Prepared by Dr. Niyazi IGDE
Palliative surgery in orthopaedic oncology aims to relieve pain, preserve function, and improve quality of life in patients with advanced or incurable musculoskeletal malignancies.
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
