Revision of THR to Adler Pantheon proximal femoral EPR for metastatic bone disease progression surgical technique
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Metastatic bone disease commonly presents to the orthopaedic surgeon, bone being the most common site of metastasis. There are various Skeletal Related Events, or “SREs”, related to malignant bone disease most commonly pathological or impending fracture, hypercalcaemia, spinal cord compression and severe pain. These may require surgery and/or radiotherapy to palliate pain and also to maintain both the capacity to walk and quality of life.
Due to advances in the holistic management of common malignancies, particularly breast and prostate carcinoma, patient survival has been extended to the point that these are now considered chronic diseases rather than terminal diseases. Consequently, the prevalence of metastatic bone disease continues to escalate.
The goals of surgical intervention for solitary metastases are to resect the tumour en-bloc and reconstruct with curative intent but as a minimum to extend life. To reconstruct segmental bone defects after en-bloc excision endoprosthetic replacements are commonly used. Other options include allograft or allograft-prosthetic composites, but these would not typically be appropriate in metastatic bone disease. Such cases should be referred to a centre specialising in orthopaedic oncology.
With multiple sites of disease a cure is not possible surgically, therefore the treatment intent is to palliate pain, allow early weight-bearing and minimise the risk of mechanical failure, necessitating revision surgery. Carefully planning the right operation to achieve these goals is imperative. Reconstructions should aim to last the lifetime of the patient and therefore a revision procedure such as this case should be avoided. These are the guiding principles described in the British Orthopaedic Oncology Society guidelines 2015, which are also navigable from the guidelines section associated with this technique.
In this case none of those clear principles were adhered to. This patient had a solitary femoral metastasis treated intra-lesionally with a cemented total hip replacement which failed due to tumour progression within six months necessitating revision surgery for limb-salvage.
The Adler Pantheon endoprosthetic replacement utilises the latest technologies to avoid the commonest causes of failure and revision in proximal femoral endoprostheses: a 3D printed bridging collar encourages both periosteal and endosteal ingrowth and ongrowth to prevent aseptic loosening; Agluna (silver) surface treatment is now available to prevent early prosthetic joint infection.
Author: Jonathan Stevenson FRCS(Tr & Orth)
Institution: Royal Orthopaedic Hospital, Birmingham, UK
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