current reconstructive procedures, including cemented total hiparthroplasty, the saddle or periacetabular endoprosthesis, andporous tantalum implants, are based on the quality of remainingacetabular bone as well as the patient’s level of function andgeneral health. Well-executed acetabular reconstructions canprovide durable hip joints with good pain relief and function.

Metastatic disease of the acetabu-lum can be very painful and mayseverely limit function and activities ofdaily living. Osteolytic destructioncaused by the tumor can result in patho-logic fracture of the acetabulum and in-creased pain and inability to ambulate.These fractures have poor healing po-tential with radiotherapy.1 Fracturehealing may take longer than the pa-tient’s expected life span.2

For primary malignant bone tu-mors, wide resection is performed inan effort to cure the patient. In con-trast, metastatic disease requires amore palliative approach. In general,radical or wide resections, includinghemipelvectomy, are not indicatedfor patients with metastatic disease.Diphosphonates, narcotic analgesia,radiation therapy, and protectedweight bearing are the first steps inmanagement.

Interventional treatment, includingpercutaneous cementoplasty and ra-diofrequency ablation, is indicatedfor patients who fail nonsurgicaltreatment but are not candidates forsurgery. Large lesions with impend-ing or completed acetabular fracturesmay require surgery, with the goal ofcreating a durable hip joint to pro-vide pain relief and enable immediateweight bearing.3

Tumor Workup

The acetabular lesion should be eval-uated on a standard AP pelvic radio-graph to determine the extent of tu-mor involvement (Figure 1). Judetobturator and iliac oblique views arehelpful to assess the integrity of theanterior and posterior columns andwalls, roof, and quadrilateral plate.

Paul S. Issack, MD

Suhel Y. Kotwal, MD

Joseph M. Lane, MD

From New York–PresbyterianHospital, Weill Medical College ofCornell University, New York, NY(Dr. Issack), the School of Medicine,University of Missouri at KansasCity, Kansas City, MO (Dr. Kotwal),and the Hospital for Special Surgery,New York (Dr. Lane).

Dr. Lane or an immediate familymember is a member of a speakers’bureau or has made paidpresentations on behalf of Amgen,Eli Lilly, Novartis, and WarnerChilcott; serves as a paid consultantto Amgen, CollPlant, BoneTherapeutics, BioMimeticTherapeutics, DFINE, Graftys, andZimmer; has received research orinstitutional support from Amgen;and serves as a board member,owner, officer, or committee memberof the Orthopaedic ResearchSociety, the Musculoskeletal TumorSociety, the American Academy ofOrthopaedic Surgeons, theAssociation of Bone and JointSurgeons, the AmericanOrthopaedic Association, and theAmerican Society for Bone andMineral Research. Neither of thefollowing authors nor any immediatefamily member has receivedanything of value from or has stockor stock options held in acommercial company or institutionrelated directly or indirectly to thesubject of this article: Dr. Issack andDr. Kotwal.

J Am Acad Orthop Surg 2013;21:685-695

http://dx.doi.org/10.5435/JAAOS-21-11-685

Copyright 2013 by the AmericanAcademy of Orthopaedic Surgeons.

Review Article

November 2013, Vol 21, No 11 685

The entire femur should be imaged,as well, to identify additional dis-ease.

CT of the pelvis and acetabulum ishelpful in assessing the degree ofbony destruction and deficiency (Fig-ure 2). Three-dimensional CT mayhelp to more accurately define theextent of bony destruction and thequality and amount of bone avail-able for fixation.4 Thin-slice CT (ie,0.6 mm) allows for excellent resolu-tion of the fractured acetabulum andcan be used to generate a life-sizeplastic model of the pelvis and areasof pathologic destruction. This canallow for highly accurate estimationof implant position for optimal fixa-tion and screw length.5

MRI of the pelvis is less helpfulthan CT in evaluating metastatic ac-etabular disease and bony integrity,and MRI may overestimate the de-gree of bony involvement.6 Addi-tional imaging studies, includingbone scanning and/or skeletal sur-veys, can help to determine whetherthe acetabular lesion is a primarybone tumor or a metastatic lesion.7

Biopsy always should be per-formed to confirm that the acetabu-lar lesion is a metastatic tumor andnot a primary bone tumor, but insome cases it is not necessary to waitfor the biopsy result before proceed-ing with treatment. In a patient witha solitary acetabular lesion and withno history of cancer, biopsy must beperformed. In patients aged >40years, a solitary acetabular lesion islikely to be a metastatic lesion, evenin the absence of a history of cancer.8

With a history of cancer, a solitaryacetabular tumor is even more likelyto be a metastatic lesion; in suchcases, biopsy is required. A patientwith a history of cancer and withmultiple visceral metastases and ac-etabular lesion does not require bi-opsy before surgery. During acetabu-lar reconstruction, tissue from the

Standard AP pelvic radiograph demonstrating a pathologic left acetabularfracture with destructive lesions in the acetabulum extending proximally intothe ilium and distally into the ischium in a 57-year-old woman who wasdiagnosed with metastatic breast carcinoma and who presented withincreased left hip pain and inability to ambulate.

Figure 1

Axial CT scans of the same patient as in Figure 1 demonstrating destructivelesions in the left acetabulum extending from the iliac wing (A), theacetabular dome (B), the posterior wall (C), and the ischial tuberosity (D).

Figure 2

Management of Metastatic Bone Disease of the Acetabulum

686 Journal of the American Academy of Orthopaedic Surgeons

lesion can be sent for pathologicanalysis.8

Biopsy may be performed usingfine-needle aspiration, core biopsy,or open incisional biopsy techniques.CT-guided fine-needle aspiration andcore biopsy reduce the risk of con-tamination of the biopsy tract. Openincisional biopsy should be per-formed through a small longitudinalincision in line with the incision; thissame incision may ultimately be usedin wide excision of the tumor and bi-opsy tract if the lesion turns out tobe a primary bone sarcoma. Meticu-lous hemostasis should be obtainedto prevent hematoma and spread oftumor cells.8,9 In the case of primarybone sarcoma, incorrect biopsy tractplacement and hematoma contami-nation of the site may result in am-putation.9

Surgical Classifications

In 1981, Harrington10 reported hisresults on hip reconstruction per-formed in 58 patients with meta-static acetabular insufficiency andfracture-dislocations. He categorizedthese lesions into three classes. Inclass I lesions, the articular surface isdisrupted but the walls and columnsare intact. Patients with class I le-sions were reconstructed with ce-mented acetabular and femoral com-ponents. In class II lesions, themedial wall and quadrilateral plateare deficient, requiring acetabular re-construction with a flanged cup totransfer weight-bearing forces awayfrom the medial acetabulum and toprevent medial collapse of the recon-struction. In class III lesions, the roofand acetabular rim are deficient andrequire reconstruction with Stein-mann pins in cement and total hiparthroplasty (THA) using a flangedcup or cage (ie, cement-reinforcedTHA).10,11

The metastatic acetabular classifi-

cation (MAC) describes lesions infour anatomic zones—the acetabulardome, medial wall, anterior column,and posterior column12,13 (Figure 3).Specific reconstructions were pro-posed based on the anatomic patternof destruction. A cavitary lesion inthe dome or roof of the acetabulumwith intact subchondral bone (ie,type 1) may be managed with cemen-tation of the lesion followed byTHA. Patients with insufficient sup-

portive subchondral bone should betreated with THA with reinforced ce-ment using a flanged cup or cage.Medial wall defects with dome de-fects (ie, type 2) require flanged cupsor cages to avoid protrusion or me-dial collapse of the reconstruction.Defects in either the anterior or theposterior column (ie, type 3) or bothcolumns (ie, type 4) may also bemanaged with cement-reinforcedTHA and cage support or a saddle

Metastatic acetabular classification system. A, Type 1, dome. B, Type 2,medial wall. C, Type 3, single column, posterior. D, Type 3, single column,anterior. E, Type 4, double column.

Figure 3

Paul S. Issack, MD, et al


prosthesis if there is adequate bonestock in the proximal ilium. For allof these reconstructions, adequatebone stock in the ipsilateral pelvisand ischium or floor of the acetabu-lum is needed for Steinmann pin andcage-screw fixation.12,13

Nonsurgical Management

Patients with painful but small ac-etabular lesions that do not compro-mise the weight-bearing posteriorcolumn, dome, or medial wall maybe treated initially with diphospho-nates, narcotic analgesics, radiationtherapy, and protected weightbearing.12-15

Diphosphonates may be used to re-duce skeletal events related to bonemetastases. One study found pami-dronate to reduce pain and hypercal-cemia in women with bone metasta-ses resulting from breast cancer.16 Ina recent meta-analysis of nine ran-domized controlled trials (2,806 pa-tients with breast cancer with bonemetastases), diphosphonates, includ-ing intravenous zoledronic acid 4 mgand intravenous pamidronate 90 mg,reduced the risk of skeletal-relatedevents by 15%.17

Administration of narcotics viaepidural catheters is an effective ap-proach to manage bone pain in pa-tients in terminal stages of their ill-ness.18,19 Jeon et al19 retrospectivelyreviewed 96 patients who received127 epidural catheters to managepain caused by terminal cancer. Theproportion of patients with severepain decreased from 78.1% to19.6%. In a meta-analysis of 31studies, Ballantyne and Carwood18

observed excellent pain relief in 72%of the patients with terminal cancerwho received epidural analgesia.There were no major complications.

Radiation therapy is indicated forradiosensitive tumors with low riskfor pathologic fractures (eg, breast

cancer, lung cancer); however, it alsomay be used for any metastatic le-sion to minimize the need for surgi-cal intervention. An early study onexternal beam irradiation in 14 pa-tients with metastatic acetabular le-sions demonstrated pain relief in allpatients.14 The Radiation TherapyOncology Group performed a ran-domized trial known as RTOG 9714comparing 8 Gy in 1 fraction with30 Gy in 10 fractions in 898 patientswith bone metastases from breast orprostate cancer. At 3-month follow-up, both groups demonstrated simi-lar responses, with partial responserates of approximately 50% in botharms; 33% of all patients no longerrequired narcotic medications.20 Cur-rently, the most commonly usedschedule in the United States formanaging oncologic bone pain is aregimen of 30 Gy given in 10 treat-ment fractions over 2 weeks.20,21

Interventional Procedures

Surgical intervention may be indi-cated for patients who have little tono pain relief and severe functionalimpairment despite adequate nonsur-gical treatment. Reconstruction ofmetastatic acetabular fractures, how-ever, is an extensive surgery with thepotential for significant blood loss,large fluid shifts, and a major sys-temic inflammatory response. Manypatients with metastatic disease areincapable of surviving or making ameaningful recovery from such aprocedure.12,13 For these patients, lessinvasive approaches may be consid-ered.

Interventional procedures, includ-ing injection of methylmethacrylateinto osteolytic lesions (eg, percutane-ous cementoplasty) may provide im-mediate stability and relatively pain-free weight bearing (Figure 4).Anterolateral and posterolateral por-tals are made under CT-guided imag-

ing to pass two vertebroplasty nee-dles into the acetabular lesion, takingcare to avoid injury to the lateralfemoral cutaneous nerve, sciaticnerve, and superior gluteal artery.22

The needle is removed, leaving thecannula behind, and a Kirschnerwire is inserted into the acetabulumthrough this cannula. Dilators maybe passed over these Kirschner wires,followed by a working cannulathrough which cement, mixed with asmall amount of contrast dye, is in-jected into the sites under imageguidance.

Cotten et al23 injected methylmeth-acrylate into 12 acetabular osteolyticlesions in 11 patients. Nine patientsexperienced pain relief within 4 days,and all patients experienced im-proved ambulation within 5 days.Scaramuzzo et al24 retrospectively re-viewed 20 patients who underwentpolymethyl methacrylate injectioninto 24 metastatic acetabular lesions.Complete pain relief was achieved in75% of patients, with a 7.3-monthmean duration of pain relief. Smaller,relatively contained lesions are likelyto do better with cementoplasty.Larger acetabular lesions that com-promise the structural support of theacetabulum, including impendingfractures, complete fractures, pelvicdiscontinuity, and fractures creatingmedial wall insufficiency, are con-traindications to percutaneous ce-mentoplasty.24 Typically, percutane-ous cementation is combined withradiation therapy, cryoablation, orradiofrequency ablation to obtain lo-cal tumor control in addition to me-chanical reinforcement of weakenedbone.

Radiofrequency ablation hasshown good results in the manage-ment of pain from bone metastases.In this technique, an electrode is in-serted into the tumor and coagulat-ing tissue. Multitined electrodes areused for larger, metastatic lesions,and the bone–soft-tissue interfaces



are included in treatment.25 Thanoset al26 reported on 30 patients (34 le-sions) with painful bone metastasesusing radiofrequency ablation. Therewas a marked decrease in scores forpain and for pain interference duringdaily life 4 and 8 weeks after treat-ment. In addition, there was amarked decrease in the use of analge-sics, with only three patients usingoral analgesics at 8 weeks.

Surgical ReconstructionProcedures

Surgical reconstruction is indicatedin the presence of a large acetabularlesion that compromises hip jointstability, pathologic acetabular frac-ture, or radioresistant tumor. Pa-tients with persistent debilitatingpain for 1 to 3 months despite eithernonsurgical management (includingnarcotic analgesics, protected weightbearing, diphosphonates, and radia-tion therapy) or interventional pro-cedures may be candidates for recon-structive acetabular surgery.12,13

Surgical PreparationPreoperative embolization is veryhelpful in reducing intraoperativeblood loss, the need for blood trans-fusion, and surgical time.27,28 Wirbelet al28 reported on 11 patients withpelvic metastases who underwent se-lective embolization before surgery.There was a significant difference inblood loss and transfusion require-ments in the embolized group com-pared with a nonembolized controlgroup of 10 pelvic metastases (P =0.05). Although preoperative embo-lization is considered to be an optionin the surgical management of all ac-etabular metastases, preoperativeembolization also should be consid-ered for hypervascular histologiessuch as renal cell, thyroid, or hepato-cellular carcinoma and/or in thepresence of a large extraosseous soft-

tissue mass. This procedure must bebalanced against potential nephro-toxicity in medically frail patients.12

Setup and ExposureThe patient should be placed in thelateral decubitus position on a well-padded bean bag and radiolucent ta-ble. This allows for intraoperativefluoroscopy to confirm placement of

supra-acetabular screws and Stein-mann pins. Furthermore, the bean-bag can be rapidly deflated and thepatient positioned supine should im-mediate access to the iliac vessels beneeded to control hemorrhage. TheC-arm may be brought in from theside opposite the operating surgeon,who typically stands posterior to thepatient. Surgical management of

AP radiograph (A) and CT scan (B) of a left hip demonstrating an area ofacetabular osteolysis in the posterior column. AP radiograph (C) and CTscan (D) obtained following percutaneous cementoplasty. (Reproduced withpermission from Maccauro G, Liuzza F, Scaramuzzo L, et al: Percutaneousacetabuloplasty for metastatic acetabular lesions. BMC Musculoskelet Disord2008;9:66.)

Figure 4



most metastatic acetabular defectscan be performed through theKocher-Langenbeck (ie, extensileposterior) approach.29

Total Hip ArthroplastyMost surgical treatment options formetastatic acetabular lesions involvevariants of THA. In the presence ofcavitary lesions with intact subchon-dral bone and medial wall (ie, Har-rington class I, MAC type 1), the ac-etabulum may be managed withcurettage and cemented THA10,12,13

(Figure 5). A simple cage is required

if the medial wall is deficient (ie,Harrington class II, MAC type 2).12,13

An extensive cage with longflanges provides a larger surface areaof contact between the acetabulumand the implant and has been pro-posed to provide greater stability inthe setting of bone destruction in-volving the acetabular roof (ie, Har-rington class III). This type of cagewas used to reconstruct the acetabu-lum in 15 patients with metastaticacetabular defects.1 At an averagefollow-up of 14 months, the overallfailure rate was 27%. Two cages

demonstrated significant looseningat 15 and 30 months. Harris hipscores improved from an average of33 (range, 25 to 39) to 69 (range, 35to 93). Significant pain relief was re-ported, and 73% of the patientsstated that they would be willing toundergo the operation again.Clayer30 retrospectively reviewed 29acetabular reconstructions using ananti-protrusio cage for metastaticacetabular disease. At a meanfollow-up of 16 months, one patientdemonstrated mechanical looseningand five patients dislocated. Twenty-

AP radiograph (A) and coronal CT scan (B) of the lefthip in a 59-year-old man with metastatic bronchogeniccarcinoma demonstrating supra-acetabular bonedestruction with an intact medial wall. C, AP radiographobtained following total hip arthroplasty using acemented acetabular component and one Steinmannpin.

Figure 5



seven of 29 patients (93%) were ableto ambulate after the procedure.

Harrington ProcedureHarrington10 reported on the resultsof cemented THA with acetabularreconstruction using Steinmann pinsin 58 patients with metastatic ac-etabular fractures. Harrington class Ilesions were treated with a cementedTHA, and Harrington class II lesionswere reconstructed with a flangedcup. Harrington class III lesions werereconstructed with retrograde place-ment of 4.8-mm Steinmann pinsthrough the superior acetabulum,into the iliac crest, and across thesacroiliac joint. The medial cavitywas then cemented to include thepins, and the flanged cup was in-serted into the cement. Thirty-sevenpatients (64%) had good to excellentpain relief 6 months postoperatively,and 45 patients (78%) were ambula-tory 6 months postoperatively. In

five cases, the prosthetic reconstruc-tion loosened because of tumor re-currence. None of the patients withclass III disease had evidence of pros-thetic loosening even though thesepatients had the greatest degree ofbone destruction.

Since the original report by Har-rington, multiple groups have demon-strated the strength of the ce-ment-reinforced hip reconstructiontechnique.13,31,32 Steinmann pins maybe placed antegrade through inci-sions over the iliac crest and directedbetween the inner and outer tablestoward the floor of the acetabulum(Figure 6). We have placed these pinswith a free-hand technique, but a tri-angulation guide may be used, aswell.13 Ho et al31 performed the pro-cedure using 3.5-mm screws ratherthan Steinmann pins in 37 patientswith class III lesions of the acetabu-lum. At a mean follow-up of 23.6months, all patients reported im-

proved pain, mobility, and function.There were six dislocations (16%),which occurred within 2 months ofthe index surgery. The authors at-tributed this to the extensive muscleresection performed during tumordebulking. Six patients developeddeep infection (16%), with five re-quiring resection arthroplasty.

Marco et al13 reported on 55 pa-tients with metastatic acetabular le-sions treated with the Harringtontechnique. Fifty-four reconstructionswere performed with an anti-protrusio cup and 1 with a hemipel-vis endoprosthesis. Thirty-six pa-tients (65%) had insufficiencies ineither the anterior or posterior col-umns (ie, MAC type 3). Ten patients(18%) had insufficiencies of both theanterior and posterior columns (ie,MAC type 4). At 6-month follow-up,19 patients had died. Of the 33 pa-tients available for follow-up at 6months, 76% had pain relief and 19

A, AP radiograph of the right hip in a 48-year-old woman with metastatic breast cancer demonstrating a largemetastatic lytic lesion in the superior dome with osteolysis of the anterior and posterior columns (ie, metastaticacetabular classification type 4). B, AP radiograph obtained following intralesional curettage of the metastatic lesionthrough a standard posterior approach to the hip. The superior dome was reconstructed using threaded Steinmannpins and cement. A flanged acetabular component was implanted with a hybrid-screws-into-cement technique. Thepatient received postoperative radiation.

Figure 6



were able to walk. Fourteen patientshad disease progression, and 5 ofthese patients had fixation failure.Early postoperative complicationsincluded deep vein thrombosis in fivepatients and superficial infection inthree.13

The Harrington reconstructiontechnique has proved to be a durablereconstruction that, in most cases,lasts the lifetime of the patient. How-ever, these are complex reconstruc-tions with high complication rates invery ill patients. Preoperative plan-ning, the presence of an operatingroom team familiar with the steps inthe procedure, and surgeon experi-ence are critical for good outcomes.

Saddle and PeriacetabularEndoprosthesesFor lesions involving the acetabulumand ischium in patients with ade-quate bone stock in the ilium, recon-struction may be performed using asaddle prosthesis.33,34 The saddleprosthesis has been proposed as anoption in cases in which tumor hasinfiltrated both the anterior and pos-terior columns with medial wall anddome insufficiency (ie, MAC type4).12 This prosthesis is a modular de-vice with a proximal U-shaped sad-dle that articulates with a notchmade in the ilium, a femoral prosthe-sis, and an intervening linking basecomponent that allows for adjust-ment of soft-tissue tension as well asrotation, abduction, adduction, flex-ion, and extension. Saddle prosthesesare primarily designed for flexionand extension; the other motions arelimited. Soft-tissue tension and thebalance of the abductors keep thesaddle prosthesis in place.35

Aboulafia et al33 reported on 17patients with malignant periacetabu-lar tumors who underwent acetabu-lar resection and reconstructionusing a saddle prosthesis. Eight pa-tients had primary malignant lesions,

and nine had metastatic lesions. Atan average follow-up of 33.4months, seven of the nine patientswho were still alive had excellent re-sults and the other two had good re-sults.

Kitagawa et al34 reported on 12 pa-tients with sarcoma and 4 with me-tastasis involving the periacetabularregion who were treated with acetab-ular resection and reconstructionwith a saddle prosthesis. At a meanfollow-up of 37 months, postopera-tive functional scores according tothe Musculoskeletal Tumor Society–International Symposium on LimbSalvage system and the Toronto Ex-tremity Salvage Score were 53% and64%, respectively, in patients under-going wide acetabular resection forsarcoma and 30% and 42%, respec-tively, in patients undergoing intrale-sional excision of the acetabulum formetastatic disease. Complications in-cluded deep infection in three pa-tients and dislocation in one, likelyfrom proximal migration of the sad-

dle and resultant soft-tissue laxity.To improve the ilium-saddle inter-

face, Menendez et al36 developed aperiacetabular endoprosthesis. Thismodular saddle prosthesis is com-posed of a wide iliac wing segmentthat is fixed to the ilium with threecross bolts and cement (Figure 7). Theyretrospectively reviewed 25 patientswho underwent pelvic resection and re-construction with this endoprosthesis.At a minimum follow-up of 13months, major complications occurredin 14 patients, including deep infectionin 6, local recurrence in 5, and disloca-tion at the constrained acetabular lineror femoral neck Morse taper in 3. Im-plant survivorship was 84% at 2 years,with no failures at the ilium-saddle in-terface.

Porous Tantalum ImplantsPorous tantalum implants have beensuccessfully used in revision hip ar-throplasty to reconstruct massive ac-etabular defects and pelvic disconti-

A, AP radiograph of a right hip demonstrating severe superior and medialperiacetabular bone destruction due to metastatic breast cancer. B, APradiograph obtained 1 year after acetabular reconstruction using aperiacetabular endoprosthesis saddle. (Images courtesy of HowardRosenthal, MD, Mid-America Sarcoma Institute, Leawood, KS.)

Figure 7



nuity secondary to osteolysis.37

Porous tantalum implants may playa role in the management of acetabu-lar reconstruction following meta-static disease. Khan et al38 reportedon the use of tantalum implants toreconstruct acetabular bone destruc-tion resulting from metastatic dis-ease, multiple myeloma, lymphoma,and Langerhans cell histiocytosis.Reconstruction was performed usingan uncemented tantalum cup withaugments if necessary. All cups werefixed with multiple screws. In casesof more substantial bone loss inwhich cup–host bone contact was in-adequate for stable fixation, the cupcage technique was used. Twenty pa-tients with a mean age of 60 yearswho underwent acetabular recon-struction with the above techniquewere followed for a mean of 56months. There were no cases ofclinical or radiographic loosening.There was one perioperative death,

one case of deep vein thrombosis,and one dislocation.38 Longer-termfollow-up on larger numbers of pa-tients is needed to confirm the dura-bility of this technique in this specificpopulation.

Resection ArthroplastyResection arthroplasty for metastaticacetabular lesions (ie, Girdlestoneprocedure) may be indicated in pa-tients with severe pain, extensive pel-vic lesions, and disease that spans thehemipelvis. These patients have few,if any, reconstructive options. Resec-tion arthroplasty is also indicated inbedridden patients who experiencepain at rest and in patients who aremedically unable to tolerate majorpelvic reconstructive surgery12,39,40

(Figure 8). This procedure is per-formed solely to relieve pain in pa-tients who cannot be treated success-fully with narcotics. Because of the

significant limb-length discrepancyand essentially flail leg, in generalthis procedure is not done to restoreambulatory function.40

ComplicationsThe complication rate associatedwith surgical reconstruction in thispatient population is high. Har-rington10 reported two deaths, onerelated to massive intraoperativeblood loss and the second due tomyocardial infarction. There werefive cases of prosthetic loosening be-cause of tumor recurrence. Majorconcerns with the saddle prosthesisare infection (with reports as high as20%) and prosthetic migration.34

Preoperative planning expeditessurgery and minimizes the risk of in-fection. The patient should have sev-eral units of packed red cells avail-able, as well as fresh-frozen plasmaand platelets to prevent dilutional

A, AP pelvic radiograph of a severely ill 67-year-old woman with metastatic breast cancer who presented with severeright hip pain that could not be controlled with narcotic medication. She could not bear any weight. She presented witha pathologic fracture involving the medial and posterior walls with massive posterior column and ischial osteolysis, aswell as central dislocation of the femoral head. Her multiple medical comorbidities and poor medical conditionprecluded prolonged surgical reconstruction. B, AP pelvic radiograph obtained following femoral head resection andintralesional curettage of the metastatic lesion.

Figure 8



coagulopathy with massive transfu-sion. Preoperative embolization ofspecific tumor types can help to limitintraoperative blood loss.

Treatment Algorithm

For painful metastatic acetabular le-sions that do not compromise ac-etabular stability, that is, that do notinvolve large areas of the dome, pos-terior column, or medial wall, andare not impending fractures, initialmanagement involves the use of nar-cotic analgesics, protected weightbearing, diphosphonates, and radia-tion therapy. Patients with a veryshort life expectancy (40 years) with adestructive bone lesion. J Am AcadOrthop Surg 2010;18(3):169-179.

9. Mankin HJ, Mankin CJ, Simon MA;Members of the Musculoskeletal TumorSociety: The hazards of the biopsy,revisited. J Bone Joint Surg Am 1996;78(5):656-663.

10. Harrington KD: The management ofacetabular insufficiency secondary tometastatic malignant disease. J BoneJoint Surg Am 1981;63(4):653-664.

11. Levine AM, Aboulafia AJ: Pathologicfractures, in Browner BD, Levine AM,Jupiter JB, Trafton PG, Krettek C, eds:Skeletal Trauma: Basic Science,Management, and Reconstruction.Philadelphia, PA, Saunders Elsevier,2008, pp 453-512.

12. Brown HK, Healey JH: Pathologic pelvisfractures and acetabular reconstructionin metastatic disease, in Tile M, HelfetDL, Kellam JF, eds: Fractures of thePelvis and Acetabulum. Philadephia, PA,Lippincott Williams and Wilkins, 2003,pp 795-806.

13. Marco RA, Sheth DS, Boland PJ,Wunder JS, Siegel JA, Healey JH:Functional and oncological outcome ofacetabular reconstruction for thetreatment of metastatic disease. J BoneJoint Surg Am 2000;82(5):642-651.

14. Cheng DS, Seitz CB, Eyre HJ:Nonoperative management of femoral,humeral, and acetabular metastases inpatients with breast carcinoma. Cancer1980;45(7):1533-1537.

15. Rebolledo BJ, Unnanuntana A, Lane JM:A comprehensive approach to fragilityfractures. J Orthop Trauma 2011;25(9):566-573.

16. Hultborn R, Gundersen S, Ryden S, et al:Efficacy of pamidronate in breast cancerwith bone metastases: A randomized,double-blind placebo-controlled



multicenter study. Anticancer Res 1999;19(4C):3383-3392.

17. Wong MH, Stockler MR, Pavlakis N:Bisphosphonates and other bone agentsfor breast cancer. Cochrane DatabaseSyst Rev 2012;2:CD003474.

18. Ballantyne JC, Carwood CM:Comparative efficacy of epidural,subarachnoid, and intracerebroven-tricular opioids in patients with pain dueto cancer. Cochrane Database Syst Rev2005;(1):CD005178.

19. Jeon YS, Lee JA, Choi JW, et al: Efficacyof epidural analgesia in patients withcancer pain: A retrospectiveobservational study. Yonsei Med J 2012;53(3):649-653.

20. Hartsell WF, Scott CB, Bruner DW, et al:Randomized trial of short- versus long-course radiotherapy for palliation ofpainful bone metastases. J Natl CancerInst 2005;97(11):798-804.

21. Ben-Josef E, Shamsa F, Williams AO,Porter AT: Radiotherapeuticmanagement of osseous metastases: Asurvey of current patterns of care. Int JRadiat Oncol Biol Phys 1998;40(4):915-921.

22. Maccauro G, Liuzza F, Scaramuzzo L,et al: Percutaneous acetabuloplasty formetastatic acetabular lesions. BMCMusculoskelet Disord 2008;9:66.

23. Cotten A, Deprez X, Migaud H,Chabanne B, Duquesnoy B, Chastanet P:Malignant acetabular osteolyses:Percutaneous injection of acrylic bonecement. Radiology 1995;197(1):307-310.

24. Scaramuzzo L, Maccauro G, Rossi B,Messuti L, Maffulli N, Logroscino CA:Quality of life in patients followingpercutaneous PMMA acetabuloplasty foracetabular metastasis due to carcinoma.Acta Orthop Belg 2009;75(4):484-489.

25. Volkmer D, Sichlau M, Rapp TB: Theuse of radiofrequency ablation in thetreatment of musculoskeletal tumors.J Am Acad Orthop Surg 2009;17(12):737-743.

26. Thanos L, Mylona S, Galani P, et al:Radiofrequency ablation of osseousmetastases for the palliation of pain.Skeletal Radiol 2008;37(3):189-194.

27. Sun S, Lang EV: Bone metastases fromrenal cell carcinoma: Preoperativeembolization. J Vasc Interv Radiol 1998;9(2):263-269.

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Review Article Management of Metastatic Bone Disease of ...upload.orthobullets.com/journalclub/free_pdf/24187038_24187038.pdfthan CT in evaluating metastatic ac-etabular disease and