CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 443, pp. 287–295 © 2006 Lippincott Williams & Wilkins Complications of Cemented Long-stem Hip Arthroplasties in Metastatic Bone Disease R. Lor Randall, MD, FACS*†; Stephen K. Aoki, MD†; Patrick R. Olson, MD‡; and Steven I. Bott, MD§ It is controversial whether a cemented long-stem femoral arthroplasty is a safe surgical option for patients with metastatic bone disease of the hip. Cemented long stems increase the risk of embolic cascades and may cause subsequent cardiopulmonary complications, particularly in patients with metastatic disease. We retrospectively reviewed results of 29 long-stem cemented femoral arthroplasties in 27 patients in which surgical techniques that minimized intramedullary debris and canal pressurization were used. The surgical techniques minimized intraoperative cement-related emboli with aggressive medullary lavage, intraoperative canal suctioning during cementation, use of early low-viscosity polymethylmethacrylate, and slow, controlled insertion of the long-stem prosthesis. Cement-associated hypotension occurred in four (14%) patients, sympathomimetics were administered in nine (31%) patients, and a worsening mental status occurred postoperatively in one (3%) patient. There were no cementassociated desaturation events, cardiac arrests, or intraoperative deaths. No patients required prolonged intubation, and there were no postoperative cardiopulmonary events. Cemented long-stem femoral arthroplasty is a safe procedure for patients with high-risk metastatic disease. Increased awareness of cement-related cardiopulmonary pathophysiology, and modifying conventional surgical techniques can minimize cement-associated complications. Level of Evidence: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence. Metastatic bone disease afflicts more than 1⁄2 of the 1.2million new patients diagnosed annually with cancer.17,27 Bony involvement can be a major source of morbidity and mortality if not treated appropriately.9,16,40,44 The femur is the most common long bone affected, with 25% involving the proximal 1⁄3 of the femur.17,48,50 For cases involving the femoral head, neck, and intertrochanteric area, the cemented femoral arthroplasty is an important surgical option for impending and realized fracture management.50 The use of polymethylmethacrylate (PMMA) is well established as a bone fixation adjuvant in patients with metastatic bone disease.16,19,20,23,41 Cementing femoral components provides structural support to the weakened bone, improved ambulation, pain relief, and decreased implant failure rates.16 A long-stem femoral component may be used to maximally stabilize the length of the femur. Cemented long-stem components provide fixation distal to the local disease at the time of surgery and additional fixation if subsequent local disease progression occurs. However, cemented femoral arthroplasty is not without inherent risk. Perioperative cardiopulmonary complications associated with cementing hip components are well described.4–6,22,24–26,33,39,38,42,43,51,52 Cement-associated desaturation and hypotension, pulmonary hypertension, cardiogenic shock, cardiac arrest, and intraoperative death are complications that can occur during femoral cementation and component placement secondary to canal pressurization.12,15,21,34,36 Patients who have cemented arthroplasties have been reported to have more embolic events compared with patients who have noncemented arthroplasties, with greater intramedullary (IM) pressures observed with cementation.25,33,38,39,42 Any factor that increases extrusion of femoral IM contents has been suggested to elevate the risk of cardiopulmonary embolic complica- Received: January 9, 2005 Revised: July 30, 2005 Accepted: September 21, 2005 From the *Huntsman Cancer Institute, Department of Orthopaedics, Salt Lake City, UT; the †Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City, UT; the ‡Department of Orthopaedic Surgery, Dartmouth School of Medicine, Hanover, NH; and the §Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT. One or more of the authors (RLR) has received funding from Biomet for research support. Each author certifies that his or her institution has approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research, and that informed consent was obtained. Correspondence to: R. Lor Randall, MD, FACS, Huntsman Cancer Institute, Department of Orthopaedics 2000 Circle of Hope, Suite 4260, Salt Lake City, UT 84112. Phone: 801-585-0300; Fax: 801-585-0159; E-mail: firstname.lastname@example.org. DOI: 10.1097/01.blo.0000191270.50033.3a 287 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 288 Clinical Orthopaedics and Related Research Randall et al tions.4,24–26,33,38,39,43,51,52 In addition to cementation, this includes porous bone and the use of long-stem femoral implants. Long-stem components have been proposed to increase pressurization of the canal producing more embolic events, with cardiopulmonary complications reported as high as 62%.21,36 Metastatic bone allows greater extrusion of emboli because of its permeative qualities and increased vascular supply. Therefore, patients with metastatic bone disease having long-stem cemented femoral arthroplasties are at a particularly high risk for cardiopulmonary compromise. Various surgical techniques have been proposed to reduce perioperative canal debris and/or IM pressurization.5,6,31,38,39,43,51 The use of low-viscosity cement, IM venting, retrograde injection, thorough IM lavage, and intraoperative canal suctioning during cementing are techniques used to decrease embolic events and decrease perioperative complications.5,6,31,38,39,43,51 Long-stem cemented femoral arthroplasties for patients with metastatic bone disease is controversial. Some surgeons remain trepid in the general use of cemented long-stem femoral arthroplasties for patients with metastatic bone disease because of the aforementioned risks.12,14,15,21,34,36 Combining cementation with a longstem femoral component further increases the possibility of complications, especially in a patient with metastatic bone disease who has poor quality bone and severe preexisting medical conditions.36 Therefore, it is not clear whether the additional femoral stability from a cemented long-stem arthroplasty is worth the increased risk of a life-threatening cardiopulmonary embolic event. We hypothesized that by using aggressive medullary lavage, intraoperative long-tip canal suction, and low-viscosity PMMA, the morbidity of patients with a cemented long-stem (300 mm) arthroplasty could be minimized. bone disease. All surgeries were performed by the senior author (RR). Institutional review board approval was obtained from the senior author’s (RR) institution. The study complies with regulations of the Health Insurance Portability and Accountability Act (HIPAA). Seventeen men and 10 women were included in our study. Two patients had bilateral involvement. The mean age of the patients was 63.3 years (range, 24–87 years) at the time of surgery. There were 15 hemiarthroplasties and 14 total hip arthroplasties (THA) performed. There were 11 impending fractures and 18 realized fractures of the hip. The mean average Mirels’ score32 was 10.2 in 23 recorded patients (range, 8–12). There were five previously instrumented canals. The histologic subtypes included seven breast carcinomas, five prostate carcinomas, four myelomas, four primary adenocarcinomas of unknown origin, three renal carcinomas, two lung carcinomas, one bladder carcinoma, one neuroendocrine tumor, one uterine carcinoma, and one endometrial carcinoma (Table 1). Data from surgeries performed between June 1999 and August 2003 were collected. Surgical inclusion criteria included all patients with metastatic bone disease who had substantial acetabular, femoral head, and/or neck lesions with realized or impending fractures, and a Mirels’ score of 8 or greater.32 Patients had long-stem femoral instrumentation regardless whether the disease was more distal in the ipsilateral femur. Femoral hemiarthroplasty was performed when no acetabular lesions or arthritis was present. Total hip arthroplasties were performed for any acetabular involvement.18 All surgeries were performed using a posterior approach to the hip. In patients with substantial acetabular involvement, an all-polyethylene cup was cemented in place and augmented with large fragment screws and/or threaded Steinmann pins to serve as a rebar.32 Femoral preparation and component placement were performed in a similar systematic fashion. After the femoral neck cut was completed with an oscillating saw, the canal was pre- TABLE 1. Demographic Data Parameters MATERIALS AND METHODS We retrospectively reviewed the first 29 consecutive cemented long-stem femoral hip arthroplasties using the same femoral component (BiMetric威 custom-blasted long-stem 300 mm × 9 mm, Biomet, Warsaw, IN) (Fig 1) in 27 patients with metastatic Fig 1. The 300-mm x 9-mm BiMetric姞 (Biomet, Warsaw, IN) custom-blasted long stem is shown. Gender Male Female Mean age (years) Impending fracture Realized fracture Mirels’ score (mean) Hemiarthroplasty Total hip arthroplasty Histologic subtype Breast Prostate Myeloma Adenocarcinoma of unknown origin Renal Lung Other Totals 17 patients 10 patients 63.3 (range, 24–87) 11 fractures 18 fractures 10.2 points (range, 8–12 points) 15 patients 14 patients 7 patients 5 patients 4 patients 4 3 2 4 patients patients patients patients Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Number 443 February 2006 pared with flexible reaming and broaching of the canal. The canal was suctioned between subsequent reamers. The canal then was brush lavaged thoroughly using the Pulsavac (Zimmer, Warsaw, IN) system. Three batches of Surgical Simplex™ P bone cement (Howmedica, Mahwah, NJ) mixed with 3.6 g tobramycin were used for femoral cementation because of the immunocompromised conditions of the patients. Simplex™ P bone cement was used because of its low viscous qualities on immediate mixing. Once the cement was mixed (< 1 minute), it immediately was injected into the femur in its early, liquefied cure state using a long cement gun. A long laparoscopic suction device (Conmed Corp, Utica, NY) was used to aspirate the canal immediately before and during application of PMMA (Fig 2). The femoral prosthesis then was inserted slowly into the femoral canal and allowed to settle with minimal manual force to avoid high peak pressurization. All excess cement was removed, and the implant was held in position until the PMMA had hardened. No distal venting was performed to avoid potential distal stress risers and minimize operative time. No cement restrictors were used. The primary outcome variables were perioperative complications identifying possible complications secondary to embolic phenomena at approximately the time of cementation. Intraoperative variables include cement-associated desaturation, cement-associated hypotension, sympathomimetic administration, and intraoperative death. Immediate postoperative variables include prolonged intubation, mental status changes, cardiopulmonary compromise, and death. Delayed perioperative variables included, periprosthetic fractures, wound complications, deep venous thrombosis (DVT), infections, and dislocations. A retrospective review was done of all patients treated by the senior author (RR) with long-stem femoral implants. Patients who did not have the BiMetric威 custom-blasted 300-mm × 9-mm long stems implanted, or patients who did not have metastatic bone disease with at least two sites of involvement were excluded from this analysis. Patients with a solitary bone metastasis frequently had resection of the lesion and were not included in this study. The data were collected through review of hospital inpatient, anesthesia, and outpatient records, and telephone communications. Data including age, gender, cancer subtype, previous IM instrumentation, Mirels’ scores, impending versus realized fractures, and hemiarthroplasty versus THA were collected. Perioperative complications including pneumonias, Fig 2. The laparoscopic suction device that was used to aspirate any residual bone marrow contents immediately before and concurrent with cement application throughout the length of the femur is shown. Complications of Cemented Arthroplasty 289 periprosthetic fractures, wound hematomas, DVT, infections, dislocations, or neurovascular injuries were recorded. Anesthesia records and operative reports were reviewed to identify intraoperative complications. Because this was a retrospective review, not all anesthesia records noted the exact time of cementation. The last 2 hours of the anesthesia records were scrutinized to assure that cementation occurred within our defined time, as femoral cementation is the last step. This time covered all but the anesthesia induction times, which were excluded as all patients were uniformly labile during this period. Cement-associated desaturation events were considered significant if there was a decrease less than 90%. Cement-associated hypotension was determined by taking an average of the first five systolic blood pressures after induction (blood pressures recorded every 5 minutes). Any decrease greater than 30% from the initial baseline systolic average was considered a significant event. Any sympathomimetic administration during the last 2 hours of recorded anesthesia was considered significant regardless of dose. Immediate postoperative outcomes including required prolonged intubation, cognitive changes, cardiopulmonary compromise, and death, were obtained from postoperative care unit and inpatient records. Prolonged intubation was defined as needing ventilatory support more than 2 hours after leaving the operating room. Cognitive changes compared with baseline were evaluated daily during inpatient stays with noted changes in alertness and orientation to name, location, and date. A Kaplan-Meier survival analysis was performed. RESULTS At the time of data collection, 17 of 27 (63%) patients had died. The range of survival was from 14 days to 1.4 years (mean, 26.5 weeks; median, 14.3 weeks) (Fig 3). The length of survival ranges from 2 months to 4.2 years (mean, 1.9 years; median, 1.5 years) for the 10 patients currently living. The histologic subtypes of patients who currently are living include: three multiple myelomas, three breast carcinomas, and one each of prostate, uterine, renal, and lung cancer. Perioperative complications were limited to transient cement-associated hypotension in four patients that resolved without sequelae (Table 2). Sympathomimetics were administered in nine patients (31%). All four patients with cement-associated hypotension were given sympathomimetics. No recorded episodes of hypotension or desaturation occurred in patients while in the postoperative or intensive care units. There were no cases of prolonged intubation, although two patients were not extubated in the operating room. Both patients were taken to the surgical intensive care unit for postoperative monitoring and were extubated the day of surgery. There were no catastrophic cardiopulmonary events attributed to cementation, and no patients had cardiopulmonary compromise throughout the hospitalization or at fol- Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 290 Clinical Orthopaedics and Related Research Randall et al DISCUSSION Fig 3. A Kaplan-Meier analysis shows overall patient survival. Censoring times are denoted by vertical hash marks. The dashed lines represent the 95% confidence interval. The time of last radiographic examination was the last followup. For patients who had two surgeries, only the first surgery was used in the calculation. lowup. One patient had a notable mental status change that worsened postoperatively. This patient had delirium, disorganized thoughts, hallucinations, and paranoid behavior preoperatively. No deaths occurred during inpatient hospitalization, and all patients were medically stable at the time of discharge. However, two deaths (7%) attributed to advanced metastatic cancers occurred within 3 weeks postoperatively (Days 14, 21). Both patients had preoperatively realized fractures. Two patients had pneumonia (7%). One patient had aspiration pneumonia secondary to a swallowing dysfunction, and one patient had a questionable pneumonia and was treated with antibiotics. There was one (3%) periprosthetic fracture at the distal end of the femoral stem that was further stabilized with a lateral supracondylar plate (Fig 4). The fracture was caused by a direct fall onto the knee while ambulating. One wound hematoma was treated with surgical evacuation. No patients had DVT, surgical infections, dislocations, or neurovascular injuries. Patients were evaluated clinically for DVT, and no additional workup was done without clinical suspicion of DVT. TABLE 2. Perioperative Complications Cement-associated desaturation Cement-associated hypotension Synpathomimetics (including prophylaxis) Prolonged extubation PACU/SICU desaturation PACU/SICU hypotension 0/29 (0%) 4/29 (14%) 9/29 (0%) 0/29 (0%) 0/29 (0%) 0/29 (0%) Significant cardiopulmonary complications including hypotension, desaturation, cardiac arrest, and death have been reported to occur during cementation of femoral arthroplasties.12,15,21,34,36 The proposed mechanism of cement-associated cardiopulmonary compromise is well documented. 4–6,22,24–26,33,38,39,42,43,51,52 Using transesophageal echocardiography and/or hemodynamic monitoring, numerous studies have documented the correlation between increased IM pressures, embolic phenomena, and subsequent compromise of the cardiopulmonary system.4,6,22,24,26,42,43,51 However, rates of clinically significant cardiopulmonary events are highly variable because of differences in study populations and variations in surgical cementing techniques.6,12,15,16,21,25,28,30,34,36,38,39 Healthy patients having elective hip replacement rarely have cardiopulmonary complications related to cementation. This may be related to the fact that many anesthesiologists often give prophylactic sympathomimetics (information that routinely is not typically relayed to the surgeon during or after surgery). Conversely, patients with metastatic disease, preexisting medical conditions, realized hip fractures, and those treated with long-stem femoral arthroplasties have been identified as being at risk for cementrelated complications, and accordingly, prophylactic sympathomimetics frequently are given. We evaluated the anesthesia records in cooperation with the anesthesia department to maximally detect adverse cardiopulmonary events relating to our techniques. Although our study is limited by its retrospective analysis of one surgeon’s patient cohort, all patients treated with this endoprosthesis and the described techniques were treated consecutively in an identical manner regardless of comorbidities. The value of the study is depreciated by a lack of uniform documentation in the anesthesia records of the precise moment when the femoral cementation occurred. Sometimes we made stringent assumptions as to when effects of anesthesia had maximally ameliorated, with the patient subsequently achieving cardiopulmonary equilibrium before femoral canal preparation. We always erred on the side of attributing any possible cardiopulmonary effects to our described femoral techniques rather that to anesthetic lability, the latter of which is prevalent in this patient population. As expected, change in intraoperative blood pressure was common in our patient cohort, and numerous had chronic hypertension. It was assessed as being clinically relevant to placement of the prosthesis if systolic blood pressure was decreased by greater than 30% of the patient’s baseline, even if the baseline was markedly elevated. This individualized definition of hypotension is commonly used for patients with hypertension because of Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Number 443 February 2006 Complications of Cemented Arthroplasty 291 Fig 4A–E. A 75-year-old man with metastatic prostate cancer initially was treated with a second-generation IM nail for a pathologic hip fracture. (A) This radiograph shows subsequent failure of proximal fixation. The patient then had a cemented long-stem hemiarthroplasty. One week after the conversion surgery, the patient fell directly onto his right knee sustaining a periprosthetic femur fracture distal to the long stem as seen on the (B) AP and (C) lateral radiographs. (D) Anteroposterior and (E) lateral radiographs show the periprosthetic fracture treated with a lateral supracondylar plate. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 292 Randall et al compromised cerebral and coronary autoregulation secondary to chronic hypertension.37,46 In general, this concept requires more precise control of blood pressure. Long-term baseline blood pressures were not available in the patient’s anesthesia records, therefore, the average blood pressure was recorded early during the surgical procedure when the anesthesiologist’s goal was normotension based on preoperative blood pressure, history, and physical examination. Perioperative hypoxemia, defined as arterial oxygen desaturation less than 90% despite supplemental oxygen administration, was used as a marker of significant embolic pulmonary injury. Smaller decreases in oxygen saturation are not clinically significant and occur frequently. The rate of cement-associated intraoperative death has been reported as 0.01–11%, with rates varying with different study populations.12,15,21,34,36 The rate of intraoperative death in patients having elective THA is very low. Parvizi et al reported an 0.01% intraoperative death rate in their study of 30,714 patients who had elective THAs.34 Conversely, Duncan reported six (11%) intraoperative deaths and a cardiac arrest rate of 15% in 52 consecutive cemented femoral arthroplasties performed on patients at high-risk for hip fractures.12 Parvizi et al35 reviewed 23 intraoperative deaths in patients with primary hip arthroplasties. All sudden deaths occurred because of cardiopulmonary compromise during cementation. Their overall intraoperative death rate was 0.06%. When looking only at patients with metastatic pathologic fractures, their sudden death rate was greater at 4.3%. Given that the addition of antibiotics increases cement viscosity during the curing process in general, but perhaps not initially, and that we had no clinically substantial cement-associated complications, results of this study do not warn against addition of antibiotics in patients having long-stem femoral components implanted. However, avoiding their use may minimize cement-associated hypotensive events. Long-stem femoral components have a greater rate of cement-related problems for two reasons.21,36 First, more surface area is exposed in the femoral canal and more extrusion of emboli is allowed.21,36 Second, the long-stem prosthesis generates greater pressures in the proximal femur as it is inserted past the isthmus, essentially acting as a cement restrictor.21,36 Herrenbruck et al21 retrospectively reviewed 55 consecutive patients with metastatic disease or having revision surgery who had long-stem femoral components implanted. They reported a 62% rate of adverse events including cement-associated postoperative hypotension and desaturation, use of sympathomimetics, and intraoperative catastrophic events.21 The rate of catastrophic events was 5.5% with all episodes occurring in Clinical Orthopaedics and Related Research patients with metastases. Patterson et al36 reported a case series of seven patients who had cardiac arrest during cementation of a long-stemmed femoral component. Only three patients had metastatic bone disease; all were treated with 300 mm stems. The other four stems ranged from 225–260 mm. All seven patients were of advanced age, and had osteoporosis, long-stem components, and previously uninstrumented canals. They recommended invasive hemodynamic monitoring including arterial lines and Swan-Ganz catheters, neither of which were used routinely in our cohort, and retrograde cement injection after seating of the component. Numerous surgical techniques have been used to minimize complications from cement implantation. These techniques have focused on decreasing the amount of debris available for embolization or decreasing IM pressures during cementation. Some investigators support using thorough IM lavage to decrease medullary debris available for embolization.5,6,43,51 Intramedullary canal suctioning during the cementing process is another technique to decrease the quantity of debris available for embolization and minimize hemodynamic changes.38,39 In elective arthroplasty, it is important to obtain a good cement mantle with interdigitation of the cement-bone interface.7,31,49 The quality of interdigitation is largely dependent on pressurization of the canal during cementing and insertion of the prosthesis. Churchill et al compared early versus late-stage cement and the differences in generated intramedullary pressure, showing that highviscosity cement had greater femoral pressures and intrusion factors than low-viscosity cement.7 In the population having elective surgery, embolic cardiopulmonary complications are rarely a concern.7,11,30 This is in contrast to patients with metastases in whom high medullary pressures often may be fatal. Most case series evaluating cemented femoral arthroplasties involve the general population or involve numerous fixation methods in the population with metastatic disease.1–3,10,29,47,53 Little, if any, critical comment is made in these studies1–3,10,29,47,53 regarding the effect of cementation on cardiopulmonary parameters. Numerous surgeons performing arthroplasties do not inquire about the subtleties of the interventions performed by anesthesiologists during routine and nonconventional cemented proximal femoral arthroplasties and may be unaware of the potential transient cardiopulmonary changes. To our knowledge, two studies address cemented femoral arthroplasties for treatment of metastatic disease, although neither directly addresses perioperative complications.8,28 Clarke et al8 reviewed 28 patients with metastases treated with cemented femoral replacements. Their surgical technique included pulsatile lavage with digital pressurization of the cement after retrograde delivery with Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Number 443 February 2006 Complications of Cemented Arthroplasty 293 a cement gun.8 Only one patient experienced substantial intraoperative hypotension and hypoxemia and this occurred in their only patient with a 300-mm stem.8 Lane et al28 studied 167 patients treated with proximal femoral replacements. Their cementing technique for hemiarthroplasties entailed canal irrigation followed by placement of the prosthesis with retrograde injection of methylmethacrylate through a distal posterolateral 6.4-mm diameter hole.28 Components were cemented from the proximal end. Intraoperative complications were not addressed; however, there were no intraoperative deaths.28 The use of long-stem femoral components reduces the potential need for additional surgery in this patient population, particularly given increasing life spans with adjunctive therapy. Treatment should be definitive, addressing all areas of metastatic disease and areas of potential spread. The implant should be a stable construct allowing immediate ambulation and improving quality of life. Radiographic evidence of local disease progression occurred in one patient (Fig 5). Without additional distal fixation, a conventional-length implant would have a greater likelihood of failure compared with a long-stem implant. Because the femur had been fixed with a long stem, no additional workup of possible diaphyseal spread was necessary. There were no subsequent, noncontiguous distal metastatic foci seen on conventional radiographs, although two final radiographic reports noted possible middiaphyseal spread that was seen on radiographs obtained at followup. The workup of additional femoral spread is often difficult secondary to the inability to recognize lesions on plain radiographs without at least 30%–50% bone loss.13,45 Because of the dynamic nature of the disease process, potential local disease progression, and poor bone quality, we think the benefits of long-stem components in arthroplasties outweigh the risks when appropriate safety measures are taken. With improvements in adjuvant therapy and increased life expectancy, definitive femoral fixation becomes more important. With careful attention to thorough medullary lavage, early use of PMMA, and suction via a long laparoscopic device, cemented long-stem femoral arthroplasties can be used safely in patients with advanced metastatic disease with no additional risks than those seen with conventional cemented stems. Fig 5A–B. A 69-year-old man with a history of metastatic prostate cancer sustained a pathologic femoral neck fracture that was treated with a cemented long-stem hemiarthroplasty. (A) A radiograph taken immediately postoperatively shows adequate cementation without complication. (B) A radiograph taken at the 3-month followup shows increased radiolucencies in Gruen Zones I and VII from local disease progression. No radiolucencies were seen in Zones II–VI. Acknowledgment We thank Aniko Szabo, PhD, for assistance with statistical analysis. References 1. Aaron AD. Treatment of metastatic adenocarcinoma of the pelvis and the extremities. J Bone Joint Surg Am. 1997;79:917–932. 2. Algan SM, Horowitz SM. Surgical treatment of pathologic hip le- Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 294 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. Clinical Orthopaedics and Related Research Randall et al sions in patients with metastatic disease. Clin Orthop Relat Res. 1996;32:223–231. Behr JT, Dobozi WR, Badrinath K. The treatment of pathologic and impending pathologic fractures of the proximal femur in the elderly. Clin Orthop Relat Res. 1985;98:173–178. Breed AL. Experimental production of vascular hypotension, and bone marrow and fat embolism with methylmethacrylate cement. Clin Orthop Relat Res. 1974;102:227–243. Byrick RJ, Bell RS, Kay JC, Waddell JP, Mullen JB. High-volume, high-pressure pulsatile lavage during cemented arthroplasty. J Bone Joint Surg Am. 1989;71:1331–1336. Christie J, Robinson CM, Singer B, Ray DC. Medullary lavage reduces embolic phenomena and cardiopulmonary changes during cemented hemiarthroplasty. J Bone Joint Surg Br. 1995;77:456– 459. Churchill DL, Incavo SJ, Uroskie JA, Beynnon BD. Femoral stem insertion generates high bone cement pressurization. Clin Orthop Relat Res. 2001;393:335–344. 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