Skip to main content

Advertisement

SpringerLink
Log in

Distal Medullary Canal Decompression in Long Stem Hip Replacement in Long Bone Metastasis

Does it Reduce Cardiopulmonary Complications?

  • Symposium - Musculoskeletal Oncology
  • Published:
Indian Journal of Orthopaedics Aims and scope Submit manuscript

Abstract

Background

The femur is the most common long bone affected by metastatic bone disease, with 25% involving the proximal third of the femur. Long stem cemented hip replacement (LHR) is an important option for cases of impending fracture. Pulmonary embolism is a critical complication that can occur. This study evaluates the effectiveness of distal femoral canal decompression in reducing the risk of cardiopulmonary events.

Materials and Methods

Thirty two patients with metastatic bone disease of the proximal femur undergoing LHR were recruited and randomized. Conventional technique was used in 16 cases and distal decompression of the medullary canal was carried out for the other 16 patients. The decompression was carried out through a trocar inserted into the distal medullary canal, connected to a vacuum suction. Quantity of emboli was detected through A4 chambers transesophageal echocardiography; the blood pressure and oxygen saturation readings were also recorded.

Results

The decompression group experienced significantly lower Grade 2 and Grade 3 embolic events compared to the conventional group (11 vs. 26), and the duration of the embolic phenomena was shorter. Insertion of the stem and relocating the hip gave the highest amount embolic events. There was a significant drop in systolic blood pressure (SBP) in 12 out of 16 patients (75.0%) in the conventional group and 5 out of 16 patients in the decompression group (31.3%). This is statically significant (P = 0.0124). The average drop in SBP for the conventional group is 45.8 mmHg and the decompression group was 32.9 mmHg. Oxygen saturation remained at above 96% in the decompression group. However, in the conventional group, 25% of the patients had their oxygen saturation drop to below 96% during the insertion of stem and relocation of hip joint.

Conclusion

Distal femoral canal decompression is an effective method in reducing the risk of cardiopulmonary embolic events associated with LHR.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Swanson KC, Pritchard DJ, Sim FH. Surgical treatment of metastatic disease of the femur. J Am Acad Orthop Surg 2000;8:56–65.

    Article  CAS  Google Scholar 

  2. Manoso MW, Healey JH. Metastatic cancer to the bone. Principles and Practice of Oncology. 7th ed. Philadelphia: Lippincott Williams and Wilkins; 2005. p. 2368–80.

    Google Scholar 

  3. Dorfman HD. Metastatic Tumors in Bone – Bone Tumors. St. Louis: Mosby; 1998. p. 1009–40.

    Google Scholar 

  4. Bickels J, Dadia S, Lidar Z. Surgical management of metastatic bone disease. J Bone Joint Surg Am 2009;91:1503–16.

    Article  Google Scholar 

  5. Roodman GD. Mechanisms of bone metastasis. N Engl J Med 2004;350:1655–64.

    Article  CAS  Google Scholar 

  6. Chow E, Hoskin P, van der Linden Y, Bottomley A, Velikova G. Quality of life and symptom end points in palliative bone metastases trials. Clin Oncol (R Coll Radiol) 2006;18:67–9.

    Article  CAS  Google Scholar 

  7. Patterson BM, Healey JH, Cornell CN, Sharrock NE. Cardiac arrest during hip arthroplasty with a cemented long-stem component. A report of seven cases. J Bone Joint Surg Am 1991;73:271–7.

    Article  CAS  Google Scholar 

  8. Hattori H, Mibe J, Matsuoka H, Nagai S, Yamamoto K. Surgical management of metastatic disease of the proximal femur. J Orthop Surg (Hong Kong) 2007;15:295–8.

    Article  CAS  Google Scholar 

  9. Winkler M, Marker E, Hetz H. The peri-operative management of major orthopaedic procedures. Anaesthesia 1998;53:37–41.

    Article  Google Scholar 

  10. Choong PF. Cardiopulmonary Complications of intramedullary fixation of long bone metastases. Clin Orthop Relat Res 2003;415:245–53.

    Article  Google Scholar 

  11. Pitto RP, Koessler M, Kuehle JW. Comparison of fixation of the femoral component without cement and fixation with use of a bone-vacuum cementing technique for the prevention of fat embolism during total hip arthroplasty. A prospective, randomized clinical trial. J Bone Joint Surg Am 1999;81:831–43.

    Article  CAS  Google Scholar 

  12. Pearson AC, Labovitz AJ, Tatineni S, Gomez CR. Superiority of transesophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology. J Am Coll Cardiol 1991;17:66–72.

    Article  CAS  Google Scholar 

  13. Koessler MJ, Pitto RP. Fat and bone marrow embolism in total hip arthroplasty. Acta Orthop Belg 2001;67:97–109.

    CAS  PubMed  Google Scholar 

  14. Ashford RU, Pendlebury S, Stalley PD. Management of metastatic disease of the appendicular skeleton. Orthop Trauma 2006;20:299–315.

    Google Scholar 

  15. Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res 1989;249:256–64.

    Google Scholar 

  16. Gainor BJ, Buchert P. Fracture healing in metastatic bone disease. Clin Orthop Relat Res 1983;178:297–302.

    Google Scholar 

  17. Damron TA, Sim FH. Operative treatment for metastatic disease of the pelvis and proximal end of the femur. J Bone Joint Surg 2000;82:113–26.

    Article  Google Scholar 

  18. Goad KE, Gralnick HR. Coagulation disorders in cancer. Hematol Oncol Clin North Am 1996;10:457–84.

    Article  CAS  Google Scholar 

  19. Bick RL. Coagulation abnormalities in malignancy: A review. Semin Thromb Hemost 1992;18:353–72.

    Article  CAS  Google Scholar 

  20. Green KB, Silverstein RL. Hypercoagulability in cancer. Hematol Oncol Clin North Am 1996;10:499–530.

    Article  CAS  Google Scholar 

  21. DeLoughery TG. Management of acquired bleeding problems in cancer patients. Emerg Med Clin North Am 2009;27:423–44.

    Article  Google Scholar 

  22. Letai A, Kuter DJ. Cancer, coagulation, and anticoagulation. Oncologist 1999;4:443–9.

    Article  CAS  Google Scholar 

  23. Enneking FK. Cardiac arrest during total knee replacement using a long-stem prosthesis. J Clin Anesth 1995;7:253–63.

    Article  CAS  Google Scholar 

  24. Fitzgerald R, Mason L, Kanumilli V, Kleinhomer K, Sakamoto A, Johnson C, et al. Transient cardiac standstill associated with embolic phenomena diagnosed by intraoperative transesophageal echocardiography during cemented total hip arthroplasty. Anesth Analg 1994;79:382–5.

    Article  CAS  Google Scholar 

  25. Kerr PS, Jackson M, Atkins RM. Cardiac arrest during intramedullary nailing for femoral metastases. J Bone Joint Surg Br 1993;75:972–3.

    Article  CAS  Google Scholar 

  26. Lewis RN. Respiratory complications of bone cement insertion during total hip replacement under spinal anaesthesia. Eur J Anaesthesiol 1997;14:52–4.

    Article  CAS  Google Scholar 

  27. Parvizi J, Holiday AD, Ereth MH, Lewallen DG. The frank stinchfield award. Sudden death during primary hip arthroplasty. Clin Orthop Relat Res 1999;369:39–48.

    Google Scholar 

  28. Byrick RJ, Mullen JB, Mazer CD, Guest CB. Transpulmonary systemic fat embolism. Studies in mongrel dogs after cemented arthroplasty. Am J Respir Crit Care Med 1994;150:1416–22.

    Article  CAS  Google Scholar 

  29. Edmonds CR, Barbut D, Hager D, Sharrock NE. Intraoperative cerebral arterial embolization during total hip arthroplasty. Anesthesiology 2000;93:315–8.

    Article  CAS  Google Scholar 

  30. Pell AC, Hughes D, Keating J, Christie J, Busuttil A, Sutherland GR, et al. Brief report: Fulminating fat embolism syndrome caused by paradoxical embolism through a patent foramen ovale. N Engl J Med 1993;329:926–9.

    Article  CAS  Google Scholar 

  31. Peng X, Pentassuglia L, Sawyer DB. Emerging anticancer therapeutic targets and the cardiovascular system: Is there cause for concern? Circ Res 2010;106:1022–34.

    Article  CAS  Google Scholar 

  32. Panjabi MM, Goel VK, Drinker H, Wong J, Kamire G, Walter SD, et al. Effect of pressurization on methylmethacrylatebone interdigitation: An in vitro study of canine femora. J Biomech 1983;16:473–80.

    Article  CAS  Google Scholar 

  33. Juliusson R, Arve J, Ryd L. Cementation pressure in arthroplasty. In vitro study of cement penetration into femoral heads. Acta Orthop Scand 1994;65:131–4.

    CAS  PubMed  Google Scholar 

  34. Smith BN, Lee AJ, Timperley AJ, Whitehouse SL, Crawford RW. The effect of the rim cutter on cement pressurization and penetration on cemented acetabular fixation in total hip arthroplasty: An in vitro study. Proc Inst Mech Eng H 2010;224:1133–40.

    Article  CAS  Google Scholar 

  35. Coutance G, Cauderlier E, Ehtisham J, Hamon M, Hamon M. The prognostic value of markers of right ventricular dysfunction in pulmonary embolism: A meta-analysis. Crit Care 2011;15:R103.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cardiology, University Malaya Medical Center, Kuala Lumpur, Malaysia

    Ramesh Singh Veriah

  2. Departments of Orthopaedics (Noceral), University Malaya Medical Center, Kuala Lumpur, Malaysia

    Vivek Ajit Singh & Siamak Sarrafan

Authors
  1. Vivek Ajit Singh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Siamak Sarrafan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ramesh Singh Veriah
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Vivek Ajit Singh.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Singh, V.A., Sarrafan, S. & Veriah, R.S. Distal Medullary Canal Decompression in Long Stem Hip Replacement in Long Bone Metastasis. IJOO 52, 15–21 (2018). https://doi.org/10.4103/ortho.IJOrtho_101_17

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.4103/ortho.IJOrtho_101_17

Keywords

MeSH terms

Search

Navigation