This 2004 state-of-the-art review from the Mayo Clinic addresses systematic evaluation and surgical management of pathologic fractures of the proximal femur, with emphasis on metastatic carcinoma and multiple myeloma. It covers initial workup, biopsy indications, implant selection, PMMA augmentation, prosthetic reconstruction, and postoperative radiotherapy.
The orthopedic trauma surgeon is often the first physician to see a patient with a pathologic fracture, before oncology has been involved. The reflex to "just fix it" is dangerous: 10–20% of solitary lesions in patients with cancer history are not metastatic, and nailing a primary sarcoma contaminates the field and can turn a limb-salvage case into a hemipelvectomy.
When you see a proximal femur fracture in a patient with known or suspected malignancy, obtain the full workup first (bone scan, CT chest/abdomen/pelvis, labs including SPEP) and get tissue diagnosis before the OR. Biopsy alone identifies the primary only 8% of the time without that workup.
For implant selection: use a reconstruction nail with femoral head/neck interlocks for virtually all femoral metastatic lesions, not a standard nail. The intertrochanteric and basicervical region is the most common site of femoral metastatic involvement, so protecting it from the start avoids a second operation. Add PMMA augmentation whenever there is an open section defect or greater than 50% cortical destruction.
Post-op radiotherapy is not optional — it cuts reoperation rates from 15% to 3% and must cover the entire surgical field. Plan for this before you choose your construct, because the entire canal that was reamed needs to be in the field.
This 2004 state-of-the-art review from the Mayo Clinic addresses systematic evaluation and surgical management of pathologic fractures of the proximal femur, with emphasis on metastatic carcinoma and multiple myeloma. It covers initial workup, biopsy indications, implant selection, PMMA augmentation, prosthetic reconstruction, and postoperative radiotherapy.
The orthopedic trauma surgeon is often the first physician to see a patient with a pathologic fracture, before oncology has been involved. The reflex to "just fix it" is dangerous: 10–20% of solitary lesions in patients with cancer history are not metastatic, and nailing a primary sarcoma contaminates the field and can turn a limb-salvage case into a hemipelvectomy.
When you see a proximal femur fracture in a patient with known or suspected malignancy, obtain the full workup first (bone scan, CT chest/abdomen/pelvis, labs including SPEP) and get tissue diagnosis before the OR. Biopsy alone identifies the primary only 8% of the time without that workup.
For implant selection: use a reconstruction nail with femoral head/neck interlocks for virtually all femoral metastatic lesions, not a standard nail. The intertrochanteric and basicervical region is the most common site of femoral metastatic involvement, so protecting it from the start avoids a second operation. Add PMMA augmentation whenever there is an open section defect or greater than 50% cortical destruction.
Post-op radiotherapy is not optional — it cuts reoperation rates from 15% to 3% and must cover the entire surgical field. Plan for this before you choose your construct, because the entire canal that was reamed needs to be in the field.