Surgical management of metastatic lesions of the proximal femur with pathological fractures using intramedullary nailing or endoprosthetic replacement

Endoprosthetic replacement (EPR) and intramedullary nailing (IMN) are the two most commonly applied surgical methods used to treat proximal metastatic lesions; however, indication of the above procedures remains controversial. The aim of the present study was to evaluate the clinical, functional and oncological outcomes of patients who underwent EPR compared to IMN for the treatment of proximal femur metastases to investigate the surgical indication for patients. The records of patients (n=88) with pathological fractures secondary to metastatic tumors of the proximal femur admitted between January 2005 and December 2014 to West China Hospital, Sichuan University (Chengdu, China) were retrospectively studied. A total of 57 patients were treated with EPR (34 males and 23 females; mean age, 62.5 years) and 31 patients were stabilized with IMN (19 males and 12 females; mean age, 60.2 years). Patients were analyzed regarding surgery time, blood loss, hospital stay, Musculoskeletal Tumor Society (MSTS) score, survival, recurrence and complications. The median follow-up period was 12.9 (range, 3-98) months. The median survival time in EPR was 10.0 months and 7.5 months in IMN. The surgery time was 142.6 +/- 22.7 min in the EPR group and 98.7 +/- 19.5 min in the IMN group (P=0.001). Significantly less blood loss was observed in the IMN group (345.2 +/- 66.4 ml) than in the EPR group (631.5 +/- 103.6 ml; P=0.001). The median hospital stay in the EPR group was 8 (quartile range, 7-9) days and 5 (quartile range, 5-6) days in the IMN group (P=0.001). Local recurrence rate was 10.5% (6/57) in the EPR group and 25.8% (8/31) in the IMN group (P=0.074). The complication rates were 10.5% (6/57) in the EPR group and 29.0% (9/31) in the IMN group (P=0.038). MSTS-93 score was higher in IMN compared with EPR at 6 weeks postoperatively (P=0.001), while the EPR group demonstrated a higher score at 6 months postoperatively (P=0.001). EPR has the advantage of better functional outcomes and higher life quality in the long term, with lower complication rates in treating metastatic lesions of the proximal femur with pathological fractures. EPR is recommended for patients with relatively good general condition and prognosis. IMN is best indicated when the patient's life expectancy is extremely limited.