CORR Insights^®: Complications of Cemented Long-stem Hip Arthroplasties in Metastatic Bone Disease Revisited

Excerpt

Metastatic bone disease occurs in patients who often are older, sicker, and more debilitated than patients without such disease. Many patients with metastatic cancer have spent considerable time, effort, and resources on their treatment prior to the diagnosis of metastasis. As surgeons, we do not wish to add any more to the treatment burden than is necessary. Therefore, when surgery is called for, we seek to perform one durable operation that relieves pain, preserves function, and minimizes complications in these patients. Too little surgery may be quick and easy, but provides poor durability. Too much surgery may provide a more durable reconstruction, but at the cost of unnecessary postoperative morbidity. Predicting the future response of the disease to systemic treatment, radiation therapy, and bisphosphonates adds further complexity to the decision. Conventional wisdom suggests that in the risk/benefit analysis, prophylactically stabilizing the femur with a long stem is preferable, preventing the need for a second operation. Case reports of intraoperative death attributed to a large monomer load and marrow embolization raised concerns about the safety of this technique. In the current study, Price and colleagues reported transient cardiopulmonary derangements, but concluded that long-stem femoral implants are an appropriate surgical option, and remain their preference. However, another recent CORR ^® publication [1] found a lack of disease progression in patients with tumors other than myeloma and renal cell carcinoma, along with a similar rate of physiologic nonfatal complications. This led the senior author to state in the Editor’s Spotlight/Take 5 interview [2], “I have been less aggressive with putting in long-stem cemented femoral components that protect the entire femur.” The unanswered questions are how often does a metastasis actually develop distal to the tip of a conventional femoral stem? If it happens often enough — such that conventional wisdom is right — are there specific techniques or subgroups of patients that will allow for safe use of long cemented stems? …