The burden of metastatic disease presenting with axial skeleton lesions is exponentially rising predominantly due to advances in oncological therapies. A large proportion is these lesions are located in the proximal femora, which given its unique biomechanical architecture is problematic. These patients are frequently comorbid and require prompt and concise decision making regarding their orthopaedic care in line with recent British Orthopaedic Association guidelines. We present data detailing the outcomes for patients with proximal femoral metastatic disease referred and treated over a three year period in an Regional Cancer Centre. We retrospectively reviewed a prospectively maintained database of all patients referred for discussion at MDT with axial skeletal metastatic disease. From this we isolated patients with femoral disease. Demographic data along with primary tumour and metastatic disease site were assessed. Treatment regimens were analysed and compared. Finally predicted and actual mortality data was collated. 331 patients were referred over the analysed time period, of which 99 had femoral disease. 66% of patients were managed conservatively with serial monitoring while 34% underwent operative treatment. 65% of those received an intramedullary fixation while 35% had arthroplasty performed. There was a 51:49 split male to female with Prostate, Lung and Breast being the predominant primary tumours. Concurrent spinal metastatic disease was noted in 62% of patients while visceral mets were seen in 37%. Mortality rate was 65% with an average prognosis of 388 days (1.06years) while average mortality was noted within 291 days (0.8 years). Proximal femoral metastatic disease accounts for a large volume of the overall mets burden. There is an overall tendency towards conservative management and of those requiring surgery IM nailing was the treatment of choice. The data would indicate that outcomes for these patients are guarded and on average worse than those predicted

Previous studies have shown improved outcome following surgery for spinal cord compression due to metastatic disease. Further papers have shown that many patients with metastatic disease are not referred for orthopaedic opinion. The aims of this paper are to study the survival and morbidity of patients with spinal metastatic disease who receive radiotherapy. Do patients develop instability and progressive neurological compromise? Can we predict which patients will benefit from surgery?. Retrospective review of patients receiving radiotherapy for pain relief or cord compression as a result of metastatic disease. Patients were scored with regards to Tomita and Tokuhashi, survival and for deterioration in neurology or spinal instability. 94 patients reviewed. All patients were followed up for a minimum of 1 year or until deceased. Majority of patients had a primary diagnosis of lung, prostate or breast carcinoma. Mean Tomita score of 6, Tokuhashi score 7, and mean survival following radiotherapy of 8 months. 11:94 patients referred for surgical opinion. Poor correlation with Tomita scores (-0.25) & Tokuhashi scores (0.24) to predict survival. Four patients developed progressive neurology on follow-up. One patient developed spinal instability. The remainder of the patients did not deteriorate in neurology and did not develop spinal instability. All patients with normal neurology at time of radiotherapy did not develop spinal cord compression or cauda equina at a later date. This study suggests that the vast majority of patients with spinal metastatic disease do not progress to spinal instability or cord compression, and that prophylactic surgery would not be of benefit. The predictive scoring systems remain unreliable making it difficult to select those patients who would benefit. The referral rate to spinal surgeons remains low as few patients under the care of the oncologists develop spinal complications

Previous studies have shown improved outcome following surgery for spinal cord compression due to metastatic disease. Further papers have shown that many patients with metastatic disease are not referred for orthopaedic opinion. The aims of this paper are to study the survival and morbidity of patients with spinal metastatic disease who receive radiotherapy. Do patients develop instability and progressive neurological compromise?. Do patients require surgery or are the majority adequately treated by oncologists?. Review of patients receiving radiotherapy for pain relief or cord compression as a result of metastatic disease. Patients were scored with regards to Tomita and Tokuhashi, survival and for deterioration in neurology or spinal instability. 94 patients reviewed. All patients were followed up for a minimum of 1 year or until deceased. Majority of patients had a primary diagnosis of lung, prostate or breast carcinoma. Mean Tomita score of 6, Tokuhashi score 7, and mean survival following radiotherapy of 8 months. 11:94 patients referred for surgical opinion. Four patients developed progressive neurology on follow-up. One patient developed spinal instability. The remainder of the patients did not deteriorate in neurology and did not develop spinal instability. All patients with normal neurology at time of radiotherapy did not develop spinal cord compression or cauda equina at a later date. This study suggests that the vast majority of patients with spinal metastatic disease do not progress to spinal instability or cord compression, and that prophylactic surgery would not be of benefit. The referral rate to spinal surgeons remains low as few patients under the care of the oncologists develop spinal complications

Several different algorithms attempt to estimate life expectancy for patients with metastatic spine disease. The Skeletal Oncology Research Group (SORG) has recently developed a nomogram to estimate survival of patients with metastatic spine disease. Whilst the use of the SORG nomogram has been validated in the international context, there has been no study to date that validates the use of the SORG nomogram in New Zealand. This study aimed to validate the use of the SORG nomogram in Aotearoa New Zealand. We collected data on 100 patients who presented to Waikato Hospital with a diagnosis of spinal metastatic disease. The SORG nomogram gave survival probabilities for each patient at each time point. Receiver Operating Characteristic (ROC) Area Under Curve (AUC) analysis was performed to assess the predictive accuracy of the SORG score. A calibration curve was also performed, and Brier scores calculated. A multivariate Cox regression analysis was performed. The SORG score was correlated with 30 day (AUC = 0.72) and 90-day mortality (AUC = 0.71). The correlation between the SORG score and 90-day mortality was weaker (AUC = 0.69). Using this method, the nomogram was correct for 79 (79%) patients at 30-days, 59 patients (59%) at 90-days, and 42 patients (42%) at 365-days. Calibration curves demonstrated poor forecasting of the SORG nomogram at 30 (Brier score = 0.65) and 365 days (Brier score = 0.33). The calibration curve demonstrated borderline forecasting of the SORG nomogram at 90 days (Brier score = 0.28). Several components of the SORG nomogram were not found to be correlated with mortality. In this New Zealand cohort the SORG nomogram demonstrated only acceptable discrimination at best in predicting life 30-, 90- or 356-day mortality in patients with metastatic spinal disease

The management of primary malignant bone tumors with metastatic disease at presentation remains a challenge. While surgical resection has been shown to improve overall survival among patients with non-metastatic malignant bone tumors, current evidence regarding the utility of surgery in improving overall survival in metastatic patients remains limited. The 2004–2016 National Cancer Database (NCDB) was queried using International Classification of Diseases 3rd Edition (ICD-O-3) topographical codes to identify patients with primary malignant bone tumors of the extremities (C40.0-C40.3, C40.8 and C40.9) and/or pelvis (C41.4). Patients with malignant bone tumors of the axial skeleton (head/skull, trunk and spinal column) were excluded, as these cases are not routinely encountered and/or managed by orthopaedic oncologists. Histological codes were used to categorize the tumors into the following groups - osteosarcomas, chondrosarcomas, and Ewing sarcomas. Patients who were classified as stage I, II or III, based on American Joint Commission of Cancer (AJCC) guidelines, were excluded. Only patients with metastatic disease at presentation were included in the final study sample. The study sample was divided into two distinct groups – those who underwent surgical resection of the primary tumors vs. those who did not receive any surgery of the primary tumor. Kaplan-Meier survival analysis was used to report unadjusted 5-year overall survival rates between patients who underwent surgical resection of the primary tumor, compared to those who did not. Multi-variate Cox regression analyses were used to assess whether undergoing surgical resection of the primary tumor was associated with improved overall survival, after controlling for differences in baseline demographics, tumor characteristics (grade, location, histological type and tumor size), and treatment patterns (underwent metastatectomy of distal and/or regional sites, positive vs. negative surgical margins, use of radiation therapy and/or chemotherapy). Additional sensitivity analyses, stratified by histologic type for osteosarcomas, chondrosarcomas and Ewing sarcomas, were used to assess prognostic factors for overall survival. A total of 2,288 primary malignant bone tumors (1,121 osteosarcomas, 345 chondrosarcomas, and 822 Ewing sarcomas) with metastatic disease at presentation were included – out of which 1,066 (46.0%) underwent a surgical resection of the primary site. Overall 5-year survival rates, on unadjusted Kaplan-Meier log-rank analysis, were significantly better for individuals who underwent surgical resection vs. those who did not receive any surgery (31.7% vs. 17.3%; p<0.001). After controlling for differences in baseline demographics, tumor characteristics and treatment patterns, undergoing surgical resection of primary site was associated with a reduced overall mortality (HR 0.42 [95% CI 0.36–0.49]; p<0.001). Undergoing metastectomy (HR 0.92 [95% CI 0.81–1.05]; p=0.235) was not associated with a significant improvement in overall survival. On stratified analysis, radiation therapy was associated with improved overall survival for Ewing Sarcoma (HR 0.71 [95% CI 0.57–0.88]; p=0.002), but not for osteosarcoma (HR 1.14 [95% CI 0.91–1.43]; p=0.643) or chondrosarcoma (HR 1.08 [95 % CI 0.78–1.50]; p=0.643). Chemotherapy was associated with improved overall survival for osteosarcoma (HR 0.50 [95% CI 0.39–0.64]; p<0.001) and chondrosarcoma (HR 0.62 [95% CI 0.45–0.85]; p=0.003), but not Ewing sarcoma (HR 0.79 [95% CI 0.46–1.35]; p=0.385). Surgical resection of the primary site significantly improves overall survival for primary malignant bone tumors with metastatic disease at presentation. Physicians should strongly consider surgical resection of the primary tumor, with adjunct systemic and/or radiation therapy (dependent on tumor histology), in patients presenting with metastatic disease at presentation

The outcome of complex acetabular reconstruction was evaluated in twenty-one patients who were confined to a wheelchair or bed because of pain from acetabular metastases. Reconstruction rings were used where bone loss exceeded 50% of the acetabulum. Six roof reinforcement-rings, eight ilioischial-rings and eight Harrington reconstructions were performed. All but two patients(90%) became ambulatory without pain. Median survival was nine months. Two patients underwent acetabular revision for recurrence. These results support the role of acetabular reconstruction for palliation of pain in appropriate patients with acetabular metastases. Metastatic disease of the acetabulum is painful and disabling. Operative intervention is indicated in certain patients with pathologic fractures, and non-responders to adjuvant treatment. The functional outcome of hip arthroplasty with reconstruction rings was evaluated in twenty-one patients with acetabular metastases between 1989 and 2001. Preoperatively all patients were confined to a wheelchair or bed and used significant narcotic medications. Preoperative radiotherapy was employed in eighteen cases (90%) and 30% had undergone chemotherapy. AAOS classification of the acetabular lesion revealed: six-type II, seven-type III and eight-type IV deficiencies. All cases required a reconstruction ring due to bone loss exceeding 50% of the acetabular dome. Six roof reinforcement rings, eight ilioischial rings and eight Harrington reconstructions with rings were performed in this group. Determination of the reconstructive technique was based on preoperative computerized tomography and intraoperative examination of the acetabular deficiency. All but two patients (90%) became ambulatory without significant pain. Eleven patients used a walker or two canes and nine walked with one or no canes. Median survival was nine months and patients with visceral involvement had a shorter duration. Eight early post-operative complications developed in six patients (29%). In two patients the acetabular construct failed with cup migration due to locally recurrent disease; both were successfully revised. The results of complex acetabular reconstruction for metastatic disease validate its role for palliation of pain and to improve ambulatory status. Preoperative planning with computerized tomography can assist in classifying acetabular bone loss and determining optimal reconstruction technique

To assess the referral system and the clinical notes and radiographs of patients presenting with metastatic disease of long bones. All oncology consultants and registrars received a questionnaire regarding referral to the orthopaedic department for metastatic disease of the appendicular skeleton. Ninety three percent of oncologists did not use a reliable scoring system to assess risk of pathological fracture. The majority of oncologists referred with regards to degree of cortical erosion and increased pain on weight-bearing. Sixty percent felt an improvement in communication between the departments was required. The notes and radiographs were reviewed of twentyfive patients presenting with femoral metastatic lesions to the oncology department. Mirels scoring system was then applied to each patient to assess the risk of the possibility of a pathological fracture. Ten patients had a Mirels score of greater than eight. Three patients were referred for an Orthopaedic opinion regarding prophylactic fixation. Two patients had no fracture of the femur after three months. Five patients had a pathological fracture within three months, resulting in an emergency admission for surgery. Three patients had a Mirels score of 8. One patient suffered a pathological fracture. Twelve patients had a Mirels score of less than 8. None of these patients were referred for an Orthopaedic opinion. None of these patients had a pathological fracture within three months. In conclusion, we presently do not offer a multidisciplinary approach to metastatic disease affecting the appendicular skeleton. The majority of patients’ who score eight or above in the Mirels scoring system are at risk of fracture and do require prophylactic surgery. In keeping with the BOA guidelines, “Metastatic Bone Disease: A Guide to Good Practice”, we would recommend the introduction of a multidisciplinary approach and the use of a recognised scoring system to improve patient care

Purpose; To show that Distal Femoral Endoprosthetic Replacement for metastatic disease can be performed with relatively few complications and allows good pain control and mobilisation for otherwise severely compromised patients. Method; This is a retrospective study, using the oncology database, patient records and local correspondence, looking at 23 patients with distal femoral metastases who had limb salvage with a Distal Femoral Endoprosthesis (DF EPR). Results; There were 10 males (43%) and 13 females (57%), mean age 65 (38–84). 13 (57%) had Renal, 6 (26%) Breast and 5 other primaries identified. Five had additional metastases. 8 (35%) had pathological fractures. The mean time for diagnosis of mets was 67 months ranging from 0 (i.e. at the time of primary tumour) to 30 years since the original diagnosis. 15 patients had surgery alone. 3 patients were lost to follow up. 15 patients have diseased at a mean of 26 months (4–58) post op. There was one intra-op and four post-op complications. The majority of the patients were satisfied post op with regards to pain and mobility. The generally unfavourable prognosis and perceived risks have led surgeons to palliate, stabilise in situ or amputate for distal femoral metastases despite recognised morbidity and life style restrictions. We conclude that DF EPR should be considered as a limb salvage option in patients with distal femoral mets

The treatment of bone metastases is usually palliative and aims to achieve adequate control of pain, to prevent and resolve compression of the cord in lesions of the spine and to anticipate or stabilise pathological fractures in the appendicular skeleton. In selected cases the complete resection of an isolated bone metastasis may improve the survival of the patient. During recent decades, the life expectancy of patients affected with metastatic carcinoma has improved considerably because of advances in chemotherapy, immunotherapy, hormonal treatment and radiotherapy. This improvement requires greater reliability in the reconstructive procedure in order to avoid mechanical failure during prolonged survival of the patient. The author experience with modular megaprosthesis by Link (megasystem C) allowed us to present a rapid, effective and functional solution. From June 2001 to December 2007 225 patients have been operated with a megaprosthesis C for tumoral resection. The new megaprosthesis C by Link represents a wide-ranging system that can afford a large variety of reconstructions in the inferior limb, from very short replacement of 5 cm in proximal femur, to a total femur and proximal tibia replacement. Modularity is represented by 1 cm increase in length. The different options of cemented and not cemented stem may be used with intraoperative decision. In cemented stem a rough collar seals the osteotomy and prevents polyethylene debris from entering the femoral canal by inducing a scar tissue around the stem entrance (so-called purse-string effect). Moreover in patients with solitary lesions and very good prognosis an allograft-prosthesis composite can be performed with improved clinical results on walking and function. Of the 225 patients that underwent tumoral resection and reconstruction with a modular megaprosthesis approximately 43% (97 cases) were operated for metastatic disease. Among these cases 55 cases were proximal femoral recontructions, 39 cases were distal femoral reconstructions and 3 cases were proximal tibial reconstructions. All cases were performed with cemented stems. We experienced a 7% of postoperative infections, 2% of dislocations of proximal femoral prosthesis and 3% of mechanical failures. While infections and dislocation rates were in the average for this surgery, mechanical failures seemed relatively high. However in patients with relatively long resections and muscle deficiency the mechanical stress exerted on the prosthesis can explain this kind of mechanical failure

Purpose: A systematic review of Health Related Quality of Life Outcomes(HRQOL) in metastatic disease of the spine and content validation of a new Spine Oncology Study Group Outcomes Questionnaire(SOSGOQ). To identify HRQOL questionnaires previously reported for spinal metastases and to validate the content of the new SOSGOQ based on the International Classification of Function and disability(ICF). Method: A systematic review identified 141 studies. Reported outcome tools were enumerated. The most commonly utilized (ESAS, Karnofsky Scale and ODI) and the SOSGOQ were linked to the ICF. Descriptive statistics examined the frequency and specificity of the ICF linkage. Linkage reliability was evaluated by inter-investigator percentage agreement. Results: The SOSGOQ contains 56 concepts, with all 4 domains of the ICF represented. 4 concepts could not be linked. There was 100% inter-observer agreement(IOA) for total number of concepts and for those ‘not covered’. 100% of concepts had ‘First and Second’ level linkage. 100% IOA exists at both ‘Component’ and “First Level’ linkage. There was 96.1% IOA at ‘Second’ Level. 33 concepts linked to Third Level with 96.9% IOA. 10 concepts linked at the Fourth Level with 100% IOA. Conclusion: The SOSGOQ includes all domains relevant for measurement of function and disability and it’s content validity is confirmed by linkage with the ICF. This new questionnaire has superior content capacity to measure disease burden of patients with metastatic disease of the spine than any instruments previously identified in the literature

Purpose: To determine the surgical and functional outcome of an anatomically based approach to hip reconstruction for metastatic bone disease. Methods: Records of 123 consecutive patients who underwent hip arthroplasty for metastatic bone disease were reviewed. Sixty one patients (63 hips) had pelvic involvement that required periacetabular reconstruction. Sixty two patients (64 hips) had proximal femoral involvement but no acetabular disease. Operative technique was guided by the extent of column and dome disease in addition to the extent of involvement of the femur. Demographic variables, functional data (ECOG scores) and survival data were analyzed. Results: : The cohort included 94 females and 29 males, mean age 62 years (range, 39–85). Breast, lung and kidney were the most common primary sites. The average time from initial primary diagnosis to surgery was 42 months. The average time from initial primary diagnosis to surgery was significantly longer for those with breast cancer compared to those with other primary sites (65 vs. 21 months, P< 0.001). Average blood loss was 788 ml (range, 200–3800 ml) and average operative time was 2.3 hours (range, 2–6 hours). There were three perioperative deaths. Functional scores improved from an average of 2.7 preoperatively to 1.4 postoperatively (P< 0.05). Two patients required closed reduction, two required open trochanteric repair and one required ace-tabular revision. Median survival time was 15 months (range, 0–172 months). Patients with breast cancer enjoyed longer survival compared to patients with other primaries (21 vs. 9 months, P=0.02). Conclusions: Despite the moderate risk of operative complications, an anatomically based approach to reconstruction of metastatic hip disease is effective in improving functional outcome and quality of life in many patients

Aims. Socioeconomic and racial disparities have been recognized as impacting the care of patients with cancer, however there are a lack of data examining the impact of these disparities on patients with bone sarcoma. The purpose of this study was to examine socioeconomic and racial disparities that impact the oncological outcomes of patients with bone sarcoma. Methods. We reviewed 4,739 patients diagnosed with primary bone sarcomas from the Surveillance, Epidemiology and End Results (SEER) registry between 2007 and 2015. We examined the impact of race and insurance status associated with the presence of metastatic disease at diagnosis, treatment outcome, and overall survival (OS). Results. Patients with Medicaid (odds ratio (OR) 1.41; 95% confidence interval (CI) 1.15 to 1.72) and uninsured patients (OR 1.90; 95% CI 1.26 to 2.86) had higher risks of metastatic disease at diagnosis compared to patients with health insurance. Compared to White patients, Black (OR 0.63, 95% CI 0.47 to 0.85) and Asian/Pacific Islander (OR 0.65, 95% CI 0.46 to 0.91) were less likely to undergo surgery. In addition, Black patients were less likely to receive chemotherapy (OR 0.67, 95% CI 0.49 to 0.91) compared to White patients. In patients with chondrosarcoma, those with Medicaid had worse OS compared to patients with insurance (hazard ratio (HR) 1.65, 95% CI 1.06 to 2.56). Conclusion. In patients with a bone sarcoma, the cancer stage at diagnosis varied based on insurance status, and racial disparities were identified in treatment. Further studies are needed to identify modifiable factors which can mitigate socioeconomic and racial disparities found in patients with bone sarcomas. Cite this article: Bone Joint Res 2022;11(5):278–291

Objective: In 1989 Mirels published a scoring system for identifying impending pathological fractures in long bones. However, the spine is the most common site of skeletal metastases. A MR-based scoring system is proposed to quantify the risk of sustaining a pathological fracture through a metastatic lesion in a vertebral body.

Methods: A retrospective analysis of 101 vertebral body metastatic lesions was carried out. The metastases were identified through the onco-radiology database. Only lesions with a MR scan and subsequent imaging within 24-months of the index scan were included. Variables potentially predictive of impending fracture were analysed for significance. The significant variables were then statistically weighted. The original MR scans were scored, and the subsequent imaging was used to identify which lesions fractured. The scores were compared between the fracture and non-fracture group. Analysis was carried out for each predictive variable to establish whether they were individually as good as the scoring system alone in predicting fracture. Intra and inter-observer variability was assessed using kappa statistics.

Results: Twenty-one of the 101 lesions fractured within 24 months. A mean score of 0.65 was identified in the non-fracture group, whilst the fracture group had a mean score of 6.52 (p< 0.0001). The percentage risk of a lesion sustaining a pathological fracture was calculated for any given score. As the score increased above 4, so did the percentage risk of fracture (sensitivity 85.7%, specificity 97.5%). Very good intra and inter-observer agreement was present, showing the scoring system to be reliably reproducible.

Conclusions: The authors propose that all painful vertebral body metastatic lesions be evaluated by MR scanning. Lesions with a score of 3 or less can be left untreated. Lesions with scores of 4 or higher are at risk of fracture and should be considered for prophylactic cement augmentation.

Objective: In 1989 Mirels published a scoring system for identifying impending pathological fractures in long bones, and it is now standard practice that long bones with metastases at risk of fracture are treated with prophylactic internal fixation. The spine is the most common site of skeletal metastases, with spinal metastases present in up to 36% of patients with terminal cancer. A pathological fracture through a vertebral body can result in paralysis, incontinence and severe pain. However, there is no equivalent of the Mirels’ scoring system to aid the spinal surgeon in determining the probability of an impending spinal fracture.

A weighted scoring system is proposed to quantify the risk of sustaining a pathological fracture through a metastatic lesion in a vertebral body. This system analyzes and combines four magnetic resonance (MR) risk factors into a single score.

Methods: A retrospective analysis of 100 vertebral body metastatic lesions was carried out. The original MR scans were scored, and the subsequent imaging was used to identify which vertebral body lesions fractured. Patients with no subsequent imaging within 12 months were excluded.

Results: Twenty of the 100 lesions fractured within 12 months. A mean score of 0.64 was identified in the non-fracture group, where as the fracture group had a mean score of 6.80. The percentage risk of a lesion sustaining a pathological fracture was calculated for any given score. As the score increased above 3, so did the percentage risk of fracture (sensitivity 90%, specificity 91%).

Conclusions: The authors propose that all painful vertebral body metastatic lesions be evaluated by MR scanning. Lesions with a score of 2 or less can be left untreated, while lesions with scores of 3 or higher should be considered for prophylactic balloon kyphoplasty.

There is comprehensive data addressing the 6 to 18-month survival in patients with pathological neck of femur (NOF) fractures due to bony metastases. However, little is known about early mortality in this group. The aim was to quantify 30 and 90-day mortality in patients with pathological NOF lesions/fractures and identify biochemical markers associated with early death.

Orthopaedic trauma lists over one year were used to identify patients with a pathological NOF fracture/lesion.

33 patients had a metastatic NOF fracture/lesion and were compared to a control group of age and gender-matched non-pathological NOF fractures. Time from referral to surgery was higher in patients with a pathological fracture compared to a pathological lesion (average 7.4 and 0.6 days, p<0.05). 30 and 90-day mortality was higher in the metastatic group compared to controls (15% 5/33 vs 9% 3/33 p<0.05, and 42% 14/33 vs 12% 4/33 p<0.01, respectively).

Patients with early mortality had lower average sodium (135 vs 138, p<0.05), creatinine (48 vs 62, p<0.05) and APTT (27 vs 32, p<0.05). They had a higher average WCC (11.3 vs 7, p<0.05) and CRP (55 vs 18, p<0.01). Metastatic patients with early mortality had lower albumin (20 vs 30, p<0.01) and haemoglobin (102 vs 121, p<0.01), which were higher in the control NOF group with early mortality (albumin 28 and haemoglobin 118 respectively, p<0.05).

Patients with pathological NOF lesions have multiple biochemical abnormalities associated with early mortality. A prospective study is proposed to assess whether correction of these abnormalities can improve survival in this group.

To evaluate and compare the stability of an anterior cement construct following total spondylectomy for meta-static disease against alternative stabilization techniques.

After intact analysis of ten cadaveric spines (T9–L3), a T12 spondylectomy was performed. Three reconstruction techniques were tested for their ability to restore stiffness to the specimen using non-destructive tests:

1) multilevel posterior pedicle screw instrumentation (PPSI) from T10–L2 {MPI}, 2) anterior instrumentation from T11–L1 with PPSI {AMPI}, and 3) anterior cement and pins construct (T12) with PPSI {CMPI}.

Circumferential stabilization {AMPI, CMPI} restored stiffness to a level of the intact spine. CMPI provided more stability to the specimen than AMPI. MPI alone did not restore stiffness to the intact level.

Circumferential reconstruction using an anterior cement construct following total spondylectomy is biomechanically superior to posterior stabilisation alone.

Introduction: Patients with spinal metastases often have patterns of disease requiring both an anterior and posterior surgical decompression and stabilisation. Subtotal spondylectomy and circumferential stabilisation can be safely performed via a single posterior transpedicular approach. Polymethyl-methacrylate bone cement (PMMA) has been widely used in spinal column reconstruction with mixed results. PMMA is a potential means for local drug delivery in the prevention of locally recurrent disease. The biomechanical characteristics of anterior reconstruction using PMMA have not been adequately evaluated.

Purpose: To evaluate the stability of an anterior cement construct following total spondylectomy and to compare this reconstruction against alternative stabilisation techniques.

Methods: Ten fresh-frozen human cadaveric spines (T9-L3) were used. After intact analysis, a total spondylectomy was performed at T12. Three potential reconstruction techniques were tested for their ability to restore stiffness to the specimen: (1) multi-level posterior pedicle screw instrumentation from T10-L2 {MP1} [Depuy Acromed], (2) anterior instrumentation [ATL Z-plate II™, Medtronic, Sofamor Danek Instruments] and rib graft at T11-L1 with multi-level posterior instrumentation from T10-L2 {AMPI}, and (3) anterior cement [Simplex P] and pins construct (T12) with multi-level posterior instrumentation from T10-L2 {CMPI}. Each of the three potential reconstruction techniques was tested on each specimen in random order. Non-destructive testing was performed under load control. The specimen was positioned vertically for axial compression and torsion testing, and horizontal for flexion/extension and lateral bending tests. A customised jig was manufactured for this latter purpose.

Results: Only circumferential stabilisation techniques (AMPI, CMPI) restored stiffness to a level equivalent or higher to that of the intact spine in all loading modes (p< 0.05). CMPI provided more stability to the specimen than AMPI in compression and flexion testing (p< 0.05). Posterior instrumentation alone (MPI) did not restore stiffness to the intact level in compression and flexion testing (p< 0.005).

Conclusions: Circumferential reconstruction using an anterior cement construct provides equal or more stability than the intact spine in all testing modes. Posterior stabilisation alone is an inadequate method of reconstruction following total spondylectomy. PMMA has the advantage over traditional anterior reconstruction techniques in that it can be inserted using a single posterior approach and offers the potential value of local drug delivery.

Purpose: To examine the effect of image resolution and structural model on quantifying architectural differences between healthy and metastatically involved vertebrae.

Method: Lumbar vertebrae of healthy(n=6) and meta-statically involved(n=6) rnu/rnu rats were utilized. Osteolytic vertebral metastases were developed via intracardiac injection of human MT1 breast cancer cells. μCT images of the vertebrae were acquired ex vivo at 14μ isotropic spatial resolution. The whole vertebrae were segmented using an automated atlas based demons deformable registration followed by level set curvature evolutions. A subsequent iteration of level set was used to yield a segmentation of the trabecular centrum. The individual trabecular network was further segmented using intensity based thresholding. Architectural parameters were computed from the segmented μCT images: Cortical Bone Volume(CBV), Trabecular Bone Volume(TBV), Trabecular Bone Surface Area and the degree of anisotropy based on Mean Intercept Length(MIL). From this, trabecular Thickness(TbTh), Trabecular Number(TbN) and Trabecular Separation(TbS) were calculated using the Parfitt Model (Parfitt, Bone & Mineral. 1987). TbTh was also calculated separately using the Hilderbrand model (Hilderbrand, J of Microscopy 1997). The degree of anisotropy was determined via Mean Intercept Length (MIL) measured utilizing a binary shift/subtraction approach. The measures of TbTh and MIL were compared for each image at 8.725(high), 17.45(medium) and 34.9(low) μm3 isotropic spatial resolutions.

Results: Parfitt’s plate model showed a significant decrease in TBV, TbN and CBV and a significant increase in TbS in the metastatic vertebrae in comparison to the healthy group at the highest resolution. In both Hilderbrand’s and Parfitt’s models at the highest resolution there was no significant difference in TbTh between the healthy and metastatic groups. In both models, TbTh and TbS values rose while TBV and TbN decreased as the resolution was lowered. Significant reductions were observed only in TbTh between the healthy and metastatic vertebrae at the medium and low resolutions. In all cases, the Hildebrand model yielded lower values of TbTh than the Parfitt model. However, achieving robust automated results using the Hildebrand method was limited in the final stage of the segmentation due to sensitivity to small islands of bone. Structural anisotropy remained consistent in all groups at all resolutions, with ~3x greater MIL in the superior/inferior direction. The degree of anisotropy was, however, consistent in both groups suggesting that the metastatic destruction does not have any directional preference.

Conclusion: The automated use of Parfitt’s plate model along with the MIL method can be used to yield quantitative analyses demonstrating differences in vertebral microstructure due to metastatic involvement. However the sensitivity of these architectural parameters to resolution motivates the need for high resolution scanning in future preclinical applications.

To assess how effective are the prognostic scores and the role of delayed presentation in predicting the outcomes in patients with metastatic spine disease. Retrospectively data collected from December 2006 to December 2009. Medical records review included types of tumours, duration of symptoms, duration from referral to definitive treatment, expected survival, functional status before and after treatment. Karnofsky performance score and Modified Tokuhashi were used. Results: 50 patients underwent surgical stabilisation for metastatic spine disease with or with out cord compression. Age ranged from 39 to 87 years (Avg: 64). Patients had four main types of tumours; (Myeloma 30%, Lymphoma 22% Lung CA 16% and Renal 12 %). Inpatients without cord compression, the average time from referral to definitive treatment is 17 days. Over all fictional status improved in 70% of cases following surgical intervention. Patients who presented with cord compression had surgery with in 49 hours. Patients with high prognostic scores did not survive as long as expected. On the contrary, patients with poor prognostic scores survived longer than expected. This discrepancy is significant in patients with lung and renal malignancies. Patients with Myeloma did well as per the prognostic scores. Prognostic scores are not uniformly effective in all types of malignancies. Factors like delayed presentation and general condition were not included in the prognostic factors. Hence, we conclude that we cannot make a decision purely based on the prognostic scores to perform either palliative or definitive surgery

Objectives. In this cross sectional study, the impact and the efficacy of a surveillance programme for sarcomas of the extremities was analysed. Methods. All patients who had treatment with curative intent for a high-grade sarcoma and were diagnosed before 2014 were included and followed for a minimum of two years. Results. Of the 909 patients who had a review appointment in 2014, 131 were under review for a high-grade sarcoma of the extremities following treatment with curative intent. Of these patients, three patients died of disease, two patients died of other causes, 12 are alive, with disease, and 114 have no evidence of disease. The surveillance programme accounts for 14% of all review appointments. Four of five patients (80%) who developed local recurrence identified the recurrence themselves. Chest radiographs are adequate in identifying metastatic disease and 11 (73%) of metastases were diagnosed during a routine follow up visit. However, the chance of cure is small and only two patients were referred for a metastatectomy. Of these only one survived for more than two years. The mean time for developing metastatic disease and local recurrence was 2.0 and 3.9 years respectively. Once identified, the mean time to death was 2.1 years for patients with metastatic disease. Conclusions. Surveillance of sarcoma patients makes up a substantial amount of the workload of a sarcoma unit. The chance of cure following identification of local recurrence or metastatic disease, however, is small. Alternative methods of surveillance that allow better evaluation of the patient’s needs are recommended. Cite this article: P. Cool, G. Cribb. The impact and efficacy of surveillance in patients with sarcoma of the extremities. Bone Joint Res 2017;6:224–230. DOI: 10.1302/2046-3758.64.BJR-2016-0253.R1