Is hip replacement recommended for a patient with stage 4 (four) breast cancer who has suffered a femoral neck fracture?

Hip Replacement in Stage 4 Breast Cancer with Femoral Neck Fracture

Yes, hip replacement (arthroplasty) is strongly recommended for a stage 4 breast cancer patient with femoral neck fracture, as it provides superior pain relief, immediate weight-bearing capability, and restoration of function compared to internal fixation, which has high failure rates in metastatic disease. 1

Surgical Approach Selection

For displaced femoral neck fractures in metastatic disease, arthroplasty is the definitive treatment over internal fixation. 1 The AAOS guidelines provide strong evidence that arthroplasty should be performed for unstable (displaced) femoral neck fractures, and this recommendation becomes even more critical in pathological fractures where bone healing is compromised. 1

Type of Arthroplasty

The choice between hemiarthroplasty and total hip arthroplasty depends on several factors:

• Hemiarthroplasty is generally preferred for patients with metastatic disease and limited life expectancy, as it provides adequate pain relief and function with lower surgical complexity and shorter operative time. 1

• Total hip arthroplasty may be considered in properly selected patients with better prognosis, pre-existing hip arthritis, and higher functional demands, though it carries increased risk of dislocation. 1

• Cemented femoral stems are mandatory regardless of which arthroplasty type is chosen, as they provide immediate stability in compromised bone. 1

Critical Technical Considerations

Assessment of Entire Femur

Before proceeding with arthroplasty, imaging of the entire femur is essential to identify additional metastatic lesions that may require concurrent treatment. 1 If distal femoral lesions are present, consider:

• Combined reconstruction with arthroplasty and spanning plate fixation distally 1
• Long-stem prosthesis that bypasses distal lesions by at least two cortical diameters 1

Surgical Approach

Either anterolateral or posterior approach is acceptable, with no superior approach demonstrated in the guidelines. 1 The choice should be based on surgeon experience and patient anatomy.

Perioperative Management Protocol

Preoperative Optimization

• Surgery should occur within 24-48 hours of admission to optimize outcomes and reduce complications. 1, 2
• Either spinal or general anesthesia is appropriate, with strong evidence supporting both options. 1
• Multimodal analgesia with preoperative nerve block should be administered for pain control. 1, 2

Intraoperative Measures

• Tranexamic acid administration is mandatory to reduce blood loss and transfusion requirements. 1
• Prophylactic antibiotics within one hour of incision per standard protocols. 2

Postoperative Care

• Immediate weight-bearing as tolerated is recommended, which is a major advantage of arthroplasty over fixation in metastatic disease. 1, 2
• VTE prophylaxis with fondaparinux or low molecular weight heparin for 4 weeks postoperatively. 2
• Transfusion threshold of 8 g/dL for asymptomatic patients, with lower threshold for symptomatic anemia. 1, 2

Adjuvant Treatment

Postoperative radiation therapy to the entire femur is recommended after surgical stabilization to prevent disease progression and reduce risk of additional skeletal-related events. 1 Radiation should be delivered after adequate wound healing, typically 2-3 weeks postoperatively.

Bone-modifying agents (denosumab or zoledronate) should be initiated to reduce future skeletal-related events in metastatic breast cancer. 1 Denosumab is more effective than zoledronate in delaying skeletal-related events and should be administered every 4 weeks. 1

Why Internal Fixation is Contraindicated

Internal fixation with screws or plates is not effective for pathologic fractures due to lack of bone healing at the tumor site, with failure rates exceeding 50% in metastatic disease. 1, 2 Even with cement augmentation techniques, the risk of fixation failure remains unacceptably high compared to arthroplasty. 3

Prognosis and Functional Outcomes

Patients with metastatic breast cancer and femoral neck fractures who undergo arthroplasty typically achieve:

• Restoration of ambulatory capacity by 2 weeks postoperatively 1
• Effective pain relief within 3 days of surgery 3
• Return to prefracture ambulatory status in the majority of patients 3

The multidisciplinary approach involving orthopedic surgery, medical oncology, and radiation oncology is essential for optimizing outcomes. 1

Common Pitfalls to Avoid

• Failing to image the entire femur before surgery, which may result in missed lesions requiring concurrent treatment 1
• Choosing internal fixation over arthroplasty in pathologic fractures, leading to high failure rates and need for revision surgery 1, 2
• Delaying surgery beyond 48 hours, which increases complication rates and mortality 1
• Using uncemented stems, which have higher failure rates in compromised bone 1