This is a challenging problem.  First, I would NOT, emphasis added, use any kind of nail that requires entry through the greater troch.  THIS IS A CRITICAL point.  Note the lucency of the bone (greater troch) and the posteromedial bone is soft and engulfed in metastasis.  If you approach this fracture through the greater troch, it is likely to split...and this would be a disaster.  Your ONLY point for good fixation is the femoral head and the shaft of the femur.  NOTE, even if you place the hip in traction, you will NOT overcome the forces of the abductors.  That said, I would make a lateral incision and correct the varus with the screw for a DHS...you MUST use  TWO screws to prevent ROTATION..once  the plate is secure.  When I have had these kinds of fractures, I measure the angle of the non-fractured hip.  Place the screw dead center on the fractured side...using the non-fractured side as a guide.  Once the screw is seated, I reduce the fracture and secure the plate.  Again, securing the head to the shaft will provide better stability than trying to reduce the troch.  It is critical that you note that splitting the greater troch would be a disaster.  This patient needs stability and pain relief NOT a poorly stabilized fracture because there may be an argument to avoid open surgery.  Ensure labs are stabilized...blood is available and you have a well-mapped out plan before you start.  Again....do NOT split the troch by placing a rod.  This is critical

Dr. Brannon 

Thanks Dr. Brannon. In fact DHS was not considered before, so that is also interesting option. Still, there is a danger from the metastasis that is several centimeters below the fracture line - it is visible on the marigin of the x-ray. We can consider very long DHS though it's very invasive. Would you like to protect the shaft from fracture in other way? Patient seems to be treated well from oncological point of view, and definitely does not look like terminal patient.

Thank you for this opinion Dr. Zuidema, I fully agree with it and such was my first idea for treatment. The only disadvantage I see in this method is risk of poor bone quality in femoral head and neck, as well as patients obesity.

Good morning,

I note that there is a distal lesion at the bottom of your x-ray.  I have managed these kinds of fractures.  The plate does not need to be very long.  Determine the size of the diaphyseal lesion.  If it is an impending fracture, simply place the and then place a retrograde nail up the femur.  The plate screws can be used to lock the nail.  You most recognize that the primary object is to NOT fracture the bone any further, as doing so would get into a lot of bleeding.  You must have a well-thought-out plan before you start.  Alternatively, you can watch the distal lesion if it does NOT meet the need for prophylactic stabilization.  The key is to use the contralateral hip as a template for the angle and proper placement for the plate on the fractured side.  Please note how thick the cortex is.  A substantial amount of reaming would be required to drop the nail.  Noe of which wold be beneficial to the patient.

I think long PFN will do the job.

I'd like to present here the final decision. The patients was treated by the most experienced hip replacement team and they performed resectional prothesoplasty with GMRS Stryker cemented stem and Avantage Biomet head and acetabulum. Curretage of the medullary canal was performed and the lesion was filled with bone cement.

I didn't make the decision, I didn't perform the surgery. I believe that in good hands such surgery can be beneficial because of early weight bearing. Still it is very invasive and immunological status of the patient can suffer from it.

This is good decision and good perform surgery.

Verbund Osteosynthesis (The connecting osteosynthesis) with a long IMN  with augmentation with cement is also possible in such  cases

Looks like they got a good result.  My first choice would have been a long rod due to chance of other pathological fractures, and this being less invasive than the proximal femur replacement.  I also definitely would start the patient on prolia, if not already on it.

As in all difficult questions there are differnt opinions. I differ from the opinion that excludes the nailing. It is known that a Recon Nail can be used in cases like this and have good results. The fracture as it is under treatment with sometimes even chymo or radiotherapy is healing. The potential transfer of cancer cells in the periphery is negligible and the fear of desseminating metastases to other tissues via increased pressure within the canal again is not a major issue, as the fracture is at the subtrochanderic area and not at the isthmus of the femur. The exposure is much more limited and the nail can be inserted unreamed, so no reamings can contaminate the soft tissues (or this contamination can be kept to the minimum).

Operations that are exposing the tumour may result to tumour cell contamination at the soft tissues locally so DHS may be not the best idea although this is possibe to be used in case of lack of nails. Also DHS is not been successful in the transverse subtrochanderic fractures (in the past DCS was used, and also this was failing in cases that the medial wall was not anatomically reconstructed)

The questions to be answered prior to operation are:

a. what is the survivoship expectation of the patient,

b. what other secondaries do we have 

and

c. grading of the condition.

The operation performed seems to be satisfactory and it is more demading, as the question is if the patient has the abductors and rotators re-attached and if there is good function of the limb.

Very well done. I would proceed in the same way.

I think resection arthroplasty is a good choice in this case. I believe that intramedullary nailing is an option but in such  cases is prone to failing due to low bone quality and low potential of unification. My indication would also be resection arthroplasty, however I would probably apply a longer stem.

Patient has multiple skeletal metastasis, my suggestion in this case is cephalomedullary nail followed by oncology treatment

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