ORTHOPAEDIC ONCOLOGY

Surgical management of Incidence of bone metastases by primary cancer at post

mortem and using radio-isotope bone scanning1,2
skeletal metastases of the Cancer Post-mortem incidence Incidence of bone metastases

appendicular skeleton of bone metastases (%)1 on bone scanning (%)2

Breast 73 32.7
John Taylor Prostate 68 40.6
Amit Kumar Thyroid 42 e
Renal 35 e
Lung 36 62.5
Abstract GI 5 38.5
Skeletal metastases are a common cause of morbidity in cancer pa-
Table 1
tients through bone pain, pathological fracture and spinal cord
compression. With advances in surgical and medical treatment, and
a multidisciplinary approach, the outcome and survival for these pa- advances in medical therapy including hormonal treatment,
tients has improved in recent years. The orthopaedic surgeon should bisphosphonates, chemotherapy, and biologically targeted agents
be an integral part of the multidisciplinary team who provide high qual- (Table 3).4
ity treatment to these patients to optimize outcome. They should be Although patients with skeletal metastases are commonly
aware of the particular needs of these patients and the range of surgi- encountered there is a lack of awareness in the primary and
cal and non-surgical treatments available. This article outlines the pre- secondary care settings of what can be achieved with operative
sentation, diagnosis and surgical management of patients with and non-operative treatment. Up to date guidelines on the
skeletal metastases. It summarizes the relevant best practice guide- management of skeletal metastases published by the British Or-
lines applicable to surgeons working in the UK but with worldwide thopaedic Oncology Society and British Orthopaedic Association
relevance. should be consulted to improve patient outcomes.5 There is a
need to highlight the possible positive outcomes of surgical
Keywords bone; fracture; metastases; multidisciplinary; surgery
intervention even in patients with advanced cancer.

Introduction Involvement of the orthopaedic surgeon

Over the last decade, incidence rates for all cancers combined Patients with skeletal metastases present in a variety of ways
have increased by 7% in the UK.1 At the same time cancer sur- either with acute admission with a pathological fracture or spinal
vival is improving and has doubled in the last 40 years.1 Skeletal cord compression, via referral from the oncology team, or via
metastases can occur in any cancer but most commonly in referral to an orthopaedic clinic with musculoskeletal pain. Dis-
breast, prostate, renal, lung, multiple myeloma, and thyroid covery of skeletal metastasis can be the first manifestation of
carcinomas. Accurate incidence is difficult to determine, but malignancy.
post-mortem studies have shown the presence of skeletal The orthopaedic surgeon can play one of four roles; to:
metastasis in 73% of patients with breast cancer and 68% of
establish the diagnosis of a skeletal metastasis
patients with prostate cancer.2 Table 1 shows the incidence of
treat skeletal metastasis surgically to reduce pain and/or
skeletal metastases by cancer type in post-mortem and radio- prevent fracture
isotope bone scan studies.2,3 Skeletal metastases are most com-
mon in the axial skeleton in particular the spine (Table 2).3 Adapted from Kakhki et al. Frequency of anatomical
The prognosis varies according to site of primary cancer. distribution of bone metastases in 160 patients with
Survival time from diagnosis of bone metastases in prostate prostate, breast, gastrointestinal, and lung cancers
cancer or breast cancer is measurable in years in contrast to undergoing bone scan2
advanced lung cancer where it is typically measured in months.
Anatomical site Frequency of bone metastases (%)
In recent years the prognosis for many patients with metastatic
bone disease has significantly improved principally due to Spine 30 (18.8%)
Ribs 23 (14.4%)
Pelvis 15 (9.4%)
Sternum 12 (7.5%)
John Taylor MBChB MRCS Specialty Doctor in Trauma and Femur 8 (5%)
Orthopaedics, Greater Manchester and Oswestry Sarcoma Service, Scapula 6 (3.8%)
Central Manchester NHS Trust, Manchester Royal Inrmary, Skull 6 (3.8%)
Manchester, UK. Conicts of interest: none declared. Humerus 3 (1.9%)
Amit Kumar BSc(Hons) MBBS FRCS Ed (Tr&Orth) Consultant Orthopaedic Clavicle 2 (1.3%)
Surgeon, Greater Manchester and Oswestry Sarcoma Service, Tibia and fibula 1 (0.6%)
Central Manchester NHS Trust, Manchester Royal Inrmary,
Manchester, UK. Conicts of interest: none declared. Table 2

ORTHOPAEDICS AND TRAUMA --:- 1 Crown Copyright 2017 Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Taylor J, Kumar A, Surgical management of skeletal metastases of the appendicular skeleton, Orthopaedics and
Trauma (2017), http://dx.doi.org/10.1016/j.mporth.2017.03.007
 ORTHOPAEDIC ONCOLOGY
Mirels scoring system for predicting risk of pathological
fracture. Prophylactic fixation is recommended with a
score of 9 or above10
Score 1 2 3 lesion. This approach will avoid the risk of dissemination by the
Site Upper limb Lower limb Pertrochanteric
Pain Mild Moderate Functional
Lesion Blastic Mixed Lytic
Sizea <1/3 1/3 >2/3
a
As seen on plain radiograph, maximum destruction of cortex in any view.
Table 3

stabilize or reconstruct a bone following pathological
fracture and restore function

decompress the spinal cord and/or stabilize the spine.
The orthopaedic surgeon forms part of a multidisciplinary
team required to give the best care to patients with metastatic
bone disease including oncologists, radiologists, histopatholo-
gists, and specialist cancer nurses. In addition national guidelines
advise that each hospital trust should have a designated lead
orthopaedic surgeon for appendicular metastatic bone disease
who can advise on management of patients requiring surgical
intervention.5 The designated metastatic bone disease lead
should be adequately trained in diagnosing, investigating and co-
ordinating the care of patients with metastatic bone disease and
have a network of appropriate contacts in regional and supra-
regional centres where advice on complex cases can be sought.5
Diagnosis
Appropriate investigations should be carried out to establish
diagnosis, staging, and prognosis. This will allow a decision to be
made as to whether surgery is indicated and what particular sur-
gical intervention is most appropriate. There should be no rush to
intervene surgically even in the case of pathological fracture.
Pathological fractures are mostly low energy with minimal soft
tissue injury and patients are often more comfortable once limb
immobilization and good analgesia have been provided.
Any patient presenting to an orthopaedic surgeon with a new
diagnosis of skeletal metastasis should be assessed with a full
clinical history and examination and an extensive array of in-
vestigations. These should include full blood count, renal, liver
and bone profiles, erythrocyte sedimentation rate, C-reactive
protein, tumour markers and myeloma screen. Radiological in-
vestigations should include plain radiographs and MRI scan of
the lesion to differentiate the lesion, assess size, and to assess the
extent of bony and soft tissue invasion. CT of the chest abdomen
and pelvis, and isotope bone scan should also be undertaken to
assess for a primary tumour, to assess the number and distri-
bution of other skeletal metastasis, and to assess the extent of
visceral metastasis.
Role of biopsy
If a patient presents with skeletal metastasis in a previously
diagnosed disseminated malignancy then biopsy is not necessary
prior to surgical intervention. However if there is any doubt
about the underlying pathology, for example when a patient
ORTHOPAEDICS AND TRAUMA --:-
Please cite this article in press as: Taylor J, Kumar A, Surgical management of skeletal metastases of the appendicular skeleton, Orthopaedics and
Trauma (2017), http://dx.doi.org/10.1016/j.mporth.2017.03.007
presents with an isolated metastasis some time after curative
treatment of a previously diagnosed carcinoma then biopsy is
indicated. In addition biopsy is essential to establish a tissue
diagnosis in the first presentation of a patient with a solitary bone
undertaking of inappropriate surgery.
Bone biopsies are usually performed percutaneously with
image guidance by an adequately trained practitioner, following
discussion with the surgical team or radiologists to avoid inap-
propriate biopsy tracts. The principles of biopsy must also be
considered including:

longitudinal incision

confined to a single compartment

haemostasis and drain if required

no penetration of neurovascular structures

exiting within the line of potential surgical incision.
Indications and aims for surgery
The orthopaedic surgeon should have an in depth discussion
with the patient and family including what surgery involves, the
perceived benefits and the perceived potential risks and com-
plications. The orthopaedic surgeon should also consult with
members of the multidisciplinary team including the treating
oncologist regarding the appropriateness of a surgical interven-
tion, the timing of the intervention and if non-surgical oncologic
treatment would be preferable. This is particularly important in
patients with poor performance status and life expectancy. It has
been recommended that surgery should only be undertaken if life
expectancy is at least 1 month for a weight bearing bone and 3
months for a non-weight bearing bone.6
Indications for surgical intervention fall broadly into two
categories, to:

improve survival

alleviate symptoms and improve quality of life.
There is some evidence that appropriate and timely surgical
treatment of metastatic bone disease can improve survival.7 This
is more likely in patients with better prognosis such as those with
breast and renal cancers particularly with a solitary bone
metastasis. In these cases endo-prosthetic replacement may be an
appropriate surgical option.5
Where surgery is not curative, the role of surgery is to relieve
pain and to maintain or restore mobility, function, and quality of
life. Surgery should be undertaken prophylactically in patients
with a significant risk of pathological fracture as this can be
planned and is associated with less risk of complications, shorter
operative time, and shorter hospital stay.8 Non-surgical treat-
ment should be considered as an alternative and/or adjunct to
surgical intervention.
Pathological fracture risk assessment
A sudden increase in pain in an area of known metastasis should
alert the patient and surgeon as to a potentially impending
fracture. The presence of functional pain is thought to be the
most important indication of an impending pathological frac-
ture.6 Classical criteria attributed to Harrington that suggest a
high risk of impending pathological fracture are:9

cortical bone destruction greater than 50%

a lesion of more than 2.5 cm in the proximal femur
2 Crown Copyright 2017 Published by Elsevier Ltd. All rights reserved.
 ORTHOPAEDIC ONCOLOGY

a pathological avulsion fracture of the lesser trochanter

persisting stress pain despite irradiation.
Table 1 shows Mirels scoring system for assessing fracture
risk in metastatic bone disease and Table 2 shows his recom-
mendations.10 Mirels retrospectively studied 78 irradiated bone
lesions in 38 patients to develop a system for quantifying the risk
of pathological fracture through a metastatic lesion in a long
bone. Unlike all the previous studies, Mirels combined four
different features of bone lesions in an attempt to create a more
reliable risk assessment. He recommended prophylactic fixation
in lesions with a score of 9 or more which equated to a rate of
fracture of at least 33%.10 He also studied each variable inde-
pendently and found the rate of fracture was 81% for lesions
occupying more than two-thirds of the cortex, and 100% for
patients with functional pain.10
In addition to full length radiographs in two views (including
the joint above and below), further imaging, typically with CT
should be used to evaluate the bone lesion further in particular
the degree of cortical destruction.
Scoring systems and imaging studies should be used in
conjunction with the clinical assessment. The patients prog-
nosis, fitness for surgery, the demands of the patient, the effec-
tiveness and availability of conservative options should all be
taken into account.
Principles underlying the management of pathological
fracture management
C A primary bone tumour should be excluded
C The procedure should provide immediate absolute stability
allowing weight bearing
C The surgeon must assume that the fracture will not unite
C The fixation should last the lifetime of the patient
C All lesions in the affected bone should be stabilized if reasonable
to do so
C Treatments should, where possible, be appropriate for the stage
of disease and general condition of the patient and should reflect
their preferences for treatment
Pre-operative assessment
A holistic approach should be taken to preparing the patient for
what is a major event. A full medical history and clinical ex-
amination should be undertaken and all co-morbidities should be
optimized. This should pay particular attention to nutritional
state, respiratory complications of malignancy, and pulmonary
and cardiac toxicity secondary to chemotherapy agents. A full
blood count and clotting screen should be taken to assess for
bone marrow dysfunction. Electrolyte imbalanced in particular
hypercalcaemia should be assessed and if possible corrected
prior to surgery with input from a physician.
Early anaesthetic assessment is essential to consider periop-
erative management, vascular access and the need for post-
operative critical care.
Patients with primary renal and thyroid carcinoma should be
considered for pre-operative embolization, performed less than
ORTHOPAEDICS AND TRAUMA --:-
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Trauma (2017), http://dx.doi.org/10.1016/j.mporth.2017.03.007
48 h prior to surgery.5 This is effective in reducing operative
time, blood loss and packed cell transfusion volume.11
Patients undergoing surgery for metastatic cancer, especially
when affecting the lower limb, are at significant increased risk of
thromboembolic events.12 Early mobilization and chemical and
mechanical prophylaxis should be considered for all patients.
Surgical treatment e appendicular skeleton
The choice of surgical implant and technique depends on a range
of factors and should be made on a case by case basis. In general
the options are either to replace bone or to support it by internal
fixation with intra-medullary nails or plates and screws
augmented with cement.
Internal fixation: as the metastatic lesions are likely to progress
and pathological fractures are likely not to heal, load bearing
devices such as peri-articular locking plates should be consid-
ered. Bone defects can be filled with cement to increase strength
and therefore improve pain and function and prevent implant
failure. Post-operative radiotherapy to the affected bone and
operative field should be considered in all patients. Although
internal fixation is often quicker, cheaper, with less blood loss,
there is a relatively high failure rate due to implant failure or peri-
prosthetic fracture requiring re-operation.
Endoprosthetic surgery: modular endoprostheses are princi-
pally used in the management of primary bone tumours but are
increasingly used in treating skeletal metastasis. They have been
shown to be effective in restoring function, with a low failure and
re-operation rate.13 They are often the only option for recon-
struction in cases of extensive bony destruction. Other in-
dications are isolated metastasis from a primary tumour with a
good prognosis, low volume disease, and poor response to non-
surgical treatment. The procedure is more complex, and requires
more operative expertise and experience. Although more
expensive this operative cost needs to be balanced against the
savings to the wider health community in caring for the patient.
Amputation: amputation may be an option for unresectable tu-
mours, for example tumours encasing neurovascular structures,
or fungating tumours. It can provide reliable pain relief in a
single operation and can allow good mobility and quality of life.
Lower limb
Proximal femur: approximately one-third of bony metastases
occur in the proximal femur and risk of pathological fracture is
higher than in other locations. Even amongst specialist tumour
surgeons there are differing opinions as to the best way to
manage metastases of the proximal femur. Prognosis, site of
tumour within the bone and extent of bone loss determine the
appropriate management. Several studies have demonstrated
greater durability and lower re-operation rates in the proximal
femur with endoprosthetic replacement compared with osteo-
synthesis (Figure 1a and b).14
Femoral head and neck: isolated lesions affecting the femoral
head and/or neck should be treated with cemented hemi-
arthroplasty or cemented total hip replacement. Long stem
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 ORTHOPAEDIC ONCOLOGY
prostheses should be considered where more distal lesions are
present.
Pertrochanteric: if prognosis is poor (e.g. less than 6 months), a
patient is unable to tolerate a lengthy procedure and there is
sufficient bone stock then internal fixation augmented with
cement may be appropriate. Proximal femoral replacement
should be considered in patients with good prognosis or where
there is extensive bone loss.
Subtrochanteric: metastatic deposits at this site are amongst
the most frequent causes of implant failure. Again, endopros-
thetic replacement should be considered in patients with good
Figure 1 (a) Osteolytic metastasis of the proximal femur in a female
with metastatic breast cancer. (b) Endoprosthetic replacement resec-
tion of proximal femur metastases.
ORTHOPAEDICS AND TRAUMA --:-
Please cite this article in press as: Taylor J, Kumar A, Surgical management of skeletal metastases of the appendicular skeleton, Orthopaedics and
Trauma (2017), http://dx.doi.org/10.1016/j.mporth.2017.03.007
prognosis and those with extensive bone loss. Other patients
may be managed with internal fixation in the form of cephalo-
medullary nailing (spanning the full length of femur). Sliding
hip screws should be avoided due to high failure rates
(Figure 2a and b).
Femur and tibial diaphysis: in solitary metastasis or in the
presence of massive bone loss, endoprosthetic replacement
should be considered, otherwise intramedullary nailing is usually
the procedure of choice. With multiple metastases the potential
spread of tumour cells within the medullary cavity is acceptable
within the context of palliative care. The nail should span the full
length of the bone to stabilize all metastatic lesions and reduce
Figure 2 Cephalomedullary nail used to treat long bone renal cell
carcinoma metastases, later supplemented with curettage and cement
due to ongoing pain.
4 Crown Copyright 2017 Published by Elsevier Ltd. All rights reserved.
 ORTHOPAEDIC ONCOLOGY
the requirement for further surgery. In the femur cephalo-med-
ullary nails are recommended to stabilize the femoral neck.
Proximal and distal locking screws should be used to prevent
telescoping and provide rotational stability, and large diameter
solid nails should be considered. Where present, major bone
defects can be packed with bone cement to maintain stability.
When post-operative radiotherapy is considered the entire bone
and operative field should be included.
Distal femur and proximal tibia: in most cases, fixation with an
anatomically contoured locking plate augmented with cement is
the treatment of choice. Again if prognosis is good or there is
massive bone loss that precludes fixation then distal femoral
replacement should be considered.
Distal tibia: surgical management in this area is very challenging
due to high risk of operative complications. Where possible
surgery in the form of locking plate fixation with cement
augmentation should be considered. In other cases non-operative
management in the form of radiotherapy or medical therapy,
with plaster or boot stabilization may be more appropriate. In
patients with significant bone loss and severe symptoms ampu-
tation may be most appropriate.
Upper limb
In the upper limb risk of pathological fracture is lower and where
pain is minimal and loss of function is tolerated many patients can
be treated non-operatively for example with functional bracing and
radiotherapy. This may also be preferred in patients where frac-
tures may heal for example in fractures associated with multiple
myeloma. Where surgical management is preferred the construct
must be durable and provide significant stability and function
should be optimized by attempting to preserve the rotator cuff.
Scapula and clavicle: metastatic lesions within the shoulder
girdle are usually managed non-operatively with radiotherapy
and medical therapy.
Proximal humerus: in patients with metastatic lesions affecting
the humeral head or where there is significant bone loss
arthroplasty is preferred. This is traditionally with hemi-
arthroplasty or proximal humeral replacement, although reverse
polarity shoulder replacement, where appropriate, may give su-
perior function. In other patients with sufficient bone stock,
fixation with cement augmented locking plates give good sta-
bility and function.
Humeral shaft: in patients with solitary bone lesions and good
prognosis endoprosthetic replacement should be considered.
Where there is a large bone defect fixation with cement
augmented extended metaphyseal locking plate can provide good
stability and durability. In patients with poor prognosis, multiple
metastases and good bone stock intramedullary nailing is the
treatment of choice.
Distal humerus: metastatic lesions affecting the distal humerus
pose a significant challenge. In most cases fixation with peri-
articular locking plates with cement augmentation is preferred. In
some cases humeral or elbow replacement may be required.
ORTHOPAEDICS AND TRAUMA --:-
Please cite this article in press as: Taylor J, Kumar A, Surgical management of skeletal metastases of the appendicular skeleton, Orthopaedics and
Trauma (2017), http://dx.doi.org/10.1016/j.mporth.2017.03.007
Forearm: in the vast majority of cases cement augmented plate
fixation is appropriate.
Pelvis
This is a common site for metastatic disease, symptoms can be
minimal until significant bone loss has occurred, and the entire
pelvis can often be involved. Due to its central role in weight
bearing and mobility, disease affecting the acetabulum can often
have a significant impact on mobility, independence and quality
of life. Pelvic disease not involving the acetabulum is usually
treated by radiotherapy alone. However this can give rise to ra-
diation necrosis of the femoral head and/or articular cartilage
with may cause significant hip pain.
Pre-operative assessment for acetabular lesions: pre-operative
imaging in the form of CT plus MRI is essential to assess the extent
of disease and adequately plan the reconstructive surgery. Po-
tential high blood loss should be anticipated and pre-operative
embolization is indicated in metastatic renal, thyroid, and liver
lesions. The anaesthetic team should be consulted early and
appropriate intra-operative monitoring must be established, and
critical care bed and blood products made available. Appropriate
equipment and adjuncts such as ligaclips, surgical ties, diathermy,
tissue sealing systems, bone cement, and adrenaline soaked swabs
should be readily available in the operating theatre (Table 4).
Principles of surgery: the aims of any surgical intervention are
to debulk as much tumour as possible, to fill or structurally
bypass the defect transferring forces proximally to intact bone,
and to create a durable joint reconstruction upon which the
patient can full weight bear. Metastatic acetabular lesions are
most commonly classified using the Harringtons classification
(Table 5).15
Type 1 defects are managed by careful curettage of the metastatic
tumour and reconstruction with cemented total hip replacement.
Occasionally prophylactic medial wall mesh augmentation is
inserted.
Type 2 defects are managed with tumour removal followed by
medial wall mesh or anti-protrusio cages and cemented total hip
replacement. The principal aim is to protect the medial wall and
restore the normal hip centre.
Type 3 defects that are less severe can be managed as above.
Those with more severe bone loss can be managed with the
Fracture risk and recommendation from Mirels scoring
system10
Score Fracture risk Recommendation
9 33%e100% Prophylactic fixation is recommended
8 15% Clinical judgment should be used
7 <4% Observation and radiation therapy
can be used
Table 4
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 ORTHOPAEDIC ONCOLOGY

Modified from Harringtons classification of acetabular insufficiency secondary to metastatic malignant disease13
Radiographic findings Treatment options

Type I (minor) Small lesions to the floor only. Intact lateral Curette cemented total hip arthroplasty
cortices, superior dome and medial wall
Type II (major) Deficient medial wall Antiprotrusio device, medial mesh, rebar
augmentation
Type III (massive) Deficient lateral cortices, medial wall Rebar augmentation of posterior
and superior dome (anterior) column
Type IV (extensive) Hemipelvic involvement  pelvic discontinuity En bloc resection graft augmentation
custom prosthesis

Table 5

Harrington technique, which transfers stresses across the defect
from the acetabulum to strong proximal bone. As above the
tumour is curetted, the medial defect is meshed, and an
arrangement of threaded Steinman pins is passed from the iliac
crest into the acetabulum bridging the defect. An anti-protrusio
cage is then implanted followed by cemented total hip
replacement.
multidisciplinary approach to management. Definitive treatment,
particularly in patients with solitary bone lesions, should be
delayed until appropriate investigations often including biopsy
have been completed in order to obtain an accurate diagnosis,
assess prognosis and plan the most appropriate surgical inter-
vention. Surgical management should allow immediate weight-
bearing and aim to last the lifetime of the patient. A

Type 4 defects are usually managed by dedicated orthopaedic

oncology surgeons within a specialist bone tumour unit due to
their complex nature and high complication rate. Operative
techniques include strut or vascularized fibular graft augmenta-
tion as well as custom, saddle and ice cream cone prosthesis
(Figure 3).
Summary
With increasing incidence and improved prognosis for patients
with metastatic bone disease, orthopaedic surgeons will more
often become involved in their management in the future. They
need to be aware of the particular needs of this set of patients and
how treatment differs from other orthopaedic practice. An
awareness is essential of relevant guidelines and recent im-
provements in the treatment options for these patients that aims
to maximize functional outcome and quality of life, and in some
cases increases survival. Orthopaedic treatment should be co-
ordinated by a nominated clinical lead and should be part of a
Take Home Messages
C Orthopaedic management of patients with metastatic bone dis-
ease should involve a lead clinician and the wider multi-
disciplinary orthopaedic oncology team
C The presence of functional pain and scoring systems can be used
to predict risk of pathological fracture
C Planned prophylactic surgical management of patients at risk of
pathological fracture is preferred due to shorter operative time,
lower risk of complications and shorter hospital stay
C Surgical treatment should be delayed until all appropriate in-
vestigations have been carried out including use of biopsy
particularly in patients with solitary bone lesions
C Wide resection of bone metastasis with endoprosthetic replace-
ment should be considered particularly where prognosis is good
C When surgical fixation of pathological fractures is undertaken the
surgeon should assume the fracture will not unite, and use an
appropriate load bearing device with or without cement
augmentation that provides immediate absolute stability and al-
lows full weight bearing

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ORTHOPAEDICS AND TRAUMA --:- 6 Crown Copyright 2017 Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Taylor J, Kumar A, Surgical management of skeletal metastases of the appendicular skeleton, Orthopaedics and
Trauma (2017), http://dx.doi.org/10.1016/j.mporth.2017.03.007
 ORTHOPAEDIC ONCOLOGY
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Trauma (2017), http://dx.doi.org/10.1016/j.mporth.2017.03.007
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