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
Taitsman LA, Safran MR. Palliative surgery in orthopaedic oncology. J Am Acad Orthop Surg. 2010;18(6):400-410.
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.
Coleman RE, Croucher PI, Padhani AR, et al. Bone metastases. Nat Rev Dis Primers. 2020;6(1):83.
Errani C, Mavrogenis AF, Cevolani L, et al. Palliative treatment of skeletal metastases: Prognostic criteria and therapy. Int Orthop. 2015;39(9):1981-1987.
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.