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.

Fig. 1A–E

(A) Completed survey responses were combined with respect to the frequency of operative strategy selection and recorded as percentages. Shown are the percentages for breakdown of total responses by (B) cancer type, (C) estimated survival, (D) fracture displacement, and (E) anatomic region of involvement. An asterisk indicates a statistically significant difference (p < 0.05) for individual group comparisons (Mann-Whitney U test).

Fig. 2A–B

Survey responders were asked to select an operative strategy for treating an impending pathologic fracture associated with a large soft tissue mass. In this scenario, the patient had a diagnosis of widely metastatic renal cell carcinoma. Responses were recorded for an estimated survival of (A) less than 6 months and (B) greater than 6 months.

Fig. 3

Survey responders were asked to recommend a minimum size threshold for wide resection in the treatment of a pathologic fracture associated with a large soft tissue mass. Data are shown as a percentage of completed responses.