Comparison of treatment options with long intramedullary nail and dynamic hip screws for metastatic subtrochanteric fracture: A cohort study.

1. INTRODUCTION

Bone represents the third most common site of metastatic spread, following the lungs and liver. 1 , 2 Advances in oncologic therapy have extended the survival of patients with skeletal metastases; however, this improved longevity has been accompanied by a steady increase in both established and impending pathological fractures. 3 , 4 Although the axial skeleton remains the predominant location for bone metastasis, metastatic lesions frequently involve the long bones of the appendicular skeleton. 5 Up to 56% of patients develop lesions in the lower-extremity long bones, and 10% to 29% of these eventually progress to overt pathological fractures. 4 Impending or completed fractures often mark the onset of dependency, as pain, mechanical instability, and loss of function require continuous assistance. Beyond physical disability, these events give rise to considerable psychological distress, collectively undermining patients’ functional capacity and quality of life. 1 , 6

The subtrochanteric region, defined as the proximal femoral segment within 5 cm distal to the lesser trochanter, accounts for approximately one-third of all pathological femoral fractures. 5 – 7 The combination of high compressive and tensile stresses across this area, particularly when the fracture involves loss of the lesser trochanter and medial buttress, predisposes the patient to fixation failure. Consequently, malunion, delayed union, and other mechanical complications occur frequently in this region. 8 – 10

The decision between surgical stabilization and nonoperative palliation depends on lesion location, tumor histology, systemic tumor burden, and the patient’s comorbid status. 4 , 6 , 11 Surgical stabilization is generally considered when life expectancy exceeds 1 to 2 months. 6 Current management strategies rely heavily on the surgeon’s judgment and typically involve internal fixation with either an intramedullary nail (IMN), a dynamic hip screw (DHS), or reconstruction using a standard or tumor-type endoprosthesis replacement (EPR). 4 , 5 , 11 , 12

Currently, no consensus exists regarding the optimal surgical management of proximal pathological fractures of the femur, and the uncertainty is even greater for fractures located in the subtrochanteric area. 4 , 5 , 11 – 13 Accordingly, the relative preference for internal fixation vs endoprosthetic reconstruction varies across institutions. Internal fixation with either an IMN or a DHS is technically less invasive and entails lower perioperative morbidity; however, it remains susceptible to nonunion and mechanical failure that may ultimately require revision. 14 In contrast, arthroplasty offers durable mechanical stability and implant longevity, 13 but its advantages must be weighed against the patient’s expected survival, functional demands, and tolerance for extensive surgery and rehabilitation. For individuals with advanced malignancy and an expected survival of 6 months or less, 15 the central question is whether the physiological burden of aggressive reconstruction is justified, given that the primary aims are pain relief, restoration of mobility, and preservation of quality of life during the remaining lifespan.

In pathological subtrochanteric fractures, IMN fixation is generally regarded as a reliable fixation method. 4 , 5 , 12 , 16 Nevertheless, favorable outcomes following DHS fixation have also been reported in carefully selected cases. 5 , 6 , 10 , 12 Among oncology patients, the reaming required for intramedullary insertion may increase cardiopulmonary compromise 4 and could theoretically disseminate tumor cells distally within the medullary canal. 17 These concerns have prompted further evaluation of patient and fracture characteristics that may influence implant selection.

In the present study, the outcomes of DHS and IMN fixation for metastatic subtrochanteric fractures were compared, focusing on local tumor progression, distal canal seeding, implant survival, and the subsequent need for revision surgery.

2. METHODS

2.1. Patients

We retrospectively reviewed all patients who sustained a pathological fracture of the subtrochanteric femur and underwent either IMN or DHS fixation at Taipei Veterans General Hospital between January 2002 and December 2018. The inclusion criteria were as follows: (1) radiographic confirmation of a pathological fracture in the subtrochanteric region, (2) intractable pain or loss of ambulation caused by an impending fracture with a Mirel score >9, (3) documented history of malignancy, and (4) histologic confirmation of primary malignancy before surgery. The preoperative workup included comprehensive oncological staging using whole-body bone scintigraphy, computed tomography (CT), or positron emission tomography (PET)-CT to identify the primary tumor and detect any multifocal or visceral metastases. Routine investigations included hematological testing, chest radiography, and biplanar radiography of the affected femur and hip. The exclusion criteria were (1) surgical management with any procedure other than IMN or DHS fixation, (2) primary bone tumor of the femur, and (3) patients deemed unsuitable for surgery by a multidisciplinary team after shared decision-making with the patient and family. Demographic data, tumor characteristics, and perioperative variables were extracted from the patients’ electronic medical records. The study protocol was approved by the Institutional Review Board of Taipei Veterans General Hospital and conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from all the participants.

2.2. Treatments

All procedures were performed under general anesthesia. In the IMN cohort, each patient underwent intralesional curettage, followed by fixation with one of the following systems: proximal femoral nail anti-rotation (PFNA; DePuy Synthes, Raynham, MA; n = 4), Cephalomedullary Nail (Zimmer Biomet, Warsaw, IN; n = 7), or Gamma-3 Nail (Stryker, Mahwah, NJ; n = 37). In the DHS cohort, stabilization was achieved using a Dynamic Hip Screw system (DePuy Synthes). Bone biopsies were routinely performed to confirm metastatic diagnosis. Bone cement augmentation was performed at the discretion of the operating surgeon, considering both the extent of bone destruction and the patient’s overall condition. Cement was avoided when extensive tumor removal was expected to cause wide wound exposure, excessive blood loss, or an increased risk of infection. Impending or minimally displaced fractures with limited cortical destruction are typically treated using closed IMN fixation. In contrast, cases of extensive osteolysis or major bone loss require an open approach for direct tumor removal using handheld curettes. When cement augmentation was indicated, the IMN was first positioned to verify length and alignment, and then partially withdrawn to allow filling of the tumor cavity with polymethylmethacrylate (PMMA). Subsequently, the nail was reinserted and locked using interlocking screws. In the DHS group, PMMA was introduced only after secure screw fixation to minimize the risk of tumor dissemination and avoid thermal or chemical injury to the surrounding viable bone and soft tissues. Standard perioperative care, including blood transfusion and anti-inflammatory therapy, was administered as required. Systemic oncological management with chemotherapy, hormonal therapy, bisphosphonates, and radiotherapy was resumed after wound healing under the supervision of an oncologist.

2.3. Outcome measures

The primary outcomes were: (1) implant breakage, (2) mechanical failure (cutout, screw pull-out, or loss of fixation), (3) periprosthetic fracture, (4) local tumor progression, (5) distal canal seeding, and (6) need for revision or reoperation. Local progression was defined as a recurrent or enlarging tumor within the operated field on follow-up imaging. 18 , 19 Distal canal seeding was considered present when progression occurred distal to the original lesion identified at the time of nail placement, with or without extension into the surrounding soft tissue. Radiographic evidence of progression was defined as the appearance of new postoperative lesions along the femoral canal. 20 Secondary outcomes included perioperative complications (infection, hematoma, venous thromboembolism, or death within 14 days) and the Musculoskeletal Tumor Society (MSTS) functional score, recorded preoperatively and at each designated postoperative evaluation. All radiographs were independently reviewed and measured by two authors (K.-C.C. and K.-H.L.). Discrepancies were resolved by consensus after reviewing the reports of the attending radiologist.

2.4. Statistical analysis

All analyses were conducted using IBM SPSS Statistics (version 22.0; IBM Corp., Armonk, NY). Continuous variables are reported as the mean ± SD and compared between groups with the independent-samples t test when normality and homogeneity of variance were satisfied; otherwise, results are presented as the median (interquartile range) and analyzed with the Wilcoxon rank-sum test. Categorical variables were compared using the chi-square or Fisher’s exact test, as appropriate. Survival probabilities were estimated using the Kaplan-Meier method. Logistic regression models were used to adjust for the potential confounding factors. Separate models were constructed for the local progression, distal canal seeding, and revision surgery. Odds ratios (ORs) with 95% CIs were calculated. All tests were two-tailed, and p < 0.05 was considered statistically significant.

3. RESULTS

3.1. Clinical and tumor characteristics

Between January 2002 and December 2018, 239 patients with proximal femoral metastatic lesions were treated at our institution. After excluding 149 cases involving femoral head, neck, or intertrochanteric metastasis, endoprosthetic reconstruction, or conservative management, 90 patients with subtrochanteric pathological fractures treated with internal fixation were eligible for analysis. Of these, 48 underwent IMN fixation, and 42 underwent DHS fixation. The mean age of the IMN and DHS groups was nearly identical (64.2 vs 64.2 years; p = 0.945). The sex distribution was similar, with 26 women and 22 men in the IMN group and 25 women and 17 men in the DHS group ( p = 0.673). The distribution of primary malignancies did not differ significantly between the groups ( p = 0.145). Similarly, the proportions of the pathological fractures were comparable—41 of 48 (85.4%) in the IMN group and 33 of 42 (78.6%) in the DHS group ( p = 0.42). The overall skeletal metastatic burden was similar between groups ( p = 0.620). The distribution of Seinsheimer fracture types showed no difference between fixation methods ( p = 0.560). The American Association of Anesthesiologists grade distribution was also comparable ( p = 0.860). Cement augmentation for bone defects was performed in 33 of 48 IMN cases (68.8%) and 28 of 42 DHS cases (66.7%), with no significant intergroup difference ( p = 0.840). Postoperative radiotherapy was administered to eight IMN cases (16.7%) and 12 DHS cases (28.6%) ( p = 0.210). The mean radiotherapy dose and fractionation were 29.4 ± 5.8 Gy (range, 20-40 Gy) in 9.3 ± 2.9 fractions (range, 5-14) for IMN, and 30.4 ± 1.8 Gy (range, 30-35 Gy) in 11.1 ± 1.0 fractions (range, 10-12) for DHS, without differences in total dose ( p = 0.500) or number of fractions ( p = 0.120). In contrast, radiographic metastasis size was larger in the DHS group (6.0 cm) than in the IMN group (4.5 cm; p = 0.023) (Table 1 ).

3.2. Surgical outcomes

Among the 48 IMN and 42 DHS cases, implant breakage occurred in one (2.1%) and seven (16.7%) cases, respectively, and was more frequent following DHS fixation ( p = 0.023). Although mechanical failures and periprosthetic fractures did not differ significantly between the two groups, these complications were observed more often after IMN and accounted for most instances requiring re-open reduction and internal fixation (ORIF). Local tumor progression occurred in 11 of 48 IMN cases (22.9%) compared with two of 42 DHS cases (4.8%; p = 0.017). Distal canal seeding was identified only among IMN cases (nine of 48, 18.8%) and in none of the DHS cohorts ( p = 0.003) (Table 2 , Fig. 1 ). Subgroup analysis showed no difference in distal canal seeding between patients with a single metastatic focus and those with multiple lesions (Table 3 ). The revision surgery rates were comparable between fixation methods—7 of 48 IMN cases (14.6%) and 9 of 42 DHS cases (21.4%; p = 0.422); among these, conversion to an endoprosthesis was performed in three IMN cases (6.3%) and three DHS cases (4.8%; p = 1.000), whereas revision ORIF was performed in four IMN (8.3%) and seven DHS (16.7%) cases ( p = 0.335) (Table 2 , Fig. 2 ).

Perioperative complications were infrequent and did not differ significantly between groups. Surgical-site infections occurred in approximately 4% of all cases; no postoperative hematoma or deaths within 14 days were recorded. Venous thromboembolism developed in 8.3% of IMN cases and 0% of DHS cases ( p = 0.12). Functional recovery corroborated these findings. The mean MSTS scores were comparable between groups, both preoperatively (8.27 ± 0.43 vs 7.71 ± 0.49; p = 0.390) and postoperatively (17.44 ± 0.35 vs 17.12 ± 0.46; p = 0.580) (Table 4 ). Kaplan-Meier survival analysis is presented in Fig. 3 . The median survival times were 20.1 months for the IMN group and 20.3 months for the DHS group ( p = 0.938).

3.3. Logistic regression analysis

In the logistic regression analysis, the fixation method remained the only variable independently associated with local progression. IMN fixation was associated with a higher likelihood of local progression than DHS fixation (OR = 5.12, p = 0.017) (Supplementary Table S1, https://links.lww.com/JCMA/A359 ). No other examined covariates—including patient demographics, primary tumor type, lesion size, Seinsheimer classification, cement augmentation, or postoperative radiotherapy—showed significant associations with local progression, distal canal seeding, revision surgery, or mechanical failure (Supplementary Tables S1–S4, https://links.lww.com/JCMA/A359 ).

4. DISCUSSION

Our findings indicate that DHS fixation merits renewed consideration in the management of pathological subtrochanteric fractures. DHS fixation was associated with lower rates of local progression and distal canal seeding—events observed more frequently after long IMN—and provided comparable functional outcomes and survival rates. These advantages were particularly evident in technically challenging situations, such as extensive bone loss, narrow medullary canals, or in patients with compromised hemodynamic stability or increased thromboembolic risk. Although implant breakage occurred more frequently in the DHS group, this did not translate into a higher revision rate, and the postoperative survival was similar between cohorts. Collectively, these observations suggest that DHS fixation is a reasonable and functionally comparable alternative to IMN fixation in appropriately selected patients.

Long IMN is traditionally regarded as the standard approach for stabilizing pathological subtrochanteric fractures because it offers several important advantages, including load-sharing properties, durable fixation, and early pain relief, which together facilitate prompt mobilization even in advanced disease. 21 Piccioli et al 16 reported a mean time to full weight bearing of 4 days, with 85% of patients regaining independent ambulation within 3 months. The technique is reproducible and minimally invasive, making it suitable for frail oncology patients. Gao et al 22 found significantly shorter operative times and hospital stays for IMN than for DHS in a cohort limited to metastatic proximal femoral lesions. In addition, long nails span the entire femur, offering prophylactic protection against future lesions at non-contiguous sites. 23 , 24 These attributes explain why IMN remains widely used in the management of pathological subtrochanteric fractures.

However, IMN is not appropriate for all patients. Previous series have reported local tumor progression adjacent to IMNs in approximately 5% of cases during the first postoperative year, occasionally necessitating reoperation, particularly among patients with renal cell carcinoma. 25 Jiang et al 20 described a rod-retaining percutaneous salvage technique combining radiofrequency ablation and cementoplasty to treat distal metastatic spread along an existing nail, thereby delaying or avoiding extensive open surgery in patients with advanced disease. Our findings align with these observations: distal seeding occurred only after IMN (9/48; 18.8%) and was absent after DHS fixation ( p = 0.003). Similarly, local progression was observed in 11 IMN cases (22.9%) and two DHS cases (4.8%; p = 0.017). Fixation of metastatic bone differs fundamentally from traumatic fracture management because malignant tissue often necessitates intralesional excision, the bone stock is frequently deficient, and postoperative irradiation may impair bone healing. These factors likely contribute to a nonunion rate of up to 7.2% reported by Maria et al. 5 Surgeons must also remain vigilant regarding systemic complications. Shallop et al 26 observed postoperative venous thromboembolism in 7.1% of patients undergoing IMN fixation for skeletal metastases, most commonly in patients with lung carcinoma, despite standard prophylaxis. Lesion length is another practical limitation. Gao et al 22 advised using IMN only when the longitudinal extent of bony destruction is <5 cm, a threshold consistent with the mean radiographic bone metastasis size of 4.52 cm observed in our IMN group. Taken together, these findings underscore that long IMN should be reserved for patients with limited intramedullary tumor extension, whereas DHS may be advantageous when intramedullary dissemination or substantial bone loss is anticipated, or when patients have a heightened risk of cardiopulmonary or thromboembolic complications.

Thus, DHS fixation can serve as a practical alternative to IMN fixation for selected subtrochanteric lesions. Arshad et al 10 demonstrated that in non-pathological subtrochanteric fractures, DHS fixation was associated with lower estimated blood loss, reduced fluoroscopic exposure, and lower implant cost compared with IMN. Such perioperative and economic benefits are particularly relevant for oncology patients who often face limited physiologic reserve and significant treatment expenditures. The integrity of the medial subtrochanteric cortex is crucial for the lateral plate to act effectively as a tension band. In relatively stable fracture configurations, specifically Seinsheimer types I and II, the DHS side plate converts lateral tensile forces into medial compressive stresses through the preserved cortical buttress, providing mechanical stability and clinical outcomes comparable to those of intramedullary fixation. 8 , 27 However, in our cohort, the Seinsheimer classification was not significantly associated with mechanical failure. This finding suggests that fracture morphology alone may not independently predict construct failure. Nonetheless, DHS fixation should be reserved for biomechanically favorable and relatively stable patterns. Lateral plating may circumvent the limitations imposed by an osseous defect exceeding 5 cm, a narrow femoral canal, or dense osteoblastic metastases that make reaming technically demanding or hemodynamically hazardous (Fig. 4 ). 26 In such contexts, DHS offers a less invasive, cost-effective, and mechanically sound option compared with long IMN.

Although DHS provides a technically accessible and less invasive option for selected patients, its mechanical constraints warrant consideration. In this study, implant breakage occurred more often in the DHS group ( p = 0.023); however, this did not result in an increased number of reoperations. Revision rates were similar—7 of 48 IMN cases (14.6%) and 9 of 42 DHS cases (21.4%; p = 0.422). Likewise, the pre- and postoperative MSTS scores did not differ significantly between the groups.

This study has several strengths that enrich the current understanding of pathological subtrochanteric fracture management. First, our cohort comprised 90 cases, one of the largest series to date, specifically focusing on pathological subtrochanteric fractures, with balanced baseline characteristics, including tumor type, anesthetic risk, and functional status, between the IMN and DHS cohorts. Second, our institutional pathway mandates referral to radiation oncology once wound healing permits; adjuvant radiotherapy is then discussed with the patient to determine the need for local disease control. 20 , 28 This standardized approach enables the detection of late oncological events in an increasing number of long-term survivors. Notably, distal canal seeding and local progression occurred more frequently after nailing, a finding now gaining recognition in the recent literature and underscoring the need to reassess implant selection for this patient population. 20 , 25 Although cement augmentation did not independently influence revision or local recurrence risk in our multivariate analysis, previous studies have outlined several potential advantages of PMMA cement use (Supplementary Tables S1 and S3, https://links.lww.com/JCMA/A359 ). PMMA provides immediate biomechanical reinforcement, thereby improving construct rigidity and allowing for early mobilization. 29 , 30 Furthermore, its exothermic polymerization reaction can reach temperatures exceeding 49°C, inducing thermal necrosis of residual tumor cells and possibly contributing to local control. This exothermic reaction may also cause sensory nerve ending necrosis within the lesion and adjacent soft tissue, providing an additional analgesic effect. 31 These properties may explain the clinical preference for cement augmentation despite inconsistent evidence regarding its long-term oncological or mechanical benefits. Finally, although we initially incorporated the Seinsheimer classification to explore the relationship between fracture morphology and implant performance, no significant correlation was observed with mechanical failure (OR = 2.35, p = 0.297) (Supplementary Table S4, https://links.lww.com/JCMA/A359 ). Thus, although this classification may provide a useful framework for evaluating biomechanical stability, it should not be interpreted as an independent predictor of implant durability in pathological subtrochanteric fractures.

Despite these strengths, this study also has limitations inherent to its retrospective design. Follow-up at our tertiary center was not always feasible for patients with advanced-stage disease; however, complete outcome data were obtained through electronic records or contact with the treating physicians or family members. The 17-year study period encompassed incremental refinements in nail design and manufacturing, while the operative principles and biomechanics of fixation remained consistent, thereby minimizing potential bias. Irrespective of the study design, identifying an appropriate control group is impossible in this context, making a randomized controlled trial impossible. Most cases in our series were treated before the introduction of reliable prognostic instruments—such as the Skeletal Oncology Research Group machine-learning algorithms (SORG-MLAs), which were published and externally validated only in 2020—became available. 32 , 33 Consequently, survival estimation during the early study period relied primarily on clinical judgment. Furthermore, the study period spanned an era of remarkable advances in systemic oncology, including targeted therapy, immunotherapy, and precision medicine, which have substantially prolonged survival and improved disease control across various malignancies. Although the distribution of primary tumors did not differ significantly between the IMN and DHS groups, our cohort included several histologies with favorable prognoses (eg, breast, thyroid, lymphoma, and multiple myeloma). 1 , 16 These factors likely contributed to the relatively long mean survival (20 months) and may have increased the cumulative mechanical load borne by fixation constructs, thereby partially accounting for the higher overall failure rate observed compared to the contemporary series. 5 Although the two cohorts were demographically comparable, they differed in the magnitude of bone loss: larger defects were more common in the DHS group. The existing literature recommends DHS when bone defects exceed 5 cm, 22 and this imbalance may have led us to overestimate the failure rate of DHS fixation, albeit without achieving statistical significance. Finally, the lengthy inclusion period encompassed successive evolutions in systemic therapies that could have influenced bone healing and implant longevity, which are difficult to control in a retrospective analysis.

Although IMN remains indispensable for many pathological subtrochanteric fractures, its association with higher rates of local progression and distal canal seeding emphasizes the importance of careful patient selection. In selected scenarios—such as extensive bony destruction, narrow medullary canals, or in patients with compromised hemodynamic stability or increased thromboembolic risk—DHS fixation may provide a less invasive and potentially oncologically favorable alternative. With appropriate indications, DHS fixation can achieve functional and survival outcomes comparable to those of IMN without increasing the risk of revision surgery, thereby broadening the surgical options for this complex patient population.

APPENDIX A. SUPPLEMENTARY DATA

Supplementary data related to this article can be found at https://links.lww.com/JCMA/A359 .

Footnotes

Conflicts of interest: Dr. Po-Kuei Wu and Dr. Wei-Ming Chen, editorial board members at Journal of the Chinese Medical Association , had no role in the peer review process of or decision to publish this article. The other authors declare that they have no conflicts of interest related to the subject matter or materials discussed in this article.

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