(a, b) Sixty-one year-old woman with metastatic breast cancer who sustain a fracture after biopsy which was treated with cephallomedullary nail but failed to heal. She still had pain and presented with radiographic findings of failed hardware. (c, d) She underwent removal of hardware, proximal femoral resection, and endoprosthetic prosthetic reconstruction
(a, b) Seventy-seven year-old man with history of pathologic fracture secondary to metastatic prostate and renal cell carcinoma initially treated with plate fixation and cementation. He presented with pain and failure of fixation. (c, d) He underwent distal femoral resection and endoprosthetic reconstruction and ultimately died of disease approximately 5 months afterwards
Minimally Invasive Procedures
In patients with impending fractures, minimally invasive procedures such as radiofrequency ablation and cementoplasty or a combination have been utilized to relieve pain and prevent fracture . The exact indications for these treatment modalities are yet to be established.
The proximal femur has been thought to be a location for which cementoplasty was contraindicated. Recent data suggest that when utilized under specific parameters it can be considered. These parameters include, less than 30 mm of cortical involvement and no history of fracture of the lesser trochanter. If either of these scenarios is present, then the risk of fracture is too great and cementoplasty should not be attempted . Plancarte-Sanchez et al. also reported a series of patients for which cementoplasty or as they call it femoroplasty was performed for symptomatic bone lesions of the head, neck, and proximal one-third of the femur. They reported pain reduction in the patients who underwent the procedure. They did not encounter any significant complications .
In patients with pain secondary to femoral metastatic disease, intramedullary nails (IMN) have utility in both patients with impending and realized pathologic fractures. IMN function as a load-sharing device that allows for early mobilization and weight bearing. It has been shown that patients who underwent reamed IMN for femoral metastatic bone disease had improvement in pain at rest and with activity  (Fig. 24.3). Preoperative radiofrequency ablation of painful osteolytic bone lesion has been suggested as an adjuvant to reduce tumor dissemination, intraoperative blood loss, and improve pain management .
(a, b) Fifty-seven year-old man presented with severe left lower extremity pain and abnormal femoral radiographic findings. He was found to have widespread metastasis, with unknown primary. (c, d) He underwent biopsy and stabilization with cephallomedullary nail as he refused hip disarticulation. He unfortunately continued to have severe pain and ultimately underwent palliative hip disarticulation and died of disease approximately 3 months afterwards
Protecting the entire bone is often the recommendation when using IMN for femoral metastasis. Cephallomedullary devices are often used to protect the femoral neck (Fig. 24.1). Recent data from MD Anderson suggest that cephallomedullary nail may not be needed. Their data suggest that for those with diaphyseal disease, a standard nail is sufficient as there was no development of metastatic lesions in the femoral head and neck region after stabilization .
When using an intramedullary device, one must be aware of risks and complications associated with intramedullary nail placement in those with metastatic bone disease. Given that metastatic bone disease more frequently occurs in older adults, these patients may have compromised pulmonary function secondary primary lung disease such as chronic obstructive pulmonary disease. One must also take into account the effect malignancy may have on the lungs. These patients may have metastatic disease involving the lung, decreased pulmonary function or atelectasis secondary to prolonged immobilization, a history of prior radiation to the lungs, or toxicity associated with pharmacologic treatment for malignancy.
Additionally, complications are thought to be related to embolic phenomena; fat or malignant cells. There have been reports of intraoperative cardiac arrest and intraoperative deaths related to reaming and nail insertion . Additionally, reaming the femur is thought to produce a release of inflammatory mediators, which may activate the coagulation cascade. Because of these potential complications, placing intramedullary devices into multiple long bones in one operative setting is not usually recommended. However, Moon et al. presented data showing that simultaneous intramedullary nailing had mortality rates similar to that for staged nailing; suggesting that while still associated with increased mortality, simultaneous nailing may be performed and that staging multiple intramedullary nailing procedures is not absolutely necessary .
Data extrapolated from animal studies have demonstrated a reduction of embolic phenomena with the use of a reamer-irrigator aspirator (RIA) (Synthes, Paoli, PA) [22, 23]. The RIA is designed to remove intramedullary contents, to minimize heat generation and fat embolization. It has also been used to harvest bone graft. Cipriano et al. have demonstrated that the RIA is successful in retrieving intramedullary contents including tumor cells and they suggest that it may prevent systemic dissemination . In this study, they did not have any canal perforations however, one must use extreme caution with this device in metastatic bone, as the reamers are sharper that conventional reamers and may create cortical breaches in already weak bone.
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Open Reduction and Internal Fixation
Open reduction and internal fixation of proximal femoral metastatic bone lesions is associated with a high rate of failure secondary to nonunion, implant failure, and need for reoperation . Its use is surgeon-dependent. Some favor plate fixation when dealing with osteoblastic metastasis, as the passage of intramedullary devices in this situation may be challenging . Depending on the amount of bone destruction, cement augmentation may also be required to create a more durable construct and allow the patient to weight-bear in the postoperative period . In the situation of impending pathologic fractures in solitary lesions, one can consider plate fixation augmented with polymethymethacrylate and postoperative radiation therapy. This surgical procedure can also be considered in those who are not expected with limited life expectancy  (Fig. 24.4).
(a, b) Sixty-one year-old woman with metastatic breast cancer who complain of right knee pain for over a year, thought to be secondary to arthritis. Presented with gross motion at the distal femur and the radiographic findings seen here. (c, d) The patient had a chronic non-healing breast wound and significant organ involvement with a poor prognosis. It was decided that plate fixation with cement augmentation would be best in this situation. Postoperatively, the patient had pain free motion and ambulation and died of disease 4 months after surgery