title: Which implant is best after failed treatment for pathologic femur fractures?
abstract: BACKGROUND
  Successful treatment of pathologic femur fractures can preserve a patient's independence and quality of life. The choice of implant depends on several disease- and patient-specific variables; however, its durability must generally match the patient's estimated life expectancy. Failures do occur, however, it is unclear which implants are associated with greater risk of failure.
  
  
  OBJECTIVE
  We evaluated patients with femoral metastases in whom implants failed to determine (1) the rate of reoperation; (2) the timing of and most common causes for failure; and (3) incidence of perioperative complications and death.
  
  
  METHODS
  From a prospectively collected registry, we identified 93 patients operated on for failed treatment of femoral metastases from 1990 to 2010. We excluded five patients who subsequently underwent amputations leaving 88 who underwent salvage procedures. These included intramedullary nails (n = 11), endoprostheses (n = 61), and plate fixation (n = 16). The primary outcome was reoperation after salvage treatment.
  
  
  RESULTS
  Seventeen of the 88 patients (19%) required subsequent reoperation a median of 10 months (interquartile range, 4-14) from the time of salvage surgery: 15 for material failure, one for local progression of tumor, and one for a combination of these. Five patients died within 4 weeks of surgery. Although perioperative complications were higher in the endoprosthesis group and dislocations occurred, overall treatment failures after salvage surgery were lower in the that group (four of 61) compared the group with plate fixation (eight of 16) and intramedullary nail groups (five of 11).
  
  
  CONCLUSIONS
  Despite relatively common perioperative complications, salvage using endoprostheses may be associated with fewer treatment failures as compared with internal fixation.
  
  
  METHODS
  Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
authors.affiliation: Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD 20910, USA. jaforsberg@me.com
authors.forename: Jonathan Agner
authors.initials: JA
authors.lastname: Forsberg
authors.forename: Rikard
authors.initials: R
authors.lastname: Wedin
authors.forename: Henrik
authors.initials: H
authors.lastname: Bauer
mesh_terms: D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D016009:Chi-Square Distribution; D018450:Disease Progression; D005260:Female; D005264:Femoral Fractures / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D005266:Femoral Neoplasms / Q000150:complications / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D005593:Fracture Fixation, Internal / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D005598:Fractures, Spontaneous / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D006622:Hip Prosthesis; D006801:Humans; D016268:Internal Fixators; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011474:Prosthesis Design; D012042:Registries; D012086:Reoperation; D013997:Time Factors; D017211:Treatment Failure