SURGICAL TREATMENT OFFRACTURES THROUGH METASTASES …€¦ · offractures ofthe femoral neck and...

$: SURGICAL TREATMENT OFFRACTURES THROUGH METASTASES …€¦ · offractures ofthe femoral neck and ofthe intertrochanteric region caused byskeletal metastases. MATERIAL During theeleven$
VOL. 50 B, NO. 4, NOVEMBER 1968 743

SURGICAL TREATMENT OF FRACTURES THROUGH METASTASES

IN THE PROXIMAL FEMUR

JOHANNES POIGENFURST,* VIENNA, AUSTRIA, RALPH C. MARCOVEt and

THEODORE R. MILLER4 NEW YORK, UNITED STATES OF AMERICA

From the Bone Service of the Department of Surgerv, Memorial Hospitalfor Cancer and Allied Diseases,

Memorial Sloaiz-Kettering Cancer Center, and the James Ewing Hospital of the City of New York

One-sixth of all fractures through skeletal metastases are in the proximal fourth of the

femur (Clam 1965). Closed treatment in general leads to union in only 5 per cent of fractures

through metastases (Clam !oc. cit.), and in the hip region Francis, Higinbotham, Carroll,

Jacobs and Graham (1962) have never found union. The period of survival after fracture

averages eight months, and functional rehabilitation rather than mere palliation should,

therefore, be attempted. The possibility of bilateral involvement makes it even more desirable

to maintain stability of at least one hip. A comparison was therefore made of the efficiency

of internal fixation, resection of the femoral head and prosthetic replacement in the treatment

of fractures of the femoral neck and of the intertrochanteric region caused by skeletal

metastases.

MATERIAL

During the eleven years from 1956 to 1966 surgeons of the Bone Service at Memorial

Hospital, New York City, performed 121 operations on 1 12 patients for fractures through

histologically proven metastases in the femoral neck or intertrochanteric region. Of these,

I 10 operations on 101 patients were analysed. Eleven patients were excluded because either

records or radiographs were not available. Essential details were coded (Table I) and

statistically evaluated (Snedecor 1956). Operation numbers quoted correspond to those in

Table I.

OBSERVATIONS

Distribution ofsex and age-Seventy-three of the patients were women and twenty-eight men.

Their ages at the time of operation ranged from thirteen to eighty-four years. The mean age

for women was sixty-two years and for men fifty-seven

years (Table Il). Neck Head

Type ofprimary tumour-Mammary carcinoma was the

most common type (fifty-five patients). The next most

frequent groups were renal carcinoma (five patients),

carcinoma of the lung (five patients) and carcinoma

of the thyroid gland (four patients). Among the re-

maining thirty-two patients, twenty-one had carcinoma

of various origins, eight had sarcoma and three had

multiple myeloma.

Type offracture and radiographic extent of bone involve-

nient-In fifty-two patients the fracture was in the Intertrochanteric region

femoral neck and in fifty-eight in the intertrochanteric FIG. 1

region. All fractures showed metastases in the femoral Diagram showing radiologically visiblemetastatic involvement of the proximal

neck. In thirty-two these changes were restricted to femur in 110 fractures.

* Formerly Orthopaedic Fellow, the Hospital for Special Surgery, affiliated with the New York Hospital-Cornell

University Medical College, New York.

t Assistant Attending, Bone Service, Department of Surgery, Memorial Hospital for Cancer and Allied Diseases.

� Chief of Bone Tumor Service, Memorial-Sloan-Kettering Cancer Center.

- Yes 16 months

- - Yes 8 months

- - Yes 64months

Yes - Yes Still alive

Yes - Yes 8 mOnths

- - Yes 4 months

- - Yes 8 months

Yes - Yes 16 months

Yes - Yes 64 months

Yes - Yes 16 months

Yes - Yes 4 months

- - Yes 16 months

Yes - Yes 16 months

- - Yes 32 months

- - Yes l6months

- - Yes 32 months

- - Yes 16 months

Yes - Yes 4 months

Yes - Yes 16 months

Yes - Yes 8 months

* Second operation in patients who underwent operation on both sides.

THE JOURNAL OF BONE AND JOINT SURGERY

744 J. POIGENFURST, R. C. MARCOVE AND T. R. MILLER

TABLE I

CLINICAL CHARACTERiSTICS IN 1 10 OPERATIONS FOR FRACTURES THROUGH METASTASES iN NECK

AND INTERTROCHANTERIC PART OF THE FEMUR

I Metastases Complications FunctionSurvival

Sex Age Site Bone involved present in (technical(years)� of fracture acetabulum difficulties (ability timeor infection) to walk)

Resection

1 Female 43 Neck Femoral neck only




5 Male 65 Neck Femoral neck only

More than

6 Female 64 Neck femoral neck

More than7 Male 55 Neckfemoral neck

More than8 Female 29 Neck

femoral neck

More than9 Female 69 Neckfemoral neck


femoral neck

More than11 Male 35 Neck femoral neck

12 Female 57 Intertrochanteric Femoral neck only

13 Female 43 Intertrochanteric Femoral neck only

More than14 Female 76 Intertrochanteric

femoral neck

More than15 Female 54 Intertrochantericfemoral neck


femoral neck



More than19* Female 65 Intertrochanteric

femoral neck


femoral neck

21 Female ��

52 I IntertrochantericMore than

femoral neckYes - Yes

IStill alive

22 Male � 68 Intertrochanteric More thanfemoral neck �

Yes - Yes 8 months

23 Male 59 Neck More than I

femoral neck IYes Yes 8 months

24 Female � 62 Neck More thanfemoral neck

Yes I Yes Yes : 16 months�

25I I

� Male 58 Neck More thanfemoral neck �

Yes I Yes YesI

32 months

26 Female � 67 Neck More thanfemoral neck I

Yes�

I� 16 months

27 I Female 54 Neck More thanfemoral neck �

Yes�

- 16 months

28 Female I 72 Neck More thanfemoral neck

Yes Yes - 32 months

29 Female 72 Neck More thanfemoral neck �

Yes Yes -�

8 months

30 Male 66 Neck More thanfemoral neck

Yes Yes - 2 months

31 Female 64 Intertrochanteric More thanfemoral neck

Yes - 4 months

32 Male 52 Intertrochanteric More thanfemoral neck

Yes - 8 months

33 Male 13 Intertrochanteric IMore than

femoral neckYes

I

- 8 months

34 I� Female 36 Intertrochanteric More thanfemoral neck �

Yes � Yes�

- 8 months

35 Male I Neck Femoral neck only � - - - 4 months

36 Female 58 Neck Femoral neck only � Yes - - 8 months

37 Female 50 Neck Femoral neck only I Yes - - 2 months

38 Male 84 Neck Femoral neck only I Yes - - 4 months

39 Female 54 Neck More thanfemoral neck - -

2 months

40 Female 59 Neck IMore than

femoral neckI 2 months

SURGICAL TREATMENT OF FRACTURES THROUGH METASTASES IN THE PROXIMAL FEMUR 745

VOL. 50 B, NO. 4, NOVEMBER 1968

TABLE I-co,ztiizued

CLINICAL CHARACTERISTICS IN I 10 OPERATIONS FOR FRACTURES THROUGH METASTASES IN NECK


Case � Sex Age � Sitenumber� (years) of fracture

Metastases Complications� Function� (technical � (ability SurvivalBone involved � present in � difficulties

I or infection) � to walk) timeacetabulum

Resection-continued

number Sex Age Site(years) of fracture

Metastases Complications Function(technical SurvivalBone involved present in difficulties (ability

or infection) to walk) I time

acetabulum

Resection-continued

- 8 months

- - 4 months

- - 4 months

- - 2 months

- - 4weeks

- - 8 months

- I Yes 16 months

- Yes 16 months

- Yes 8 months

- Yes 16 months

- Yes 8 months

- Yes 64 months

- Yes 16 months

- Yes Still alive

- Yes 32 months

- Yes 8 months

- Yes 4 months

- Yes 8 months



TABLE I-continued



41 � Female � 35 Neck� � More than Yesfemoral neck

42 Female 38 � Intertrochanteric � Femoral neck only � -

� � � I: �43 � Female 74 � Intertrochanteric � Femoral neck only -

44* Male 42 Intertrochanteric � Femoral neck only � Yes

� More than45 � Female � 49 I Intertrochantericfemoral neck �

More than46 Female 72 Intertrochanteric YesI femoral neck

Internal fixation

47 Female 40 I Neck Femoral neck only -

48 Female 44 Neck Femoral neck only -



51 Male 42 Neck Femoral neck only -

More than9* Female 71 Neck Yesfemoral neck

19 Female 65 Intertrochanteric Femoral neck only Yes

I I Morethan

femoral neck -

52 Female 52 IntertrochantericMore than

53 Female � 67 lntertrochantericfemoral neck -

I Morethan54 Female I 38 Intertrochanteric

femoral neck -

More thanYes10* Female 44 Intertrochanteric femoral neck

More than55 Male 74 Intertrochanteric Yesfemoral neck I


- Yes Yes 16 months

Yes Yes Yes 64 months

- Yes Yes 32 months

- Yes Yes Still alive

- Yes Yes 8 months




Yes Yes - 64 months

Yes Yes I - 8 months

- Yes - 2weeks

- Yes I - 8 months

Yes Yes - 4 months

- - - lweek

- - - 4months

- - - 4weeks

Yes - - 4weeks

Yes - - 4 months

SURGICAL TREATMENT OF FRACTURES THROUGH METASTASES IN TilE PROXIMAL FEMUR 747

VOL. 508, NO. 4, NOVEMBER 1968

TABLE I-conti,zued

CLINICAL CHARACTERISTICS IN I 10 OPERATIONS FOR FRACTURES THROUGH MFTASTASES IN NECK


� Metastases Complications� FunctionCase Age Site Bone involved present in (technical Survival

number Sex (years) of fracture acetabulum difficulties (ability timeto walk)or infection)

Internal fixation-continued


� � More than57 Female 52 I Neck� femoral neck

More than58 Female 48 lntertrochantericfemoral neck

More than59 Ma!e 65 Intertrochanteric femoral neck

� More than60 Male 60 Intertrochantericfemoral neck

� More than61 � Female 56 IntertrochantericI femoral neck

More than62 Female 65 � Intertrochanteric

� femoral neck

More than63 Male 60 lntertrochantericfemoral neck


femoral neck

I More than65 Female 46 I Neck

I femoral neck

66 Male 70 Intertrochanteric Femoral neck only

67 Male 70 Intertrochanteric More thanfemoral neck

44 Male 42 tntertrochanteric More thanfemoral neck

3* Female 47 Neck Femoral neck only

68 Female 38 Neck I Femoral neck only



femoral neck

I More than71 Female 48 Neck

femoral neck



TABLE I-contiiiued



Case � Age � Site � Bone involved � present in � difficulties (ability timeComplicationsMetastases (technical FunctionSurvivalnumber Sex �(years)� of fracture � acetabulum � or infection) � to walk)

Internal fixation-continued

72 Female 49 Intertrochanteric Femoral neck only - - - 4 months

72* Female 49 Intertrochanteric I Femoral neck only - - - 4 weeks

73 Female 61 Intertrochanteric � Femoral neck only � - - - I 8 months

74 Male 83 Intertrochanteric � Femoral neck only � - � - - � 4 months

75 Female 54 Intertrochanteric Femoral neck only � Yes - - 8 months

More than I76 Female 53 I Intertrochanteric 2 monthsfemoral neck

More than77 Female 70 � lntertrochanteric 2 monthsfemoral neck � I

I � More than78 Female � 70 Intertrochanteric 8 monthsfemoral neck �

� More than79 Female 63 Intertrochanteric 1 weekfemoral neck

More than80 Male 49 Intertrochanteric 2 weeksI femoral neck - - -

More than81 Male 30 Intertrochanteric 2 weeksfemoral neck - - --

More than Yes - - lweekfemoral neck

82 Female I 44 IntertrochantericMore than Yes - - 4 months83 Male 35 Intertrochanteric femoral neck

More than84 Male 54 Intertrochanteric Yes - - 32 monthsfemoral neck

Prosthesis

85 Female 82 Neck Femoral neck only I - - Yes 8 months

More than86 Female 53 Neck Yes Still alive

femoral neck - -



More than87 Female 48 Neckfemoral neck

- I Yes 4 months

88 Female 41 Neck More thanfemoral neck

Yes - Yes 32 months


Yes -- Yes 8 months

89* Female � 55 Neck More thanfemoral neck

Yes - Yes 8 months

90

91

Female

� Female �

53

57

Neck

Intertrochanteric

More thanfemoral neck

More thanfemoral neck

Yes - Yes

Yes

16 months

16 months

91 * FemaleI

57 Intertrochanteric More thanfemoral neck

Yes 8 months

92 Female 40 lntertrochanteric More thanfemoral neck

Yes 2 weeks

92* Female 40 Intertrochanteric More thanfemoral neck

Yes 8 months


Yes Still alive

94 Male 61 Intertrochanteric More thanfemoral neck Yes Still alive


Yes - Yes 4 months


Yes Yes Yes I 6 months

97 Female � 37 Neck Femoral neck only - Yes - 32 months

98 Female 46 Neck Femoral neck only Yes Yes - 8 months

99 Male � 80 Neck More thanfemoral neck

Yes - I week


Yes Yes - 8 months

101 Male 68 Intertrochanteric � More thanfemoral neck

Yes Yes - 4 months

SURGICAL TREATMENT OF FRACTURES TEIROUGII METASTASES IN TIlE PROXIMAL FEMUR 749


TA BLE 1-conti,iuc’d

CLINIcAl. CHARACTERISTICS IN 1 10 OPERATIONS FOR FRACTURES THROUGH METASTASES IN NECK


CaseSex Agenumber (years)

Siteof fracture

Metastases Complications� Function Survival(technicalBone involved present in diffi�fles (ability time

or infection) to walk)acetabulum

Prosthesis-co,zti,zued


Sex Age (years)Operation Number � �

Female Male Range I Mean

Internal fixation 44 31 13 21-83 55 :: 13

Resection . 46 34 12 13-84 55*14

Prosthesis . 20 17 3 40-80 56* 13

Total . 110 82 28 13-84 55� 13



the neck (Fig. I). Six had, in addition, signs ofdisease in the femoral head, fortyhad metastases

in the intertrochanteric region also, which often extended into the proximal shaft. In thirty-two

fractures the entire proximal end of the femur was involved (Fig. 1). Forty-nine patients had

additional metastatic lesions in the ilium and forty-eight had lesions in both femora.

TABLE 11

DIsTRIBUTioN OF SEX AND AGE

OPERATIVE PROCEDURES

Three methods of operation were used (Fig. 2): 1) internal fixation of the femoral neck

(forty-four cases) ; 2) resection of the femoral head (forty-six cases) ; and 3) prosthetic

replacement of the femoral head (twenty cases). In none of the three methods was any

particular type of tumour preferred or excluded. Among the three procedures, distribution of

male and female patients and their ages did not differ significantly (Table II), nor did the

extent of bone involvement.INTERNAL FIXATION

In this series the first nailing with a Smith-Petersen nail for pathological fracture through

a metastasis of the femoral neck was in 1957 (Case 68). Three further patients were treated

in this way (Cases 56, 84, 66). Because of

secondary displacement of the fragments

none regained the ability to walk and this

method was therefore discontinued. In all

the other forty operations a combination

nail with plate was used. As a rule, a plate

with five to twelve holes was applied:

shorter plates did not provide sufficient

stability.

Complications and post-operative changes-In ten operations the position of the frag-

ments underwent secondary changes such as

increasing varus position or shortening of

the femoral neck. Five of these were further

complicated by penetration of the nail into

the acetabulum. In one patient the shaft

fractured below the plate, and in another

the screws broke and allowed the plate to

FIG. 2 loosen. Because of these complications,Relative frequency of use of internal fixation, resection nine re-operations were necessary, as fol-and prosthetic replacement for fractures of the femoral .

neck and the intertrochanteric region. lows : second attempt at internal fixation(Cases 58 and 19); exchange for a longer

plate (Case 65); removal ofthe Smith-Petersen nail (Cases 67 and 57); resection ofthe femoral

head (Cases 64 and 59): resection of the femoral head and replacement with a Moore


prosthesis and later removal of the prosthesis (Case 56). Three operations (Cases 47, 67, 62)

were followed by wound infection.

RESECTION OF THE FEMORAL HEAD AND NECK

The discouraging results of internal fixation led to a preference for resection of the femoral

head and neck which was first carried out in 1956 (Case 32). Francis and colleagues (1962)

reported the results of nineteen resections and emphasised the rapid and atraumatic nature

of this operation. Our operations in Cases 3, 57 and 31 were reported individually in their

paper.

Complications and post-operative changes-In nine cases the proximal end of the femur

underwent secondary changes after operation : separation of the greater trochanter (Cases 19,

16, 13, 32) or lysis of the greater trochanter (Cases 29, 25, 1 7, 23, 22). It seems that separation

is the first step to lysis and that both are caused by progressive disease. Resection through the

shaft, as necessary for intertrochanteric fractures, also appears to increase resorption, probably

because of remaining tumour. The changes described were independent of irradiation or

weight-bearing. Eight patients had wound infections with persistent drainage.

PROSTHETIC REPLACEMENT OF FEMORAL HEAD

Since 1960 the self-locking Moore prosthesis has been used in six patients, for the first

time in Case 97. Since 1965 the long stem intramedullary prosthesis has been preferred and

by the end of 1966 had been used for fourteen fractures.

Complications and post-operative changes-A well known disadvantage of the short stem

prosthesis, even in normal bone, is that the stem does not always lock sufficiently without use

of acrylic cement. instability was noted in one patient (Case 97), who was unable to

walk. In Case 56, included in the group of internal fixation, the short stem prosthesis which

replaced the Smith-Petersen nail had to be removed later for instability, so that finally a

condition resulted as after resection.

The problem of instability can be overcome with a long stem prosthesis which fits tightly

into the medullary cavity (Matchett 1965). The insertion ofthe long stem prosthesis is, however,

slightly more difficult. During two operations the greater trochanter broke, and twice the distal

end of the stem perforated the anterior cortex of the shaft. Propagation of tumour into the

distal part ofthe shaft was seen after one operation only (Case 100). Two long stem prostheses

migrated into the diseased acetabulum. Two operations were followed by wound infection.

TIME OF SURVIVAL AFTER SURGERY

Only five out of 101 patients are still alive. Two of them are in generally good condition.

The other three are in hospital because of progressive disease. Two patients could not be

followed owing to change of address, but it is known that in 1966 both were still alive. All the

other ninety-three patients died within five years of their operations for fracture. The average

survival time was eight and a half months. Six patients died within two weeks after internal

fixation and one after prosthetic replacement.

FUNCTION AFTER OPERATION

The success of operation was assessed by the patient’s ability to walk. it was postulated

for a successful result that the patient should be able to walk sufficiently to take care of himself.

Temporary or permanent use of a stick or crutches was not considered to imply failure.

Restriction to a few steps between bed and wheelchair was not regarded as ability to walk,

even if the patient was free from pain.

Sixty patients regained ability to walk according to our definition. Eleven patients died

within a month after operation without starting to walk, and in thirty-nine fractures operation

failed to restore function.


FIG. 7

Case 91. Figure 3-March 1966: intertrochanteric fracture through right femur.Figures 4 and 5-Treatment by insertion of long stem prosthesis into right femurand of medullary nail into left femur. Figure 6-June 1966. Fracture throughneck of left femur. Figure 7-Insertion of long stem prosthesis into left femur.



FIG. 8



CASE REPORTS

Case 91-A woman of fifty-six underwent nephrectomy for carcinoma in 1965. In March 1966 therewas an intertrochanteric fracture of the right femur through a metastasis (Fig. 3). The pelvis was not

involved. There was also secondary deposit in the shaft of the left femur. The right femoral headwas removed and a long stem prosthesis was inserted. A nail was inserted down the medullary cavity

of the left femur (Figs. 4 and 5). In June 1966 the left femoral neck broke (Fig. 6). The medullarynail and the femoral head were removed and a long stem prosthesis was inserted (Fig. 7). The patientwas able to walk after both operations. She died from widespread metastases six months after the

second operation.

Case 96-A woman of seventy suffering from an infiltrating duct carcinoma of the breast refusedmastectomy but later, in December 1965, underwent hypophysectomy because of skeletal metastasis.In April 1966 the right femoral neck broke through a metastasis. A long stem prosthesis was inserted(Fig. 8). The patient was able to walk without support in spite of multiple metastases. She died frompulmonary embolism a little over one year after operation.

Case 96-April 1966. Extensive metastatic involvement of pelvis andfernora. Long stem prosthesis inserted for fracture of right femoral

neck.

Case 98-A woman of forty-six began in 1966 to get pain in the right hip. Radiographs showeddiffuse metastases in the pelvis and both femora. There was evidence of impending fracture throughthe neck of the right femur. The primary tumour was a breast cancer. In November 1966 the rightfemoral neck broke, and four weeks later a long stem prosthesis was inserted (Figs. 9 and 10). Thepatient could not walk. In March 1967 the prosthesis was seen to be migrating centrally, and threemonths later it penetrated the floor ofthe acetabulum (Figs. 1 1 and 12). The patient died seven months

after operation.

COMPARATIVE RESULTS

The success of each operative procedure was judged according to I ) post-operative

complications, and 2) ability to walk.

Post-operative complications-The number of post-operative com plications such as instability

of nail and plate, resorption of the proximal end of the femur, migration or instability of a

prosthesis, or wound infection, were equally distributed among the surgical procedures,

probably because these complications are attributable to the basic disease or to general surgical

risks. We could not demonstrate any correlation between local or general treatment and

infection.

Ability to ira/k-Of ninety-nine patients who survived the operation long enough to

start walking, sixty actually regained walking ability. Their distribution related to the three

FIG. 11 � �.

Case 98. Figures 9 and 10-November 1966. Fracture through right femoral neck treated by insertionof long stem prosthesis. Note the metastatic involvement of femur and pelvis. Figure 11-Three monthslater: the prosthesis is migrating centrally. Figure 12-Six months later: the prosthesis has penetrated

the acetabular floor.

754 J. PO1GENFURST, R. C. MARCOVE AND T. R. MILLER


types ofoperation is shown in Table Ill. The type ofoperation and the results in nine patients

with bilateral fractures are shown in Table IV.

DISCUSSION

The functional results after internal fixation, resection and prosthetic replacement for

1 10 fractures through metastases in the proximal end ofthe femur correspond with the findings

of Francis and colleagues (1962) in so far that internal fixation does not represent a reliable

treatment (sixteen failures out of thirty-six surviving patients). Recent experience did not

show any superiority for resection (nineteen failures out of forty-four), but testified in favour

of prosthetic replacement (four failures out of twenty).

The obvious advantages of this method are maintenance of stability and early restoration

of function. This is particularly beneficial in bilateral fractures. The possibility of stabilisation

of the femoral shaft at the same time gives an additional reason for the use of the long stem

prosthesis. It is of further interest that in spite of fracture of the trochanter in two operations,

resorption after resection did not occur and the fractures healed.

Analysis of the four failures after prosthetic replacement reveals the following causes:

infection (one case), instability of short stem prosthesis (one case), and migration of the



E

prosthesis into the pelvis (two cases). Because the last two were the only patients in this

group with diffuse metastatic disease of the ilium and radiographic disappearance of the cortex,

this seems to add the further advantage of predictability. If the ilium is not involved, migration

TABLE III

ABILITY TO WALK RELATED TO TYPE OF OPERATION

Type ofoperation

Number of� operations

Number surviving �28 days or more �

Wa&ing�

Notwalking

Internal fixation 44 36 � 20 � 16

Resection . 46 44 � 25 � 19

Prosthesis . 20 19 � I S � 4

Total . 110 99 � 60 � 39

TABLE IV

BILATERAL FRACTURES AND TYPE OF OPERATION RELATED TO WALKING ABILrry

INumber of � Walking after

Type of operation � operations � first operation Walking aftersecond operation

Bilateral internal fixation . � 1 � 0 0

First side internal fixation. �Second side resection . . � 2 � 2 1

First side resection. Second �side internal fixation . . � 3 � 3 2

Bilaterallong stem prosthesis � 3 � 3 3

TABLE V

THE CHANGE IN THE TYPE OF PROCEDURE USED

Number of operations

Period � � I ProsthesesResections � � -Internal� Total fixations � � Short � Long

1956-1958 � 11 7 4 I�

1959-1960 � 24 13 10 1 -�

1961-1962 20 9 11 - -

�l963-1964 29 7 19 � 3 -

1965-1966 26 8 2 2 � 14

Total . 110 44 46 6 : 14

does not occur, because of the short life span. Even multiple nodular lesions with lytic centres

do not seem to impair the ability of the acetabulum to bear weight. Neither for internal fixation

nor for resection was it possible to correlate the radiographic appearance of metastases to the

clinical result in a similar way.


The distribution of each procedure in the eleven years from 1956 shows that the use of

prostheses in 1966 has practically replaced resection of the femoral head whereas internal

fixations were still performed in 1965 to 1966 (Table V). For further improvement of results

it would be advisable to use prostheses on an even larger scale and to discontinue internal

fixation.

SUMMARY AND CONCLUSIONS

The results of 1 10 operations for the treatment of fractures through metastases in the

femoral neck and intertrochanteric region have been studied. Of these, forty-four fractures

were treated by internal fixation, forty-six by resection of the femoral head and neck, and

t xenty by prosthetic replacement. The following conclusions were reached.

I . Prosthetic replacement of the femoral head is a reliable procedure.

2. The long stem type of prosthesis has the advantages of greater stability and simultaneous

fixation of the shaft.

3. Patients with diffuse metastatic disease of the ilium are not suitable for prosthetic

replacement. These patients should be treated by resection of the femoral head and neck.

4. Resection is a less traumatic procedure and therefore useful in the palliative treatment of

patients in poor general condition.

5. Internal fixation leads more often to complications and unfavourable results than do the

other methods.

This work was supported in part by Public Health Service General Support Grant FR-05495 of the Divisionof Research Faclities and Resources, and the Evelyn Sharp Fund.

REFERENCES

CLAiN, A. (1965): Secondary Malignant Disease of Bone. British Journal of Cancer, 19, 15.FRANCIS, K. C., HIGINBOTHAM, N. L., CARROLL, R. E., JACOBS, B., and GRAHAM, W. D. (1962): The Treatment

of Pathological Fractures of the Femoral Neck by Resection. Journal of Trauma, 2, 465.MATCHETT, F. (1965): A New Long-stem Intramedullary Vitallium Hip Prosthesis. Journal of Bone and Joint

Surgery, 47-A, 43.SNEDECOR, G. W. (1956): Statistical Methods Applied to Experiments in Agriculture and Biology. Fifth edition.

Ames, Iowa: Iowa State CoIleg� Press.


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