By Dimitrios Christoforou, MD; Alexander Golant, MD; Paul J. Ort, MD
ORTHOPEDICS 2010; 33:202
Managing skeletal metastatic disease can be a challenging task for the orthopedic surgeon. In patients who have poor survival prognoses or are poor candidates for extensive reconstructive procedures, management with intralesional curettage and stabilization with bone cement with or without internal fixation to prevent development or propagation of a pathologic fracture may be the best option. The use of bone cement is preferable over the use of bone graft, as it allows for immediate postoperative weight bearing on the affected extremity.
This article describes a case where the combined use of arthroscopy and a 2-stage cementation technique may allow preservation of the articular surface and optimization of short-term functional outcome after curettage of a periarticular metastatic lesion in a patient with an end-stage malignancy. We used knee arthroscopy to identify any articular penetration or intra-articular loose bodies after curettage and initial cementation of the periarticular lesion of the distal femur. Arthroscopic evaluation was carried out again after the lesion was packed with cement to identify and remove any loose intra-articular debris. The applicability of this technique is broad, and it can be used in any procedure involving cement packing in a periarticular location. Performed with caution, this technique can be a useful adjunct to surgical management of both malignant and locally aggressive benign bone lesions in periarticular locations.
Managing skeletal metastatic disease can be a challenging task for the orthopedic surgeon. The most common primary malignancies that metastasize to bone are lung, breast, prostate, kidney, and thyroid. Skeletal metastases, especially lytic ones, increase the risk of pathologic fracture by destroying the normal architecture of host bone. Over the past 3 decades, medical advances have led to improvements in the treatment of oncologic patients, leading to prolonged survival rates. Subsequently, an increasing incidence has been noted of recognized bone metastases and resultant pathologic fractures of the long bones, pelvis, and spine.1 When they occur, pathologic fractures often result in significant pain and disability, and ideally should be prevented by prophylactic stabilization in patients with appropriate survival prognosis and functional capacity. Current surgical techniques for preventative as well as acute stabilization of pathologic fractures have yielded good results with respect to pain relief and return to ambulation and functional activities.1-6
In a patient with a large periarticular metastasis, complete excision of the lesion along with prosthetic reconstruction of the joint may be undertaken, as long as the patient has a reasonable survival prognosis and is able to tolerate such a surgery. However, patients who have poor survival prognoses, measurable only in months, or are poor candidates for extensive reconstructive procedures may be best managed with intralesional curettage and stabilization with bone cement with or without internal fixation, to prevent development or propagation of a pathologic fracture. The use of bone cement is preferable over the use of bone graft, as it allows for immediate postoperative weight bearing on the affected extremity.
Special concerns during curettage and cementation of periarticular lesions include minimizing mechanical (from sharp instruments) and thermal (from the exothermic cement hardening process) damage to the articular surface and preventing extrusion of cement into the joint. This article describes an alternative cementation technique and the use of knee arthroscopy to help prevent articular damage during intralesional curettage and cement stabilization of a distal femoral periarticular non-small cell lung carcinoma metastasis.
A 73-year-old man with stage IV non-small cell lung cancer with metastases to the brain, T11, right symphysis pubis, right femoral head, left femoral head, and intertrochanteric region presented with left knee pain. He localized the pain to the lateral aspect of his knee, reported that it was worse with weight bearing, and required the use of crutches for ambulation.
Prior to the onset of pain, the patient was a community ambulator without assistive devices. Twenty-one months prior, he had been diagnosed with lung cancer, and he was status post several rounds of chemotherapy and radiation therapy to the brain and lower extremities. He was also 18 months status post right hip long-stem hemiarthroplasty, performed for treatment of a femoral head metastatis.
On physical examination, the patient’s left knee had a mild warm effusion and was tender to palpation over the lateral femoral condyle and the lateral joint line. Active range of motion was full, and the knee was stable and intact neurovascularly. Examination of the contralateral knee and of both hips was unremarkable.
Radiographs and a computed tomography (CT) scan of the left knee showed a lytic lesion in the posterior aspect of the lateral femoral condyle measuring up to 7.8 cm in diameter, with a thin rim of intact distal subchondral bone and with a nondisplaced fracture of the lateral cortex (Figures 1, 2). The patient was made nonweight bearing on the affected extremity and was admitted for further diagnostic workup and management.
|Figure 1: AP (A) and lateral (B) radiographs of the left knee demonstrating a large lytic lesion in the lateral femoral condyle.|
|Figure 2: Sagittal (A), axial (B, C), and coronal (D) CT images further demonstrating the extent of the lesion, its subchondral location, cortical thinning, and minimally displaced fracture in the posterolateral aspect of the condyle.|
Three-phase technetium bone scan showed increased uptake over the left knee and left T11 costovertebral junction as well as in the spinous processes of the upper thoracic spine. The distal femoral lesion was a new finding in comparison to a previous bone scan from 1 year earlier. Magnetic resonance imaging showed an aggressive-appearing subchondral lesion in the posterior lateral femoral condyle with associated synovitis and additional satellite lesions consistent with metastatic loci (Figure 3).
|Figure 3: T1 (A, B) and T1 fat-saturated (C) MR images of the left knee show absence of a soft tissue mass and additional small intramedullary satellite lesions in the distal femur.|
A multidisciplinary decision was made to perform stabilization of the lateral femoral condyle by intralesional curettage and cementation of the lesion. The goal was to alleviate pain and return the patient to his previous ambulation level with minimal or no assistive device support.
The patient was placed supine on the operating table with a padded bump under the left (ipsilateral) hip. Elevation of the extremity was done to exsanguinate it and the tourniquet was inflated. A direct longitudinal lateral incision was made, centered over the lateral femoral condyle just at the posterior aspect of the iliotibial band. Once exposed, the iliotibial band was retracted anteriorly. The periosteum was incised and elevated in the interval between the iliotibial band and the biceps femoris. At this point, a small area of cortical penetration was noted on the posterolateral aspect of the lateral femoral condyle and the tumor was grossly visualized. Next, a 2×2-cm posterolateral cortical window was created with an oscillating saw, providing access to the intramedullary cavity of the lateral femoral condyle. The contents of the cavity were carefully debrided by a curette and sent to pathology. The condyle was then irrigated, and bone wax was used to cover any areas of cortical violation to prevent extravasation of cement into the joint.
An initial base coat of cement was applied along the inner surface of the condyle without pressurizing and allowed to harden. To identify any intra-articular cement or bone wax extravasation, diagnostic knee arthroscopy was performed using anterolateral and anteromedial portals. Systematic arthroscopic examination of the left knee joint showed no loose bodies, no articular surface violation, and no intra-articular cement or wax (Figure 4). A second bag of cement was then mixed and used to fill the remainder of the cavity using manual pressurization.
|Figure 4: Intraoperative arthroscopic images show an intact articular surface of the distal lateral femoral condyle (A, B).|
Arthroscopic examination of the knee confirmed that the joint was free of loose cement or bone wax and that there was no distal femoral articular surface perforation in the lateral compartment. The knee joint was irrigated and the arthroscopic portals were closed. The cortical window was placed back into position. The lateral incision was irrigated and closed in layers. Postoperative radiographs were taken in the operating room prior to extubation.
Postoperatively prophylactic antibiotics were administered for 24 hours. The patient was allowed partial weight bearing with crutches and started on a physical therapy program for ambulation re-training. He progressed to full weight bearing by 5 weeks postoperatively and was able to ambulate without significant pain in the community setting. The patient died from complications of his lung cancer 4 months postoperatively.
Lung cancer is the leading worldwide cause of smoking- and cancer-related mortality in both men and women. Nearly 70% of patients with lung cancer present with locally advanced or metastatic disease at the time of their diagnosis. Non-small cell lung cancer accounts for approximately 75% to 80% of all lung cancers.2 Five-year survival rate for all stages of non-small cell lung cancer combined is approximately 15%.2 According to one study, 8% of patients with non-small cell lung carcinoma had bone pain secondary to metastases as their initial presenting symptom.3
Patients with lung cancer that has metastasized to bone have a poor prognosis, with average survival of <6 months.2 Prophylactic fixation for long bone metastases is recommended in cases where 30% to 50% of the cortex has been destroyed, when pain is present following radiotherapy, or in patients with an overall life expectancy of >3 months.4 A multidisciplinary approach, involving medical and surgical oncology specialists as well as radiation oncologists, is essential for appropriate treatment of these patients.
Peri-articular metastases in patients with advanced stages of cancer are unusual and are most commonly seen affecting the proximal aspect of the femur. Furthermore, lung cancer metastatic to bone is known for a pattern of unusual metastatic spread, such as metastasizing subperiosteally or distal to the knee or the elbow.2,7 Significant pain and disability can result from these lesions, especially when subchondral bone and integrity of a weight-bearing joint such as the knee or the hip, is compromised.
Curettage has been used for the treatment of locally aggressive benign, low-grade malignant, and metastatic bone tumors. In the periarticular regions of the weight-bearing joints such as the knee, lesions that are at a particularly high risk of pathologic fracture are those that occupy >60% of the metaphysis in the anteroposterior projection or >80% in the medial to lateral projection, as well as those lesions that are <4 mm away from the joint line.5 After the lesion is curetted, residual bone defect is typically reconstructed with cement or bone graft, with or without supplemental internal fixation.
Bone cement is often used as an adjunct for stabilization following curettage of benign, malignant, and metastatic bone lesions. Local tumor recurrence rates have been decreased by the addition of cementation after curettage of giant cell tumors.6 This could be the result of direct cytotoxic effects of the methylmethacrylate monomer on tumor cells or from local tissue hyperthermia due to the heat generated from polymerization of the cement. When cement is used after curettage of periarticular lesions, generation of significant heat during the exothermic process of methylmethacrylate hardening can cause thermal damage to articular cartilage.
In our patient, proximity of the lesion to the knee joint and cortical penetration of the lesion posed 2 potential problems: (1) the risk of articular cartilage damage during curettage and cementation, and (2) cement extravasation into the knee joint. To avoid these potential complications that would likely compromise a patient’s functional outcome, after performing curettage of the lesion we initially used bone wax to cover any sites of cortical disruption to prevent cement extravasation into the joint. Cement was mixed and applied in 2 separate stages, with the first thin layer applied without pressurization to ensure that the curetted cavity was sealed from the joint, and a second bag mixed and applied later with manual pressurization to fill the defect and provide structural support to the distal femoral metaphysis.
Reasons for performing 2-stage cementation are to (1) decrease the risk of thermal injury to the subchondral bone and articular cartilage, and (2) isolate the curetted cavity from and prevent cement extravasation into the joint.
Several published reports address the use of arthroscopy in the surgical management of musculoskeletal tumors.7-16 Arthroscopic excision of intra-articular tumors has been reported in several joints, including the shoulder, hip, knee, and ankle.13-17 This technique offers several advantages, most notably minimal invasion of the tissues and direct visualization of the joint surface.
Ayerza et al18 described successful endoscopic resection of symptomatic osteochondroma of the distal femur with favorable functional outcome scores in their patients. Takahashi et al19 arthroscopically identified an intra-articular osteochondroma and performed a shaving procedure and excision to restore distal femoral anatomy and provide relief of mechanical symptoms.
Randelli et al20 recently reported successful and minimally invasive arthroscopic curettage and bone grafting of a unicameral bone cyst of the humeral head. Alvarez and Arnold21 described using the arthroscope to directly observe curettage of a calcaneal unicameral bone cyst. By placing the arthroscope directly into the cystic cavity, they were able to maintain the bony pillars inherently supporting the calcaneus from collapse. A similar technique was used in the resection of a chondroblastoma of the femoral head where the arthroscope was used endosteally to confirm preservation and prevent damage of the femoral head and neck.22 Combined use of CT and arthroscopy in the removal of an osteoid osteoma of the patella has also been described.23
In our patient, we used knee arthroscopy to identify any articular penetration or intra-articular loose bodies after curettage and initial cementation of the periarticular lesion of the distal femur. Identification of any articular penetration would have suggested the need for additional coating of the cavity walls with bone wax and a light coat of cement without pressurization to prevent subsequent extravasation of cement into the knee joint.
Arthroscopic evaluation was performed again after the lesion was packed with cement to identify and remove any loose intra-articular cement (none was found). Notably, the applicability of this technique is broad and can be used in any procedure involving cement packing in a peri-articular location (eg, giant cell tumor, osteonecrosis). Performed with caution, this technique can be a useful adjunct to surgical management of both malignant and locally aggressive benign bone lesions in periarticular locations.
The risks of performing arthroscopy on a joint with an adjacent periarticular malignant lesion arise from potential extravasation of fluid into the lesion, which could result in seeding of the joint and adjacent soft tissues with malignant cells. Therefore, this approach should not be used in patients with an isolated primary malignant or metastatic bony lesion and a good survival prognosis. In our patient, the long-term survival probability was low.
In a case where the primary goal of surgery is to achieve optimal function of the patient’s knee to allow pain-free and independent ambulation, the benefits of arthroscopy outweigh the risk of local spreading of malignant cells. Similarly, although many oncologic surgeons would consider the use of internal fixation such as a lateral plate for stabilization, given the patient’s medical comorbidities and poor survival prognosis, a shorter, better tolerated procedure with less risk was chosen in accordance with the literature.4
- Harrington KD. Orthopaedic surgical management of skeletal complications of malignancy. Cancer. 1997; 80(8 suppl):1614-1627.
- Riccio AI, Wodajo FM, Malawer M. Metastatic carcinoma of the long bones. Am Fam Physician. 2007; 76(10):1489-1494.
- Sosin P, Dutka J. Clinical and radiographic evaluation of mechanical sufficiency of the operative treatment of pathological fractures in bone metastases. Orthop Traumatol Rehabil. 2003; 5(3):290-296.
- Sarahrudi K, Hora K, Heinz T, Millington S, Vécsei V. Treatment results of pathological fractures of the long bones: a retrospective analysis of 88 patients. Int Orthop. 2006; 30(6):519-524.
- Dijstra S, Wiggers T, van Geel BN, Boxma H. Impending and actual pathological fractures in patients with bone metastases of the long bones. A retrospective study of 233 surgically treated fractures. Eur J Surg. 1994; 160(10):535-542.
- Atesok K, Liebergall M, Sucher E, Temper M, Mosheiff R, Peyser A. Treatment of pathological humeral shaft fractures with unreamed humeral nail. Ann Surg Oncol. 2007; 14(4):1493-1498.
- Lewis VO. What’s new in musculoskeletal oncology. J Bone Joint Surg Am. 2007; 89(6):1399-1407.
- Molina JR, Yang P, Cassivi SD, Schild SE, Adjei AA. Non-small cell lung cancer: epidemiology, risk factors, treatment, and survivorship. Mayo Clin Proc. 2008; 83(5): 584-594.
- Eguchi K, Saijo N, Shinkai T, et al. Recent status of the diagnosis and treatment of bone metastasis in patients with advanced lung cancer [in Japanese]. Gan To Kagaku Ryoho. 1987; 14(5 pt 2):1696-1703.
- Katakami N. Lung cancer with bone metastasis [in Japanese]. Gan To Kagaku Ryoho. 2006; 33(8):1049-1053.
- Pritsch T, Bickels J, Wu C, Squires HM, Malawer MM. The risk for fractures after curettage and cryosurgery around the knee. Clin Orthop Relat Res. 2007; (458):159-167.
- Nelson DA, Barker ME, Hamlin BH. Thermal effects of acrylic cementation at bone tumour sites. Int J Hyperth. 1997; 13(3):287-306.
- Gunes T, Erdem M, Bostan B, Sen C, Sahin SA. Arthroscopic excision of the osteoid osteoma at the distal femur. Knee Surg Sports Traumatol Arthrosc. 2008; 16(1):90-93.
- Alvarez MS, Moneo PR, Palacios JA. Arthroscopic extirpation of an osteoid osteoma of the acetabulum.Arthroscopy. 2001; 17(7):768-771.
- Bojaniæ I, Orliæ D, Ivkivoc A. Arthroscopic removal of a juxtaarticular osteoid osteoma of the talar neck. J Foot Ankle Surg. 2003; 42(6):359-362.
- Heuijerjans W, Dandy DJ, Harris D. Arthroscopic excision of an intra-articular osteoid osteoma at the knee.Arthroscopy. 1986; 2(4):215-216.
- Kelly AM, Selby RM, Lumsden E, et al. Arthroscopic removal of an osteoid osteoma of the shoulder.Arthroscopy. 2002; 18(7):801-806.
- Ayerza MA, Abalo E, Aponte-Tinao L, Muscolo DL. Endoscopic resection of symptomatic osteochondroma of the distal femur. Clin Orthop Relat Res. 2007; (459):150-153.
- Takahashi M, Nishihara A, Ohishi T, Shiga K, Yamamoto K, Nagano A. Arthroscopic resection of an intra-articular osteochondroma of the knee in the patient with multiple osteochondromatosis. Arthroscopy. 2004; 20(suppl 2):28-31.
- Randelli P, Arrigoni P, Cabitza P, Denti M. Unicameral bone cyst of the humeral head: arthroscopic curettage and bone grafting. Orthopedics. 2009; 32(1): 54.
- Alvarez RG, Arnold J. Technical tip: arthroscopic assistance in minimally invasive curettage and bone grafting of a calcaneal unicameral bone cyst. Foot Ankle Int. 2007; 28(11):1198-1199.
- Thompson MS, Woodward JS Jr. The use of the arthroscope as an adjunct in the resection of a chondroblastoma of the femoral head. Arthroscopy. 1995; 11(1):106-111.
- Franceschi F, Longo UG, Ruzzini L, et al. En-bloc retrograde resection of an osteoid osteoma of the patella using computed tomography under arthroscopic control. J Knee Surg. 2008; 21(2):136-140.
Drs Christoforou and Ort are from the Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, and Dr Ort is also from the Department of Orthopedic Surgery, Manhattan VA Hospital, New York, and Dr Golant is from the Department of Orthopedics and Rehabilitation, New York Hospital Queens, Flushing, New York.
Drs Christoforou, Golant, and Ort have no relevant financial relationships to disclose.
This investigation was conducted at the Veterans Affairs Hospital, Manhattan Campus, New York, New York.
Correspondence should be addressed to: Dimitrios Christoforou, MD, Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, 301 E 17th St, 14th Floor, New York, NY 10003 (firstname.lastname@example.org).