New trends in the management of lower extremity metastases.

Metastases involving the pelvis and lower extremities are common among the large population of cancer patients presently treated by hormonal or chemotherapy. The use of methylmethacrylate as an adjunct to conventional fracture fixation has improved markedly the results of pathological fracture management. Intertrochanteric femoral fractures should be internally fixed by a combination of a compression hip screw and methylmethacrylate. Subtrochanteric pathological fractures should be internally fixed using a Zickel nail and methylmethacrylate. Pathologic fractures of the femoral neck should be treated by replacement with a long-stem proximal femoral prosthesis. Fractures of the acetabulum must be analyzed as to the extent of medial wall or superior wall osteolysis. Prosthetic hip replacement is appropriate for these fractures but must be augmented by specialized fixation devices, depending on the extent of tumor osteolysis. The indications for prophylactic fixation of lytic lesions of the femur include: (1) a lesion 2.5 cm or larger in size; (2) a lesion destroying 50% or more of the femoral cortex; and (3) a lesion causing local pain with weight-bearing despite adequate radiotherapy. Local radiotherapy can be administered in an abbreviated interval and with much lower dosage than has been accepted conventionally, and the results with regard to tumor control, fracture healing, and cost to the patient will be much improved.