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Unlabelled: Surgical treatment of metastatic fractures of long bones is mostly a palliative one. Intramedullary stabilisation without resection of metastases follows the aim of the palliative therapy concept., Patients and Methods: From 01.01.1995 to 30.08.2001 36 manifest and 4 impending long bone fractures were registered in 22 female and 16 male patients, with a mean age of 63 years. In addition, one revision was necessary due to persisting instability after humeral intramedullary bundle nailing. Pathological fractures were found in the humerus (n=11), femoral neck (n=6), per- and subtrochanteric region (n=12), femoral shaft (n=10) and tibia (n=2). Most of them were malignancies of the kidneys (n=13), bronchi (n=7) and breast (n=6). One patient with a solitary metastasis in the humerus received curative treatment by resection, open reduction and internal fixation. All other cases underwent palliative stabilisation. Metastatic lesions of the femoral neck were treated by resection and prosthetic replacement. The remaining fractures were stabilized intramedullarily without resection of metastases or use of bone cement. In 9 cases, a locking nail was implanted in the humerus, and one patient received humeral bundle nailing. In the lower extremities, we used a classic-nail or gamma-nail in 15 and a locking nail in 8 cases. Two moribund patients did not undergo surgery., Results: No intraoperative complications occurred. 63 % of the patients with stabilisation of the leg were able to walk at the time of discharge. The mean survival time (Kaplan-Meier) of patients after palliative operation amounted to 161.5 days (95 % CI 92.7; 230.3). We found 6 postoperative complications: temporary palsy of the radial nerve (n=1), soft tissue infection (n=1), dislocation of the nail (n=2), loosening of the distal locking screw (n=1), proceeding osteolysis with high fracture risk (n=1)., Conclusion: Intramedullary stabilisation without resection of metastases using locking nails meets the requirements of palliative therapy. This procedure is less invasive and allows early weight bearing.

Bone metastases are located most frequently in cancellous bone according to the higher blood perfusion rate. In contrast, pathological fractures are most frequently found in the biomechanically highest loaded parts of the skeleton and are therefore most frequent in the proximal femur end. For definition of impending pathological fracture the Mirels Score should be used today. Because of the short life expectancy of the patients with pathological fractures caused by bone metastases immediate pain relief, function and weight bearing capacity must be achieved. In the proximal femur stabilisation can be performed with a hip tumor prosthesis or, as joint preserving device, a double plate compound osteosynthesis (DPCO). The results of 30 patients treated with hip tumor prosthesis and 30 patients treated with a DPCO of the proximal femur between 1985-1989 were compared. The local complication rate of the tumor prosthesis was significantly higher (16.6% vs 46.6%) due to 11 hip luxations seen in 7 of the 30 patients. The time of hospitalisation as well as the costs of the device are higher for the tumor prosthesis. The functional and subjective results were similar. Only in patients with very advanced carcinoma and a life expectancy under 3 months osteosynthesis without resection of the metastasis should be performed. For this indication only locked nail systems should be used today. We found the best functional results among 134 patients treated between 1982-1989 in our hospital in patients with impending pathological fractures. The functional results as well as the survival time were up to 3 times superior to those of patients with occurred pathological fractures.(ABSTRACT TRUNCATED AT 250 WORDS)

Because of the increasing survival-time of tumor-patients bone metastasis is becoming an important subject in surgery. In the case of osteolysis of the femur a concept of treatment in consideration of various localisations is presented. In 81 patients with pathological fractures of the femur or osteolysis in this region from January 1987 to June 1992 96 stabilizing operations were performed. Almost one half of the patients suffered from breast carcinoma followed by hypernephroma, Plasmocytoma, bronchial-carcinoma and prostate-carcinoma. The average survival time after stabilization of the femur was 8.3 months. After the operation the condition of the patients improved on an average by 0.64 units of the modificated Karnowsky-Index. Surgical treatment of osteolysis in the femur is indicated either in pathological fractures or if instability is imminent. Moreover patients who suffer from severe pain should also receive palliative surgery. With regard to the site of the lesion various types of endoprostheses and osteosynthesic devices can be used. If the femoral neck or the intertrochanteric region is affected arthroplasty with cemented endoprosthesis may be performed. In subtrochanteric osteolysis long and thin endoprosthesis can be used as well as Gamma-nails. Pathological fractures in the shaft of the femur should be treated with intramedullary static locked nails, which can be strengthened by supplementary lateral plates. If the distal metaphysis of the femur is involved compound osteosynthesis with methylmethacrylate and dynamic condylar screws or angle plates can be used.