METASTATIC DISEASE OF THE FEMUR: Surgical Management

The femur is the long bone most commonly afflicted with metastatic carcinoma. This metastatic involvement causes two primary clinical problems—pain and mechanical disruption. The pain that arises from the presence of the tumor itself usually can be managed satisfactorily with radiation therapy and other palliative measures. The loss or impending loss of bone integrity because of pathologic fractures is the feature of femoral bone involvement that usually brings the patient to the attention of the orthopedic surgeon. Three factors make metastatic disease of the femur the most common metastatic problem to present to the orthopedic surgeon: (1) the necessity of an intact femur for weight bearing, (2) the high frequency of metastases to the femur, and (3) the high biomechanical loads placed on the femur. For example, during the consecutive period from August 20, 1991, through September 20, 1999, the senior author (W. G. W.) surgically treated 213 long bone, pelvic, or scapular metastatic lesions, of which 117 (54%) involved the femur (Table 1), confirming the high frequency of surgically significant femoral metastatic lesions. The cancer patient with metastases has a shortened remaining life span. The progressive disease continually erodes the patient's ability to withstand future surgical interventions; the initial operative interventions to reconstruct the femur should be definitive, durable, and sufficiently solid to allow immediate weight bearing. Otherwise, the impaired femur severely restricts the patient's mobility, diminishes the patient's quality of life, and causes significant pain. To meet these goals of providing a definitive, durable, and solid reconstruction for most patients, evaluation and treatment must be planned and performed thoughtfully. This article presents an approach to metastatic femoral lesions that allows the orthopedic surgeon to maintain or restore function to most patients, cause the least morbidity, and provide the greatest durability.