Which implant is best after failed treatment for pathologic femur fractures?
BACKGROUND Pathologic proximal femur fractures result in substantial morbidity for patients with skeletal metastases. Surgical treatment is widely regarded as effective; however, failure rates associated with the most commonly used operative treatments are not well defined. QUESTIONS/PURPOSES We therefore compared surgical treatment failure rates among intramedullary nailing, endoprosthetic reconstruction, and open reduction-internal fixation when applied to impending or displaced pathologic proximal femur fractures. PATIENTS AND METHODS We retrospectively compared the clinical course of 298 patients who underwent intramedullary nailing (n = 82), endoprosthetic reconstruction (n = 197), or open reduction-internal fixation (n = 19) from 1993 to 2008. Primary outcome was treatment failure, which was defined as reoperation for any reason. Treatment groups were compared for differences in demographic and clinical parameters. RESULTS The number of treatment failures in the endoprosthetic reconstruction group (3.1%) was significantly lower than in the intramedullary nailing (6.1%) and open reduction-internal fixation (42.1%) groups. The number of revisions requiring implant exchange also was significantly lower for endoprosthetic reconstruction (0.5%), compared with intramedullary nailing (6.1%) and open reduction-internal fixation (42.1%). CONCLUSIONS Endoprosthetic reconstruction is associated with fewer treatment failures and greater implant durability. Prospective studies are needed to determine the impact of operative strategy on function and quality of life. LEVEL OF EVIDENCE Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.