Palliative Surgery

General Principles

· Goal: Not curative, but aimed at improving quality of life.

· Priorities: Pain control, restoration of function/mobility, prevention of complications.

· Decision Basis: Expected survival, tumor type, anatomical site, patient performance status, and multidisciplinary evaluation.

1. Pathological Fractures

Indications

· Fractures due to metastatic lesions (especially in weight-bearing bones).

· Severe pain, loss of function, or bed confinement.

· If pain is controllable in terminal patients with very poor performance status → consider non-operative palliation (brace/orthosis, analgesia, radiotherapy).

Surgical Goals

· Pain palliation, reduction of opioid requirement.

· Early mobilization, prevention of immobility-related complications.

· Restoration of mechanical stability for the remainder of life.

Preferred Techniques

· Intramedullary Nailing: First-line for long bone fractures, spanning the entire bone.

· Endoprosthesis (Joint Replacement): For intra-articular or periarticular fractures (e.g., proximal femur/humerus).

· Cement Augmentation (PMMA): Fills defects, increases implant stability, provides immediate fixation.

· Segmental Resection + Reconstruction: Rare, reserved for select cases (e.g., myeloma with healing potential).

Key Considerations

· Definitive diagnosis required: Biopsy before fixation.

· Suspected primary tumors require oncologic (curative) approach if feasible.

· Pre-op embolization for hypervascular tumors (renal, thyroid).

· Post-op radiotherapy is frequently indicated.

· Implants must provide stability throughout the patient’s expected survival.

· Risks: poor bone integration, implant failure, wound healing issues, infection.

2. Impending (High-Risk) Fractures

Indications

· Cortical destruction >50%, lesion involving >2/3 of bone diameter, >2.5 cm lytic lesions.

· Severe mechanical pain.

· Critical sites: subtrochanteric femur, femoral neck, vertebrae.

· Mirels Score ≥8 → strong indication for prophylactic fixation.

Surgical Goals

· Prevent fractures before they occur.

· Reduce morbidity compared to post-fracture surgery.

· Preserve function, maintain ambulation.

· Allow continuation of systemic therapies without interruption.

Preferred Techniques

· Intramedullary Nailing: Standard for long bones.

· Plates + Screws: In regions unsuitable for nailing, ideally cement-augmented.

· Endoprosthesis: For periarticular lesions at high fracture risk (e.g., femoral neck, proximal humerus).

· Cement Augmentation: Following curettage of cavities for added stability.

Key Considerations

· Not an emergency → allows for pre-op biopsy + staging.

· Mirels ≤7: radiotherapy and close follow-up preferred.

· Radiosensitive tumors (myeloma, lymphoma) often respond to radiotherapy alone.

· Always combine with systemic therapy (chemotherapy, hormonal, bisphosphonates/denosumab).

3. Spinal Metastases

Indications

· Instability: SINS ≥13 → surgical stabilization; 7–12 → case-dependent.

· Neurological Compression: Progressive weakness, paraplegia, sphincter dysfunction → urgent decompression + stabilization.

· Intractable Pain: Not controlled by radiotherapy or medical management.

Surgical Goals

· Decompression of spinal cord/nerve roots.

· Stabilization of spinal column, preventing deformity and mechanical pain.

· Preservation or improvement of neurological function.

· Enhanced quality of life.

Preferred Techniques

· Posterior Decompression + Instrumentation (two levels above and below).

· Anterior Corpectomy + Cage/Plate (especially cervical or thoracolumbar).

· Cement Augmentation (Vertebroplasty/Kyphoplasty): For pain relief when no neurological compression exists.

· Pre-op Embolization: Strongly recommended for hypervascular metastases.

Key Considerations

· Apply the NOMS framework (Neurologic, Oncologic, Mechanical, Systemic).

· Radiosensitive tumors (lymphoma, myeloma, prostate, breast) → consider radiotherapy first if no deficit.

· Tokuhashi score for prognosis and extent of surgery.

· High complication risks: wound issues, infection, implant failure → must weigh risks vs benefit.

4. Pelvic Metastases

Indications

· Periacetabular metastases with subchondral roof involvement (Harrington class II–III).

· Severe pain, inability to mobilize.

· Fungating, bleeding, or ulcerating local tumor masses.

Surgical Goals

· Pain palliation.

· Restoration of hip stability for sitting, standing, or limited ambulation.

· Debulking to reduce tumor burden.

Preferred Techniques

· Harrington Procedure + Cemented Prosthesis.

· Cementoplasty: For localized lesions with intact subchondral bone.

· Cemented THA (with cage/augment as needed).

· Custom Tumor Prostheses: Reserved for advanced cases.

· Minimally Invasive Acetabuloplasty: In poor surgical candidates.

Key Considerations

· Harrington classification guides technique selection.

· High bleeding risk → pre-op embolization essential.

· High infection risk → fill dead space, use prophylactic antibiotics.

· Weight-bearing protocols individualized by intra-op stability.

5. Palliative Amputation (Primary Tumors)

Indications

· Locally uncontrolled tumors (progressive, painful, infected, or bleeding).

· Severe pain and loss of function.

· Fungating wounds with foul odor/discharge.

· Non-salvageable complications (infected megaprosthesis).

Surgical Goals

· Pain control.

· Elimination of infection, odor, bleeding.

· Facilitate care and hygiene.

· Restore limited mobility (wheelchair/prosthesis).

· Psychosocial relief.

Key Considerations

· Amputation level: balance between adequate control and healing potential.

· Multidisciplinary decision, family consent critical.

· Expected survival should justify recovery from surgery.

6. Debulking / Revision Surgery

Indications

· Symptomatic bulky tumors causing compression, obstruction, or infection.

· Implant breakage/loosening.

· Local recurrence.

· Prosthesis/implant infection.

Surgical Goals

· Symptom palliation (pain, mass effect, infection).

· Maintenance of previously achieved function.

· Preserve or restore quality of life.

Techniques

· Intralesional curettage + PMMA cementation.

· Implant/prosthesis revision with stronger fixation.

· Soft tissue debulking + flap reconstruction.

· Minimally invasive ablation + cement augmentation when indicated.

7. Pediatric Patients

· Indications similar to adults (fractures, instability, severe pain, compression).

· Growth plate preservation whenever possible.

· For limited survival, adult principles apply.

· Always involve a multidisciplinary team and family.

8. Supportive Therapies

· Radiotherapy: First-line for painful metastases; SBRT highly effective for spine.

· Systemic therapy: Chemotherapy, hormonal therapy, immunotherapy.

· Bone-targeted agents: Bisphosphonates, denosumab reduce fracture risk and pain.

· Radionuclide therapies: Ra-223, Sm-153, Sr-89 (especially prostate/breast).

· Analgesics: WHO ladder approach (non-opioid → opioid → strong opioid ± adjuvants).

· Orthoses/Braces: For stabilization and pain relief when surgery not feasible.

· Rehabilitation & Psychosocial Support: Essential for patient and family.

Conclusion

· Palliative orthopedic surgery is an active therapeutic intervention.

· When properly indicated, it achieves:
➝ Pain relief
➝ Restoration of mobility
➝ Preservation of dignity and independence

· Always individualized, multidisciplinary, and guided by the principle of “first, do no harm.”

References

1. Taitsman LA, Safran MR. Palliative surgery in orthopaedic oncology. J Am Acad Orthop Surg. 2010;18(6):400-410.

2. Piccioli A, Maccauro G, Spinelli MS, Biagini R, Rossi B. Surgical management of metastatic bone disease: A comprehensive review. Surg Oncol. 2012;21(3):161-169.

3. Coleman RE, Croucher PI, Padhani AR, et al. Bone metastases. Nat Rev Dis Primers. 2020;6(1):83.

4. Errani C, Mavrogenis AF, Cevolani L, et al. Palliative treatment of skeletal metastases: Prognostic criteria and therapy. Int Orthop. 2015;39(9):1981-1987.

5. Fourney DR, Frangou EM, Ryken TC, et al. Spinal instability neoplastic score: An analysis of reliability and validity from the spine oncology study group. Spine (Phila Pa 1976). 2011;36(22):E1221-1229.