Journal of Orthopaedic Surgery 2007;15(3):295-8

Surgical management of metastatic disease of

the proximal femur
H Hattori

Department of Orthopedic Surgery, Tokyo Medical University, Tokyo, Japan

J Mibe

Department of Orthopedic Surgery, Tokyo Metropolitan Ohtsuka Hospital, Tokyo, Japan

H Matsuoka, S Nagai, K Yamamoto

Department of Orthopedic Surgery, Tokyo Medical University, Tokyo, Japan

patients with better preoperative medical status.

ABSTRACT
Purpose. To review the surgical treatment for
metastatic disease of the proximal femur.
Methods. Records of 8 patients who underwent
endoprosthetic replacement with tumour resection
(group 1) and 8 others who underwent intramedullary
nailing without tumour resection (group 2) were
reviewed. Treatments were based on the disease
progression and patients condition.
Results. In groups 1 and 2, the respective mean
survival periods were 16 and 4 months. All patients in
group 1 regained preoperative mobility, but only one
patient in group 2 was able to walk with crutches.
Conclusion. This was a retrospective, rather than
comparative study of endoprothetic replacement
and intramedullary nailing for metastatic disease of
the proximal femur. Both procedures are considered
palliative, and not curative. The longer survival
period in group 1 was mainly due to selection of

Key words: bone neoplasms; femur; neoplasm metastasis;

surgical procedures, operative

INTRODUCTION
The proximal femur is the most common long bone
site subject to metastatic disease and/or actual or
impending pathological fractures. The treatment goals
are pain relief and restoration of ambulatory function.
Surgical management is based on the location, type,
and extent of tumour, and patients general condition.1
Surgery should be aggressive (such as endoprosthetic
replacement or internal fixation and augmentation
with methylmethacryate, together with tumour
resection) when the chance of recovery is high. Patients
who are in a poor condition or considered unlikely to
recover may be more suitable for palliative treatment
(such as intramedullary nailing or external fixation
without tumour resection), despite being restricted to

Address correspondence and reprint requests to: Dr Hiroyuki Hattori, Department of Orthopedic Surgery, Tokyo Medical
University, 6-7-1, Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan. E-mail: hiroyuki.hattori@jcom.home.ne.jp

Journal of Orthopaedic Surgery

296 H Hattori et al.

(a)

(a)

(b)

(b)

Figure 2 Anteroposterior radiographs of the right proximal

femur showing (a) pathologic subtrochantric fracture, and
(b) progression of the lesion to the intertrochantric region
causing loosening of the proximal lag screw one month
after long intramedullary nailing without tumour resection.

(c)

Figure 1 Anteroposterior radiographs of

the hip showing (a)
extensive bony destruction from the right
intertrochanter to subtrochanter, (b) pathologic fracture after
ch e m o radiotherapy,
and (c) endoprosthetic
r e p l a c e ment
with
tumour resection.

bed and chair after surgery.1

We report outcomes of 16 patients with metastatic
lesions of the proximal femur and discuss the
advantages and shortcomings of 2 surgical methods.
MATERIALS AND METHODS
Between 1993 and 2002, records of 8 patients aged 37
to 72 (mean, 54) years who underwent endoprosthetic
replacement with tumour resection (group 1, Fig.
1) and 8 others aged 64 to 76 (mean, 70) years who
underwent intramedullary nailing without tumour

resection (group 2, Fig. 2) were reviewed. All patients

were able to walk before their fracture and received
adjuvant chemotherapy, radiotherapy, and/or
hormonal therapy before surgery. The indication
for surgery was actual or impending pathologic
fracture. The prerequisites for surgery were fitness
for anaesthesia and having a predicted survival
of 2 to 4 weeks. Patient selection was based on the
prognosis (disease progress, patients age, and general
condition).
In group 1, patients were expected to survive for
more than a few months. The surgery involved subfascial resection of the tumour and joint capsule, while
the muscles around the hip joint were preserved.
The greater trochanter with both gluteus medius and
vastus lateralis and the femur were osteotomised
at least 2 cm beyond the margin of tumour. For
impending fractures, an extralesional resection was
performed. In actual fractures, in most instances,
intralesional resection (without resecting the muscles
in the compartment) was performed. A tumour
endoprosthesis (Howmedica Modular Resection
System; Stryker Howmedica Osteonics, Allendale

Vol. 15 No. 3, December 2007

Surgical management of metastatic disease of the proximal femur 297

Table
Patient characteristics and outcomes

Patient Sex/age (years) Primary tumour Secondary location Metastatsis

No.
Group 1 (endoprosthetic replacement with tumour resection)
1
F/65
Breast
Intertrochanter
2
F/37
Breast
Intertrochanter
3
F/38
Breast
Intertrochanter
4
M/71
Renal
Intertrochanter
5
F/54
Breast
Femoral neck
6
M/46
Adorenal
Intertrochanter
7
M/72
Prostate
Intertrochanter
8
M/49
Lung
Femoral neck
Group 2 (intramedullary nailing without tumour resection)
9
F/70
Breast
Subtrochanter
10
F/76
Ovary
Subtrochanter
11
F/73
Lung
Subtrochanter
12
F/66
Breast
Intertrochanter
13
F/64
Breast
Intertrochanter
14
M/71
Prostate
Subtrochanter
15
M/70
Liver
Subtrochanter
16
F/73
Rectum
Subtrochanter

[NJ], US) was inserted. The external rotators and the

psoas were sutured tightly around the prosthesis neck,
forming a noose that provided immediate stability.
The remaining fragment of the greater trochanter was
fixed to the prosthesis with the plate-screw system.
This enabled walking with full weight bearing for the
expected survival period.
In group 2, patients were not expected to recover
and did not want to commit time and expenses. They
underwent intramedullary nailing (Gamma nail)
without tumour resection to improve pain and avoid
being bedridden.
RESULTS
In groups 1 and 2 respectively, patients were followed
up for a mean of 27 (range, 1187) and 11 (range, 2
37) months (Table). Respective mean operating times
were 195 (range, 130282) and 113 (range, 66180)
minutes, intra-operative blood losses were 858 (range,
4101700) and 243 (range, 0700) g, postoperative
decreases in haemoglobin levels were 2.3 (range, 0.5
4.3) and 3.5 (range, 15.9) g/ml, and peri-operative
units of blood transfused were 1.75 (range, 08) and
2.63 (range, 014).
In group 1, functional results were satisfactory; 5
were able to walk independently, 3 using a stick or
crutches. In group 2, only one patient was able to walk
with crutches. The respective mean survival periods
were 16 (range, 931) and 4 (range, 27) months, and

Fracture type

Follow-up Survival
(months)

Multiple+skeletal
Solitary
Multiple+skeletal
Multiple+lung
Multiple+skeletal
Multiple+skeletal
Multiple+skeletal
Solitary

Pathologic
Impending
Pathologic
Pathologic
Impending
Impending
Impending
Impending

12
34
15
20
12
28
87
11

Dead
Dead
Dead
Alive
Alive
Alive
Alive
Dead

Multiple+lung+liver
Multiple+lung
Multiple+lung+liver
Multiple+skeletal
Multiple+skeletal
Multiple+liver
Multiple+skeletal
Solitary

Pathologic
Pathologic
Pathologic
Pathologic
Pathologic
Pathologic
Pathologic
Pathologic

7
2
3
25
37
5
3
3

Dead
Dead
Dead
Dead
Alive
Dead
Dead
Dead

the respective one-year survival rates were 69 and

13%. Serious complications, including deep infection,
dislocation, displacement, and breakage of the
endoprosthesis or nail implant, were not encountered.
Most patients in each group achieved the goal of their
surgical methods.
DISCUSSION
Proximal femur-replacing prostheses result in loss
of hip flexor and abductor strength and permanent
gait disturbance,1 despite yielding good functional
results.25 Double plate osteosynthesis combined with
polymethylmethacrylate has been recommended,6
but is highly invasive and difficult.
In group 1, normal distal bone was adequately
resected (even in intralesional resection) and muscles
around the hip joint were preserved as much as
possible. This treatment is safer, because the risk of hip
dislocation decreases as the hip joint is reconstructed
with preserved muscles and blood loss is minimised
by subfascial resection without substantial exposure
of the tumour.
In group 2 the functional results were poor.
Nonetheless, good outcomes (walking with crutches
or a frame) have been reported in 24 of 30 patients
who underwent unreamed intamedullary nailing for
pathologic femoral fracture.7 However, healing of
pathologic fractures is impeded by both the metastatic
tumour and radiotherapy, with a union rate of 35%.8

298 H Hattori et al.

In group 2, intramedullary nailing was not sufficient

to stabilise pathologic fractures of the proximal femur
to enable full weight bearing, and was associated
with a low union rate and high risk of recurrence
and metastasis. It was only used to facilitate nursing
care and avoid being bedridden. We used the thickest
nails possible in order to attain rigid stabilisation.
Nonetheless, reaming increased postoperative blood
loss, even in carefully performed closed reduction
and internal fixation without exposure of the focus.
Complete pathologic fracture should be stabilised
immediately, even if the patients condition is poor
and/or the expected survival period is short. The
anticipated period of survival was determined by the
nature of the primary tumour, rather than the surgery

Journal of Orthopaedic Surgery

performed. Patients should undergo surgery if the

expected period of survival exceeds the recovery
time. Even experienced oncologists cannot accurately
estimate the survival period; some patients in group
2 survived longer than predicted. Therefore, the
choice of surgical method should be based more on
preoperative activities of daily living than on the
tumour type or estimated survival period.
This was a retrospective, rather than comparative study of endoprothetic replacement and
intramedullary nailing for metastatic disease of the
proximal femur. Both procedures are considered
palliative, rather than curative. The longer survival
period in group 1 was mainly due to selection of
patients with better preoperative medical conditions.

REFERENCES
1. Swanson KC, Pritchard DJ, Sim FH. Surgical treatment of metastatic disease of the femur. J Am Acad Orthop Surg 2000;8:56
65.
2. Algan SM, Horowits SM. Surgical treatment of pathologic hip lesions in patients with metastatic disease. Clin Orthop Relat
Res 1996;332:22331.
3. Damron TA, Sim FH. Surgical treatment for metastatic disease of the pelvis and the proximal end of the femur. Instr Course
Lect 2000;49:46170.
4. Rompe JD, Eysel P, Hopf C, Heine J. Metastatic instability at the proximal end of the femur. Comparison of endoprosthetic
replacement and plate osteosynthesis. Arch Orthop Trauma Surg 1994;113:2604.
5. Wedin R. Surgical treatment for pathologic fracture. Acta Orthop Scand Suppl 2001;72:129.
6. Broos P, Reynders P, van den Bogert W, Vanderschot P. Surgical treatment of metastatic fracture of the femur improvement
of quality of life. Acta Orthop Belg 1993;59(Suppl 1):S526.
7. Giannoudis PV, Bastawrous SS, Bunola JA, Macdonald DA, Smith RM. Unreamed intramedullary nailing for pathological
femoral fractures. Good results in 30 cases. Acta Orthop Scand 1999;70:2932.
8. Gainor BJ, Buchert P. Fracture healing in metastatic bone disease. Clin Orthop Relat Res 1983;178:297302.