A 71-year-old woman with worsening left hip pain that became acutely severe
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A 71-year-old woman presented to the ED with gradually worsening left hip pain that became acutely severe. She had known metastatic thyroid cancer and was receiving palliative therapy.
The patient reported an inability to bear weight on her left lower extremity for several days, but had no recent falls or trauma. She denied night pain or pain at rest. On exam, the patient was mildly tender to palpation over the hip, particularly on the lateral side. She had full and painless active and passive range of motion and no pain with log roll while lying supine. An anteroposterior (AP) radiograph of the pelvis demonstrated a large periacetabular lytic lesion with superolateral migration of the femoral head (Figure 1).
1. An AP pelvis radiograph demonstrated a large periacetabular lytic lesion with collapse of the superolateral acetabular dome and migration of the femoral head.
Source: Felasfa Wodajo, MD
What is the next step in management for this patient?
See answer below.
Cross-sectional imaging, palliative ‘acetabular hemiarthroplasty’ preceded by embolization
A CT scan of the pelvis was performed, which demonstrated a near complete lysis of the posterior column and superior weight-bearing dome of the acetabulum with superior migration of the femoral head (Figure 2). Given the amount of disease the patient had with subchondral involvement of the acetabulum, operative intervention was recommended to restore the structural integrity of the patient’s left hip and to provide for early ambulation.
With her history of known metastatic thyroid carcinoma, the patient was first treated by interventional radiology with pelvic embolization to reduce the risk of intraoperative bleeding. She was taken to the OR the next day for a modified hemiarthroplasty. As the region of bone loss was primarily posterior, a posterolateral approach was utilized (for anterior column bone loss, we would consider an ilioinguinal approach). The patient was placed in the lateral decubitus position on a radiolucent operative table. A standard Kocher-Langenbeck approach to the acetabulum was performed and a corticotomy in the posterior column was made to expose the lytic region. The hip capsule was never violated during the procedure. The tumor was removed using a curette and the femoral head was directly visualized through the cortical window in the pelvis. Subchondral bone loss was measured using direct visualization and determined to be approximately 4 cm in arc length.
Modified acetabular liner
A 40-mm acetabular liner was modified to fit the 4-cm arc using a small oscillating saw (Figure 3). Approximately two-thirds of the cup was discarded and the retained portion of the liner was inserted through the corticotomy using a Kocher clamp and was confirmed to provide good coverage of the femoral head on fluoroscopy. A cement gun was used to inject methylmethacrylate bone cement into the space between the pelvis bone and the polyethylene liner. The cement was pressurized using hand packing (Figure 4). Range of motion testing on the table demonstrated excellent stability through maximum internal rotation with the hip flexed to 90°. The wound was copiously irrigated and closed in a standard fashion. The patient was taken to the recovery room in stable condition.
Postoperatively, the patient was made weight-bearing as tolerated. She successfully mobilized on postoperative day 1 with physical therapy and was able to ambulate approximately 30 feet. Her postoperative radiographs demonstrated appropriate alignment of the acetabular component and cement after weight-bearing (Figure 5). She was discharged to an acute rehabilitation facility on postoperative day 3. After discharge, she completed a course of palliative radiotherapy to the acetabulum. Approximately 1 year after surgery, she developed a separate, new painful metastasis in the ipsilateral posterior pelvis, which was successfully palliated with radiotherapy alone. At her last follow-up visit 18 months after surgery, she reported minimal pain, was using a walker for community ambulation and did not need assistive devices while at home.
Discussion
The pelvis is a common site for metastatic carcinoma. Periacetabular lesions can be managed nonoperatively if they remain small and located outside the weight-bearing regions of the joint. In addition to pain control and diphosphonate therapy, radiation can provide adequate palliation in most instances. Surgical management is required in cases of significant destruction of periacetabular bone, as well as when patients experience persistent pain and functional deficits despite nonoperative modalities.
Several surgical techniques are described in the literature. A minimally invasive approach is to inject cement into the defect without the need for arthroplasty, but these methods may not be feasible when there is severe bone loss, as was seen in the patient presented. In the setting of metastatic disease, margins are not considered, but the goal of curettage is removal of the lytic mass until healthy bone is palpated along the walls of the defect. This step provides local control of disease and ensures the durability of the reconstruction with weight-bearing and postoperative radiotherapy. Total hip arthroplasty is the most commonly reported technique in patients with larger defects. Variations of THA are performed depending on the level and location of bone loss. For example, patients with an intact medial wall and adequate subchondral bone can be successfully managed with curettage and a cemented cup. The reconstructive techniques become more invasive in cases of significant bone loss. If the patient has a medial wall deficit, a cage is used to reconstruct the defect. More destructive disease patterns involving the acetabular roof often require an extensive cage with flanges to provide stability. A “Harrington” procedure is another method that involves placement of retrograde Steinmann pins in the periacetabulum followed by a cemented cup to fill in for the missing bone. Although THA and cage variations provide hip stability and functional improvement, there is a significant complication rate due to dislocation, prosthesis loosening, blood loss and infection. One study reported that patients who underwent cage reconstruction required an average of 2.6 units of packed red blood cells during hospitalization. Additionally, up to 26% of patients required revision for infection, dislocation and implant loosening.
It is worth noting that a “tripod” method was recently reported in which three percutaneous cannulated screws were inserted in the periacetabulum of 20 patients with metastatic disease. The authors of the study cited prolonged surgical time, substantial blood loss and the 30% complication rate associated with reconstructive techniques as the motivation to develop more minimally invasive methods to restore acetabular stability. Although the follow-up period was modest, 80% of patients were able to mobilize on the first postoperative day. Additionally, patients experienced significant improvement in their pain and functional scores at near-term follow-up and had no reported complications.
Similar to the “tripod” technique, we describe here a novel procedure that allows for restoration of joint function in the setting of severe periacetabular bone loss without performing THA. In contrast, the authors of the “tripod” technique excluded patients with articular surface disruption or protrusio. The technique we describe provides an option for restoring subchondral integrity without the need for THA. Furthermore, the novel technique may decrease the risk of dislocation by preserving the integrity of the hip capsule compared with THA. Due to the reduced surgical trauma, patients may also experience a more rapid recovery and resume necessary palliative systemic therapy. This novel “acetabular hemiarthroplasty” technique may be a valuable option for surgical palliation of periacetabular metastatic disease with significant bone loss.
- References:
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- For more information:
- Stephen Lockey, MD, MBA, is a resident in orthopedic surgery at Medstar Georgetown University Hospital. He can be reached at 3800 Reservoir Road NW, Washington, DC 20007; email: sdlockey4@gmail.com.
- Felasfa Wodajo, MD, is an orthopedic oncologist at Virginia Cancer Specialists. He can be reached at 8503 Arlington Blvd., Suite 400, Fairfax, VA 22031; email: wodajo@tumors.md.
- Edited by Travis Frantz, MD, and Ian Savage-Elliott, MD. Frantz is a sports medicine and shoulder fellow at TRIA Orthopaedic Center in Minneapolis. He completed his orthopedic surgery residency at The Ohio State University Wexner Medical Center in Columbus, Ohio. Savage-Elliott is a chief resident in the department of orthopedic surgery at Tulane University Medical Center in New Orleans. He will pursue fellowship training in foot and ankle and sports medicine following residency completion. For information on submitting Orthopedics Today Grand Rounds cases, please email: orthopedics@healio.com.
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