Arch Orthop Trauma Surg (1992) 111 : 73-77
Orthopaedic andTl'aumaSurgery
Archivesof
© Springer-Verlag1992
Pathological fractures of the femur: improvement of quality of life after surgical treatment P. L. O. Broos, P. M. Rommens, and M. J. U. Vanlangenaker Surgical Clinic, Department of Traumatology and Emergency Surgery, Katholieke Universiteit Leuven, Belgium
Summary. R a d i o t h e r a p y and c h e m o t h e r a p y will result in an increase in the n u m b e r of pathological fractures that occur, principally as a consequence of metastatic disease. These lesions are painful, especially at the level of the femur, and are apt to m a k e invalids of the patient. If surgical intervention is applied as quickly as possible, (compound double-plate osteosynthesis or endoprosthesis), preferably before the lesion becomes a real fracture, the patient still has a chance of keeping a good, painless and well-functioning limb. This report concerns 40 patients with 48 pathological femoral fractures. Seventy-five percent of the lesions were localised at the level of the proximal extremity (femoral head or neck, trochanteric region, subtrochanteric region). Twenty cases were treated with an endoprosthesis, 28 by osteosynthesis; 4 patients died within the 1st m o n t h after surgery. In two of them, the data when considered postfacto were judged to show that any surgery would be too risky. Forty-five percent of patients survived for m o r e than 1 year after operation. The average survival time of the whole group was slightly over 10 months. One pa, tient is still going strong m o r e than 35 months after surgery. Survival time was essentially dependent on the prim a r y underlying malignant process. The results obtained have b e e n m o r e than reasonable: in 67% recovery of walking capacity, in 75% an effective fight against the pain.
Pathological fractures are often the result of already well-advanced malignant disease. Because of the progress m a d e in radiotherapy and chemotherapy, the lifespan of such patients continues to lengthen as time goes on, and surgeons will be m o r e and m o r e frequently confronted with this kind of lesion in the future. These fractures often occur in the long bones, especially the femur. Offprint requests to: Prof. Dr. P. L. O. Broos, Department of Traumatology and Emergency Surgery, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium
The question is whether an aggressive surgical operation p e r f o r m e d on patients with a limited life expectancy will succeed in relieving pain and in improving the patients' walking capacity. Our personal experience of such operations covers 40 patients with 48 pathological femoral fractures. The results were satisfying.
Patients and methods From 1980 to 1988, 40 patients (29 women and 11 men) with 48 pathological fractures of the femur were operated on in the Department of Surgery at the Leuven University Hospital. In 6 cases there was an impending fracture. The average age was 62 years (range 38-86 years). Twelve patients also had tumour in other parts of the skeleton. Eight had bilateral femoral lesions. Table i shows that metastatic spread from breast cancer was by far the most frequent pathology (65%), and that primary bone tumours (7.5%) are usually rather rare causes of pathological frac-
Table 1. Pathological femoral fractures in 40 patients: primary pathology
B one metastasis Breast cancer Bronchial carcinoma Grawitz tumour Prostate cancer Thyroid carcinoma Kahler's disease Plasmocytoma Immunocytoma Primary bone tumour Chondrosarcoma Osteosarcoma Angiosarcoma
No. of patients
%
33
82.5 65
26 2 2 2 1 2 1 1 3 1 1 1
7.5
74 N
%
"- ~ x_~......... 12 10 25 211 ........... 77
is
osteosynthesis: 25 patients had a compound double-plate fixation with additional use of bone cement (Table 2). Special attention was given to functional results, the remaining pain complaints and the length of survival.
31j Results
l ~
11 23
Fig. 1. Localisation of the 48 lesions
tures. Thirty-seven fractures out of the 48 (77%) occurred at the level of the proximal end of the femur (Fig. 1). In ten cases the fracture was intracapsular, in 12 others it was at the level of the trochanter, and in 15 it was subtrochanteric. Only 11 fractures occurred in the femoral shaft. In 6 cases a "prophylactic" osteosynthesis was performed because of an impending fracture (Fig. 2). For the other injuries, we always tried to reduce to a minimum the delay between the actual time of the fracture and operation. Thus, 22 fractures (51%) were operated on within the first 48h and 36 (75%) within the 1st week. Any much longer waiting period would be due to a prolonged stay in the oncological department for additional preoperative preparation (dehydration, hypercalcaemia, evaluation of the tumoral disease, etc.). Endoprosthetic surgery was performed in 20 cases: in 14 a conventional total hip prosthesis (Fig. 3), in 5 a tumour prosthesis, in 1 a total replacement of the femur (Fig. 4). In 28 cases we performed
The patients remained in the T r a u m a D e p a r t m e n t for a fortnight on average. Following discharge, 24 patients were r e m o v e d to another ward for rehabilitation therapy or for further oncological treatment. Twenty seven patient (67.5%) obtained very reasonable functional results: 7 were able to walk quite independently again, 20 only needed the help of a stick, crutches or an ambulator. Thirteen patients were totally unable to walk after the operation. Eight of them, however, had already been bedridden before the fracture because of their bad general condition of health. A good analgesic effect was obtained for 30 patients (75%): 9 patients felt no pain at all, 20 needed minor painkillers only sporadically; only 5 depended on regular major analgesic medication. O f the remaining 2 patients, one of t h e m needed mechanical ventilatory support until he died; the other was a psychiatric patient. A t the end of this study (i.e. in O c t o b e r 1989), 6 patients were still alive with an average survival time of 22 months. The optimal survival time was 35 months. The survival time for the whole group reached an average of 10.2 months. Forty-five percent survived surgery for at least 12 months, 21% held out for only 18 months and 8% for only 24 months. The prognosis was somewhat better for patients with breast cancer (average survival time 12 months) than for patients with other malignant diseases (average survival time 9 months).
Fig. 2a-c. Impending fracture; compound double-plate osteosynthesis
75
Fig. 3a, b. Intracapsular fracture; conventional total hip prosthesis Only 4 patients (10%) died within 30 days after the operation. One patient died of a myocardial infarction immediately after nephrectomy for a Grawitz tumour 11 days after surgical treatment of the femoral shaft fracture. A second patient suffering from prostate cancer with pulmonary metastasis and pathological fractures of the left femur, right femur and right humerus, died of respiratory distress 12 days after operation despite uninterrupted mechanical ventilatory support. A third patient operated on for a fracture on the left side and an impending fracture on the right side died a fortnight later because of multiple organ failure due to generalised metastatic disease. The last patient died on the 19th day in a state of untreatable hypercalcaemic coma due to disseminated breast cancer. Two mechanical complications occurred (4%). In one case, after internal fixation for a subtrochanteric fracture, the plate broke and a resection prosthesis had to be inserted as a secondary procedure (Fig. 5). A progressive varus deformation appeared in the only case of shaft fracture treated with an interlocking nail. The patient felt no pain, however, and considering the progress of the tumour, reintervention was not carried out, as there was no possible hope of his ever walking again. The nonlethal complications were, as it were, negligible: no major wound problems, one case of deep thrombophlebitis and one pulmonary embolism.
Discussion Secondary bone metastases are the most frequent malignant causes of pathological fractures [3, 6, 7]. A primary malignant bone tumour, generally speaking, rarely brings on a fracture [5, 6]. The most common localisations are the spine, the ribs, the pelvis and the epi-metaphysis of the long bones [1, 5, 10, 12]. Their prediliction for these
Fig. 4a-c. Chondrosarcoma of the femur; total femoral replacement
spots is indubitally connected with the important blood supply there. Real pathological fractures at the level of the pelvis, the ribs and the spine usually occur late in the course of the malignant disease. In these there is a progressive compression of the cancellous bone that occurs with less pain and functional impairment. This contrasts with femoral fractures, which are not only very painful, but also turn the patient into an invalid [4]. Aggressive surgery is often the only possible treatment for such patients, who in many cases may live on for several weeks, months or years. Stabilising these fractures will facilitate nursing care, reduce hospitalisation time and hospital fees and have a psychologically beneficial effect [3, 9, 10, 11, 13]. Contraindications, however, are: a survival expectancy of less than 4 weeks, a poor general condition that is an obstacle to a safe operation, or complete mental deterioration that renders the struggle against pain unnecessary [2, 13]. Taking all this into account, one has post facto, to concede that for 2 of the 4 patients who died within 1 month after operation, the decision to perform surgery was maybe a little too hasty.
76 Table 2. Pathological femoral fractures (n = 48): localisation and treatment Localisation
n
Endoprosthesis 20
Osteosynthesis 28
Conventional prosthesis
Tumour prosthesis
. 2 3
Intracapsular Trochanteric Subtrochanteric Diaphyseal
10 12 15 11
10 4 .
Total
48
14
.
Total femoral prosthesis
.
. 5
. 1 . 1
95° Angled plate
Dynamic hip screw
. 1
1 -
5 10 10
1
1
25
1
.
.
. 1
Compound Interloocing osteonail synthesis double plate
• Persistent disturbing pain in spite of radiotherapy [9, 10, 14]. A selective intervention according to these criteria is often simple and offers the patients the psychological advantage that they will never have to face a real fracture as a result of the progressing tumoral disease [2, 10, 13, 14]. In the case of intracapsular fractures, a conventional prosthesis is considered the best treatment [9]. Should the fracture be m o r e distal, it is better to resort to osteosynthesis - a c o m p o u n d double-plate fixation or a medullary nailing, depending on the position and extension of the lesion [1, 3, 5, 7]. Prosthetic surgery is, however, in m a n y cases a good if not the only alternative for fractures with b o n e destruction running up proximally from the intertrochanteric line [8]. In one patient with a femoral shaft fracture on a chondrosarcoma, a total femoral prosthesis was put in as soon as it had b e e n clearly proved that there was not slightest evidence of metastasis. Now, m o r e than 2 years after treatment, the patient's functional condition is still good and there is no sign of turnout recurrence.
Conclusion
Fig. Sa-c. Subtrochanteric fracture; a fi~ed with angled plate and bone cement; b implant failure; c resection prosthesis If possible, internal fixation should be p e r f o r m e d prophylactically, before a real fracture occurs. The indications are: • A lytic zone of m o r e than 2.5 cm diameter [9, 12-14]. • Destruction of the cortex involving m o r e than 50% of the bone [9, 12, 13].
T r a u m a and orthopaedic surgeons are going to be increasingly confronted by pathological fractures. Femoral fractures especially lead to considerable functional disturbance and pain. Rapid, rigorously carried out treatm e n t is far better during the impending fracture phase. Depending on the position and extension of the pathological reaction, the treatment should be either compound double-plate osteosynthesis or placement of an endoprosthesis. W h a t m a y sometimes seem a fairly serious surgical intervention is nevertheless well tolerated by the cancer patients. Their expected life span should be a m i n i m u m of 4 weeks, although of course a precise estimate is difficult. Well-established indications and technique ensure reasonable results: we saw a noticeable functional imp r o v e m e n t in 67.5% of the patients and a m a r k e d alleviation of pain in 75%. The incidence of mechanical complications (4%) is no higher than in any other kind of major hip surgery. E v e n if the intervention does not prolong the patient's life, it does improve its quality.
77
References 1. Berentey G (1983) Ausnahmeindikation ftir die Verriegelungsnagelung. Die pathologische Fraktur im Metastasenherd. Hefte Unfallheilkd 161 : 170-179 2. Dittel KK, M~irklin HN (1985) Behandlungsergebnisse nach Verbundosteosynthesen. Aktuel Traumatol 15 : 115-119 3. Dwars B J, Patka DP, Van Mourik JC (1985) Surgical treatment of pathological fractures caused by bone metastases. Neth J Surg 37 (5) : 137-140 4. Friedl W, Ruf W, Krebs H (1986) Funktionelle Ergebnisse nach konservativer und operativer Therapie pathologischer Frakturen bei malignen Erkrankungen. Langenbecks Arch Chir 386 : 185-196 5. Friedl W, Ruf W, Mischkowsky T (1986) Die Doppelplattenverbundosteosynthese bei subtrochanteren pathologischen Frakturen. Chirurg 57 : 713-718 6. Ganz R, Isler B, Mast J (1984) Internal fixation technique in pathological fractures of the extremities. Arch Orthop Trauma Surg 103 : 73-80
7. Holz U (1985) Verbundosteosynthese bei Spontanffakturen. Aktuel Traumatol i5 !100-103 8. Huckstep RL (1987) Stabilisation and prosthetic replacement in difficult fractures and bone tumors. Clin Orthop 224:12-25 9. Jeffers TB, Dolezi WR, Badrinath K (1985) The treatment of pathologic and impending pathologic fractures of the proximal femur in the elderly. Clin Orthop 198 : 173-178 10. Katzner M, Babin SR, Schvingt E (1985) Bilan de 20 arts d'osteosynth6se des metastases osseuses. Int Orthop 9 : 89-96 11. Kramer W, Gaebel G, Stuhldreyer G, Heitland W (1987) Ergebnisse der Behandlung pathologischer Frakturen langer R6hrenknochen. Unfallchirurgie 13 : 22-26 12. Nilsonne U (1984) Surgery for bone metastases. Acta Orthop Scand 55 : 489-490 13. Sangeorzan B J, Ryan JR, Salcicioli GG (1986) Prophylactic femoral stabilisation with Zickel nail by closed technique. J Bone Joint Surg [Am] 68 : 991-999 14. White RR, Seligson D (1983) Operative Stabilisierung pathologischer Frakturen. Beitr Orthop Traumato130 (11) : 567-571
Orthopaedic andTl'aumaSurgery
Archivesof
© Springer-Verlag1992
Pathological fractures of the femur: improvement of quality of life after surgical treatment P. L. O. Broos, P. M. Rommens, and M. J. U. Vanlangenaker Surgical Clinic, Department of Traumatology and Emergency Surgery, Katholieke Universiteit Leuven, Belgium
Summary. R a d i o t h e r a p y and c h e m o t h e r a p y will result in an increase in the n u m b e r of pathological fractures that occur, principally as a consequence of metastatic disease. These lesions are painful, especially at the level of the femur, and are apt to m a k e invalids of the patient. If surgical intervention is applied as quickly as possible, (compound double-plate osteosynthesis or endoprosthesis), preferably before the lesion becomes a real fracture, the patient still has a chance of keeping a good, painless and well-functioning limb. This report concerns 40 patients with 48 pathological femoral fractures. Seventy-five percent of the lesions were localised at the level of the proximal extremity (femoral head or neck, trochanteric region, subtrochanteric region). Twenty cases were treated with an endoprosthesis, 28 by osteosynthesis; 4 patients died within the 1st m o n t h after surgery. In two of them, the data when considered postfacto were judged to show that any surgery would be too risky. Forty-five percent of patients survived for m o r e than 1 year after operation. The average survival time of the whole group was slightly over 10 months. One pa, tient is still going strong m o r e than 35 months after surgery. Survival time was essentially dependent on the prim a r y underlying malignant process. The results obtained have b e e n m o r e than reasonable: in 67% recovery of walking capacity, in 75% an effective fight against the pain.
Pathological fractures are often the result of already well-advanced malignant disease. Because of the progress m a d e in radiotherapy and chemotherapy, the lifespan of such patients continues to lengthen as time goes on, and surgeons will be m o r e and m o r e frequently confronted with this kind of lesion in the future. These fractures often occur in the long bones, especially the femur. Offprint requests to: Prof. Dr. P. L. O. Broos, Department of Traumatology and Emergency Surgery, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium
The question is whether an aggressive surgical operation p e r f o r m e d on patients with a limited life expectancy will succeed in relieving pain and in improving the patients' walking capacity. Our personal experience of such operations covers 40 patients with 48 pathological femoral fractures. The results were satisfying.
Patients and methods From 1980 to 1988, 40 patients (29 women and 11 men) with 48 pathological fractures of the femur were operated on in the Department of Surgery at the Leuven University Hospital. In 6 cases there was an impending fracture. The average age was 62 years (range 38-86 years). Twelve patients also had tumour in other parts of the skeleton. Eight had bilateral femoral lesions. Table i shows that metastatic spread from breast cancer was by far the most frequent pathology (65%), and that primary bone tumours (7.5%) are usually rather rare causes of pathological frac-
Table 1. Pathological femoral fractures in 40 patients: primary pathology
B one metastasis Breast cancer Bronchial carcinoma Grawitz tumour Prostate cancer Thyroid carcinoma Kahler's disease Plasmocytoma Immunocytoma Primary bone tumour Chondrosarcoma Osteosarcoma Angiosarcoma
No. of patients
%
33
82.5 65
26 2 2 2 1 2 1 1 3 1 1 1
7.5
74 N
%
"- ~ x_~......... 12 10 25 211 ........... 77
is
osteosynthesis: 25 patients had a compound double-plate fixation with additional use of bone cement (Table 2). Special attention was given to functional results, the remaining pain complaints and the length of survival.
31j Results
l ~
11 23
Fig. 1. Localisation of the 48 lesions
tures. Thirty-seven fractures out of the 48 (77%) occurred at the level of the proximal end of the femur (Fig. 1). In ten cases the fracture was intracapsular, in 12 others it was at the level of the trochanter, and in 15 it was subtrochanteric. Only 11 fractures occurred in the femoral shaft. In 6 cases a "prophylactic" osteosynthesis was performed because of an impending fracture (Fig. 2). For the other injuries, we always tried to reduce to a minimum the delay between the actual time of the fracture and operation. Thus, 22 fractures (51%) were operated on within the first 48h and 36 (75%) within the 1st week. Any much longer waiting period would be due to a prolonged stay in the oncological department for additional preoperative preparation (dehydration, hypercalcaemia, evaluation of the tumoral disease, etc.). Endoprosthetic surgery was performed in 20 cases: in 14 a conventional total hip prosthesis (Fig. 3), in 5 a tumour prosthesis, in 1 a total replacement of the femur (Fig. 4). In 28 cases we performed
The patients remained in the T r a u m a D e p a r t m e n t for a fortnight on average. Following discharge, 24 patients were r e m o v e d to another ward for rehabilitation therapy or for further oncological treatment. Twenty seven patient (67.5%) obtained very reasonable functional results: 7 were able to walk quite independently again, 20 only needed the help of a stick, crutches or an ambulator. Thirteen patients were totally unable to walk after the operation. Eight of them, however, had already been bedridden before the fracture because of their bad general condition of health. A good analgesic effect was obtained for 30 patients (75%): 9 patients felt no pain at all, 20 needed minor painkillers only sporadically; only 5 depended on regular major analgesic medication. O f the remaining 2 patients, one of t h e m needed mechanical ventilatory support until he died; the other was a psychiatric patient. A t the end of this study (i.e. in O c t o b e r 1989), 6 patients were still alive with an average survival time of 22 months. The optimal survival time was 35 months. The survival time for the whole group reached an average of 10.2 months. Forty-five percent survived surgery for at least 12 months, 21% held out for only 18 months and 8% for only 24 months. The prognosis was somewhat better for patients with breast cancer (average survival time 12 months) than for patients with other malignant diseases (average survival time 9 months).
Fig. 2a-c. Impending fracture; compound double-plate osteosynthesis
75
Fig. 3a, b. Intracapsular fracture; conventional total hip prosthesis Only 4 patients (10%) died within 30 days after the operation. One patient died of a myocardial infarction immediately after nephrectomy for a Grawitz tumour 11 days after surgical treatment of the femoral shaft fracture. A second patient suffering from prostate cancer with pulmonary metastasis and pathological fractures of the left femur, right femur and right humerus, died of respiratory distress 12 days after operation despite uninterrupted mechanical ventilatory support. A third patient operated on for a fracture on the left side and an impending fracture on the right side died a fortnight later because of multiple organ failure due to generalised metastatic disease. The last patient died on the 19th day in a state of untreatable hypercalcaemic coma due to disseminated breast cancer. Two mechanical complications occurred (4%). In one case, after internal fixation for a subtrochanteric fracture, the plate broke and a resection prosthesis had to be inserted as a secondary procedure (Fig. 5). A progressive varus deformation appeared in the only case of shaft fracture treated with an interlocking nail. The patient felt no pain, however, and considering the progress of the tumour, reintervention was not carried out, as there was no possible hope of his ever walking again. The nonlethal complications were, as it were, negligible: no major wound problems, one case of deep thrombophlebitis and one pulmonary embolism.
Discussion Secondary bone metastases are the most frequent malignant causes of pathological fractures [3, 6, 7]. A primary malignant bone tumour, generally speaking, rarely brings on a fracture [5, 6]. The most common localisations are the spine, the ribs, the pelvis and the epi-metaphysis of the long bones [1, 5, 10, 12]. Their prediliction for these
Fig. 4a-c. Chondrosarcoma of the femur; total femoral replacement
spots is indubitally connected with the important blood supply there. Real pathological fractures at the level of the pelvis, the ribs and the spine usually occur late in the course of the malignant disease. In these there is a progressive compression of the cancellous bone that occurs with less pain and functional impairment. This contrasts with femoral fractures, which are not only very painful, but also turn the patient into an invalid [4]. Aggressive surgery is often the only possible treatment for such patients, who in many cases may live on for several weeks, months or years. Stabilising these fractures will facilitate nursing care, reduce hospitalisation time and hospital fees and have a psychologically beneficial effect [3, 9, 10, 11, 13]. Contraindications, however, are: a survival expectancy of less than 4 weeks, a poor general condition that is an obstacle to a safe operation, or complete mental deterioration that renders the struggle against pain unnecessary [2, 13]. Taking all this into account, one has post facto, to concede that for 2 of the 4 patients who died within 1 month after operation, the decision to perform surgery was maybe a little too hasty.
76 Table 2. Pathological femoral fractures (n = 48): localisation and treatment Localisation
n
Endoprosthesis 20
Osteosynthesis 28
Conventional prosthesis
Tumour prosthesis
. 2 3
Intracapsular Trochanteric Subtrochanteric Diaphyseal
10 12 15 11
10 4 .
Total
48
14
.
Total femoral prosthesis
.
. 5
. 1 . 1
95° Angled plate
Dynamic hip screw
. 1
1 -
5 10 10
1
1
25
1
.
.
. 1
Compound Interloocing osteonail synthesis double plate
• Persistent disturbing pain in spite of radiotherapy [9, 10, 14]. A selective intervention according to these criteria is often simple and offers the patients the psychological advantage that they will never have to face a real fracture as a result of the progressing tumoral disease [2, 10, 13, 14]. In the case of intracapsular fractures, a conventional prosthesis is considered the best treatment [9]. Should the fracture be m o r e distal, it is better to resort to osteosynthesis - a c o m p o u n d double-plate fixation or a medullary nailing, depending on the position and extension of the lesion [1, 3, 5, 7]. Prosthetic surgery is, however, in m a n y cases a good if not the only alternative for fractures with b o n e destruction running up proximally from the intertrochanteric line [8]. In one patient with a femoral shaft fracture on a chondrosarcoma, a total femoral prosthesis was put in as soon as it had b e e n clearly proved that there was not slightest evidence of metastasis. Now, m o r e than 2 years after treatment, the patient's functional condition is still good and there is no sign of turnout recurrence.
Conclusion
Fig. Sa-c. Subtrochanteric fracture; a fi~ed with angled plate and bone cement; b implant failure; c resection prosthesis If possible, internal fixation should be p e r f o r m e d prophylactically, before a real fracture occurs. The indications are: • A lytic zone of m o r e than 2.5 cm diameter [9, 12-14]. • Destruction of the cortex involving m o r e than 50% of the bone [9, 12, 13].
T r a u m a and orthopaedic surgeons are going to be increasingly confronted by pathological fractures. Femoral fractures especially lead to considerable functional disturbance and pain. Rapid, rigorously carried out treatm e n t is far better during the impending fracture phase. Depending on the position and extension of the pathological reaction, the treatment should be either compound double-plate osteosynthesis or placement of an endoprosthesis. W h a t m a y sometimes seem a fairly serious surgical intervention is nevertheless well tolerated by the cancer patients. Their expected life span should be a m i n i m u m of 4 weeks, although of course a precise estimate is difficult. Well-established indications and technique ensure reasonable results: we saw a noticeable functional imp r o v e m e n t in 67.5% of the patients and a m a r k e d alleviation of pain in 75%. The incidence of mechanical complications (4%) is no higher than in any other kind of major hip surgery. E v e n if the intervention does not prolong the patient's life, it does improve its quality.
77
References 1. Berentey G (1983) Ausnahmeindikation ftir die Verriegelungsnagelung. Die pathologische Fraktur im Metastasenherd. Hefte Unfallheilkd 161 : 170-179 2. Dittel KK, M~irklin HN (1985) Behandlungsergebnisse nach Verbundosteosynthesen. Aktuel Traumatol 15 : 115-119 3. Dwars B J, Patka DP, Van Mourik JC (1985) Surgical treatment of pathological fractures caused by bone metastases. Neth J Surg 37 (5) : 137-140 4. Friedl W, Ruf W, Krebs H (1986) Funktionelle Ergebnisse nach konservativer und operativer Therapie pathologischer Frakturen bei malignen Erkrankungen. Langenbecks Arch Chir 386 : 185-196 5. Friedl W, Ruf W, Mischkowsky T (1986) Die Doppelplattenverbundosteosynthese bei subtrochanteren pathologischen Frakturen. Chirurg 57 : 713-718 6. Ganz R, Isler B, Mast J (1984) Internal fixation technique in pathological fractures of the extremities. Arch Orthop Trauma Surg 103 : 73-80
7. Holz U (1985) Verbundosteosynthese bei Spontanffakturen. Aktuel Traumatol i5 !100-103 8. Huckstep RL (1987) Stabilisation and prosthetic replacement in difficult fractures and bone tumors. Clin Orthop 224:12-25 9. Jeffers TB, Dolezi WR, Badrinath K (1985) The treatment of pathologic and impending pathologic fractures of the proximal femur in the elderly. Clin Orthop 198 : 173-178 10. Katzner M, Babin SR, Schvingt E (1985) Bilan de 20 arts d'osteosynth6se des metastases osseuses. Int Orthop 9 : 89-96 11. Kramer W, Gaebel G, Stuhldreyer G, Heitland W (1987) Ergebnisse der Behandlung pathologischer Frakturen langer R6hrenknochen. Unfallchirurgie 13 : 22-26 12. Nilsonne U (1984) Surgery for bone metastases. Acta Orthop Scand 55 : 489-490 13. Sangeorzan B J, Ryan JR, Salcicioli GG (1986) Prophylactic femoral stabilisation with Zickel nail by closed technique. J Bone Joint Surg [Am] 68 : 991-999 14. White RR, Seligson D (1983) Operative Stabilisierung pathologischer Frakturen. Beitr Orthop Traumato130 (11) : 567-571
