The palliative role of orthopaedics

Palliative care for patients with cancer is well established and provides important benefits. Orthopaedic interventions in terminal care are, however, underused in the United Kingdom, despite the fact that conditions that are amenable to orthopaedic intervention occur often in the terminal stages of cancer. Though the evidence base for many orthopaedic palliative interventions is not strong, since there are no trials, clinical experience and expert consensus opinion¹ suggest that such interventions can ease the pain and comfort of terminally ill cancer patients with pathological fractures and other musculoskeletal effects of malignancy.

About 9000 breast cancer patients develop metastatic bone disease each year in the UK.¹ O'Donoghue et al showed that referral to an orthopaedic surgeon is requested in less than half of these patients.² Orthopaedic input into the management of breast cancer occurs in some parts of the UK but is not national practice, and the same applies to other cancers.

Several indications justify orthopaedic intervention. The most relevant is pain. Pain is commonly related to the presence of pathological fractures and malignancies that cause mechanical instability, but pain secondary to myelopathy and radiculopathy from spinal disease and the “functional pain” of patients with malignancy of limb bones may also benefit from surgery. Indeed, any severe pain refractory to non-surgical treatment requires surgical consideration. Functional compromise, in particular difficulty with mobilisation, and neurological compromise such as paraplegia, paraesthesia, or sphincter disturbance are other indications.

Pathological fractures are an obvious indication for orthopaedic surgery. In terminally ill patients the aim in fixing the fracture differs from that in patients with traumatic fractures. In such patients the primary tumour diagnosis is already known and tissue diagnosis is not usually needed. Bone healing in these lesions is impaired and often the bones do not unite. The fracture therefore needs to be fixed by a method that focuses on forming a strong, permanent, stable construct that can allow an immediate return to normal function and that will last the life of the patient, rather than using a method that focuses on fracture healing. A study by Gainor et al of 129 pathological fractures secondary to bone metastasis in 123 patients showed that several factors were associated with rates of bone healing.³ Bone healing varied according to survival (74% bone healing rate in patients with a survival of six months or more) and the type of cancer (67% bone healing in multiple myeloma, 44% in hypernephroma, 37% in breast cancer, and 0% in lung cancer). The study also showed that a total radiotherapy dose of 3000 rad or less did not inhibit callus formation and that internal fixation improved the rate of fracture union by 23% compared with cast immobilisation.

All patients with pathological fractures should be considered for surgery and can be surgically managed in several different ways. When plates, screws, or intramedullary rods are contraindicated then resection of tumour may be followed by reconstruction using an endoprosthesis to replace a whole segment of bone and if necessary an adjacent joint. Cement can be used to good effect in combination with an endoprosthesis. It fills gaps from debulking of large tumours, adds mechanical stability, and through its exothermic reaction may help minimise tumour cell contamination and haemostasis.

Some malignant bone lesions cause symptoms in the absence of a fracture but may cause a fracture in the future. Generally metastases in long bones progress to fractures in about 25% of cases (about 60% if located in the proximal femur).⁴ The extra pain, loss of function, and more hazardous surgery of a fracture argue for performing surgery before the fracture occurs, and there is evidence that outcomes for surgical management of impending pathological fractures are better than for actual fractures. Ward et al compared outcomes for the treatment of 97 impending versus 85 actual pathological fractures.⁵ They showed better outcomes in patients with impending fractures for perioperative blood loss (438 v 636 ml), shorter hospital stay (7 v 11 days), greater likelihood of discharge home instead of to extended care (79% v 56%), and greater likelihood of resuming support-free ambulation (35% v 12%). Orthopaedic surgeons often use Mirel's scoring system for deciding whether to operate on impending fractures.⁶ This scores the risk of fracture on the basis of site (arms, legs, or peritrochanteric), the amount of pain, the type of lesion (blastic, mixed, lytic), and the extent of destruction of the cortex seen on radiographs. Generally a score of 9 or more indicates the need for surgery, though clinical judgment is a more accurate predictor of fracture risk.

In spinal metastasis the principal palliative aims are to reduce or eliminate pain, recover and sustain patients' ambulation, and achieve continence. Surgical goals also include providing fixation to last the lifetime of the patient. Spinal cord function is maintained by decompressing neural structures, debulking tumour mass, stabilisation to allow weight bearing, and realignment of spinal deformity. Several studies have reported significant improvements in patients' symptoms. For example, in a series of 100 patients described by Onimus et al 96 presented with pain, 50 couldn't walk, and 38 had neurological deficits. After surgery 62 patients left hospital without the need for analgesics, 35 regained their ability to walk, and 30 had improved neurological status.⁷

Survival rates of patients with metastatic bone disease continue to increase owing to advances in radiotherapy and chemotherapy. Orthopaedic interventions can provide these patients with the best achievable remaining quality of life.