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

Abstract

Background Several strategies for the treatment of pathologic proximal femur fractures are practiced but treatment outcomes have not been rigorously compared. Questions/purposes Major variations in the use of intramedullary fixation, extramedullary/plate-screw fixation, and endoprosthetic reconstruction techniques for pathologic proximal femur fractures in patients with skeletal metastases are reported. The clinical and surgical variables that influence this choice differ among treating surgeons. To characterize the technique preferences and to identify areas of consensus regarding specific clinical presentations, we administered an online survey to the Musculoskeletal Tumor Society (MSTS) membership. We also tested whether responses correlated with the respondents' years in practice and asked about the indications for wide tumor resection and the role of tumor debulking and adjuvant cementation. Methods A 10-minute, web-based survey was sent via email to 244 MSTS members. The survey queried participants' musculoskeletal oncology training and experience and presented case scenarios illustrating different combinations of four variables that influence decision-making: cancer type, estimated patient survival, fracture displacement, and anatomic region of involvement. Results Forty-one percent (n = 98) of MSTS members completed the survey. Intramedullary nail fixation (IMN; 45%) and proximal femur resection and reconstruction (34%) were the most commonly recommended techniques followed by long-stem cemented hemiarthroplasty/cemented hemiarthroplasty (15%) and open reduction and internal fixation (7%). Most respondents (56%) recommended use of cementation with IMN. Differences of opinion on recommended treatment were associated with variations in cancer type, fracture displacement, and anatomic region of involvement. Conclusions Our online survey showed a trend among MSTS members for selecting IMN and arthroplasty-related techniques to treat pathologic fractures of the proximal femur, but major differences in preferred operative technique exist. Prospective studies are needed to develop consistent, evidence-based treatment recommendations.

Is Prophylactic Intervention More Cost-effective Than the Treatment of Pathologic Fractures in Metastatic Bone Disease?

“…We also believe that performing surgery semielectively for prophylactic purposes may provide less inherent risk for complications than operating on a fracture and performing unplanned surgery urgently, which was reported in one fracture study [3]. Steensma et al [21,22] reported that patients sustaining a pathologic fracture treated with arthroplasty had fewer treatment failures and revision surgeries than those treated with internal fixation. Because of improved outcomes with arthroplasty in pathologic fractures, trends are shifting toward treating more patients with pathologic fractures with joint replacements (Fig.…”

What Are the Functional Results and Complications With Long Stem Hemiarthroplasty in Patients With Metastases to the Proximal Femur?

“…Endoprosthetic reconstruction is a surgical modality commonly used to reach these goals, but the outcomes of specific approaches such as stem length, cement use, and Table 3. type of prosthesis continue to be controversial [15,31,35]. This study seeks to elucidate the survival, functional outcomes, and complications associated with long stem cemented hemiarthroplasty in a small group of patients treated for impending and actual pathologic fractures of the proximal femur resulting from metastatic bone disease.…”

“…Treatment of pathologic fracture, therefore, is intended to restore function of the affected limb, relieve pain, improve quality of life, and facilitate custodial care as well as additional medical testing and treatment as quickly as possible. Substantial variation exists in approaching treatment for impending or actual pathologic fractures of the proximal femur [31]. Surgical interventions for pathologic fractures of the proximal femur resulting from metastatic bone disease traditionally include fixation with intramedullary nailing supplemented with polymethylmethacrylate bone cement, osteosynthesis with a plate-screw construct and polymethylmethacrylate, or endoprosthetic reconstruction [31].…”

“…Substantial variation exists in approaching treatment for impending or actual pathologic fractures of the proximal femur [31]. Surgical interventions for pathologic fractures of the proximal femur resulting from metastatic bone disease traditionally include fixation with intramedullary nailing supplemented with polymethylmethacrylate bone cement, osteosynthesis with a plate-screw construct and polymethylmethacrylate, or endoprosthetic reconstruction [31]. Despite the frequent practice of these treatments, treatment outcomes have not been rigorously compared [31].…”

CORR Insights®: What Are the Functional Results and Complications With Long Stem Hemiarthroplasty in Patients With Metastases to the Proximal Femur?

“…Most of these are caused by metastatic disease, and these fractures cause pain, morbidity, and in some patients, premature death. In a survey of members of the Musculoskeletal Tumor Society (MSTS) presenting multiple clinical scenarios, a wide range was noted in the preferred treatments, including intramedullary nail fixation, proximal femur resection and reconstruction, cemented hemiarthroplasty, and open reduction internal fixation [2]. Furthermore, there was a nearly equal split regarding the use of polymethyl methacrylate around intramedullary nails.…”