Review Question - QID 951

The clinical presentation is consistent with metastatic bone disease to the femur with a high risk of pathologic fracture in a patient with a limited life expectancy. Prophylactic fixation with a modern cephallomedullary interlocking nail protects the entire bone and allows for immediate weight bearing.

Jacofsky et al discuss the evaluation and treatment of metastatic pathologic lesions and fractures of the proximal femur. They report 50% will be at the femoral neck, 30% at the IT region, and 20% at the subtrochanteric region. They recommend optimal treatment consists of a stable implant that protects the entire bone and will allow for immediate weight bearing (as up to 50% of pathologic fractures may not heal).

Figure A and B show a large lytic lesion in the subtrochanteric region of the proximal femur which occupies the majority of the metaphyseal diameter. Illustration A demonstrates a cephallomedullary nail spanning a lesion in the peritrochanteric region of the left femur (of note this is a long nail which extends to the supracondylar region of the femur).

Incorrect Answers:
Answer 1: A sliding hip screw will not protect the entire bone.
Answer 3: A proximal femoral locking plate will not protect the entire bone and would not allow for immediate weight bearing.
Answer 4: Hemiarthroplasty will not protect the entire bone and is not necessary given that the pathologic lesion is in the subtrochanteric region.
Answer 5: Proximal femoral replacement is not indicated as it is an aggressive treatment typically reserved for the curative treatment of primary bone tumors.