Oncological and functional outcomes of pathological fractures of lower extremities in patients with malignant bone tumors

Abstract

Abstract Background: Managing pathological fractures of the extremities can be difficult. We aimed to suggest our treatment algorithm for lower bone malignancies. Methods: Thirty-eight patients with impending and pathological fractures treated at our department were included. Age, sex, fracture site, type of primary malignancy, number of metastases, pre-fracture Eastern Cooperative Oncology Group performance status (ECOG-PS) score, adjuvant therapy, treatment modality, operative time, blood loss, postoperative complications, Musculoskeletal Tumor Society (MSTS) score, outcomes, and follow-up period were retrospectively surveyed. Post-treatment MSTS scores in cases of impending and pathological fractures were compared. The MSTS scores were compared between intramedullary nail fixation and surgical procedures other than intramedullary nail fixation. The postoperative 1-year survival rate was calculated using the Kaplan–Meier method. Results: The median age of the sample was 68 years. The disease sites were the subtrochanteric femur in 10 patients, the trochanteric femur in eight, the femoral diaphysis in seven, the femoral neck in five, the bilateral trochanteric femur in three, the proximal tibia in three, and the distal femur in two. Ten patients had metastases in ≤3 and 20 sites. The median pre-fracture ECOG-PS score was 1. As adjuvant chemotherapy, radiotherapy was administered to five, chemotherapy to eight, and radiotherapy and chemotherapy to 10 patients. Surgical procedures included intramedullary nails in 18 patients; tumor arthroplasty in four; plate fixation in three; artificial head replacement in three; compression hip screw (CHS) in three; conservative treatment in two; bilateral intramedullary nail fixation in two; and artificial bone stem with combined intramedullary nail and plate fixation, right-sided artificial head replacement, and left-sided CHS in one each. The operating time was 100±45.8 minutes, and blood loss was 63±153.4 mL. The MSTS score was 19.9±8.95 for intramedullary nail fixation and 24.3±7.45 for other procedures, with a negative correlation between the MSTS score and pre-fracture ECOG-PS. The median follow-up period was 8 months. The outcomes were as follows: alive with disease, 23 patients; continued disease-free, 1 patient; and dead due to disease, 14 patients. The 1-year postoperative overall survival rate was 60.5%. Conclusions: Our treatment algorithm for malignant bone tumors of the lower extremity was useful.