We report the case of an 80-year-old woman treated by palliative knee arthrodesis for metastases of the proximal left tibia secondary to bladder carcinoma, using percutaneous femortibial intramedullary arthrodesis nailing.

The technique provided a simple alternative to massive allografting, total joint prosthesis or amputation, with advantages of low morbidity, short operating time, minimal blood loss, immediate ambulation and weight bearing, relief of pain, restoration of independence, and ease of nursing care.

We are satisfied with the procedure of percutaneous femorotibial intramedullary nailing as a palliative treatment of proximal tibial metastases in an elderly patient.

Aims. With recent progress in cancer treatment, the number of advanced-age patients with spinal metastases has been increasing. It is important to clarify the influence of advanced age on outcomes following surgery for spinal metastases, especially with a focus on subjective health state values. Methods. We prospectively analyzed 101 patients with spinal metastases who underwent palliative surgery from 2013 to 2016. These patients were divided into two groups based on age (< 70 years and ≥ 70 years). The Eastern Cooperative Oncology Group (ECOG) performance status (PS), Barthel index (BI), and EuroQol-5 dimension (EQ-5D) score were assessed at study enrolment and at one, three, and six months after surgery. The survival times and complications were also collected. Results. In total, 65 patients were aged < 70 years (mean 59.6 years; 32 to 69) and 36 patients were aged ≥ 70 years (mean 75.9 years; 70 to 90). In both groups, the PS improved from PS3 to PS1 by spine surgery, the mean BI improved from < 60 to > 80 points, and the mean EQ-5D score improved from 0.0 to > 0.7 points. However, no significant differences were found in the improvement rates and values of the PS, BI, and EQ-5D score at any time points between the two groups. The PS, BI, and EQ-5D score improved throughout the follow-up period in approximately 90% of patients in each group. However, the improved PS, BI, and EQ-5D scores subsequently deteriorated in some patients, and the redeterioration rate of the EQ-5D was significantly higher in patients aged ≥ 70 than < 70 years (p = 0.027). Conclusion. Palliative surgery for spinal metastases improved the PS, activities of daily living, and quality of life, regardless of age. However, clinicians should be aware of the higher risk of redeterioration of the quality of life in advanced-age patients. Cite this article: Bone Joint J 2020;102-B(12):1709–1716

Aims. Frailty has been gathering attention as a factor to predict surgical outcomes. However, the association of frailty with postoperative complications remains controversial in spinal metastases surgery. We therefore designed a prospective study to elucidate risk factors for postoperative complications with a focus on frailty. Methods. We prospectively analyzed 241 patients with spinal metastasis who underwent palliative surgery from June 2015 to December 2021. Postoperative complications were assessed by the Clavien-Dindo classification; scores of ≥ Grade II were defined as complications. Data were collected regarding demographics (age, sex, BMI, and primary cancer) and preoperative clinical factors (new Katagiri score, Frankel grade, performance status, radiotherapy, chemotherapy, spinal instability neoplastic score, modified Frailty Index-11 (mFI), diabetes, and serum albumin levels). Univariate and multivariate analyses were developed to identify risk factors for postoperative complications (p < 0.05). Results. Overall, 57 postoperative complications occurred in 47 of 241 (19.5%) patients. The most common complications were wound infection/dehiscence, urinary tract infection, and pneumonia. Univariate analysis identified preoperative radiotherapy (p = 0.028), mFI (p < 0.001), blood loss ≥ 500 ml (p = 0.016), and preoperative molecular targeted drugs (p = 0.030) as potential risk factors. From the receiver operating characteristic curve, the clinically optimal cut-off value of mFI was 0.27 (sensitivity, 46.8%; specificity, 79.9%). Multivariate analysis identified mFI ≥ 0.27 (odds ratio (OR) 2.94 (95% CI 1.44 to 5.98); p = 0.003) and preoperative radiotherapy (OR 2.11 (95% CI 1.00 to 4.46); p = 0.049) as significant risk factors. In particular, urinary tract infection (p = 0.012) and pneumonia (p = 0.037) were associated with mFI ≥ 0.27. Furthermore, the severity of postoperative complications was positively correlated with mFI (p < 0.001). Conclusion. The mFI is a useful tool to predict the incidence and the severity of postoperative complications in spinal metastases surgery. Cite this article: Bone Joint J 2024;106-B(12):1469–1476

Aims. Bone is a common site of metastatic disease. Skeletal complications include disabling pain and pathological fractures. Palliative surgery for incurable metastatic bone lesions aims to preserve quality of life and function by providing pain relief and stable mobility with fixation or replacement. Current literature has few treatment studies. We present a 5 year longitudinal cohort study of surgery for metastatic bone disease at our large teaching hospital reviewing our complication and mortality rates. Methods. Patients that underwent palliative surgery for metastatic bone lesions were identified from operative records. Demographics, clinical details and outcomes were recorded. Kaplan-Meier analysis was used to calculate survivorship. Results. 43 patients were treated for 44 bone metastases (34 IM Nails, 9 prosthetic replacements, 1 plate). The median age at primary diagnosis was 66 (33–92). Lung cancer was the most common primary. 56% presented with complete fractures and 44% with impending fractures (median Mirel score of 10). Pertrochanteric bone lesions were the most common (74%). Two out of 43 patients died within one day of surgery. 30 day mortality was 12% and 45% at 1 year. In those surviving the 30 day perioperative period, we report a complication rate of 14%. One patient had a dislocated prosthesis. Two patients had delayed or non union and two patients had failure of metalwork. No patient required re operation. Conclusion. Our series observed a 5% fixation failure rate and significant perioperative mortality. Whilst surgery may offer benefit in the non moribund patient with pathological fracture the decision to offer prophylactic surgery is more difficult in light of the high perioperative mortality seen in our study. Indeed, the patients in our study who died within 24 hours of surgery had prophylactic fixations. We conclude that surgical intervention must be carefully considered with realistic expectations of outcomes

Introduction and purpose: The most frequent neurological complication of humeral fractures is radial nerve palsy. Most patients with humeral fractures and radial nerve palsy recover with conservative treatment. But a small percentage of patients require surgical treatment; these are patients who show no clinical improvement of their nerve lesion after 3 months of conservative treatment, those with an open fracture, an associated vascular lesion, secondary radial palsy or patients who require open fracture osteosynthesis. The aim of this study is to assess and analyze humeral fractures with radial palsy that have required surgical treatment. Materials and methods: A prospective pre and postoperative study with a protocol was carried out between 1999 and 2007 in which 28 patients with humeral fractures and radial palsy required surgical treatment. Of the patients studied 10 were women and 18 were men. Their ages varied from 18 to 74 years of age. As to the type of radial palsy, it was primary in 11 patients, secondary in 2 patients (included in the fracture callus) and postoperative in 15. Neurolysis was performed in 20 patients and fascicular grafts were used in 8. Results: Time to fracture healing was 14.2 + 5.6 weeks. The period of radial nerve recovery was 7.2 + 5.7 months. Neurolysis was performed in 20 patients and fascicular grafts in 8. There were 20 complete recoveries, 4 incomplete but useful, in 4 cases there was no recovery and palliative surgery was subsequently performed. Conclusions: Surgical treatment of humeral fractures with radial palsy is indicated in patients who show no clinical improvement of their nerve lesion after 3 months of conservative treatment, those with an open fracture, an associated vascular lesion, secondary radial paralysis or in patients who require an open fracture osteosynthesis. Functional recovery rates are high if surgery is carried out during the appropriate period of time. Treatment is neurolysis or fascicular grafts. Palliative surgery is reserved for cases in which complete recovery is not achieved

Purpose of the study: Balistic nerve injury is not common in civil medicine. We analyzed a series of 30 patients who underwent surgery for this type of injury suffered in the Gaza strip between 2002 and 2004. All patients presented paralysis of the sciatic nerve or one of its major branches. All injuries were caused by war weapons. Material and methods: The series included 28 men and two women, mean age 22 years (range 2.5–65). The injury had occurred more than one year earlier for 33% of patients. The injury was situated at the knee level in twelve patients and in the thigh in ten. Complete nerve section was observed in 12 patients and partial section in two. Loss of nervous tissue was significantly greater for lesions around the knee. Nineteen patients underwent surgery for: neurolysis (n=3), direct nerve suture (n=8) and nerve grafts (n=8). Eleven patients were reviewed at mean 13.7 months (range 3–30 months). There were no failures. Results of reinnervation of the tibial nerve territory were better than for the fibular nerve. Sixteen patients underwent palliative transfer for a hanging foot for more than six months: 15 transfers of the posterior tibial muscle through the interosseous membrane and hemitransfer of the Achilles tendon. Seven patients underwent Achilles tendon lengthening at the same time and five had a reinnervation procedure on the common fibular nerve. Results: Seven patients were reviewed with a mean follow-up of 1.8 years (range 4–30 months. None of the patients used an anti-equin orthesis. There were three cases of forefoot malposition. The overall Stanmore score was good at 75.4/100 (range 59–100). Discussion: High-energy ballistic trauma creates a specific type of injury. Nervous surgery can be indication early to favor spontaneous recovery. Palliative surgery for fibular lesions provides regularly good results. Conclusion: Nerve injuries due to ballistic trauma should be explored surgically because of the possibility of direct nerve repair. In addition, depending on the type of paralysis, reliable palliative surgery can be proposed

Purpose: Pluridisciplinary therapeutic management is well defined for metastatic long bones. There are few prognostic criteria enabling an evidence-based choice between palliative surgery or abstention. We report a series of 24 metastatic femurs treated by palliative surgery and evaluated with the Tokuyashi score. Material and methods: Sixteen women and eight men, mean age 71 years (5!-89) underwent centromedullary nailing of a metastatic femur (13/16 breast cancer in women, 20.24 other metastases. The Toskuhashi score was > 6 for 16/24 patients with pain unresponsive to morphine. Thirteen patients had fractured femurs and eleven had frail femurs due to the metastasis. Mean time to surgery was six days (1–15). Results: A solid nail was used for four patients and a reconstruction nail for twenty. Operative time was 93 minutes (57–123). Blood loss was 200 l (150–350). There no intraoperative complications (fat embolus) excepting one tulip femur. Hospital stay was 23 days (8–55). Survival was 148 days (8–510) in patients with a frail metastatic tumour. Eight deaths occurred in patients with a fractured metastatic tumour (six within the first three postoperative weeks), two after preventive nailing. Weight bearing in living patients with a fractured femur was possible at 57 days (30–90). Only six patients required morphine in the early postoperative period. For the femurs with an isolated metastasis, the antalgesic effect of centromedullary nailing was significant (p< 0.05). There was a significant correlation between thee Tokuyashi score and mean survival. Mean survival in patients with a score < 3 was 2.1 months. Mean survival in patients with a score > 6 was 17 months. Conclusion: Centromedullary nailing of the femur for metastatic fracture or fragilisation remains the treatment of choice for patients with short life expectancy. This technique limits pain while preserving independence as long as possible. The Tokuyashi score is correlated with patient survival. If this easy to establish score is too low (< 3), the survival can be expected to be insufficient for any surgical benefit

Introduction An international six-centre prospective observational cohort study. Objective. To assess the feasibility of radical surgical excisional treatment of spinal metastasis. Materials and methods. Patients with histologically confirmed spinal metastasis originating from epithelial primary site mostly treated with instrumented surgery were studied. Surgical strategies were either radical excisional (enbloc and debulking) or palliative decompressive surgery. Outcomes assessed were measures of quality of life including pain, mobility, sphincter and neurological functions. Results. A total of 223 patients with a mean age of 61 years and equal number of males and females were studied. Breast, renal, lung and prostate accounted for three quarters of tumours and 60% had metastasis that extended beyond one vertebra. Most patients presented with pain (92%), paraparesis (24%) and abnormal urinary sphincter 22% (5% were incontinent). Seventy four percent of patients underwent radical surgery, 92% of all patients had instrumented fixation. 73% of the radical group had improved pain control (63% for palliative group), 72% regained ability to walk (45% for palliative group), 92% maintained a functional neurological function of Frankel E/D (64% for palliative) and 55% had improved sphincter control (21% for palliative group). Overall of all petients who underwent surgery, 71% had improved pain control, 53% regained mobility, 64% improved by at least one Frankel grade or maintained normal neurology and 39% regained normal urinary sphincter function. While 18% were bed bound preoperatively, only 5% were still in bed postoperatively. Perioperative mortality rate was 5.8% and morbidity was 21%. The median survival for the cohort was 352 days (11.7 months). The radical surgery group had a median survival of 438 days and the palliative group 112 days (P = 0.003). Conclusion. Surgical treatment of spinal metastatic tumour is feasible with low mortality, an acceptably low morbidity and affords patients better quality of remaining life. Radical surgical excision has better outcome than palliative surgery in pain control and in neurological function rescue including regaining mobility and improvement in sphincter control

Aim: To investigate the natural history and the impact of reconstruction in shoulder deformities due to obstetrical brachial plexus palsy. Methods: Pre and postoperative CT scans of bilateral upper extremities of 28 patients with obstetrical palsy were studied. The age during the preoperative CT scan ranged from 1.5 months to 10 years (average: 4 ± 3 years). 17 patients had Erbñs palsy and 11 global plexus involvement. Eighteen had primary shoulder reanimation mainly via intraplexus neurotization. Palliative surgery in 25 patients included trapezius transfer for shoulder abduction, adductors release and rerouting of the latissimus dorsi and terres major for external rotation, scapula stabilization and rotational osteotomy of the humerus. The CT measurements included: humeral head retroversion, spinoscapular angle, glenoid fossa inclination, congruence of the humeral head to the glenoid and distance of the lower angle of the scapula from the midline. Results: Preoperatively the humeral head was subluxated or dislocated posteriorly and had decreased retroversion. The hypoplastic scapula had winging and increased distance from the midline, while the glenoid fossa was more retroverted. Postoperatively all the above measurements were improved. Conclusions: Novel measurements on CT scans of bilateral shoulders provide valuable information. Surgical intervention signiþcantly improves the functional anatomy and the dynamics of the shoulder joint

The aim of this study was to assess the significance of the extent and adequacy of the surgical margin on three outcome variables; survival, metastasis and local recurrence. We statistically analysed (Cox proportional hazards regression modelling) 279 consecutive patients who presented with soft tissue sarcoma without meta-static disease. They were treated by a single surgeon to a standard protocol in two centres. In terms of overall survival, the failure to achieve a wide surgical margin by contaminating the resection, led to an elevenfold increase in the relative death rate (p=0.04). However, where the margin was not contaminated (even if the margin was closer than 1 mm) then the overall survival rate was similar across all groups of patients with a clear margin up to 20 mm. A large margin greater than 20mm afforded the lowest risk to overall survival. The extent of the surgical margin was not statistically significant in the development of metastatic disease. The presence of a contaminated surgical margin and a narrow margin less than 1mm led to a significantly higher rate of local recurrence (p=0.02) A margin greater than 1 mm allowed a satisfactory outcome in terms of a low local recurrence rate and the extent of the margin up to 20mm was not statistically important. Patients who had radical resections did poorly and generally represent a group where palliative surgery was performed, and there was a very high relative metastasis and death rate. Our study provides statistically significant evidence that increasing width of resection improves local control and overall survival. However a narrow margin due to anatomical constraints such as bone or neurovascular structures does not significantly compromise patient outcome and this provides guidance for surgical decision making in limb salvage surgery

Introduction: There is increasing evidence that surgical treatment in tumour surgery can influence survival times. Renal cell carcinoma can lead to single or few sites of metastasis that are amenable to extirpative surgery with reconstruction in the spine. 1. Such treatment can also be beneficial to improve quality of surviving years. Methods: Retrospective cohort study of 10 consecutive patients treated for spinal metastatic renal cell carcinoma. Case note review and patient or general practitioner contact was used to ascertain number of metastases, treatment given, survival time from diagnosis and survival time from surgery. All primary tumours were treated with nephrectomy. Results: Of the 10 patients, 6 had extirpative treatment, while 4 had palliative surgery including decompression of the neural elements. Patients treated with extirpative surgery to spinal metastases from a renal cell carcinoma primary had a significantly longer survival time from surgery to those treated with palliative decompressions alone. There were no significant differences in age or time from diagnosis to surgical treatment between groups. There were no cases of operative mortality, but significant intraoperative bleeding was encountered in extirpative treatment of the affected vertebra, despite preoperative embolisation. Discussion: The role of surgical treatment in metastasis to the spine is of current interest. Our results have shown significant survival times are possible with extirpative treatment of renal metastases. Whilst this may not apply directly to metastases from other primary tumours, careful selection of cases and co-operation between spinal surgeons and oncologists is important to ensure maximal quality and length of survival for these patients. These cases are surgically challenging, and care is required to minimise and anticipate blood loss

Purpose of the study: We report a series of 12 patients who underwent surgery in 2003 or 2004 for spinal shortening as treatment for thoracic or lumbar metastasis. Material and method: This series included seven females and five males, mean age 56.5 years (range 34–80 years). The operation was a resection of the vertebral body in a one-stage procedure. A simple posterior approach was used for two patients and a wider costotransversectomy approach was required for ten. Posterior fixation was installed with pedicle screws in the two vertebrae above and two below the resection. Mean operative time was 343 minutes (range 260–420 min). Mean blood loss was 2380 cc (range 600–5000). There were few surgery-related complications: one dural breach and one pulmonary breach. Results: The decision to undertake surgery was made on the basis of neurological problems in seven patients. All patients were Frankel class C, unable to walk. Among these patients, five died in less than six months. For the two survivors, they were scored 7 on the Tokuhashi scale. The remainder scored 5. For the two survivors, one recovered walking capacity (Frankel D) and the other achieved a normal status (Frankel E). The five other patients underwent surgery for pain related to a kyphosis callus threatening the cord. We used the Karnofsky and the Oswestry score to analyze outcome. The score did not regress in any of the patients after surgery. Three patients improved their score significantly. The three others had an unchanged score. The best correction of the kyphosis callus was obtained when the vertebral collapse was greater than 50%. The preoperative regional deformity was measured at 23.2° (range 15–35°) which postoperatively reached 0.5° (range 20 to −17°). Conclusion: This technique for spinal shortening appears to be a better alternative to anterior reconstruction, especially when the vertebral collapse is greater than 50%. In this context, this palliative surgery enables improved quality-of-life for a patient with often advanced disease

Aims: Evalutation of the different surgical option (simple decompression and stabilization vs. intralesional excision vs. en bloc resection) in the treatment of spinal metastases from RCC. Methods: Sixty-one cases in 56 patients with symptomatic spine metastases secondary to Renal Cell Carcinoma (RCC) were treated between 1991 and august 2002. The metastases was located in 43 cases in the lumbar spine, in 23 cases in the thoracic spine and in 4 cases in the cervical spine. Twelve patients were submitted only to radiation therapy. Different procedure was done in the remainder cases: in 16 cases a palliative procedure, in 22 cases a curettage and in 6 cases a en bloc resection. Radiation therapy (RTR) was performed after surgery in 37 cases, Selective Arterial Embolization (SAE) in 29 cases, Chemotherapy (different protocols) in 5 cases and Immunotherapy (IL 2+IFN) in 22 cases. Results: Fifteen patients only were followed for 24 months at least. Of 3 patients submitted to palliative surgery, 1 is alive without disease (NED) at 28 months from treatment, while 2 are dead at 24 and 27 months. Of 10 patients submitted to curettage 5 are continuous disease free (CDF) (24 to 44 months; average: months); 1 is NED at 56 months, 2 are alive with disease (AWD) at 24 and 25 months and 2 are dead after 40 and 68 months. Two patients were submitted to en bloc resection and are CDF at 24 and 30 months after tretament. Conclusions: The treatment of spine metastases of RCC is multidisciplinary: the eligibility of patients to en bloc resection both on the basis of general conditions and local tumor expansion is critical for the local control of the disease. If en bloc resection is not feasible, combination of SAE, complete intralesional excision, RTR, Immunotherapy seem to be the most appropriate treatment

Purpose: The aims of this work were to assess very long-term outcome and to assess functional course of talocrural arthrodesis as well as to determine the clinical and radiological impact on adjacent joints. Material and method: Fifty-two talocrural arthrodeses performed in 52 patients between 1963 and 1981 served as the reference population for this study. Clinical and radiological assessment of this series of patients was conducted in 1983, then again in 1999. Twenty-five talocrural arthrodeses in 25 patients were reviewed at a mean 23 years (19 to 36 years) (six patients were lost to follow-up, 20 had died, one had had leg amputation. The arthrodesis had been performed for advanced degenerative joint disease or to correct for post-traumatic deformity, or in two cases, for neurological varus equinus. Functional outcome was evaluated on the Duquennoy and Stahl score (100 points) that was also used for the intermediary assessment. Radiographic assessment included the position of the arthrodesis, the status of the adjacent joints (subtalar and mediotarsal), and residual motion of the forefoot. Results: At 23 years follow-up, 13 patients (52%) had good (five patients) or very good (eight patients) function and 12 (48%) had fair function, according to the 100 point scale. There were no patients with poor function. Patients without intercurrent conditions (neurological or heart disease, obesity) had good or very good function in 80% of the cases. Patients were very satisfied in 48% of the cases, having “forgotten” their ankle. At the seven-year follow-up analysis, 15 patients (60%) had a very good (ten patients) or good (five patients) result, seven had a fair result, and three had a poor result. Comparing the 7-year and 23-year assessments did not disclose any significant degradation of the result (p = 0.07). Intercurrent conditions explained the two functional degradations, but there were also three functional improvements over the same period. Talocrural arthrodesis induced stiffness in the subtalar joint in all cases, associated with severe osteoarthritis with little clinical expression. There was a slow degradation of the mediotarsal joint but hypermobility useful for good function was maintained in 45% of the cases (mean 24°). Fair results were related to development of subtalar osteoarthritis, malposition of the arthrodesis in the frontal plane (rear foot varus) and presence of intercurrent conditions (cardiovascular, neurological disease). Conclusion: Talocrural arthrodesis is a safe and reliable procedure for the treatment of destroyed joints. This palliative surgery can restore satisfactory function which persists in the long term

Objectives

In this prospective cohort study, we investigated whether patient-specific finite element (FE) models can identify patients at risk of a pathological femoral fracture resulting from metastatic bone disease, and compared these FE predictions with clinical assessments by experienced clinicians.