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Bilateral pathologic fractures of the hip and acetabulum treated with cementless total hip arthroplasty
The Journal of Arthroplasty Vol. 17 No. 5 2002
Case Report
Bilateral Pathologic Fractures of the Hip and Acetabulum Treated With Cementless Total Hip Arthroplasty Cyna Khalily, MD,* Victor M. Ilizaliturri, Jr., MD,† and D. Kevin Lester, MD‡
Abstract: Pathologic fractures from metastatic cancer pose formidable challenges to the orthopaedic surgeon technically and in terms of surgical decision making with regards to patient quality of life. We present the case of a 47-year-old woman with simultaneous bilateral pathologic femoral neck and acetabulum fractures and severe pulmonary shunt, who was treated successfully with cementless femoral and acetabular implants. Key words: pathologic fracture, cementless total hip arthroplasty (THA), simultaneous bilateral THA. Copyright 2002, Elsevier Science (USA). All rights reserved.
The pelvis and proximal femur are frequent sites of metastatic involvement in patients with breast cancer. Pathologic fractures in this area pose formidable challenges to the orthopaedic surgeon not only in terms of technical difficulty, but also in terms of decision making with regards to patient quality of life. Solutions range from conservative medical treatment to operative stabilization to prosthetic replacement. We present the case of a 47-year-old woman with advanced metastatic breast cancer who presented with simultaneous bilateral pathologic fractures of both acetabula and femoral necks and life-threatening pulmonary shunt secondary to
tumor infiltration of the pulmonary lymphatic system. Simultaneous bilateral total hip arthroplasty (THA) was done with cementless femoral and acetabular implants without any intraoperative or postoperative complications. Early ambulation resulted in a significant increase in quality of life with no evidence of loosening at 3-year follow-up.
Case Report A 47-year-old woman presented in the emergency department after suffering a seizure. She had no previous history of seizure disorder and was not under medical care for any acute or chronic illness. Initial assessment revealed bilateral femoral neck and acetabulum fractures (Fig. 1). Lytic lesions in the pelvis and proximal femur suggested a pathologic process. Further investigation revealed biopsyproven right breast carcinoma with positive lymph nodes and metastasis to brain, liver, and bone. Metastatic involvement of the lung with a significant pulmonary shunt also was found. Oncology consultation suggested that even in the face of stage
From *Private practice, Wellington Orthopaedics and Sports Medicine, Cincinnati, Ohio; †Private practice, Mexico City, Mexico; and ‡Private practice, Fresno, California. Submitted April 30, 2001; accepted February 2, 2002. No benefits or funds were received in support of this study. Reprint requests: Cyna Khalily, MD, Wellington Orthopaedics and Sports Medicine, 5589 Cheviot Road, Cincinnati, OH 45247. E-mail: [email protected] Copyright 2002, Elsevier Science (USA). All rights reserved. 0883-5403/02/1705-0011$35.00/0 doi:10.1054/arth.2002.32703
664
THA for Bilateral Pathologic Fracture • Khalily et al.
665
initiated with cyclophosphamide, methotrexate, and 5-fluorouracil. At 56-month follow-up, the patient had a Harris hip score of 92 and no radiographic evidence of implant loosening.
Discussion
Fig. 1. At presentation, radiographs revealed bilateral femoral neck and acetabulum fractures.
4 metastatic disease, a patient could live years with proper treatment. The tumor was found to be amenable to tamoxifen therapy. After extensive pulmonary treatments, medical clearance was obtained 12 days after presentation, and simultaneous bilateral THA was done. A cementless metal-backed implant with multiple screw fixation and a locking ring acetabular insert was used for acetabulum reconstruction (SROM; Johnson & Johnson Orthopaedics, Raynham, MA). Because late aseptic loosening is potentially less of a concern in a patient with a limited life expectancy, it was thought that constrained acetabular liners would allow for earlier mobilization with less risk of dislocation in this patient with bilateral simultaneous THA. A cementless tapered titanium femoral component with a grit-blasted surface (Zweymuller; PLUS Endoprothetik, Mo¨dling, Austria) with a cobalt-chrome femoral head was used on the femoral side (Fig. 2). Surgical pathology of the resected femoral heads revealed metastatic adenocarcinoma. There were no intraoperative or perioperative complications. A miniposterior approach was used with a total estimated blood loss of 600 mL [1]. The miniposterior approach is an abbreviated version of the traditional posterior approach with a smaller skin incision that still allows adequate exposure of the proximal femur and acetabulum but results in less blood loss and shorter operative time. Mobilization with weight bearing as tolerated was initiated immediately. The patient was full weight bearing without any assistive devices at 3 months. Her disease progressed 36 months later, and chemotherapy was
Patient comfort, safety, and rapid return to the best possible quality of life are paramount when considering orthopaedic intervention for pathologic fractures in patients with limited life expectancy. Relief of pain, independence in activities of daily living, and ambulation are the goals of treatment if the patient is expected to survive the primary disease process [2]. In this case of bilateral lower extremity involvement, operative intervention was indicated to allow the patient to ambulate, and prosthetic replacement was thought to be the best means to obtain early mobilization and weight bearing. Cemented THA has been used with success in pathologic fracture of the hip and in fracture-dislocations [3–7]. Reports of increased morbidity and mortality associated with cemented THA, especially
Fig. 2. Simultaneous bilateral THA was done with a tapered titanium cementless femoral component (Zweymuller, PLUS; Switzerland). A modular cementless component with multiple screw fixation and a constrained liner was used for acetabulum reconstruction (SROM; Johnson & Johnson Orthopaedics, Raynham, MA).
666 The Journal of Arthroplasty Vol. 17 No. 5 August 2002 with regard to potential embolic phenomenon to the lungs with cement pressurization [8 –10], and the presence of a significant pulmonary shunt in this patient suggested that cementless fixation would be preferable in this scenario. This type of femoral component has shown reliable osseointegration in a variety of unfavorable situations, including Dorr type C bone and in elderly patients [11–15]. Cementless fixation and satisfactory outcome were achieved in this patient. The goals of rapid recovery, ambulation, and weight bearing were achieved without the concomitant risks of cemented fixation. Cementless fixation with this type of implant should be considered in patients with pathologic fractures of the hip.
References 1. Lester DK, Helm MH: Limited approach to total hip arthroplasty. J Orthop Traumatol No 4, 2001, pp 245-253 2. Peer PG, Verbeek AL, Mravunac M, et al: Prognosis of younger and older patients with early breast cancer. Br J Cancer 73:382, 1996 3. Algan SM, Horowitz SM: Surgical treatment of pathologic hip lesions in patients with metastatic disease. Clin Orthop 332:223, 1996 4. Coventry MB: The treatment of fracture-dislocation of the hip by total hip arthroplasty. J Bone Joint Surg Am 56:1128, 1974 5. Matta JM: Operative treatment of acetabular fractures through the ilioinguinal approach: a 10-year perspective. Clin Orthop 335:10, 1994 6. Papagelopoulos PJ, Galanis EC, Greipp PR, Sim FH:
7.
8.
9.
10.
11.
12.
13.
14.
15.
Prosthetic hip replacement for pathologic or impending pathologic fractures in myeloma. Clin Orthop 341:192, 1997 Voggenreiter G, Assenmacher S, Klaes W, SchmitNeuerburg K: Pathological fractures of the proximal femur with impending shaft fractures treated by THR and cemented intramedullary nailing: a report of nine cases. J. Bone Joint Surg Br 78:400, 1996 Ereth MH, Weber JG, Abel MD, et al: Cemented versus noncemented total hip arthroplasty— embolism, hemodynamics, and intrapulmonary shunting. Mayo Clin Proc 67:1066, 1992 Francis CW, Marder VJ, Evarts CM: Lower risk of thromboembolic disease after total hip replacement with non-cemented than with cemented prostheses. Lancet 1:769, 1986 Lennox IA, McLauchlan J: Comparing the mortality and morbidity of cemented and uncemented hemiarthroplasties. Injury 24:185, 1993 Kutschera HP, Eyb R, Schartelmuller T, et al: [Cement-free Zweymuller hip system: results of a 5-year follow-up study]. Z Orthop Ihre Grenzgeb 131:513, 1993 Lester DK: 100-year-old patient with pressfit prosthesis: a postmortem retrieval study. Am J Orthop 25:30, 1996 Lester DK: Cross-section radiographic analysis of 10 retrieved titanium alloy press-fit femoral endoprostheses. J Arthroplasty 12:930, 1997 Zweymuller K: A cementless titanium hip endoprosthesis system based on press-fit fixation: basic research and clinical results. Instr Course Lect 35:203, 1986 Dorr LD, Faugere MC, Mackel AM, et al: Structural and cellular assessment of bone quality of proximal femur. Bone 14:231, 1993
Case Report
Bilateral Pathologic Fractures of the Hip and Acetabulum Treated With Cementless Total Hip Arthroplasty Cyna Khalily, MD,* Victor M. Ilizaliturri, Jr., MD,† and D. Kevin Lester, MD‡
Abstract: Pathologic fractures from metastatic cancer pose formidable challenges to the orthopaedic surgeon technically and in terms of surgical decision making with regards to patient quality of life. We present the case of a 47-year-old woman with simultaneous bilateral pathologic femoral neck and acetabulum fractures and severe pulmonary shunt, who was treated successfully with cementless femoral and acetabular implants. Key words: pathologic fracture, cementless total hip arthroplasty (THA), simultaneous bilateral THA. Copyright 2002, Elsevier Science (USA). All rights reserved.
The pelvis and proximal femur are frequent sites of metastatic involvement in patients with breast cancer. Pathologic fractures in this area pose formidable challenges to the orthopaedic surgeon not only in terms of technical difficulty, but also in terms of decision making with regards to patient quality of life. Solutions range from conservative medical treatment to operative stabilization to prosthetic replacement. We present the case of a 47-year-old woman with advanced metastatic breast cancer who presented with simultaneous bilateral pathologic fractures of both acetabula and femoral necks and life-threatening pulmonary shunt secondary to
tumor infiltration of the pulmonary lymphatic system. Simultaneous bilateral total hip arthroplasty (THA) was done with cementless femoral and acetabular implants without any intraoperative or postoperative complications. Early ambulation resulted in a significant increase in quality of life with no evidence of loosening at 3-year follow-up.
Case Report A 47-year-old woman presented in the emergency department after suffering a seizure. She had no previous history of seizure disorder and was not under medical care for any acute or chronic illness. Initial assessment revealed bilateral femoral neck and acetabulum fractures (Fig. 1). Lytic lesions in the pelvis and proximal femur suggested a pathologic process. Further investigation revealed biopsyproven right breast carcinoma with positive lymph nodes and metastasis to brain, liver, and bone. Metastatic involvement of the lung with a significant pulmonary shunt also was found. Oncology consultation suggested that even in the face of stage
From *Private practice, Wellington Orthopaedics and Sports Medicine, Cincinnati, Ohio; †Private practice, Mexico City, Mexico; and ‡Private practice, Fresno, California. Submitted April 30, 2001; accepted February 2, 2002. No benefits or funds were received in support of this study. Reprint requests: Cyna Khalily, MD, Wellington Orthopaedics and Sports Medicine, 5589 Cheviot Road, Cincinnati, OH 45247. E-mail: [email protected] Copyright 2002, Elsevier Science (USA). All rights reserved. 0883-5403/02/1705-0011$35.00/0 doi:10.1054/arth.2002.32703
664
THA for Bilateral Pathologic Fracture • Khalily et al.
665
initiated with cyclophosphamide, methotrexate, and 5-fluorouracil. At 56-month follow-up, the patient had a Harris hip score of 92 and no radiographic evidence of implant loosening.
Discussion
Fig. 1. At presentation, radiographs revealed bilateral femoral neck and acetabulum fractures.
4 metastatic disease, a patient could live years with proper treatment. The tumor was found to be amenable to tamoxifen therapy. After extensive pulmonary treatments, medical clearance was obtained 12 days after presentation, and simultaneous bilateral THA was done. A cementless metal-backed implant with multiple screw fixation and a locking ring acetabular insert was used for acetabulum reconstruction (SROM; Johnson & Johnson Orthopaedics, Raynham, MA). Because late aseptic loosening is potentially less of a concern in a patient with a limited life expectancy, it was thought that constrained acetabular liners would allow for earlier mobilization with less risk of dislocation in this patient with bilateral simultaneous THA. A cementless tapered titanium femoral component with a grit-blasted surface (Zweymuller; PLUS Endoprothetik, Mo¨dling, Austria) with a cobalt-chrome femoral head was used on the femoral side (Fig. 2). Surgical pathology of the resected femoral heads revealed metastatic adenocarcinoma. There were no intraoperative or perioperative complications. A miniposterior approach was used with a total estimated blood loss of 600 mL [1]. The miniposterior approach is an abbreviated version of the traditional posterior approach with a smaller skin incision that still allows adequate exposure of the proximal femur and acetabulum but results in less blood loss and shorter operative time. Mobilization with weight bearing as tolerated was initiated immediately. The patient was full weight bearing without any assistive devices at 3 months. Her disease progressed 36 months later, and chemotherapy was
Patient comfort, safety, and rapid return to the best possible quality of life are paramount when considering orthopaedic intervention for pathologic fractures in patients with limited life expectancy. Relief of pain, independence in activities of daily living, and ambulation are the goals of treatment if the patient is expected to survive the primary disease process [2]. In this case of bilateral lower extremity involvement, operative intervention was indicated to allow the patient to ambulate, and prosthetic replacement was thought to be the best means to obtain early mobilization and weight bearing. Cemented THA has been used with success in pathologic fracture of the hip and in fracture-dislocations [3–7]. Reports of increased morbidity and mortality associated with cemented THA, especially
Fig. 2. Simultaneous bilateral THA was done with a tapered titanium cementless femoral component (Zweymuller, PLUS; Switzerland). A modular cementless component with multiple screw fixation and a constrained liner was used for acetabulum reconstruction (SROM; Johnson & Johnson Orthopaedics, Raynham, MA).
666 The Journal of Arthroplasty Vol. 17 No. 5 August 2002 with regard to potential embolic phenomenon to the lungs with cement pressurization [8 –10], and the presence of a significant pulmonary shunt in this patient suggested that cementless fixation would be preferable in this scenario. This type of femoral component has shown reliable osseointegration in a variety of unfavorable situations, including Dorr type C bone and in elderly patients [11–15]. Cementless fixation and satisfactory outcome were achieved in this patient. The goals of rapid recovery, ambulation, and weight bearing were achieved without the concomitant risks of cemented fixation. Cementless fixation with this type of implant should be considered in patients with pathologic fractures of the hip.
References 1. Lester DK, Helm MH: Limited approach to total hip arthroplasty. J Orthop Traumatol No 4, 2001, pp 245-253 2. Peer PG, Verbeek AL, Mravunac M, et al: Prognosis of younger and older patients with early breast cancer. Br J Cancer 73:382, 1996 3. Algan SM, Horowitz SM: Surgical treatment of pathologic hip lesions in patients with metastatic disease. Clin Orthop 332:223, 1996 4. Coventry MB: The treatment of fracture-dislocation of the hip by total hip arthroplasty. J Bone Joint Surg Am 56:1128, 1974 5. Matta JM: Operative treatment of acetabular fractures through the ilioinguinal approach: a 10-year perspective. Clin Orthop 335:10, 1994 6. Papagelopoulos PJ, Galanis EC, Greipp PR, Sim FH:
7.
8.
9.
10.
11.
12.
13.
14.
15.
Prosthetic hip replacement for pathologic or impending pathologic fractures in myeloma. Clin Orthop 341:192, 1997 Voggenreiter G, Assenmacher S, Klaes W, SchmitNeuerburg K: Pathological fractures of the proximal femur with impending shaft fractures treated by THR and cemented intramedullary nailing: a report of nine cases. J. Bone Joint Surg Br 78:400, 1996 Ereth MH, Weber JG, Abel MD, et al: Cemented versus noncemented total hip arthroplasty— embolism, hemodynamics, and intrapulmonary shunting. Mayo Clin Proc 67:1066, 1992 Francis CW, Marder VJ, Evarts CM: Lower risk of thromboembolic disease after total hip replacement with non-cemented than with cemented prostheses. Lancet 1:769, 1986 Lennox IA, McLauchlan J: Comparing the mortality and morbidity of cemented and uncemented hemiarthroplasties. Injury 24:185, 1993 Kutschera HP, Eyb R, Schartelmuller T, et al: [Cement-free Zweymuller hip system: results of a 5-year follow-up study]. Z Orthop Ihre Grenzgeb 131:513, 1993 Lester DK: 100-year-old patient with pressfit prosthesis: a postmortem retrieval study. Am J Orthop 25:30, 1996 Lester DK: Cross-section radiographic analysis of 10 retrieved titanium alloy press-fit femoral endoprostheses. J Arthroplasty 12:930, 1997 Zweymuller K: A cementless titanium hip endoprosthesis system based on press-fit fixation: basic research and clinical results. Instr Course Lect 35:203, 1986 Dorr LD, Faugere MC, Mackel AM, et al: Structural and cellular assessment of bone quality of proximal femur. Bone 14:231, 1993