Specific Management


Most common locations


1. Femur

- femoral neck

- subtrochanteric / femoral shaft

- acetabular

- femoral shaft

- supracondylar


2. Humerus

- proximal humerus

- humeral shaft


3. Tibia


Femoral Neck pathological fracture / Major bone loss


Intertrochanteric MetastasisIntertrochanteric Met Prosthesis



- fracture unlikely to heal

- hemi versus THA

- long versus short stems


Hemi v THA


Consider life expectancy of patient


Varady et al J Arthroplasty 2019

- hemiarthroplasty versus total hip arthroplasty for pathological femoral neck fractures

- THA longer operative times

- no difference 30 day complication rate


Femoral stem length


Xing et al CORR 2013

- 203 patients with proximal femoral metastasis treated with arthroplasty

- no increased revision rate with short stems

- increased complications with long stems, especially cardiopulmonary complications


Fem met 1Fem met 2Fem met 3


Femoral neck stabilization



- sufficient bone for fixation?

- determine if lesions further down femur (xray entire femur)

- consider augmentation with PMMA / cement


Hip metFemoral met


Plate versus IM nail


Meynard et al Orthop Traumatol Surg Res 2020

- 309 cases proximal femoral metastasis

- plate versus IMN versus arthroplasty

- no difference in functional outcome

- increased complications with plating


Subtrochanteric / Femoral shaft metastasis


Subtrochanteric Metastasis and Nail0001Subtrochanteric Metastasis and Nail0002


Metastasis Femoral Shaft0002Metastasis Femoral Shaft0001




Reconstruction nail

- consider cement

- consider venting




Chafey et al CORR 2018

- 217 patients treated with cephalomedullary nails for proximal femoral metastasis

- revision surgery required in 10%

- more common with survival > 7 months




Kim et al Bone Joint J 2016

- 43 patients with IMN + cement of femur and humerus versus 27 IMN

- lower pain scores with cement

- some reduction of metastasis progression with cement


Venting / Negative pressure reaming / Reamer Irrigator Aspirator


Risk of cardiopulmonary complications from fat / air / cancer emboli


Cole et al Injury 2000

- 73 femoral nails for metastatic impending fracture

- 2 deaths from fat embolism


Bilateral nails


Nian et al Cancers 2023

- systematic review of staged versus simultaneous IMN for femoral metastasis

- 156 IMN in 78 patients

- lower total complications with staged

- no difference in mortality


Acetabular Metastasis


Harrington classification


Type Defect
Type I

Minor cavitary defect

Medial and superior walls intact

Type II

Major deficit in medial wall

Rim intact

Type III Massive deficit in lateral wall & superior cortex




Tantalum augmented cups

Cemented Harrington technique / steinmann pins



Metastasis Acetabulum Type III APMetastasis Acetabulum Type III LateralAcetabular Metastasis Steinman Pins

Harrington technique


Acetab met 1Acetab met saddle 1Acetab met saddle 2

Cup-cage technique


Acetabular Metastasis Type IIAcetabular Metastasis Antiprotrusio Cage




Houdek et al JBJS Am 2020

- 78 patients with Harrington technique versus 37 tantalum acetabular reconstruction

- overall, 21% required additional surgical procedures

- tantalum cups more durable with fewer complications


Rowell et al CORR 2019

- cup cage in 47 hips with acetabular metastases

- one patient had loosening due to recurrence 8 years post surgery


Supracondylar Femur 




Plate / dual plate

Retrograde nail  

Modular knee prosthesis


Metastasis Distal Femur CTRenal Met EmbolisationMetastasis Distal Femur Plate and PMMA


Dis femur met 1Dis femur met 2Dis femur met 4Dis femur met 5


Supra met 1Supra met 2Supra met 3


Proximal Humerus 




ORIF with plate +/- cement

IMN +/- cement

Tumour prosthesis



Prox humerus met 1Prox humerus met 2


Shoulder RCCShoulder RCC embolisation 1Shoulder tumour prosthesis




Wu et al J Orthop Traumatol 2023

- 45 patients with proximal humerus metastasis

- IM nailing + cement versus plate

- lower blood loss and shorted hospital stay with IMN

- better pain relief with IMN


Humeral shaft 




Plate +/- cement

IMN +/- cement


Humeral shaft metsHumeral met IMN


Metastasis Humerus Plate PMMA0001Metastasis Humerus Plate PMMA0002


Path # humerus Path # plate


Results IMN


Moura et al Rev Bras Ortop 2019

- 86 pathological humeral fractures treated with IMN

- 5% surgical complication rate


Kobryn et al Cancers 2023

- 100 IMN for pathological humerus fracture

- surgical complication rate 11% with cement, 4% without


Results plate


Weiss et al JBJB Br 2011

- 63 pathological humerus fractures

- all treated with cement + plate

- 11% reoperation rate


IMN versus plate


Hoellwarth et al Injury 2020

- stabilization of humerus pathological fracture

- broken implant 0% IMN at final follow up

- broken implant 14% plate + cement at final follow up




Tibia met 1Tibia met 2Tibia met 3Tibia met 4


Greenbaum et al Am J Orthop 2017

- 43 tibial metastasis

- proximal tibia most common

- variety of treatements

- plate / nail / arthroplasty