Metastatic Disease of the Femur: Surgical Treatment

Abstract

The senior author's 12-year consecutive series of surgery for metastatic disease of the femur was reviewed. Treatment of 97 impending pathologic fractures yielded better results than treatment of 85 completed pathologic fractures with less average blood loss (438 cc versus 636 cc), shorter hospital stay (7 days versus 11 days), greater likelihood of discharge to home as opposed to an extended care facility (79% versus 56%) and greater likelihood of resuming support-free ambulation (35% versus 12%). Internal stabilization with a reconstruction-type intramedullary nail provided satisfactory pain relief and functional preservation for most patients with impending pathologic femur fractures (69 of 97, 71%), although alternate forms of internal fixation (21 of 97, 22%) or cemented arthroplasty (seven of 97, 7%) were used successfully. Completed pathologic fractures were more likely to require some form of arthroplasty (47 of 85, 55%), although reconstruction-type nails (20 of 85, 24%), and other internal fixation techniques (18 of 85, 21%) also were used. Modular oncology-type arthroplasty systems offered a viable salvage option in both groups. In the absence of conflicting goals or contraindications, internal stabilization of impending pathologic fractures before the completion of the fracture seems to be reasonable and appropriate.

Endoprostheses Last Longer Than Intramedullary Devices in Proximal Femur Metastases

“…The MSTS functional scores were similar (p = [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27], respectively.…”

“…The presence of fracture resulted in an increased rate of reoperation and subsequent mechanical failure in the intramedullary nail group. Implant failure has been reported in other series evaluating IMN for metastatic lesions with a failure rate ranging between 2% and 22% [13,[26][27][28]. This probability of implant failure increases with longer patient survival and the presence of nonunion [6].…”

“…Surgical options that have emerged to achieve these goals include plate fixation [13,27], intramedullary fixation [6,13,24,26,27], and endoprosthetic reconstruction [4,5,19,[28][29][30]. Plate fixation has an unacceptably high mechanical failure rate of 44% to 70% [6,13,30].…”

Trends in the Surgical Treatment of Pathologic Proximal Femur Fractures Among Musculoskeletal Tumor Society Members

“…We reviewed the peer-reviewed literature from 1980 through 2011 and found 14 articles describing outcomes for IMN, PFRR, LSCH/CH, and ORIF in patients treated for femoral metastases. Notably, few studies examined proximal femur fractures specifically, and 14 of 15 studies were retrospective, citing either a retrospective cohort (Level of Evidence IV) or retrospective comparison design (Level of Evidence III) (Table 5) [2,4,5,[7][8][9][10][11][12][13][14][15][18][19][20]. A single, prospective study (Level I) was found that showed functional improvement in patients undergoing surgery for nonspinal bone metastases [17], but outcomes specific to the proximal femur were not reported.…”

Are Allogeneic Blood Transfusions Associated With Decreased Survival After Surgery for Long-bone Metastatic Fractures?

“…Bone metastatic disease adversely affects quality of life and survival [3,22], and many patients with bone metastases undergo surgery to treat or prevent a pathological fracture [3,5,22]. Blood loss during operative treatment of metastatic fractures can be substantial and blood transfusions frequently are administered [25]. Although studies suggest that transfusions increase the risk of metastasis and death [1,15,23,26], we do not know whether allogeneic blood transfusions influence survival in patients with already disseminated cancer.…”