Abstract
Background:
The incidence of metastatic cancer continues to increase, becoming a prevalent condition in oncology orthopaedic practice. The proximal femur is the third most common site of skeletal metastases. Two possible options for endoprosthetic reconstruction of proximal femur metastasis include proximal femur resection and replacement with megaprosthesis and hemiarthroplasty with a long-cemented revision stem.
Methods:
To facilitate better decision making, we conducted a retrospective study comparing these alternatives. This is a single-institution, retrospective, observational study. Patients with metastatic disease of proximal femur who had a reconstruction with either a proximal femoral replacement (group A, 27 patients) or reconstruction using a hemiarthroplasty with long revision cemented stem (group B, 31 patients) were included for analysis.
Results:
Group A was associated with higher estimated blood loss than group B (1027.8 vs. 491.9 mL, P = 0.007). Group A was associated with higher surgical time (148.9 vs. 116.6 minutes, P = 0.04). More patients were associated with intense care unit transfer in group A (P = 0.04). Group B was associated with a shorter average time to full weight-bearing (6.2 vs. 11.5 weeks, P = 0.03). Group B was associated with shorter time to discharge (9.4 vs. 17.0 days, P = 0.04). Group A was associated with more postoperative complications (n = 5, 18.5% vs. n = 0, 0%), (P = 0.02).
Conclusion:
In patients with metastatic disease of the proximal femur, reconstruction with a long revision stem hemiarthroplasty was associated with better performance regarding surgical outcomes (estimated blood loss, surgical time, transfer to intensive care unit vs. regular floor). Furthermore, patients with hemiarthroplasties presented an association with shorter rehabilitation time and less complications.
The incidence of metastatic cancer continues to increase,1-3 and it has become a prevalent condition in oncology orthopaedic practice. Approximately 70% of patients with breast and prostate cancer will develop skeletal metastases during treatment.4-6 Furthermore, in developed countries, up to 30% of patients with metastatic carcinoma die due to causes not directly related to their oncological diagnosis.7 Emphasis on the quality and durability of surgical reconstructions increases as a consequence of the continuously improving patient survival. From palliative intramedullary nailing, the focus of surgical treatment has gradually shifted toward more complex resection and reconstructions using tumor megaprostheses.8 This is both due to the demand for a reconstruction that will outlast the patient's more optimistic prognosis and more complex and larger metastatic lesions.9
The proximal femur is the third most common site of skeletal metastases after the spine and pelvis.10,11 Treatment goals for patients who sustain pathological fractures of the proximal femur include pain relief, return to function, and the avoidance of further surgery. Intramedullary nailing of proximal femur metastases has a high risk of mechanical failure when a cortical defect is present, regardless of the cancer diagnosis.12-14 In addition, potential disease progression increases the possibility of osteosynthesis reconstruction failure. Retrospective studies have suggested that endoprosthesis reconstruction might be superior to osteosynthesis in terms of patient function and durability of the construct.15,16 Arthroplasty has also shown an association with survival benefit over osteosyntheses in multivariate analyses.17,18 Standard arthroplasty implants present a relatively high risk of aseptic loosening due to disease progression and/or radiation therapy with reported revision rate of 12%.19
Two options employed for surgical treatment include proximal femur resection and replacement with megaprosthesis (proximal femoral replacement [PFR]) and hemiarthroplasty with a long cemented revision stem (LSH). The advantages of en bloc tumor resection are a potentially positive effect on local control and overall prognosis, and lower risk of disease progression.20-23 The PFR can address any size of tumor, although the bigger implant is potentially at a higher risk of complications (Figure 1). Conversely, the revision stem hemiarthroplasty alternative, presumably, results in better function given most surrounding muscle insertions are preserved. Hence, it might allow earlier rehabilitation and faster discharge for the patient (Figure 2). However, intralesional resection carries increased risk of perioperative bleeding and higher risk of local recurrence, potentially resulting in failure of the construct and the need for revision surgery. Although endoprosthesis reconstruction is generally preferred according to the current literature, few studies have compared outcomes between these two reconstructive options.24 The indication criteria are not well defined and are mainly derived from surgeons' preference.
Figure 1.
Images of a69-year-old woman with metastatic breast cancer showing a pathological fracture of the proximal femur. The patient was treated with revision stem hemiarthroplasty and plate osteosynthesis. Functional results at 3 months postoperatively: functional score of 25 Musculo-Skeletal Tumor Society and 83 Harris hip score.
Figure 2.
Images showingtwo cases of proximal femur replacement for solitary metastatic disease of proximal femur (31-year-old man with renal cell carcinoma and 42-year-old woman with breast cancer). Whenever possible, if the greater trochanter region is free of disease, we try to preserve it, hence maintaining continuity between gluteus medius and vastus lateralis muscles. This prevents proximal migration of the gluteus insertion, and reinsertion to a lateralized proximal piece of the endoprosthesis improves postoperative abduction strength.
To facilitate enhanced decision making, we conducted a retrospective study comparing these two reconstruction methods. At our institution, the method of hemiarthroplasty with long cemented revision stems has been primarily dedicated to patients with adverse oncological prognosis as an alternative technique to the more extensive and complex PFR. This single-institution retrospective study compares medium-term results of these two techniques.
Three hypotheses were postulated:
Hypothesis 1: Because of preservation of pelvic-femoral muscle attachments, patients in the revision hemiarthroplasty group have better functional scores, expedited return to full weight-bearing status, expedited discharge home, and lower need for inpatient rehabilitation.
Hypothesis 2: Patients in the revision hemiarthroplasty group have lower risk of complications due to faster and technically simpler surgery.
Hypothesis 3: Patients in the PFR group have better oncological outcomes and local disease control due to wide resection margins.
Methods
Data from a tertiary center of oncology orthopaedics were analyzed. This is a single-institution, retrospective, observational study. Patients with metastatic disease of proximal femur extending into the subtrochanteric region who had a reconstruction with either a PFR (group A) or reconstruction using a hemiarthroplasty with long revision cemented stem (group B) from 2018 to 2023 were included. Final data collection was in April 2024, with a minimum 4-month follow-up for all included patients.
The reconstruction technique was chosen by the surgical team considering the overall patient prognosis and local disease status. Demographic data, oncologic data (“tumor type,” extent of metastatic involvement), indication parameters (pain, impending fracture, fracture, failure of previous reconstruction, oncological indication), use of adjuvant therapy (embolization, radiation therapy, chemotherapy, biological therapy), and surgical data (surgical time, blood loss, need for postoperative observation in the intensive care unit [ICU]) were recorded. Postoperatively, time to discharge from the hospital and discharge location (home vs. acute rehab) were assessed. The time from index surgery to full weight-bearing status and complications (short term, long term, infectious, and mechanical) was also monitored. Functional outcomes were assessed using the Harris hip score (HHS) and the Musculo-Skeletal Tumor Society (MSTS) functional score. The best score achieved was recorded as the functional status of patients deteriorated with the progression of cancer independently of reconstruction outcome. The extent of metastatic involvement was defined as solitary, oligometastatic (up to three skeletal metastases), and polymetastatic involvement in case of more than three skeletal metastases or if other organ systems were affected.
Inclusion criteria were data completeness and postoperative follow-up at our clinic. To achieve a more uniform cohort, patients with acetabular reconstruction of any kind except for the simple acetabular cup, namely, patients with augmented acetabular plates, revision cups, or Harrington type reconstruction, were excluded given its more complex recovery.16 The end of follow-up was defined as either extraction of the reconstruction or death of the patient. Over the 5-year period from 2018 to 2023, we operated on 92 patients with metastatic disease of the proximal femur. Of these, 23 patients had osteosynthesis reconstruction and 69 patients had endoprosthetic reconstruction. Among these, six patients had standard hip arthroplasty, 31 patients had a PFR, and 32 patients had reconstruction using a LSH. All patients in the LSH group had a 300-mm-length stem implant. Venting of the canal while cementing was not routinely performed. We excluded four patients from the PFR group and one patient from the LSH group. Three patients were excluded due to missing data, one had concurrent spinal surgery, making the data not comparable, and one patient was postoperatively recategorized as a primary bone tumor and no longer met the inclusion criteria for metastatic disease. A total of 27 patients with PFR (group A) and 31 patients with long cemented stems (group B) were included in the study. All patients were followed in our outpatient clinic according to the standard protocol. At each visit, functional status was assessed and standard radiograph was obtained. Failure of the reconstruction was defined as major revision surgery resulting in implant removal or debilitating pain preventing the patient from weight-bearing due to implant failure. Statistical analysis was done with SPSS version 29.0 statistic software package.
Results
In group A (PFR), 11 men and 16 women were included. The average age at the time of surgery was 64.5 years (range, 31 to 78 years, SD, 10.3). The mean follow-up was 16.9 months (range, 0.5 to 63 months, SD, 17.6). At the time of data collection, 10 patients (37.0%) were alive with disease with a mean follow-up of 25.4 months (SD, 21.0) and 17 patients (63.0%) died of the disease with mean follow-up of 11.9 months (SD, 12.9). Eight patients (29.6%) had solitary metastasis, six patients (22.2%) oligometastatic disease, and 13 patients (48.1%) polymetastatic spread. The indication for surgery was pain with weight-bearing in 12 patients (44.4%) and pathological fracture in 15 patients (55.6%). Nine patients (33.3%) had an acetabular implant added to the PFR construct, and 18 patients (66.7%) had bipolar partial arthroplasty type of PFR. The average surgical time was 148.9 minutes (range, 90 to 290 minutes, SD, 46.8), and the average blood loss was 1027.8 mL (300 to 3000 mL, SD, 843.6). Two patients received preoperative tumor embolization. Four patients required transfer to the ICU with delayed weaning from anesthesia. Five patients reported with postoperative complications. One patient required revision surgery due to postoperative bleeding, one patient had an implant dislocation that was reduced without surgery, and three patients developed deep infections that required additional surgeries. All patients retained their implant. No cases of local disease progression were reported in this group. Average time to discharge from the hospital was 17 days (range, 7 to 64 days, SD, 12.1). Ten patients (37.0%) were discharged to acute rehabilitation centers at an average of 13.2 days after surgery, and 17 patients (63.0%) were discharged home at average of 19.4 days from surgery. The mean maximal MSTS score in this group was 19/30 (range, 8 to 27, SD, 5.2), and mean HHS was 66.2% (range 33% to 87%, SD, 16.7). All patients were ambulatory; although, nine were never able to fully weight-bear. Nine patients walked without support, and 19 patients required some form of walking aid most of the time. The average time to full weight-bearing was 11.5 weeks (range, 6 to 20 weeks, SD, 4.4).
In group B (LSH), there were nine men and 22 women with a mean age of 66.9 years (range, 32 to 88 years, SD, 13.3). The mean follow-up was 14.9 months (range, 3 to 51 months, SD, 13.4). At the time of data collection, 10 patients (32.3%) were alive with disease with a mean follow-up of 16.8 months (SD, 15.8), 19 patients (61.3%) died of the disease with a mean follow-up of 12.5 months (SD, 9.8), and two patients (6.5%) were alive with no evidence of disease, due to a good response to systemic treatment, with a mean follow-up of 29 months (SD, 19). Five patients (16.1%) had oligometastatic disease at the time of diagnosis, and 26 patients (83.9%) had poly-metastatic spread. No patients with solitary metastasis were observed in group B. The indication for surgery was pain with weight-bearing in four patients, failed prior nail-osteosynthesis in three patients and pathologic fracture in 24 patients. Ten patients had augmented reconstruction, mostly with osteosynthesis using an Locking Compression Plate (LCP) plate (Figure 3). Three patients (9.7%) had acetabular components; all others had partial replacements using a bipolar implant (90.3%). The average surgical time was 116.6 minutes (range, 60 to 190 minutes, SD, 26.7) and the average blood loss was 812.9 mL (100 to 2500 mL, SD, 491.9). No patient received preoperative tumor embolization. All patients were transferred to the standard postoperative unit. None required transfer to the ICU with delayed extubation. No postoperative complications were observed in this group. No cases of deep infection, implant dislocations, or mechanical failures occurred. Local disease progression was noted in seven cases (22.6%), but none had implant loosening (Figure 4).
Figure 3.
Radiographs of 52-year-old woman with metastatic breast cancer (left) and 59-year-old man with metastatic bronchogenic carcinoma. Both patients suffered a pathological fracture of the proximal femur and were treated with revision stem hemiarthroplasty with concomitant plate osteosynthesis.
Figure 4.
Radiographs of 73-year-old woman with metastatic follicular thyroid carcinoma. The patient had a notable local disease progression despite adjuvant radiation therapy. Patient died of disease at 28 months of follow-up without loosening of the implant and was able to ambulate without pain until her demise.
The average time to discharge was 9.4 days (range, 3 to 19 days, SD, 3.3). Seven patients (22.6%) were discharged to acute rehabilitation at an average of 9.2 days, and 24 patients (77.4%) were discharged home at an average of 9.7 days from surgery. The mean maximal MSTS score in this group was 24/30 (range, 15 to 30, SD, 3.9), and the mean HHS was 82.2% (range, 49% to 100%, SD, 12.3). All patients were ambulatory, six of them required walking aid device at all times, and two additional patients used a cane only for long walks. Average time to full weight-bearing, when allowed, was 6.2 weeks (range, 2 to 17 weeks, SD, 2.9).
Group Comparison
The comparative analysis of the two groups did not find statistically significant differences in terms of demographic variables (age P = 0.2, sex P = 0.4), and the two groups were comparable regarding those variables (Table 1). Group A (PFR) had a higher number of solitary metastatic lesions (P = 0.002). The local disease control was markedly higher in the PFR group (100% vs. 22%, P = 0.01); however, the oncological prognosis did not prove to be better for this group. To compare survival among both groups, a Kaplan-Meier analysis (Figure 5) was done and achieved no statistical significance (P = 0.08). Moreover, group A had higher estimated blood loss (EBL) than group B, and this was also statistically significant (1027.8 vs. 491.9 mL, P = 0.007). Surgical time on group A was higher (148.9 vs. 116.6 minutes), and this also achieved statistical significance (P = 0.04). More patients required intense care unit transfer in group A (P = 0.04). Average time to full weight-bearing, when that was possible, was shorter in patients in group B (6.2 vs. 11.5 weeks), and this was statistically significant (P = 0.03). In addition, time to discharge was shorter for group B when compared with group A (9.4 vs. 17.0 days), which was statistically significant (P = 0.04). Group A had more postoperative complications (n = 5, 18.5% vs. n = 0, 0%), (P = 0.02). When comparing patients' functional outcomes, patients in group B had higher MSTS score (24 vs. 19); however, this difference was not notable (P = 0.2). A similar difference was noted when comparing the HHS, and this outcome was higher in group B (82.2 vs. 66.2); however, it also did not achieve statistical significance (P = 0.8; Table 2).
Table 1.
Patient Demographic and Oncologic Variables
| Factor or Variable | Group A (N = 27) | Group B (N = 31) | P Value |
| Age in years | 64.5 (31-78, SD 10.3) | 66.9 (32-88, SD 13.3) | 0.2 |
| Sex | 11 M: 16 F | 9 M: 22 F | 0.4 |
| Disease | 0.002 | ||
| Solitary metastasis | 8 (29.6%) | 0 (0%) | |
| Oligometastatic | 6 (22.2%) | 5 (16.1%) | |
| Polymetastatic | 13 (48.1%) | 26 (83.9%) | |
| Follow-up time in months | 16.9 (0.5-63, SD 17.6) | 14.9 (3-51, SD 13.4) | |
| Oncologic outcome | 1.0 | ||
| Died of disease | 17 (63.0%) | 19 (61.3%) | |
| Alive | 10 (37.0%) | 12 (38.7%) |
Bolded values indicate statistical significance at p < 0.05
Figure 5.
Kaplan-Mayer analysis demonstrating no statistical difference among the groups (group A: red, group B: blue).
Table 2.
Groups' Outcomes Comparison
| Factor or Variable | Group A (N = 27) | Group B (N = 31) | P Value |
| EBL in mL | 1027.8 (300-3000, SD, 843.6) | 812.9 (100-2500, SD, 491.9) | 0.007 |
| Surgical time in minutes | 148.9 (90-290, SD, 46.8) | 116.6 (60-190, SD, 26.7) | 0.04 |
| Postoperative ICU | 4 (14.8%) | 0 (0%) | 0.04 |
| Postoperative complications | 5 (18.5%) | 0 (0%) | 0.02 |
| Local disease progression | 0 (0%) | 7 (22.5%) | 0.01 |
| Time to discharge | 17 (7-64, SD, 12.1) | 9.4 (3-19, SD, 3.3) | 0.04 |
| Acute rehabilitation facility | 10 (37.0%) | 7 (22.6%) | 0.3 |
| Full weight-bearing | 18 (66.7%) | 29 (93.5%) | 0.02 |
| Time to full weight-bearing | 11.5 (6-20, SD, 4.4) | 6.5 (2-17, SD, 2.9) | 0.03 |
| Walking assistive devices | 19 (70.4%) | 8 (25.8%) | 0.001 |
| MSTS score | 19/30 (8-27, SD, 5.2) | 24/30 (15-30, SD, 3.9) | 0.2 |
| HHS | 66.2% (33-87, SD, 16.7) | 82.2% (49-100, SD, 12.3) | 0.8 |
EBL = estimated blood loss, HHS = Harris hip score, ICU = intensive care unit, MSTS = Musculoskeletal Tumor Society
Bolded values indicate statistical significance at p < 0.05
Discussion
This study has several limitations. It is a retrospective observational study and was not randomized. There is potential for surgeon's decision, regarding the type of reconstruction, to have been influenced by personal selection bias, and the results should be analyzed under this light. This being a retrospective study, the surgeon made the decision regarding the best reconstruction alternative for the patient based on personal experience, the patient's clinical scenario, and his best assessment of the patient's oncological prognosis at the time. This fact highlights the current lack of strong evidence to ease and standardize decision making in such circumstances. In addition, the groups included patients with a range of primary tumor histologies, and because of the small sample size and heterogeneity of diagnoses, the study was not powered to allow for meaningful oncologic comparisons between the groups. The follow-up period is short, and our sample size is relatively small. The strength of our findings is limited to the association between the groups and results but not causation. However, the set follow-up time was sufficient to address the main focus of this study, which was the association with faster recovery of the patients in the revision hemiarthroplasty group. One of strengths of this study is that it was conducted in a tertiary tumor center as single-institution study; therefore, there is no bias regarding different postoperative protocols. Furthermore, all surgeries were performed by the institution's senior surgeons with homogenous surgical protocols for patients in each group, making the results comparable from a surgical protocol standpoint.
Our study found that, for patients undergoing reconstruction for metastatic lesion of the proximal femur, long revision stem hemiarthroplasty presented an association with better performance during surgery (EBL, surgical time), in the immediate postoperative period (less need for ICU care, shorter hospital admission), and during recovery (shorter time to Weight Bearing (WB), less need for walking aid devices) when compared with the more complex PFR. Nonetheless, ultimately, it will be up to the treating surgeon to consider the reconstruction alternative and its clinical appropriateness for each individualized patient.
Hypotheses #1 and #2 were confirmed; although from an associative standpoint and not as in a causation relationship, whereas we were unable to prove hypothesis #3. Patients in the revision stem hemiarthroplasty group presented an association with a shorter hospital stay and shorter time to full weight-bearing compared with those who had a PFR. The same was not true in terms of functional scores, where the difference between the two groups did not achieve statistical significance. This can potentially be attributed to the fact that despite a slower recovery, patients with PFR caught up in function with patients in the other group over time. Patients in whom pelvic-femoral muscles were preserved during the surgery achieved slightly better in terms of functional scores; however, this association was not notable. This is useful information that can aid in surgical decision making, especially for patients with an expected short survival. Patients in both groups had an association with satisfactory overall function and pain relief. The functional results are similar to previously reported literature. Peterson et al25 achieved an average MSTS score of 27 (range, 21 to 30) in a group of long stem hemiarthroplasty for proximal femoral metastasis. Angelini et al26 reports an average MSTS score of 22 for patients with PFR.
Patients who underwent PFR had an association with higher rate of postoperative complications, as well as a worse immediate outcome with more patients requiring ICU transfer. The latter finding can be connected to the fact that those patients were in the operating room longer and had higher blood loss. The higher incidence of complications in the group of PFR is comparable to prior literature. Angelini reports an overall 22.5% complication rate for PFR, with dislocation and infection being the most frequent adverse outcomes.26
Despite having more patients with solitary metastasis in the PFR group (29.6% vs. 0%) and better local control of the disease (100% vs. 22.6%), the oncological prognosis did not prove to be better for this group. Therefore, our third hypothesis was only partially true, and this may be attributed to different factors. With the advancement in the biological treatment of cancer, it has become more difficult to estimate correct patient prognosis. Patients with a good response to oncological treatment do markedly better regardless of the type of surgery. This was confirmed also by Angelini et al,26 who found no difference in terms of survival between patients with impending versus actual pathological fracture and patients with oligo versus multiple metastases. Kendal et al27 reported average survivorship of patients with PFR for metastatic disease of 19.4 months, which is comparable to our data.
There are certainly indications where PFR is a better reconstruction option. This is particularly true for patients with excellent oncological prognosis and a solitary lesion.21,22,28,29 In addition, certain primary cancer diagnoses may show a survival benefit from resecting solitary lesions, for example, renal cell carcinoma and melanoma.20,30 Assessing a patient's prognosis can be challenging, and various prognostic models have been proposed31 to ease this task, although, such predictive factors should be evaluated carefully. In addition, large masses, as shown in this illustrative case not included in our study, can be unsuitable for the revision stem hemiarthroplasty technique (Figure 6). However, for patients with guarded prognosis and anticipated prolonged survival, long stem revision prosthesis can be a better option. A revision stem hemiarthroplasty in our study was associated with faster functional recovery, a lower incidence of complications, and a faster discharge home. A meaningful benefit for patients who require noninterrupted oncological treatment due to multiple lesions where the prognosis is determined more by systemic therapy than by local treatment. Long revision stems and cemented stems of PFR may pose a problem in case of consecutive metastasis in the distal femur. However, the incidence of such event is extremely rare and accounts for only 1.5% of cases.32 The treatment of subsequent distal femur metastases is easier in cases when plate osteosynthesis of proximal femur metastasis was performed. However, the reported failure rate of this method can be as high as 42.1%15 and is therefore not justifiable. Typically, consecutive distant metastasis is treated by osteosynthesis using periprosthetic plates. A second option would be to convert the initial construct to a total femur replacement, a complex surgery not free of complications. Last but not least, although not the focus of our study, it is worth mentioning that there is also a role for a standard-length stem hemiarthroplasty in selected patients with a more contained metastatic lesion in the proximal femur, certain solitary secondary lesions or in treatment-responsive cancers.32,33 In short, we can find in the average oncology orthopaedics practice population several patients where the indications for both types of reconstruction overlap. The results of this study come in handy for the surgeon attempting to decide between one alternative versus the other, contraposing the possibility of a treatment option associated with an expeditious recovery with a risk of disease progression on a long-term survivor versus a more complex procedure with associated worse outcome but with the potential benefit of better local disease control.
Figure 6.
Radiographs of 66-year-old woman with metastatic renal cell carcinoma with voluminous metastasis after unplanned nail 14 months before referral to our center. Wide resection with proximal femur replacement was performed with good results. Illustrative case demonstrating the fate of some intramedullary nails, this patient was not included in our analysis cohort.
Conclusion
In conclusion, in patients with metastatic disease of the proximal femur, reconstruction with a long revision stem hemiarthroplasty was associated with improved performance regarding surgical outcomes (EBL, surgical time, transfer to ICU vs. regular floor), when compared with PFRs. Furthermore, patients with hemiarthroplasties demonstrated an association with better function, a shorter rehabilitation time, and less complications. Oncology orthopaedic surgeons should have these considerations in mind when presented with patients suitable for either reconstruction alternatives; however, the surgeon should ultimately make the decision based on experience and assessment of each patient's clinical scenario.
Footnotes
None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Lesensky, Dr. Blecha, Dr. Vcelak, and Dr. Belzarena.
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