Safety aspects in surgical treatment of pathological fractures of the proximal femur – modular endoprosthetic replacement vs. intramedullary nailing

BACKGROUND: Pathologic fractures of the femoral intertrochanteric and subtrochanteric region require special consideration in terms of biomechanically stable fixation and durability of the implant. In addition, the type of surgery might also influence patient survival. We conducted this retrospective study to evaluate the safety of modular proximal femur replacement compared to intramedullary nailing with patient survival being the primary and complications the secondary endpoint. METHODS: We retrospectively studied the records of 20 consecutive patients with actual pathologic fracture due to bone metastasis in the intertrochanteric and subtrochanteric part of the femur. The pathologic fractures were stabilized with a locked cephalomedullary nail in 12 patients and treated with en-bloc resection and modular proximal femur replacement in eight patients. RESULTS: In the tumor prosthesis group median patient survival was more than twice as high (4.5 months, IQR 2.3 – 16.5) than in the osteosynthesis group (2.0 months, IQR 0.3 – 20.5), but did not reach significance (p = 0.58). Besides, a significantly better preoperative general health status in patients with endoprosthetic reconstruction puts better survival into perspective. Median implant survivorship did not differ between groups with 2.5 (IQR 1.0 – 7.5) months for endoprothesis and 3.0 (IQR 0.3 – 11.0) months for osteosynthesis (p = 0.93). Complication rates were comparable with 25% in each group. CONCLUSION: Patient survival was not influenced by type of surgery or choice of implant. Preoperative general health condition and ambulatory capacity may aid in decision for type of surgery and improve patient safety, respectively.