He is known case of Ca prostate and recently sustained right sided hemiplegia.
One should rule out osteomalacia, secondaries and fluorosis.
I think THR should be a good option with grafting in the acetabulum floor to take care of protrusio.
- Unfortunately, the surgical options are not many and not very promising. Paliative care seems to be appropriate.
Reversibility of same side hemiplegia would determine success of our surgical intervention but palliative intervention can be done by THA.
Reversibility of paralysis due to spinal metastases is not probable without decompression surgery. THA is possible but the fixation of the implants is very problematic.
I would agree with Panayot both on spinal decompression and THA. If THA is selected I would cement both femoral and acetabular components. I don't believe bone grafting of the acetabulum would be necessary. A difficult case to achieve any favorable outcome.
But this pt does not have any spinal cord compression. The hemiplegia is of central origin due to CVA
If the cause for the hemiplegia is different, treatment should be administered by neurologist. The hip problem remains as discussed above.
THA with cemented proximal femur megaprosthesis as uncemented stem may loosen and fail over of time due to nonintegration after radiation or tumor induced osteolysis. Long stem prevents fractures from another lesion that may appear in the future.
I would do arthroplasty. If prognosis is not good related to Ca Prostate than palliative in form of hemiarthroplasty otherwise THR.
Girdlestone works well as palliative and salvage technique. The state in the moment resembles Girdlestone hip. Locally, I would not do replacement which is expected to be unsuccessful. I would not do "chirurgia gratia chirurgiae".
After staging with thorax and abdomen ct and a scintigraphy, I would talk with an oncologist about the prognosis of the patient , I would also get an MRI of the right hip as if it was a pathological fracture with soft tissue involvement. Then I would perform a cemented bipolar hemiarthroplasty in case of a short survival and cemented acetabular and femoral arthroplasty in case of a longer prognosis. Due to the ignored status of the case or the patient's low performance score, Girdlestone procedure is another option.
Osteoblastic metastasis from Ca Prostate are relatively benign than other metastasis. If general condition of patient will allow walking, THR should be done to improve quality of life.
Otherwise wheel chair mobilisation
All comments have merit. I am always high on THA or cemented Bipolar if the patients potential life expectations is moderate to high with the note that a hip surgeon performs the surgery. This case is beyond the skill set of a general orthopaedic surgeon (in my opinion) Panayot is correct in comment of high risk of failure.
Todays skill set for an experienced hip surgeon can replace this hip within 45 to 60 minutes and provide a stable hip for the remained of this patients life. I would also recommend a cemented stem.
Non surgical approach would be restricted to the ability of skilled hip surgeon availability and or potential life expectation of this patient.
I feel that at best we can provide only palliative treatment for this hip problem, either surgically or non-surgically. Surgically, the skill and t he experience of the surgeon should dictate the choice of implants,
Standard length or Long Stem Cemented Hip Hemiarthroplasty depending on appearance/ presence of distal lesions in the femur
The bone is more than bone hard. Think osteopetrosis. Re-establishing a medullary canal will need image intensifier and patience. I always use long stems for tumour, this is one I can imagine using an uncemented femoral component, but probably would still use a cemented C Stem (DePuy) as has the smallest diameter thus less likely to cause perforation. Acetabular side is dealers choice between bipolar and a proper cup - the Australian Orthopaedic Association National Joint registry demonstrates an increased risk of dislocation for bipolars.
Dear Dr. Mitchell, Bone in osteopetrosis is hard but brittle. The same problem exists with osteoblastic metastases. So the durability of implant fixation remains problematic.
I agree Dr Tanchev that Girdlestone is a serious consideration. I find them slow to give the degree of pain relief we would like for our patients. At a year, they're pretty good, but the first few months are hard for the patient. What we are missing is an understanding of how much pain & disability is caused by the fracture, how mobile is the patient, and whether the hemiplegia is partly resolving. My analogy to osteoporosis was a little overstated, the prostate metastases cases I've done have responded to sharp gouges. Attached article suggests fixation of uncemented components is satisfactory in prostate metastases, although I haven't done so myself.
Article Uncemented Arthroplasty for Metastatic Disease of the Hip Pr...
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