Surgical Management of Metastatic Pathologic Subtrochanteric Fractures: Treatment Modalities and Associated Outcomes

Subtrochanteric pathological fractures (PFs) occur in approximately one-third of femur bone metastases. We seek to analyze surgical treatment strategies for subtrochanteric metastatic PFs and their revision rates.

A systematic review was performed using the PubMed and Ovid databases. Reoperations as a result of complications were analyzed according to initial treatment modality, primary tumor site, and type of revision procedure.

We identified a total of 544 patients, 405 with PFs and 139 with impending fractures. The study population's mean age was 65.85 years with a male/female ratio of 0.9. Patients with subtrochanteric PFs who underwent an intramedullary nail (IMN) procedure (75%) presented a noninfectious revision rate of 7.2%. Patients treated with prosthesis reconstruction (21%) presented a noninfectious revision rate of 8.9% for standard endoprostheses and 2.5% for tumoral endoprostheses (p < 0.001). Revision rates because of infection were 2.2% for standard and 7.5% for tumoral endoprostheses. There were no infections within the IMN and plate/screws group (p = 0.407). Breast was the most common primary tumor site (41%) and had the highest revision rate (14.81%). Prosthetic reconstructions were the most common type of revision procedure.

No consensus exists regarding the optimal surgical approach in patients with subtrochanteric PFs. IMN is a simpler, less invasive procedure, ideal for patients with a shorter survival. Tumoral prostheses may be better suited for patients with longer life expectancies. Treatment should be tailored considering revision rates, patient's life expectancy, and surgeon's expertise.

Level III. See Instructions for Authors for a complete description of levels of evidence.