Palliative Medicine26(6) 788–796© The Author(s) 2011 Reprints and permission:sagepub.co.uk/journalsPermissions.navDOI: 10.1177/0269216311419882pmj.sagepub.com

PALLIATIVEMEDICINE

Introduction

Metastatic bone disease of the extremities is the most common cause of bone destruction in the palliative care setting. Although bone can also be involved by haemopoi-etic malignancies, such as myeloma or local invasion by non-bone malignancy,1,2 these are less common and pri-mary bone sarcomas are rare. The clinical presentation of patients with metastatic bone disease varies, but can include pathological fracture, bone pain and radiological abnormal-ities. Pathological fracture is usually a devastating event, associated with significant pain and disability, and yet half of the patients with a fracture will survive six months or more.3,4 Appropriate treatment of metastatic bone disease is therefore an important part of the management of many patients in the palliative care setting.5 The aim of treatment is to relieve pain, and to preserve or improve quality of life

(QoL) and physical function while minimizing the risk of complications. In some cases, the appropriate treatment of bony metastases may improve survival.6–9

Appropriate and timely orthopaedic surgery has a great deal to offer patients with metastatic bone disease, within the context of a multidisciplinary team approach, which remains the standard for care.10,11 A team approach ensures that the patient can be offered appropriate conservative treatment options, such as radiotherapy, before surgical intervention. Despite this, the decision to offer orthopaedic surgery to patients with metastatic bone disease is often difficult and requires consideration of predicted survival, the general health of the patient, the expected response to adjuvant treatment, reconstructability of the bone in ques-tion, whether or not the bone is weight bearing and the

Evidence for orthopaedic surgery in the treatment of metastatic bone disease of the extremities:A review article

Ajay Malviya Freeman Hospital, Newcastle upon Tyne, UK

Craig Gerrand Freeman Hospital, Newcastle upon Tyne, UK

AbstractBackground: The decision to offer orthopaedic surgery to patients with metastatic bone disease is often difficult and requires an understanding of the underlying disease, the patient’s needs or wishes, the expected outcomes and the principles of surgery.Aim: We aimed to look at the literature to support the role of orthopaedic surgery for skeletal metastasis in improving key outcomes such as pain, quality of life and physical functioning.Design: Review article.Data sources: The ‘Dialog Datastar’ database was used to access Medline and other resources from 1951 to December 2009 using keywords ‘Metasta$’ AND ‘Bone or Skeletal’ AND ‘Results Or Outcome Or Surg$ Or Management’.Results: The majority of the studies that have looked at these key outcomes are limited by their design and their use of non-validated outcome measures. This study has detailed the measures to assess outcome, predict survival, predict fracture and how to arrive at key decisions, such as when to operate and when not to operate on these patients.Conclusion: Timely and appropriate surgical intervention reliably alleviates pain and improves quality of life and can be undertaken with few complications in most patients. Although most procedures can be undertaken by non-specialists, consultation with other members of the multidisciplinary team is mandatory, and in complex cases, referral to a specialist orthopaedic oncology centre can be helpful.

KeywordsBone and bones, neoplasm metastasis, operative procedures, quality of life, treatment outcome

Corresponding author:A Malviya, 81 Daylesford Drive, Gosforth, Newcastle upon Tyne, NE3 1TW, UK. Email: amalviya@nhs.net

19882 PMJ26610.1177/0269216311419882Malviya and GerrandPalliative Medicine

Review

Malviya and Gerrand 789

effect of the metastasis on physical function.12 A particular difficulty arises when considering prophylactic fixation of a bony metastasis given that, despite the availability of systems to predict the risk of fracture and survival,13 considerable uncertainty remains.

The goals of surgery are to achieve local tumour control and structural stability to restore function as quickly as possible.5,14 Ideally, operative treatment should allow imme-diate weight bearing with the least possible morbidity.5,14

Surgical techniques to address bony metastases in the appendicular skeleton include internal fixation, sometimes augmented with methylmethacrylate bone cement and endoprosthetic replacement. Surgery is often associated with prolonged stays in hospital and the use of significant resources, although this can be cost effective,15 particularly when the patient continues to live independently as a result of surgical intervention. Preoperative tumour embolization can be helpful in the management of vascular tumours, such as metastases from renal cancer.

Given the complexity of decision making in this clini-cal situation, it is important to ensure that decisions are supported by the literature. The aim of this review article is to examine the literature pertaining to the surgical man-agement of metastatic bone disease of the extremities to identify how effective orthopaedic surgery is in improving symptoms, QoL and physical functioning.

Methods

The ‘Dialog Datastar’ database was used to access Medline (1951–December 2008), Allied & Complementary Medicine (1985–December 2008), British Nursing Index (1994–December 2008), CINAHL (1982–December 2008), DH-DATA (1983–December 2008), EMBASE (1974–December 2008), King’s Fund (1979–December 2008) and PsycINFO (1806–December 2008). The key-words used were ‘Metasta$’ AND ‘Bone or Skeletal’ AND ‘Results Or Outcome Or Surg$ Or Management’. A further Pubmed search was performed for articles between January 2009 and December 2009. We included only the articles published in English language. Preliminary screening of the abstracts of the articles (225) was performed and, after excluding the clearly irrelevant papers, 130 full text articles were obtained. We excluded articles looking at non-surgical management (radiotherapy or pharmacological intervention); articles on spinal, pelvic, rib cage, clavicle or skull metastasis; and also review articles or personal opin-ion (Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram). The articles on surgical management of the appendicular skeleton were shortlisted and a further hand search was done of the rele-vant references of these articles to avoid any articles that might have been missed on the initial search. A total of 64 articles have been included in this review.

We have not performed a formal assessment for the risk of bias that may affect cumulative evidence, as we have not

attempted to perform a meta-analysis, but have mentioned in the results where they may be a potential risk of selection bias in the studies. We recorded data on the number of subjects included, primary diagnosis, anatomic site, follow-up, survival, outcome measures used, impact on QoL, functional outcome, pain relief, type of intervention, use of bone cement, complications and level of evidence.

Results

These articles were further explored for the following.

1. Does orthopaedic surgery relieve pain?2. The impact of orthopaedic surgery on QoL and

physical functioning.3. Will patients live long enough to benefit? Predicting

survival.4. Predicting a fracture.5. When to operate?6. When not to operate?7. Complications of surgery.

Does orthopaedic surgery relieve pain?

Although pain relief is the primary goal of the treatment of bone metastases, not all studies include pain assess-ments.16–25 Those that do use a variety of measures, including non-validated instruments,18,26–44 subjective measures,45–49 objective measures (e.g. analgesic use),7,8,45,46,49–56 the pain domain of the Musculoskeletal Tumour Society (MSTS) score,16,57–63 or the formal pain scores in the Aboulafia50,51,58 and Allan systems.62,64

Whatever the measure, however, there is widespread agree-ment that surgical treatment of skeletal metastases leads to pain relief in the majority, if not all, patients7,8,18,26–49,52–56,58,62,65

(level of evidence III44,47 and IV).There is evidence that surgery can offer better pain

relief than conservative management. In one retrospective study47 over 80% of patients treated surgically reported satisfactory (excellent to good) pain relief, compared with 45%–60% of those treated conservatively. In another study of 60 patients,44 pain was relieved in 91% of those treated surgically compared with 59% of those treated with radia-tion and 45% of those treated by other means. Postoperative pain relief may be better in patients undergoing prophylac-tic fixation of skeletal metastases compared with those treated after pathological fracture (100% versus 70% good-to-excellent pain relief)48 and may be improved by using methylmethacrylate to supplement the fixation of femoral metastases (97% versus 83%).7

The impact of orthopaedic surgery on quality of life and physical functioning

Measures used to assess QoL and physical functioning of patients with skeletal metastases include global QoL

790 Palliative Medicine 26(6)

measures (e.g. SF-36), general performance/disability measures (e.g. Eastern Cooperative Oncology Group (ECOG), Karnofsky), combination measures (e.g. MSTS) and physical functioning measures (e.g. Toronto Extremity Salvage Score (TESS)). Compared with studies of non-surgical interventions, surgical studies more often use non-validated tools for the assessment of patient function.66

The SF-36 assessment has had limited use in this group of patients, with only one study reporting a significant improvement in the SF-36 bodily pain score following sur-gery, but no improvement in the overall score.60 The ECOG performance status is a commonly used measure of the overall functional status of patients with all types of cancer. The tool has been validated, has good inter-observer and intra-observer reliability67–69 and has been incorporated as part of a scoring system to predict outcome following surgery.70 Improvements in ECOG scores have been dem-onstrated in 67% of 107 patients undergoing orthopaedic surgery for breast cancer metastases in bone,52 and in patients undergoing acetabular reconstruction.52

The Karnofsky Performance Scale Index71 scores functional impairment, and its validity and reliability has been widely tested in a variety of cancers.72 Although the applicability of this measure to this group of patients has not been formally tested, significant improvements in the Karnofsky performance status have been demonstrated in patients with pelvic metastases following surgery73 and it has been used to predict survival.53,74

Physical function after surgery is often not reported17,20,25,75 or is assessed using non-standard measures.7,18,19,23,26–29,31–35,37–40,42–44,65 Assessments include simple descriptions of ambulatory status for tumours in the lower extremity8,21,22,30,35,36,41,46–49,54,56,76 and descriptions of upper extremity function.9,45,47,49,54,77 However, many studies have demonstrated improvement in the Musculoskeletal Tumor Society score and International Symposium on Limb Salvage score (MSTS-ISOLS)78 system.6,16,57–62 This 30-point physician-completed scoring system comprises six levels (0–5) in six domains, including pain, function, emotional acceptance, support, walking and gait. The system was originally described by Enneking et al.78 and subsequently adopted62 by the Musculoskeletal Tumor Society and the International Symposia on Limb Salvage and has low inter-observer variability.

The TESS is a patient-completed validated measure developed to evaluate physical disability in patients treated for extremity tumours79,80 and includes 30 items on activ-ity limitations in daily life, such as restrictions in body movement, mobility, self-care and performance of daily tasks. Each item is scored from 0 to 5 points and the raw score is converted to a score of 100 points. A higher score indicates less disability. A clinically significant improve-ment in TESS has been documented following surgical treatment for metastatic bone disease.60,61

Although some authors have attempted to compare out-comes after conservative and surgical treatment, these stud-ies are limited by their retrospective design and use of non-standard outcome measures.44,47

Adjuvant postoperative radiotherapy may help to improve physical functioning after surgery. Townsend et al.9

retrospectively compared 35 patients given adjuvant postop-erative radiotherapy to 29 treated with surgery alone and showed that patients given radiotherapy were more likely to return to normal function (53% versus 11.5%, p < 0.01).

The use of methylmethacrylate bone cement to supple-ment fracture fixation can also lead to improved functional outcomes by enhancing the stability of the reconstruction and allowing earlier mobilization.7,8,56,81 Habermann et al.7

reviewed a group of patients with metastases of the hip or femur and reported that 95% of patients whose fracture fixation was supplemented with cement could walk, com-pared with 75% of those treated with surgery alone. This effect is of less significance in the humerus, where both intramedullary nailing and plating with cement fixation have a similar effect on function.45

The literature therefore suggests that functional status and QoL can be improved by the surgical treatment of bone metastases, although the level of the evidence is low (level III44,47 and level IV).6,9,16,26,27,30,32,44–46,48,52–54,58,62,73,76,77,81

Will patients live long enough to benefit? Predicting survival

The median survival of patients following surgical inter-vention for metastatic bone disease in the literature ranges from 2 (Hardman et al.76) to 14 (Giurea et al.73) months, and there is little difference in survival between those treated surgically and those treated with palliative radio-therapy for bone pain.3 The most important determinants of survival are the biology of the primary cancer and the stage of the disease: patients with metastases from breast cancer have a better prognosis than those with other pri-mary tumours.3,6–8,19,22,27,32,45,70,74,82 Similarly, patients with metastases from renal,6,45,74,82 prostatic6,70 or thyroid6,70

cancer, lymphoma70,74,82 or myeloma6,70,74,82 do better than those with lung,7,32,45,70,74,82 gastric or hepatocellular pri-maries.70 Patients with visceral metastases or multiple bony metastases have a poorer prognosis.3,6,52,70,74,82,83 The six-month survival rates associated with tumours that commonly metastasize to bone have been reported to be 98% for prostate cancer, 89% for breast cancer, 50% for lung cancer and 51% for kidney tumours.14

The biology of the underlying tumour is also reflected in the time it takes for a skeletal metastasis to develop after diagnosis, which in some studies is prognostic for sur-vival.6,82,84 Bohm and Huber6 found an interval of more than three years was a good prognostic variable. Durr et al.84

found a latent period of over 12 months to be significant in

Malviya and Gerrand 791

patients with renal cancer, but not in those with breast cancer.83 In the latter group, patients with fewer than three months of symptoms had a poorer prognosis than others.83

Pathological fracture is associated with poorer sur-vival.6,52,74,76,82,83 Katzer et al.54 found shorter overall sur-vival for patients with pathologic fracture (10.3 months) than for patients undergoing prophylactic stabilization (16.2 months), although this was not statistically signifi-cant. Hardman et al.76 reported a significantly (p < 0.0001) higher median postoperative survival of patients with pro-phylactic surgery (15 months) compared with those with fracture (2 months). Unfortunately, selection bias makes it difficult to draw generalizable conclusions from these studies.

Similarly, survival has been related to the extent of skel-etal involvement,74 the use of postoperative radiotherapy,9,85

surgical margin,6,73 type of procedure (arthroplasty versus fracture fixation)6,9 and use of bone cement to supplement fixation.7,8

Predicting the likely survival of the patient is an impor-tant part of the decision to operate, and several systems are described in the literature, although none have been prospectively validated.19,70,74,82,86–88

Predicting a fracture

Clinicians are often asked to consider prophylactic internal fixation in patients with established metastatic bone disease where there is a perceived risk of fracture. The major ben-efit of this approach is that patients can be treated in a planned semi-elective fashion, which may lead to better outcomes. The difficulty is that, given that a fracture cannot be reliably predicted, some patients may undergo a procedure they would not otherwise have needed. Scoring systems (Table 1) have been developed to help with this decision, the Mirels and Harrington systems being the two most widely adopted.89 A rough estimate of the percentage probability of fracture19 can be calculated by multiplying the quotient of the diameter of the lesion and bone by 100. Zickel and Mouradian42 have proposed the concept of the femur at high risk of fracture. Although these systems can be helpful, it is telling that they are underutilized.11

Harrington’s system90 (Table 1) is easy to remember, but has not been evaluated prospectively or rigorously. Furthermore, although the criteria are extremely specific, they are poorly sensitive, and other potentially important factors (e.g. patient weight, co-morbidities, compliance, pain, local tenderness, pain medications, bisphosphonates, concurrent chemotherapy, function, primary disease, life expectancy, specific sites other than proximal femur, matrix of lesion, other lesions, concurrent disease, radiosensitivity, patient activity level and patient expectations) are not considered.89 Aaron91 states that these criteria are guide-lines and should not be strict rules, as for the lesions to become apparent on plain radiographs bone loss must

approach 30%–50%. Moreover, in lesions characterized by bone production, clear evidence of bone destruction can be difficult to assess on plain radiographs.

The Mirels13 system (Table 1) has the advantages of being relatively simple, (needing only clinical evaluation and radiographs), reproducible and valid, and has been more rigorously evaluated than Harrington’s. It is highly sensitive as a screening tool (85%–91%), and possibly even better than clinical judgment using the same clinical infor-mation and plain radiographs.89 The disadvantages include the fact that it has not been evaluated prospectively, over-looks between 9% and 15% of patients who will have a fracture, has relatively poor specificity (33%–35%) in pre-dicting actual fracture and does not account for numerous potentially important non-mechanical factors.89 A critical evaluation of the Mirels rating system by Damron et al.92

showed good agreement for site, moderate agreement for type and fair agreement for size and pain between observ-ers. They reported no significant difference over clinical judgment regardless of experience level. They concluded that although Mirels’ system was reproducible, valid and more sensitive than clinical judgment, more specific param-eters were needed.

Other systems include the criteria proposed by Beals et al.93

(Table 1), which have since been extended,7,8,19,27–29 and the well-accepted predictors of impending fractures are a pain-ful lytic lesion involving more than 2.5 cm of the cortex; a painful intramedullary lytic lesion involving more than 50% of the cross-sectional diameter of the bone; and a progres-sive painful lesion not relieved by radiotherapy. Another system identified that a rough estimate of the percentage probability of fracture19 can be calculated by multiplying the quotient of the diameter of the lesion and bone by 100.

Table 1. Commonly used radiological criteria to predict fracture.

Variables Criteria for surgery

Harrington(Proximal femoral fracture)

Size 2.5cmBone diameter 50%Lesser trochanter involvement

Fracture

Response to RT No responseMirels Pain (1 3) Cumulative score 8

Size (1 3)

Type (1 3)

Anatomic location (1 3)

Beals Size Painful cortical lesion 2.5 cm

Painful intramedullary 50% diameter

Cortical involvementPain

Zickel Lysis Presence of these signify high risk of fracture

Malignant changeCortical involvementPain

792 Palliative Medicine 26(6)

While these systems can be helpful, the clinician should consider the whole patient when deciding about surgical fixation.

When to operate?

Unfortunately, resolving the published literature into a decision about operating on an individual patient can still be difficult. Publications may reflect a number of different philosophies of treatment, ranging from a largely conserv-ative approach to the aggressive pursuit of surgical fixation whenever feasible. Although it can be helpful and rational to combine scoring systems for predicting fracture and survival, ultimately the decision to operate is an individu-alized one. Predicting survival is difficult and it may be best to assume that the patient will live longer than one anticipates.14

In the presence of a pathological fracture rendering the patient bed-bound, the decision to operate may be more straightforward, unless the patient is moribund. Given the difficulty of managing the significant unpredictable incident pain associated with fracture, and the rapid early relief of pain associated with surgical fixation, the conventional view that the recovery time from surgery should not be more than the patient’s life expectancy (a suggested minimum of 30–90 days survival8,22,27,28,30,34,77,81) may not always be appropriate. The expertise of a palliative care team in this situation is very helpful in providing a global overview of the patient’s symptoms and prognosis and in providing alter-natives to surgery, such as epidural analgesia.

Upper extremity fractures may more often be treated conservatively than those that affect the mobility of the patient. For example, if a patient sustains a fracture of the humerus during chemotherapy, it may be possible to treat this conservatively until there is a suitable window in the systemic treatment. In some cases, a good response to treatment can lead to fracture healing.

In less acute situations, the decision to operate is based on the patient’s general condition, the expected duration and QoL with or without a successful operation.94 No patient should be denied surgery on the basis of extensive bone destruction, as contemporary orthopaedic oncology tech-niques allow for replacement or stabilization of extensive bone involvement.8,23,77,81 The quality of bone should influ-ence only the choice of internal fixation device.8,77 From the oncological point of view, orthopaedic surgery may offer the only dependable treatment for some metastases (e.g. some renal metastases).3

Capanna et al.95 have provided a rational guideline for indications for surgery, the type of operation to be under-taken and the methods of reconstruction available. The aim is to offer adequate individual treatment to the patient, avoiding undertreatment or overtreatment, to achieve con-trol of pain and to manage impending and pathological frac-tures so that longer survival is associated with a better QoL.

When not to operate?

Contraindications to surgery can be described as patient specific, disease specific and procedure specific.24 The patient’s overall physical and emotional state, and willing-ness and ability to participate in rehabilitation, are impor-tant considerations and prolonged postponement of surgery should be avoided, as the patient might deteriorate and the risks of surgery increase. Relative contraindications to surgery24,30 include a moribund patient, mental obtundation, haematopoietic depression, an infected wound in the sur-gical region, an acute deep venous thrombosis (especially if accompanied by pulmonary embolism), extensive neuro-vascular encasement by soft tissue tumour extension, gen-eral debility, severe malnutrition precluding wound healing, expected survival too short for the patient to recover suf-ficiently to benefit from the operative treatment and metastases in other sites compromising function.

With the exception of the patients discussed above, the general rule is that the recovery time from surgery should not exceed the life expectancy, but authors vary on where to draw the line. Life expectancies of less than four weeks,7,18,27–29,56 six weeks22,77 and three months8,34,41 have all been stated to be major contraindications to surgery. However, it is clear that consideration of the individual patient’s circumstances is important.

Complications of surgery

There are significant risks associated with complex surgical interventions in patients with metastatic bone disease; cumulative complication rates as high as 38% have been reported.76 Major complications include peri-operative mortality, local recurrence, fixation failure, infection and thromboembolism. Mortality in the peri-operative period after surgery for metastatic bone disease is high, with rates ranging from 6% to 15%.7,8,35,39,48,54,62 Tan et al.48 reported a mortality of 10% after surgery for pathological fracture and after prophylactic fixation but a higher mortality of 33.3% in the mixed group, who had surgery for both pathological fractures and prophylactic fixation. Multiple fixations attempted at the same operative sessions were associated with a 50% mortality.

The local recurrence rate after surgical excision is as high as 25%,52 but depends on the completeness of surgical excision. Extralesional resection of pelvic metastases is associated with a lower risk of local recurrence than intral-esional resection.6,73 Appropriate surgical reconstruction can continue to benefit the patient, despite local recurrence. In one study, local recurrence was identified in 25% of patients who had undergone acetabular reconstruction, but in only 8% had the reconstruction failed.52

The risk that the fixation will fail increases with time.32,46,75 Yazawa et al.32 (N = 147) reported an overall failure rate of 8.2%, but estimated the probability of fixation

Malviya and Gerrand 793

failure as 33% at 60 months, and this was even greaterfor femoral lesions (44% at 60 months). Proximal femoral lesions treated with compression screws and nail plates had a high (23%) failure rate. In a series of 233 procedures in 199 surgically treated patients, Dijkstra et al.46 noted that 11% of implanted devices failed (cumulative probability 40% after 60 months). The probability of failure at four years was 10% for endoprostheses but 70% for angled blade blades in the femur. Bohm and Huber6 (N = 94) reported a local failure rate of 0% after biological reconstruction, 3.6% after cemented or uncemented osteosynthesis and 1.8% after prosthetic replacement. In a review of 142 patients who had undergone surgery for proximal femur lesions, Wedin and Bauer75 reported a 10.3% failure rate in the endoprosthetic group as compared with 16.2% in fixation group. The re-operation rate was lower (8.3%) in the endo-prosthetic group as compared with the internal fixation group (16.2%). This could, however, be related to the higher survival rate in the re-operation group (15 months) as com-pared with that (5 months) of patients not requiring further surgery. The authors report that the risk of re-operation increases with time (being 0.14 at one year and 0.20 at two years). The two-year risk for re-operation after any type of osteosynthesis was estimated as 0.35 as compared with 0.18 after endoprosthetic replacement. They concluded that endoprosthetic replacement is superior to fixation as it replaces bone, while osteosynthetic implants at best are load sharing and are more likely to fail, although the use of methylmethacrylate as a supplement to an internal fixation device may reduce the chance of failure.7,8,81

There is also a risk of systemic (thromboembolic, cardiac, pulmonary, cerebrovascular events) and local complications. Katzer et al.54 (N = 101) reported a systemic complication rate of 14.5% (excluding mortality), six-week mortality of 7.9%, and local complication rate of 24.8% in the operated area, leading to a revision rate of 8.5%.

The role of adjuvant radiotherapy in the postoperative period in preventing failure is uncertain. In one study, postoperative radiotherapy was found to significantly lower the incidence of a second procedure at the same site.9 In contrast, Haentjens et al.53 reported that the incidence of bone remodelling and healing after adjuvant radiotherapy was significantly (p < 0.01) lower than after surgery alone.

Discussion

The decision to operate on a patient with metastatic bone disease is often difficult and requires an understanding of the underlying disease, the demands of the patient and the principles of surgical treatment of bone metastases. Approaches that consider the biological activity of bone lesion, responsiveness of the bone lesion to medical and radiation therapy and the anatomic location of the bone metastasis and patient factors (e.g. health status, expected length of survival, compliance, and patient expectation and

needs) are helpful.12 Although scoring systems can be used to help predict the risk of fracture, in patients who have not yet had a fracture, these other considerations are often of equal importance. The decision to operate once a fracture has occurred is sometimes easier, but conservative treat-ment may be appropriate for selected patients with a very poor prognosis.

Surgical management of metastatic bone disease has been recently discussed,5,14 but these papers have mainly concentrated on the technical aspect of the problem and not on the impact on QoL, as approached in this review. Our study is limited by an alteration in the search methodology for 2009, because of the non-availability of the original ‘Dialog Datastar’ database search tool. However, a Pubmed search did not reveal any clinical article published in 2009 that could have been included in this review.

Timely and appropriate surgical intervention reliably alleviates pain and improves QoL and can be undertaken with few complications in most patients.26 Although most procedures can be undertaken by non-specialists, consul-tation with other members of the multidisciplinary team is mandatory, and in complex cases, referral to a specialist orthopaedic oncology centre can be helpful. Further research, particularly around decision making in this chal-lenging and heterogenous group of patients, may be of great benefit.

FundingThis research received no specific grant from any funding agency

in the public, commercial, or not-for-profit sectors.

Conflict of interest The authors declare that there is no conflict of interest.

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