RESUMO
Achieving bone fixation during megaprosthesis revision presents a formidable challenge in view of the substantial bone loss. We report treatment of a failed revision distal femoral replacement in an active 36-year-old male mechanic remotely treated for osteosarcoma. A custom stem and cone were manufactured to augment fixation and preserve bone stock within a short segment of the remaining proximal femur. The patient returned to regular function without the need for assistive devices. Follow-up imaging demonstrated stable implant fixation at 1-year follow-up. While cones and sleeves have vastly improved fixation in revision knee arthroplasty, a custom-made cone for the proximal femur was used to augment fixation of a revision megaprosthesis and obviate the use of a total femoral replacement.
RESUMO
BACKGROUND: Metastasis to the bone is one of the most common complications associated with advanced cancer. Patients with bone metastases are at risk of devastating skeletal related events, including pathological fractures. PURPOSE: The aim of this study was to analyze the efficacy of zoledronic acid (ZA) versus denosumab in the prevention of pathological fractures in patients with bone metastases from advanced cancers by evaluating all available randomized controlled trials (RCTs) on this subject. METHODS: A systematic search of electronic databases (PubMed and MEDLINE) was performed to identify all published RCTs comparing ZA with denosumab in prevention of pathological fractures in bone metastases. Risk of bias of the studies was assessed. The primary outcomes evaluated were pathological fractures. RESULTS: Four RCTs (7,320 patients) were included. Denosumab was superior to ZA in reducing the likelihood of pathological fractures, when all tumor types were combined (odds ratio [OR] 0.86, 95% confidence interval [CI], 0.74 to 0.99, P = 0.04). Denosumab was favored, although not statistically significant, over ZA in endodermal origin (breast and prostate) (OR 0.85, 95% CI, 0.68 to 1.05, P = 0.13) and mesodermal origin tumors (solid tumors and multiple myeloma) (OR 0.87, 95% CI, 0.71 to 1.06, P = 0.16). DISCUSSION: Denosumab moderately reduces the likelihood of pathological fractures in comparison to ZA in patients with bone metastases with statistical significance. When pathological fractures were grouped by tumor origin (endodermal or mesodermal), no statistical difference was observed between denosumab and ZA. Further long-term studies are needed to confirm the effectiveness of these treatment regimens.