First of all you need a precise histological diagnosis. Depending on the diagnosis you should chose your treatment - wide margin resection with tumor endoprosthesis or curettage with grafts augmented with osteosynthesis. 

Looking at the X-rays and having in mind the rapid development one should consider chondrosarcoma, myxosarcoma, polyhistioma or  bone metastasis. However, more benign entities like chondromyxoid fibroma, aneurysmal bone cyst and chondroblastoma should be excluded.

This pt had metastatic bone disease from Primary in the lung and multiple mets in brain, neck lymph nodes, spine etc. Mri confirmed extravasation of tumor in the soft tissues around the hip

The treatment depends on the general status. Paliative care if the patient's status is terminal. Otherwise resection of the proximal femur and tumor endoprosthesis under spinal anaesthesis is justfied to prevent pathological fracture and a better QOL. Oncologist should decide for adjuvant oncological treatment according to the histological type of tumor.

This pts' General condition was good. I preferred to do a closed PFN

Of course this is another solution belonging to paliative care.

Not surprised with this bad diagnosis regarding the aspect of this lyric extended lesion with superior erosion of the neck. I would have asked for MRI and scintigraphy and would have performed a GAMMA Nail just as you did, may be augmented by cement regarding the satisfying side effects of cement on tumor as well as improved stability...

Very nice diagnosis, treatment and answers...

all the best to U all

Biopsy confirmed metastatic adenocarcinoma. I found it impossible to inject bone cement in this cavity while doing closed PFN.

I agree with your choice. I would normally choose a γ-nail, but a PFN is an excellent choice. Did you have a bone scan? I prefer using a long γ-nail in metastatic bone disease, in case of other metastatic lesions in the diaphysis or the distal epiphysis of the femur.

There is an option to fill up the cervical screw with cement for PFN Nails during cement augmented procedures. But you may fill up as well the whole cavity with low density cement before inserting the cervical screw and after cervical reaming, just as we do for spine surgery. On my own experience it works pretty well in such cases with standard Gamma Nail. The only problem here seems to be the valgus that looks pretty high. Which angular ion did you choose?

Retrospectively in many accounts for my opinion, prophylactic stabilisation is the method of treatment of an impending pathological fracture with intact joint cartilage and not degenerative changes. I would think that an MRI or CT was done pre-operatively. This would help the imaging of the soft tissues and any dissemination of any "growth" into the area where the surgeon will approach. Cement could and in cases must be used, although I noticed that you tried and mentioned that it was not possible to inject it. With the previous history metastatic deposit is the primary diagnosis. The type of stabilisation (reconstruction type of nailing) is the correct one, but I would be potentially prefer it to be the long version that the short which it is used. Reason; in case that tumour cells were pushed distally the risk of a new deposit at the tip of the nail, or near about, could be a possibility. If the whole bone is supported there is no risk of the need to perform a second procedure. I now that this maybe controversial view, but being for so long working in NHS, time and money is an issue to look for.

I agree with George sir. The chances of dissemination of cells to distal is always possible. And as it is metastatic lesion, there are chances of lesion spreading or a skip lesion and revision is not literally possible unless patient general conditions are fair enough for procedure. Long one would have been ideal. Prophylactic fixation of intramedullary device I agree with you.

I am still not convinced about the use of long nail for this proximal lesion. Anhyway, the patient is doing fine so far with this short PFN

Dear Raju

Long nail is there only to internally support your femur and prevent any revision surgery in case of the appearance of secondary deposits or an accidental fall resulting a new fracture.

Your fixation is correct and I am not criticise it. I only said my opinion and the way of the preferred by me approach. This platform is here to help learning and not to criticise and believe me we learn from each other. Opinions, as the one expressed by me, are for discussion not to be imposed.

You have done a fixation which is functional and successful. I hope that my opinion is clearer now.

Thank you very much, for the opportunity given to discuss your interesting case.

Respectfully

George

postero lateral for biopsy first

Dear Raju

lytic lesion

location

i think it`s reach the criteria for fixation

best choice is reconstruction nail to protect entire femur

It scores high on Mirel's criteria and should be prophylactically fixed