Controversies in the surgical management of skeletal metastases.

©2005 British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.87B5. 16021 $2.00 J Bone Joint Surg [Br] 2005;87-B:608-17. The management of skeletal metastatic disease has attracted increasing attention during the past decade. In orthopaedic practice there is an increased demand for reconstructive surgery for both pathological fractures and in the management of paraplegia from compression of the spinal cord. By applying surgical techniques which have been developed in joint arthroplasty, trauma surgery, degenerative spinal disease and limb-sparing surgery, the orthopaedic surgeon is well armed for the restoration of function in cancer patients who have skeletal complications. The possibilities of treatment have not only increased in orthopaedic surgery but also in other specialties. For example, advanced management of pain can ensure freedom from pain until death, while improved techniques in radiotherapy give better analgesia with fewer complications. Home-based hospice care also allows more patients to lead an independent life. Improved knowledge of the pathophysiology of cancer-induced bone destruction has allowed the development of new drugs such as bisphosphonates, the indications for and benefits of which have not yet been fully explored. The art of caring for the patient with bone cancer is to choose from these different treatment modalities in order to give the best palliation while minimising side-effects. A variety of treatments should be explored before embarking on an orthopaedic surgical adventure. This paper will consider the diagnosis of bone lesions, the case for prophylactic stabilisation of an impending fracture, and the choice of reconstructive techniques after pathological fracture of the long bones or the acetabulum. The orthopaedic management of pathological fractures caused by haematological malignancy is similar to that needed for metastatic carcinoma. The former are also considered here although they do not represent true metastatic disease. This paper is based upon the experience gained from patients who were treated at the Department of Orthopaedic Surgery at the Karolinska Hospital between 1986 and 2003. 1