Review Article
Management of Metastatic Bone
Paul S. Issack, MD
Suhel Y. Kotwal, MD
Joseph M. Lane, MD
From New York–Presbyterian
Hospital, Weill Medical College of
Cornell University, New York, NY
(Dr. Issack), the School of Medicine,
University of Missouri at Kansas
City, Kansas City, MO (Dr. Kotwal),
and the Hospital for Special Surgery,
New York (Dr. Lane).
Dr. Lane or an immediate family
member is a member of a speakers’
bureau or has made paid
presentations on behalf of Amgen,
Eli Lilly, Novartis, and Warner
Chilcott; serves as a paid consultant
to Amgen, CollPlant, Bone
Therapeutics, BioMimetic
Therapeutics, DFINE, Graftys, and
Zimmer; has received research or
institutional support from Amgen;
and serves as a board member,
owner, officer, or committee member
of the Orthopaedic Research
Society, the Musculoskeletal Tumor
Society, the American Academy of
Orthopaedic Surgeons, the
Association of Bone and Joint
Surgeons, the American
Orthopaedic Association, and the
American Society for Bone and
Mineral Research. Neither of the
following authors nor any immediate
family member has received
anything of value from or has stock
or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Issack and
Dr. Kotwal.
J Am Acad Orthop Surg 2013;21:
685-695
http://dx.doi.org/10.5435/
JAAOS-21-11-685
Copyright 2013 by the American
Academy of Orthopaedic Surgeons.
November 2013, Vol 21, No 11
Disease of the Acetabulum
Abstract
Metastatic acetabular disease can be severely painful and may
result in loss of mobility. Initial management may consist of
diphosphonates, narcotic analgesics, radiation therapy, protected
weight bearing, cementoplasty, and radiofrequency ablation.
Patients with disease affecting large weight-bearing regions of the
acetabulum and with impending failure of the hip joint are unlikely
to gain much relief from nonsurgical treatment and interventional
procedures. The profound osteopenia of the acetabulum, limited
healing potential of the fracture, and projected patient life span and
function necessitate surgical techniques that provide immediate
stable fixation to reduce pain and restore ambulatory function.
Current reconstructive procedures, including cemented total hip
arthroplasty, the saddle or periacetabular endoprosthesis, and
porous tantalum implants, are based on the quality of remaining
acetabular bone as well as the patient’s level of function and
general health. Well-executed acetabular reconstructions can
provide durable hip joints with good pain relief and function.
M etastatic disease of the acetabu-
lum can be very painful and may
severely limit function and activities of
Interventional treatment, including
percutaneous cementoplasty and ra-
diofrequency ablation, is indicated
daily living. Osteolytic destruction for patients who fail nonsurgical
caused by the tumor can result in patho- treatment but are not candidates for
logic fracture of the acetabulum and in- surgery. Large lesions with impend-
creased pain and inability to ambulate. ing or completed acetabular fractures
These fractures have poor healing po- may require surgery, with the goal of
tential with radiotherapy.1 Fracture creating a durable hip joint to pro-
healing may take longer than the pa- vide pain relief and enable immediate
tient’s expected life span.2 weight bearing.3
For primary malignant bone tu-
mors, wide resection is performed in
an effort to cure the patient. In con-
Tumor Workup
trast, metastatic disease requires a
more palliative approach. In general, The acetabular lesion should be eval-
radical or wide resections, including uated on a standard AP pelvic radio-
hemipelvectomy, are not indicated graph to determine the extent of tu-
for patients with metastatic disease. mor involvement (Figure 1). Judet
Diphosphonates, narcotic analgesia, obturator and iliac oblique views are
radiation therapy, and protected helpful to assess the integrity of the
weight bearing are the first steps in anterior and posterior columns and
management. walls, roof, and quadrilateral plate.
685
Management of Metastatic Bone Disease of the Acetabulum

Figure 1 The entire femur should be imaged,

as well, to identify additional dis-
ease.
CT of the pelvis and acetabulum is
helpful in assessing the degree of
bony destruction and deficiency (Fig-
ure 2). Three-dimensional CT may
help to more accurately define the
extent of bony destruction and the
quality and amount of bone avail-
able for fixation.4 Thin-slice CT (ie,
0.6 mm) allows for excellent resolu-
tion of the fractured acetabulum and
can be used to generate a life-size
plastic model of the pelvis and areas
of pathologic destruction. This can
allow for highly accurate estimation
of implant position for optimal fixa-
Standard AP pelvic radiograph demonstrating a pathologic left acetabular tion and screw length.5
fracture with destructive lesions in the acetabulum extending proximally into
the ilium and distally into the ischium in a 57-year-old woman who was MRI of the pelvis is less helpful
diagnosed with metastatic breast carcinoma and who presented with than CT in evaluating metastatic ac-
increased left hip pain and inability to ambulate. etabular disease and bony integrity,
and MRI may overestimate the de-
gree of bony involvement.6 Addi-
Figure 2 tional imaging studies, including
bone scanning and/or skeletal sur-
veys, can help to determine whether
the acetabular lesion is a primary
bone tumor or a metastatic lesion.7
Biopsy always should be per-
formed to confirm that the acetabu-
lar lesion is a metastatic tumor and
not a primary bone tumor, but in
some cases it is not necessary to wait
for the biopsy result before proceed-
ing with treatment. In a patient with
a solitary acetabular lesion and with
no history of cancer, biopsy must be
performed. In patients aged >40
years, a solitary acetabular lesion is
likely to be a metastatic lesion, even
in the absence of a history of cancer.8
With a history of cancer, a solitary
acetabular tumor is even more likely
to be a metastatic lesion; in such
cases, biopsy is required. A patient
with a history of cancer and with
multiple visceral metastases and ac-
Axial CT scans of the same patient as in Figure 1 demonstrating destructive etabular lesion does not require bi-
lesions in the left acetabulum extending from the iliac wing (A), the
acetabular dome (B), the posterior wall (C), and the ischial tuberosity (D). opsy before surgery. During acetabu-
lar reconstruction, tissue from the

686 Journal of the American Academy of Orthopaedic Surgeons

 Paul S. Issack, MD, et al

lesion can be sent for pathologic Figure 3

analysis.8
Biopsy may be performed using
fine-needle aspiration, core biopsy,
or open incisional biopsy techniques.
CT-guided fine-needle aspiration and
core biopsy reduce the risk of con-
tamination of the biopsy tract. Open
incisional biopsy should be per-
formed through a small longitudinal
incision in line with the incision; this
same incision may ultimately be used
in wide excision of the tumor and bi-
opsy tract if the lesion turns out to
be a primary bone sarcoma. Meticu-
lous hemostasis should be obtained
to prevent hematoma and spread of
tumor cells.8,9 In the case of primary
bone sarcoma, incorrect biopsy tract
placement and hematoma contami-
nation of the site may result in am-
putation.9

Surgical Classifications
In 1981, Harrington10 reported his
results on hip reconstruction per-
formed in 58 patients with meta-
static acetabular insufficiency and
fracture-dislocations. He categorized
these lesions into three classes. In
class I lesions, the articular surface is
disrupted but the walls and columns
are intact. Patients with class I le-
sions were reconstructed with ce-
mented acetabular and femoral com- Metastatic acetabular classification system. A, Type 1, dome. B, Type 2,
medial wall. C, Type 3, single column, posterior. D, Type 3, single column,
ponents. In class II lesions, the anterior. E, Type 4, double column.
medial wall and quadrilateral plate
are deficient, requiring acetabular re-
construction with a flanged cup to cation (MAC) describes lesions in portive subchondral bone should be
transfer weight-bearing forces away four anatomic zones—the acetabular treated with THA with reinforced ce-
from the medial acetabulum and to dome, medial wall, anterior column, ment using a flanged cup or cage.
prevent medial collapse of the recon- and posterior column12,13 (Figure 3). Medial wall defects with dome de-
struction. In class III lesions, the roof Specific reconstructions were pro- fects (ie, type 2) require flanged cups
and acetabular rim are deficient and posed based on the anatomic pattern or cages to avoid protrusion or me-
require reconstruction with Stein- of destruction. A cavitary lesion in dial collapse of the reconstruction.
mann pins in cement and total hip the dome or roof of the acetabulum Defects in either the anterior or the
arthroplasty (THA) using a flanged with intact subchondral bone (ie, posterior column (ie, type 3) or both
cup or cage (ie, cement-reinforced type 1) may be managed with cemen- columns (ie, type 4) may also be
THA).10,11 tation of the lesion followed by managed with cement-reinforced
The metastatic acetabular classifi- THA. Patients with insufficient sup- THA and cage support or a saddle

November 2013, Vol 21, No 11 687

Management of Metastatic Bone Disease of the Acetabulum
prosthesis if there is adequate bone
stock in the proximal ilium. For all
of these reconstructions, adequate
bone stock in the ipsilateral pelvis
and ischium or floor of the acetabu-
lum is needed for Steinmann pin and
cage-screw fixation.12,13
Nonsurgical Management
Patients with painful but small ac-
etabular lesions that do not compro-
mise the weight-bearing posterior
column, dome, or medial wall may
be treated initially with diphospho-
nates, narcotic analgesics, radiation
therapy, and protected weight
bearing.12-15
Diphosphonates may be used to re-
duce skeletal events related to bone
metastases. One study found pami-
dronate to reduce pain and hypercal-
cemia in women with bone metasta-
ses resulting from breast cancer.16 In
a recent meta-analysis of nine ran-
domized controlled trials (2,806 pa-
tients with breast cancer with bone
metastases), diphosphonates, includ-
ing intravenous zoledronic acid 4 mg
and intravenous pamidronate 90 mg,
reduced the risk of skeletal-related
events by 15%.17
Administration of narcotics via
epidural catheters is an effective ap-
proach to manage bone pain in pa-
tients in terminal stages of their ill-
ness.18,19 Jeon et al19 retrospectively
reviewed 96 patients who received
127 epidural catheters to manage
pain caused by terminal cancer. The
proportion of patients with severe
pain decreased from 78.1% to
19.6%. In a meta-analysis of 31
studies, Ballantyne and Carwood18
observed excellent pain relief in 72%
of the patients with terminal cancer
who received epidural analgesia.
There were no major complications.
Radiation therapy is indicated for
radiosensitive tumors with low risk
for pathologic fractures (eg, breast
688
cancer, lung cancer); however, it also
may be used for any metastatic le-
sion to minimize the need for surgi-
cal intervention. An early study on
external beam irradiation in 14 pa-
tients with metastatic acetabular le-
sions demonstrated pain relief in all
patients.14 The Radiation Therapy
Oncology Group performed a ran-
domized trial known as RTOG 9714
comparing 8 Gy in 1 fraction with
30 Gy in 10 fractions in 898 patients
with bone metastases from breast or
prostate cancer. At 3-month follow-
up, both groups demonstrated simi-
lar responses, with partial response
rates of approximately 50% in both
arms; 33% of all patients no longer
required narcotic medications.20 Cur-
rently, the most commonly used
schedule in the United States for
managing oncologic bone pain is a
regimen of 30 Gy given in 10 treat-
ment fractions over 2 weeks.20,21
Interventional Procedures
Surgical intervention may be indi-
cated for patients who have little to
no pain relief and severe functional
impairment despite adequate nonsur-
gical treatment. Reconstruction of
metastatic acetabular fractures, how-
ever, is an extensive surgery with the
potential for significant blood loss,
large fluid shifts, and a major sys-
temic inflammatory response. Many
patients with metastatic disease are
incapable of surviving or making a
meaningful recovery from such a
procedure.12,13 For these patients, less
invasive approaches may be consid-
ered.
Interventional procedures, includ-
ing injection of methylmethacrylate
into osteolytic lesions (eg, percutane-
ous cementoplasty) may provide im-
mediate stability and relatively pain-
free weight bearing (Figure 4).
Anterolateral and posterolateral por-
tals are made under CT-guided imag-
Journal of the American Academy of Orthopaedic Surgeons
ing to pass two vertebroplasty nee-
dles into the acetabular lesion, taking
care to avoid injury to the lateral
femoral cutaneous nerve, sciatic
nerve, and superior gluteal artery.22
The needle is removed, leaving the
cannula behind, and a Kirschner
wire is inserted into the acetabulum
through this cannula. Dilators may
be passed over these Kirschner wires,
followed by a working cannula
through which cement, mixed with a
small amount of contrast dye, is in-
jected into the sites under image
guidance.
Cotten et al23 injected methylmeth-
acrylate into 12 acetabular osteolytic
lesions in 11 patients. Nine patients
experienced pain relief within 4 days,
and all patients experienced im-
proved ambulation within 5 days.
Scaramuzzo et al24 retrospectively re-
viewed 20 patients who underwent
polymethyl methacrylate injection
into 24 metastatic acetabular lesions.
Complete pain relief was achieved in
75% of patients, with a 7.3-month
mean duration of pain relief. Smaller,
relatively contained lesions are likely
to do better with cementoplasty.
Larger acetabular lesions that com-
promise the structural support of the
acetabulum, including impending
fractures, complete fractures, pelvic
discontinuity, and fractures creating
medial wall insufficiency, are con-
traindications to percutaneous ce-
mentoplasty.24 Typically, percutane-
ous cementation is combined with
radiation therapy, cryoablation, or
radiofrequency ablation to obtain lo-
cal tumor control in addition to me-
chanical reinforcement of weakened
bone.
Radiofrequency ablation has
shown good results in the manage-
ment of pain from bone metastases.
In this technique, an electrode is in-
serted into the tumor and coagulat-
ing tissue. Multitined electrodes are
used for larger, metastatic lesions,
and the bone–soft-tissue interfaces
 Paul S. Issack, MD, et al

are included in treatment.25 Thanos Figure 4

et al26 reported on 30 patients (34 le-
sions) with painful bone metastases
using radiofrequency ablation. There
was a marked decrease in scores for
pain and for pain interference during
daily life 4 and 8 weeks after treat-
ment. In addition, there was a
marked decrease in the use of analge-
sics, with only three patients using
oral analgesics at 8 weeks.

Surgical Reconstruction
Procedures
Surgical reconstruction is indicated
in the presence of a large acetabular
lesion that compromises hip joint
stability, pathologic acetabular frac-
ture, or radioresistant tumor. Pa-
tients with persistent debilitating
pain for 1 to 3 months despite either
nonsurgical management (including
narcotic analgesics, protected weight
bearing, diphosphonates, and radia-
tion therapy) or interventional pro-
cedures may be candidates for recon-
structive acetabular surgery.12,13

Surgical Preparation
Preoperative embolization is very
helpful in reducing intraoperative
blood loss, the need for blood trans-
fusion, and surgical time.27,28 Wirbel
et al28 reported on 11 patients with
pelvic metastases who underwent se-
lective embolization before surgery.
There was a significant difference in
blood loss and transfusion require-
ments in the embolized group com-
pared with a nonembolized control
group of 10 pelvic metastases (P =
0.05). Although preoperative embo-
lization is considered to be an option
in the surgical management of all ac-
etabular metastases, preoperative
embolization also should be consid-
ered for hypervascular histologies
such as renal cell, thyroid, or hepato-
cellular carcinoma and/or in the
presence of a large extraosseous soft-
AP radiograph (A) and CT scan (B) of a left hip demonstrating an area of
acetabular osteolysis in the posterior column. AP radiograph (C) and CT
scan (D) obtained following percutaneous cementoplasty. (Reproduced with
permission from Maccauro G, Liuzza F, Scaramuzzo L, et al: Percutaneous
acetabuloplasty for metastatic acetabular lesions. BMC Musculoskelet Disord
2008;9:66.)
tissue mass. This procedure must be supra-acetabular screws and Stein-
balanced against potential nephro- mann pins. Furthermore, the bean-
toxicity in medically frail patients.12 bag can be rapidly deflated and the
patient positioned supine should im-
Setup and Exposure mediate access to the iliac vessels be
The patient should be placed in the needed to control hemorrhage. The
lateral decubitus position on a well- C-arm may be brought in from the
padded bean bag and radiolucent ta- side opposite the operating surgeon,
ble. This allows for intraoperative who typically stands posterior to the
fluoroscopy to confirm placement of patient. Surgical management of

November 2013, Vol 21, No 11 689

Management of Metastatic Bone Disease of the Acetabulum

Figure 5

AP radiograph (A) and coronal CT scan (B) of the left

hip in a 59-year-old man with metastatic bronchogenic
carcinoma demonstrating supra-acetabular bone
destruction with an intact medial wall. C, AP radiograph
obtained following total hip arthroplasty using a
cemented acetabular component and one Steinmann
pin.

most metastatic acetabular defects
can be performed through the
Kocher-Langenbeck (ie, extensile
posterior) approach.29
Total Hip Arthroplasty
Most surgical treatment options for
metastatic acetabular lesions involve
variants of THA. In the presence of
cavitary lesions with intact subchon-
dral bone and medial wall (ie, Har-
rington class I, MAC type 1), the ac-
etabulum may be managed with
curettage and cemented THA10,12,13
(Figure 5). A simple cage is required
if the medial wall is deficient (ie,
Harrington class II, MAC type 2).12,13
An extensive cage with long
flanges provides a larger surface area
of contact between the acetabulum
and the implant and has been pro-
posed to provide greater stability in
the setting of bone destruction in-
volving the acetabular roof (ie, Har-
rington class III). This type of cage
was used to reconstruct the acetabu-
lum in 15 patients with metastatic
acetabular defects.1 At an average
follow-up of 14 months, the overall
failure rate was 27%. Two cages
demonstrated significant loosening
at 15 and 30 months. Harris hip
scores improved from an average of
33 (range, 25 to 39) to 69 (range, 35
to 93). Significant pain relief was re-
ported, and 73% of the patients
stated that they would be willing to
undergo the operation again.
Clayer30 retrospectively reviewed 29
acetabular reconstructions using an
anti-protrusio cage for metastatic
acetabular disease. At a mean
follow-up of 16 months, one patient
demonstrated mechanical loosening
and five patients dislocated. Twenty-

690 Journal of the American Academy of Orthopaedic Surgeons

 Paul S. Issack, MD, et al

Figure 6

A, AP radiograph of the right hip in a 48-year-old woman with metastatic breast cancer demonstrating a large
metastatic lytic lesion in the superior dome with osteolysis of the anterior and posterior columns (ie, metastatic
acetabular classification type 4). B, AP radiograph obtained following intralesional curettage of the metastatic lesion
through a standard posterior approach to the hip. The superior dome was reconstructed using threaded Steinmann
pins and cement. A flanged acetabular component was implanted with a hybrid-screws-into-cement technique. The
patient received postoperative radiation.

seven of 29 patients (93%) were able
to ambulate after the procedure.
Harrington Procedure
Harrington10 reported on the results
of cemented THA with acetabular
reconstruction using Steinmann pins
in 58 patients with metastatic ac-
etabular fractures. Harrington class I
lesions were treated with a cemented
THA, and Harrington class II lesions
were reconstructed with a flanged
cup. Harrington class III lesions were
reconstructed with retrograde place-
ment of 4.8-mm Steinmann pins
through the superior acetabulum,
into the iliac crest, and across the
sacroiliac joint. The medial cavity
was then cemented to include the
pins, and the flanged cup was in-
serted into the cement. Thirty-seven
patients (64%) had good to excellent
pain relief 6 months postoperatively,
and 45 patients (78%) were ambula-
tory 6 months postoperatively. In
five cases, the prosthetic reconstruc-
tion loosened because of tumor re-
currence. None of the patients with
class III disease had evidence of pros-
thetic loosening even though these
patients had the greatest degree of
bone destruction.
Since the original report by Har-
rington, multiple groups have demon-
strated the strength of the ce-
ment-reinforced hip reconstruction
technique.13,31,32 Steinmann pins may
be placed antegrade through inci-
sions over the iliac crest and directed
between the inner and outer tables
toward the floor of the acetabulum
(Figure 6). We have placed these pins
with a free-hand technique, but a tri-
angulation guide may be used, as
well.13 Ho et al31 performed the pro-
cedure using 3.5-mm screws rather
than Steinmann pins in 37 patients
with class III lesions of the acetabu-
lum. At a mean follow-up of 23.6
months, all patients reported im-
proved pain, mobility, and function.
There were six dislocations (16%),
which occurred within 2 months of
the index surgery. The authors at-
tributed this to the extensive muscle
resection performed during tumor
debulking. Six patients developed
deep infection (16%), with five re-
quiring resection arthroplasty.
Marco et al13 reported on 55 pa-
tients with metastatic acetabular le-
sions treated with the Harrington
technique. Fifty-four reconstructions
were performed with an anti-
protrusio cup and 1 with a hemipel-
vis endoprosthesis. Thirty-six pa-
tients (65%) had insufficiencies in
either the anterior or posterior col-
umns (ie, MAC type 3). Ten patients
(18%) had insufficiencies of both the
anterior and posterior columns (ie,
MAC type 4). At 6-month follow-up,
19 patients had died. Of the 33 pa-
tients available for follow-up at 6
months, 76% had pain relief and 19

November 2013, Vol 21, No 11 691

Management of Metastatic Bone Disease of the Acetabulum
were able to walk. Fourteen patients
had disease progression, and 5 of
these patients had fixation failure.
Early postoperative complications
included deep vein thrombosis in five
patients and superficial infection in
three.13
The Harrington reconstruction
technique has proved to be a durable
reconstruction that, in most cases,
lasts the lifetime of the patient. How-
ever, these are complex reconstruc-
tions with high complication rates in
very ill patients. Preoperative plan-
ning, the presence of an operating
room team familiar with the steps in
the procedure, and surgeon experi-
ence are critical for good outcomes.
Saddle and Periacetabular
Endoprostheses
For lesions involving the acetabulum
and ischium in patients with ade-
quate bone stock in the ilium, recon-
struction may be performed using a
saddle prosthesis.33,34 The saddle
prosthesis has been proposed as an
option in cases in which tumor has
infiltrated both the anterior and pos-
terior columns with medial wall and
dome insufficiency (ie, MAC type
4).12 This prosthesis is a modular de-
vice with a proximal U-shaped sad-
dle that articulates with a notch
made in the ilium, a femoral prosthe-
sis, and an intervening linking base
component that allows for adjust-
ment of soft-tissue tension as well as
rotation, abduction, adduction, flex-
ion, and extension. Saddle prostheses
are primarily designed for flexion
and extension; the other motions are
limited. Soft-tissue tension and the
balance of the abductors keep the
saddle prosthesis in place.35
Aboulafia et al33 reported on 17
patients with malignant periacetabu-
lar tumors who underwent acetabu-
lar resection and reconstruction
using a saddle prosthesis. Eight pa-
tients had primary malignant lesions,
692
Figure 7
A, AP radiograph of a right hip demonstrating severe superior and medial
periacetabular bone destruction due to metastatic breast cancer. B, AP
radiograph obtained 1 year after acetabular reconstruction using a
periacetabular endoprosthesis saddle. (Images courtesy of Howard
Rosenthal, MD, Mid-America Sarcoma Institute, Leawood, KS.)
and nine had metastatic lesions. At dle and resultant soft-tissue laxity.
an average follow-up of 33.4 To improve the ilium-saddle inter-
months, seven of the nine patients face, Menendez et al36 developed a
who were still alive had excellent re- periacetabular endoprosthesis. This
sults and the other two had good re- modular saddle prosthesis is com-
sults. posed of a wide iliac wing segment
Kitagawa et al34 reported on 12 pa- that is fixed to the ilium with three
tients with sarcoma and 4 with me- cross bolts and cement (Figure 7). They
tastasis involving the periacetabular retrospectively reviewed 25 patients
region who were treated with acetab- who underwent pelvic resection and re-
ular resection and reconstruction
construction with this endoprosthesis.
with a saddle prosthesis. At a mean
At a minimum follow-up of 13
follow-up of 37 months, postopera-
months, major complications occurred
tive functional scores according to
in 14 patients, including deep infection
the Musculoskeletal Tumor Society–
in 6, local recurrence in 5, and disloca-
International Symposium on Limb
tion at the constrained acetabular liner
Salvage system and the Toronto Ex-
tremity Salvage Score were 53% and or femoral neck Morse taper in 3. Im-
64%, respectively, in patients under- plant survivorship was 84% at 2 years,
going wide acetabular resection for with no failures at the ilium-saddle in-
sarcoma and 30% and 42%, respec- terface.
tively, in patients undergoing intrale-
sional excision of the acetabulum for Porous Tantalum Implants
metastatic disease. Complications in- Porous tantalum implants have been
cluded deep infection in three pa- successfully used in revision hip ar-
tients and dislocation in one, likely throplasty to reconstruct massive ac-
from proximal migration of the sad- etabular defects and pelvic disconti-
Journal of the American Academy of Orthopaedic Surgeons
 Paul S. Issack, MD, et al

Figure 8

A, AP pelvic radiograph of a severely ill 67-year-old woman with metastatic breast cancer who presented with severe
right hip pain that could not be controlled with narcotic medication. She could not bear any weight. She presented with
a pathologic fracture involving the medial and posterior walls with massive posterior column and ischial osteolysis, as
well as central dislocation of the femoral head. Her multiple medical comorbidities and poor medical condition
precluded prolonged surgical reconstruction. B, AP pelvic radiograph obtained following femoral head resection and
intralesional curettage of the metastatic lesion.

nuity secondary to osteolysis.37
Porous tantalum implants may play
a role in the management of acetabu-
lar reconstruction following meta-
static disease. Khan et al38 reported
on the use of tantalum implants to
reconstruct acetabular bone destruc-
tion resulting from metastatic dis-
ease, multiple myeloma, lymphoma,
and Langerhans cell histiocytosis.
Reconstruction was performed using
an uncemented tantalum cup with
augments if necessary. All cups were
fixed with multiple screws. In cases
of more substantial bone loss in
which cup–host bone contact was in-
adequate for stable fixation, the cup
cage technique was used. Twenty pa-
tients with a mean age of 60 years
who underwent acetabular recon-
struction with the above technique
were followed for a mean of 56
months. There were no cases of
clinical or radiographic loosening.
There was one perioperative death,
one case of deep vein thrombosis,
and one dislocation.38 Longer-term
follow-up on larger numbers of pa-
tients is needed to confirm the dura-
bility of this technique in this specific
population.
Resection Arthroplasty
Resection arthroplasty for metastatic
acetabular lesions (ie, Girdlestone
procedure) may be indicated in pa-
tients with severe pain, extensive pel-
vic lesions, and disease that spans the
hemipelvis. These patients have few,
if any, reconstructive options. Resec-
tion arthroplasty is also indicated in
bedridden patients who experience
pain at rest and in patients who are
medically unable to tolerate major
pelvic reconstructive surgery12,39,40
(Figure 8). This procedure is per-
formed solely to relieve pain in pa-
tients who cannot be treated success-
fully with narcotics. Because of the
significant limb-length discrepancy
and essentially flail leg, in general
this procedure is not done to restore
ambulatory function.40
Complications
The complication rate associated
with surgical reconstruction in this
patient population is high. Har-
rington10 reported two deaths, one
related to massive intraoperative
blood loss and the second due to
myocardial infarction. There were
five cases of prosthetic loosening be-
cause of tumor recurrence. Major
concerns with the saddle prosthesis
are infection (with reports as high as
20%) and prosthetic migration.34
Preoperative planning expedites
surgery and minimizes the risk of in-
fection. The patient should have sev-
eral units of packed red cells avail-
able, as well as fresh-frozen plasma
and platelets to prevent dilutional

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Management of Metastatic Bone Disease of the Acetabulum

coagulopathy with massive transfu-
sion. Preoperative embolization of
specific tumor types can help to limit
intraoperative blood loss.
Treatment Algorithm
For painful metastatic acetabular le-
sions that do not compromise ac-
etabular stability, that is, that do not
involve large areas of the dome, pos-
terior column, or medial wall, and
are not impending fractures, initial
management involves the use of nar-
cotic analgesics, protected weight
bearing, diphosphonates, and radia-
tion therapy. Patients with a very
short life expectancy (<3 months) are
candidates for epidural analgesia.
Patients who meet these criteria and
who have continued pain despite ra-
diation therapy are candidates for in-
terventional techniques, including
percutaneous cementoplasty and ra-
diofrequency ablation.
mediate stability for these difficult
reconstructions. Resection arthro-
plasty may be a final option to pro-
5.
vide pain relief in rare cases of severe
pain that is unrelieved with narcotic
treatment and widespread pelvic dis-
ease with no reconstructive options,
6.
in bedridden patients with pain at
rest, and in patients who are medi-
cally unable to tolerate major pelvic
reconstructive surgery.
7.
Summary
Management of painful metastatic 8.
acetabular lesion is complex and re-
quires assessment of several factors,
including tumor size and location,
9.
structural stability of the acetabu-
lum, pain relief from narcotics, radio-
sensitivity of the tumor, and expected
life span of the patient. Management
10.
may be nonsurgical, interventional,
or surgical. Reconstructions of meta-
static acetabular lesions and patho-
using CT transverse sections to automate
diagnoses and surgery managements.
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Patients with large metastatic le-
sions that compromise acetabular
stability, as well as those with patho-
logic acetabular fractures or radiore-
sistant tumors, may be candidates
for surgical stabilization provided
they are medically able to undergo
surgery and have a life span of ≥3
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