Local recurrence rates of superficial versus deep soft tissue sarcoma.

INTRODUCTION: Soft tissue sarcomas are a group of malignancies that commonly occur in the extremities. As deep lesions may exist within the confines of the muscular fascia, we postulate that local recurrence rates are higher for superficial soft tissue sarcomas managed by the standard of care. MATERIALS AND METHODS: A retrospective review was performed on 90 patients who underwent surgical resection of soft tissue sarcomas of the extremity from 2007 to 2015. Patients with minimum 2-year follow-up and adequate operative, pathologic, and clinical outcomes data were included. RESULTS: Mean age was 54 ± 18 years with 49 (54.4%) patients being male. Lesions in 77.8% of cases were deep, and 22.2% were superficial to fascia. Following the index surgical resection, a total of 33 (36.7%) patients had positive margins. A total of 17 (18.9%) patients had a local recurrence. Overall, 3-year survival was 92.7%, and 5-year survival was 79.0%. Five-year recurrence-free survival of deep sarcomas was 91.1% versus 58.2% of superficial lesions (p = 0.006). Patients with higher tumor depth had lower odds of experiencing a local recurrence (HR 0.26 [95% CI 0.09-0.72]). Local recurence rates was also associated with positive surgical margins on initial resection (33.3% versus 12.3%) (p = 0.027). CONCLUSIONS: In this series, superficial tumor depth was associated with local recurrence of soft tissue sarcomas of the extremity following surgical resection. Positive surgical margins was also associated with local recurrence.

Thighplasty at the Time of Stage-1 Bone-Anchored Osseointegration Surgery.

Background: For patients with transfemoral amputations and difficulty tolerating conventional socket-based prostheses, osseointegrated (OI) implants have enabled increased prosthetic use, improved patient satisfaction, and shown promising functional outcomes1,2. Although the use of OI implants effectively eliminates the soft-tissue-related challenges that have plagued socket-based prostheses, the presence of a permanent, percutaneous implant imparts a host of new soft-tissue challenges that have yet to be fully defined. In patients undergoing OI surgery who have redundant soft tissue, we perform a thighplasty to globally reduce excess skin and fat, tighten the soft-tissue envelope, and improve the contour of the residual limb. Description: First, the orthopaedic surgical team prepares the residual femur for implantation of the OI device. After the implant is inserted, the residual hamstrings and quadriceps musculature are closed over the end of the femur, and the subcutaneous tissue and skin are closed in a layered fashion. Although the anatomic location and amount of excess soft tissue are patient-dependent, we perform a standard pinch test to determine the amount of soft tissue that can be safely removed for the thighplasty. Once the proposed area of resection is marked, we proceed with longitudinal, sharp dissection down to the level of the muscular fascia. At this point, we use another pinch test to confirm the amount of soft-tissue resection that will allow for adequate resection without undue tension3. Excess subcutaneous fat and skin are carefully removed along the previously marked incisions, typically overlying the medial compartment of the thigh in the setting of patients with transfemoral amputations. The thighplasty incision is closed in a layered fashion over 1 or 2 Jackson-Pratt drains, depending on the amount of resection. Alternatives: Depending on the amount of redundant soft tissue, thighplasty may not be necessary at the time of OI surgery; however, in our experience, excess soft tissue surrounding the transcutaneous aperture can predispose the patient to increased shear forces at the aperture, increased drainage, and increased risk of infection4. Rationale: Although superficial infectious complications are most common following OI surgery, the need for soft-tissue refashioning and excision is one of the most common reasons for reoperation1,5. Our group has been more aggressive than most in our use of a vertical thighplasty procedure to globally reduce soft-tissue motion in the residual limb to avoid reoperation. Expected Outcomes: Although much of the OI literature has focused on infectious complications, recent studies have demonstrated reoperation rates of 18% to 36% for redundant soft tissue following OI surgery1,5. We believe that thighplasty at the time of OI not only reduces the likelihood of reoperation but may also decrease infectious complications by reducing relative motion and inflammation at the skin-implant interface4,6. Important Tips: The thighplasty procedure is ideally performed as part of the first stage of the OPRA (Osseointegrated Prosthesis for the Rehabilitation of Amputees) procedure to limit the likelihood of problematic ischemia-related complications.We utilize a confirmatory pinch test both before and throughout the thighplasty procedure to ensure adequate resection without undue tension.The thighplasty excision pattern utilizes a long vertical limb designed to decrease the circumferential laxity of the residual limb. Maximal tension is borne on the vertical limb and not on the transverse extensions, as these are prone to scar widening and distortion of surrounding tissues.Closed-suction drainage is utilized liberally to decrease the likelihood of a symptomatic seroma. Acronyms and Abbreviations: OI = osseointegratedOPRA = Osseointegrated Prosthesis for the Rehabilitation of AmputeesPVNS = pigmented villonodular synovitisT-GCT = tenosynovial giant-cell tumor.BMI = body mass indexPMH = past medical history.

Evaluating hip disarticulation outcomes in a 51-patient series.

Background: Hip disarticulations are proximal lower extremity amputations with high postoperative complication and mortality rates. The purpose of the study was to evaluate hip disarticulation outcomes at our institution. Targeted Muscle Reinnervation (TMR) is an effective surgical technique shown to reduce pain in amputees. A secondary goal of the study was to evaluate the impact of implementing TMR on this patient population. Methods: A retrospective review was performed for patients who underwent hip disarticulation with and without TMR between 2009 and 2020. Information on one-year mortality, thirty-day complication rates, operation times, surgical charges, and pain scores was collected. Results: Fifty-one patients underwent hip disarticulation, eight of which had TMR performed at the time of their hip disarticulation. The one-year mortality rate was 37% with 30-day infection, readmission, reoperation, and rates of 37%, 39%, and 27% respectively. The thirty-day major complication rate was 47% overall but not statistically significantly different between groups. There were no differences between groups with regard to 30-day readmission, reoperation, and infection rates. Conclusions: Our results represent one of the largest series of hip disarticulation outcomes. Performing TMR at the time of hip disarticulation did not negatively affect outcomes and may be a beneficial adjunct to improve pain. Further research is warranted.

Management of Metastatic Disease of the Upper Extremity.

Metastatic disease is the most common pathologic cause of bone destruction, and the upper extremity is frequently involved. This location presents many surgical challenges, but there have been several recent implant and technique-related advances that have improved outcomes. Patients can be treated nonsurgically, with radiation or with surgery, depending on patient characteristics, signs/symptoms, primary diagnosis, location, and extent of bone destruction. Most locations in the upper extremity besides the humerus can be treated nonsurgically or with radiation. This is also true of the humerus, but when surgery is indicated, plate fixation is acceptable when adequate proximal and distal cortical bone is present for screw purchase. Intramedullary nailing is used frequently in metastatic humeral disease as well, especially in the diaphysis. When extensive destruction or disease progression precludes internal fixation, a resection with endoprosthetic reconstruction can be considered. Oncologic hemiarthroplasty endoprosthetics still have a role, but reverse shoulder designs are beginning to show improved function. Humeral prosthesis designs are continuing to improve, and are becoming more modular, with custom implants still playing a role in certain challenging scenarios.

Room Traffic in Orthopedic Surgery: A Prospective Clinical Observational Study of Time of Day.

OBJECTIVE: High rates of operating room (OR) traffic may contribute to surgical air contamination and surgical site infections (SSIs). The purpose of this study was to evaluate room traffic patterns in orthopedic implant procedures to determine the frequency of door openings and if time of day had an effect on room traffic. METHODS: In 2015, OR traffic was assessed in orthopedic implant cases. Room traffic was reported as the number of door openings per minute. Counts of how many people were present in the operating room were noted in 5-minute intervals from the time of sterile case opening to dressing placement. Operative cases were observed and categorized into 3 periods (6:00-9:59, 10:00-13:59, and 14:00-17:59) to assess if time of day affected room traffic. RESULTS: Forty-six cases were observed for the present study. Among all cases, the mean room traffic rate was 35.2 openings per hour (SD, 10; range, 13.2-60.8). One-way analysis of variance revealed no statistically significant difference among groups (6:00-9:59 [n = 29], 10:00-13:59 [n = 10], and 14:00-17:59 [n = 7]) as it relates door openings per minute (room traffic rate) (P = 0.9237) or mean number of people in the OR (P = 0.3560). Pearson correlation revealed no correlation between case start time and room traffic rates (P = 0.6129, r2 = 0.0059) or between case start time and mean number of people in the OR (P = 0.3435, r2 = 0.0214). CONCLUSIONS: Room traffic rates and mean number of people in the OR do not correlate with time of day of case in orthopedic implant procedures.

Orthopedic Oncology Experience During Residency.

The objective of this study was to determine the characteristics and logistics of orthopedic oncology rotations at various residency programs across the USA and determine the effect of orthopedic oncology rotations on Orthopedic In-Training Examination (OITE) scores. An eight-question survey was sent to 162 orthopedic surgery residency programs obtained from the Accreditation Council for Graduate Medical Education public database. Pre-oncology rotation and post-oncology rotation OITE scores for 24 residents at a major academic medical center were collected and analyzed. The response rate was 43.8%. Survey results were as follows: 90.1% responded positively to having a dedicated orthopedic oncology rotation in their curriculum; 49.3% carried out their oncology rotation at a hospital outside of their home institution; 70.4% of programs had only one dedicated orthopedic oncology rotation throughout residency; 42.3% indicated that residents experience 6-10 weeks of dedicated orthopedic oncology training during the 5-year residency program; 42.2% indicated that residents experience oncology rotations during post-graduate year 4; and 80.3% of programs had orthopedic oncology trained surgeons on their faculty. The mean increase in OITE oncology scores after the rotation was 12.1% (p = 0.005). There are variations in orthopedic oncology curricula across residency programs, most notably in the number of weeks residents participate in a dedicated oncology rotation, the post-graduate year that residents rotate on an oncology service, and the location where residents obtain their orthopedic oncology training. Participating in a dedicated orthopedic oncology rotation resulted in significant improvement in scores on the oncology domain of the OITE.

The utility of fine-needle aspiration: how FNA has affected our musculoskeletal oncology practice.

Fine-needle aspiration (FNA) has been a widely accepted practice in the diagnosis of head and neck, thyroid, lung, pancreas, and many other visceral sites. This has not been the case with the diagnosis of primary bone and soft tissue lesions. FNA has been an important part of our orthopaedic oncology practice for 18 years. Our ability to efficiently and effectively care for patients dramatically improved when FNA became an option for obtaining a tissue diagnosis. We discuss the advantages and disadvantages of a pathologist-driven FNA service in orthopaedic oncology.

Is Surgical Resection of the Primary Site Associated with an Improved Overall Survival for Patients with Primary Malignant Bone Tumors Who Have Metastatic Disease at Presentation?

BACKGROUND: The management of primary malignant bone tumors in patients with metastatic disease at presentation remains a challenge. Although surgical resection has been a mainstay in the management of nonmetastatic malignant bone tumors, there is a lack of large-scale evidence-based guidance on whether surgery of the primary site/tumor improves overall survival in malignant bone tumors with metastatic disease at presentation. QUESTIONS/PURPOSES: (1) Is surgical resection of the primary tumor associated with improved overall survival in patients with primary malignant bone tumors who have metastatic disease at presentation? (2) What other factors are associated with improved and/or poor overall survival? METHODS: The 2004 to 2016 National Cancer Database (NCDB), a national registry containing data from more than 34 million cancer patients in the United States, was queried using International Classification of Diseases, 3rd Edition, topographical codes to identify patients with primary malignant bone tumors of the extremities (C40.0-C40.3, C40.8, and C40.9) and/or pelvis (C41.4). The NCDB was preferred over other national cancer registries (that is, the Surveillance, Epidemiology, and End Results database) because it includes a specific variable that codes for patients who received additional surgeries at metastatic sites. Patients with malignant bone tumors of the head or skull, trunk, and spinal column were excluded because these patients are not routinely encountered and treated by orthopaedic oncologists. Histologic codes were used to categorize the tumors into the following groups: osteosarcomas, chondrosarcomas, and Ewing sarcomas. Patients whose tumors were classified as Stage 1, 2, or 3 based on American Joint Commission of Cancer guidelines were excluded. Only patients who presented with metastatic disease were included in the final study sample. The study sample was divided into two distinct groups: those who underwent surgical resection of the primary tumor and those who did not receive any operation for the primary tumor. A total of 2288 patients with primary malignant bone tumors (1121 osteosarcomas, 345 chondrosarcomas, and 822 Ewing sarcomas) with metastatic disease at presentation were included, of whom 46% (1053 of 2288) underwent surgical resection of the primary site. Thirty-three percent (348 of 1053) of patients undergoing surgical resection of the primary site also underwent additional resection of metastases. Patients undergoing surgical resection of the primary site typically were younger than 18 years, lived further from a facility, had tumors involving the upper or lower extremity, had a diagnosis of osteosarcoma or chondrosarcoma, and had a greater tumor size and higher tumor grade at presentation. To account for baseline differences within the patient population and to adjust for additional confounding variables, multivariate Cox regression analyses were used to assess whether undergoing surgical resection of the primary tumor was associated with improved overall survival, after controlling for differences in baseline demographics, tumor characteristics (grade, location, histologic type, and tumor size), and treatment patterns (resection of distant or regional metastatic sites, positive or negative surgical margins, and use of radiation therapy or chemotherapy). Additional sensitivity analyses, stratified by histologic type for osteosarcomas, chondrosarcomas, and Ewing sarcomas, were used to assess factors associated with overall survival for each tumor type. RESULTS: After controlling for differences in baseline demographics, tumor characteristics, and treatment patterns, we found that surgical resection of the primary site was associated with reduced overall mortality compared with those who did not have a resection of the primary site (hazard ratio 0.42 [95% confidence interval 0.36 to 0.49]; p < 0.001). Among other factors, in the stratified analysis, radiation therapy was associated with improved overall survival for patients with Ewing sarcoma (HR 0.71 [95% CI 0.57 to 0.88]; p = 0.002) but not for those with osteosarcoma (HR 1.14 [95% CI 0.91 to 1.43]; p = 0.643) or chondrosarcoma (HR 1.0 [95 % CI 0.78 to 1.50]; p = 0.643). Chemotherapy was associated with improved overall survival for those with osteosarcoma (HR 0.50 [95% CI 0.39 to 0.64]; p < 0.001) and those with chondrosarcoma (HR 0.62 [95% CI 0.45 to 0.85]; p = 0.003) but not those with Ewing sarcoma (HR 0.7 [95% CI 0.46 to 1.35]; p = 0.385). CONCLUSIONS: Surgical resection of the primary site was associated with an overall survival advantage in patients with primary malignant bone tumors who presented with metastatic disease. Further research, using more detailed data on metastatic sites (such as, size, location, number, and treatment), chemotherapy regimen and location of radiation (primary or metastatic site) is warranted to better understand which patients will have improved overall survival and/or a benefit in the quality of life from resecting their primary malignant tumor if they present with metastatic disease at diagnosis. LEVEL OF EVIDENCE: Level III, therapeutic study.

Integration of denosumab therapy in the management of giant cell tumors of bone.

A review of the literature indicated denosumab is gaining favorability in the oncology community, particularly with increasing frequency in GCTB. Will denosumab be the breakthrough GCTB treatment? Here, we provide a pertinent case example, a review of the literature regarding the history and basic science behind the use of denosumab for GCTB, highlight the newest insights into the dosing and duration of treatment, and note advancements in the field.

Reverse total shoulder arthroplasty provides stability and better function than hemiarthroplasty following resection of proximal humerus tumors.

BACKGROUND: Tumors may necessitate resection of a substantial portion of the proximal humerus and surrounding soft tissues, making reconstruction challenging. We evaluated outcomes in patients undergoing treatment of tumors of the proximal humerus with reverse total shoulder arthroplasty (rTSA) or shoulder hemiarthroplasty. METHODS: Patients who underwent rTSA (n = 10) or shoulder hemiarthroplasty (n = 37) for tumors of the proximal humerus in 2009 to 2017 were reviewed. Of these patients, 27 had died, leaving 20 for review. The mean follow-up period of the survivors was 27.1 months. They were evaluated clinically and contacted to determine the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and visual analog scale score. RESULTS: Postoperative complications occurred in 13 hemiarthroplasty patients (34%). Tumor recurrence occurred in 3 hemiarthroplasty patients (7.9%), whereas in the rTSA group, 1 patient (10%) had a postoperative complication, with no recurrences. One hemiarthroplasty patient required revision surgery with rTSA to improve shoulder function. Six dislocations and two subluxations occurred in the hemiarthroplasty group, whereas no subluxations occurred in the rTSA group (P = .14). Mean range of motion was 85° of forward flexion for rTSA patients (n = 10) compared with 28° for hemiarthroplasty patients (P < .001). The mean American Shoulder and Elbow Surgeons score was 63 for hemiarthroplasty patients (n = 5) and 59 for rTSA patients (n = 4). The mean Simple Shoulder Test scores were 3.8 and 2.4, respectively. The mean visual analog scale pain scores were 2.4 and 2.5, respectively. CONCLUSION: Reverse total shoulder arthroplasty can reproducibly reconstruct the shoulder in patients requiring oncologic proximal humerus resection. Patients have good outcomes, better range of motion, and no increase in instability rates compared with hemiarthroplasty.

Targeted muscle reinnervation in oncologic amputees: Early experience of a novel institutional protocol.

BACKGROUND: We describe a multidisciplinary approach for comprehensive care of amputees with concurrent targeted muscle reinnervation (TMR) at the time of amputation. METHODS: Our TMR cohort was compared to a cross-sectional sample of unselected oncologic amputees not treated at our institution (N = 58). Patient-Reported Outcomes Measurement Information System (NRS, PROMIS) were used to assess postamputation pain. RESULTS: Thirty-one patients underwent amputation with concurrent TMR during the study; 27 patients completed pain surveys; 15 had greater than 1 year follow-up (mean follow-up 14.7 months). Neuroma symptoms occurred significantly less frequently and with less intensity among the TMR cohort. Mean differences for PROMIS pain intensity, behavior, and interference for phantom limb pain (PLP) were 5.855 (95%CI 1.159-10.55; P = .015), 5.896 (95%CI 0.492-11.30; P = .033), and 7.435 (95%CI 1.797-13.07; P = .011) respectively, with lower scores for TMR cohort. For residual limb pain, PROMIS pain intensity, behavior, and interference mean differences were 5.477 (95%CI 0.528-10.42; P = .031), 6.195 (95%CI 0.705-11.69; P = .028), and 6.816 (95%CI 1.438-12.2; P = .014), respectively. Fifty-six percent took opioids before amputation compared to 22% at 1 year postoperatively. CONCLUSIONS: Multidisciplinary care of amputees including concurrent amputation and TMR, multimodal postoperative pain management, amputee-centered rehabilitation, and peer support demonstrates reduced incidence and severity of neuroma and PLP.

Oncologic reconstruction of the proximal humerus with a reverse total shoulder arthroplasty megaprosthesis.

BACKGROUND AND PURPOSE: Both malignant and benign tumors of the proximal humerus may necessitate resection of a substantial portion of the proximal humerus, making reconstruction options challenging. While hemiarthroplasty has been a classic treatment, reverse total shoulder replacement may provide better pain relief and function for these patients. METHODS: We utilize a two-surgeon approach for these challenging cases. The orthopedic oncologist resects the tumor. A shoulder-trained surgeon implants the reverse shoulder replacement. Modern implants, with large glenospheres and modular components, can allow reliable, straightforward reconstructions for these patients. We prefer 6 weeks of postoperative immobilization to decrease the risk of instability. RESULTS: We have completed 13 reverse total shoulder replacements for oncologic shoulder resections, with acceptable clinical outcomes and no complications to date. CONCLUSION: Reverse total shoulder replacement with long-stem, modular components can reliably and reproducibly reconstruct the shoulder in patients with oncologic resections of the proximal humerus.

Factors associated with post-operative sepsis following surgery for spinal tumors: An analysis of the ACS-NSQIP database.

OBJECTIVES: Sepsis is a rare but potentially devastating complication when it occurs after surgery for spinal tumors. Given the morbidity associated with sepsis, we sought to collate evidence using a large national surgical database to identify the incidence, pre-operative predictors and post-operative factors associated with sepsis following spinal tumor surgery. PATIENTS AND METHODS: The 2005-2014 ACS-NSQIP database was queried for patients undergoing surgery for spinal tumors using ICD-9 codes for primary (170.2, 170.6, 213.2, 213.6) or secondary (198.3, 198.4 and 198.5) spinal tumor. Data were then filtered to include patients who underwent a laminectomy, corpectomy and/or spinal fusion for the tumor. A total of 1468 patients were included in the final cohort. Pre-operative risk factors were assessed using univariate regression models while adjusting for the occurrence of missing variables. Post-operative infectious sources such as urinary tract infection (UTI), pneumonia and surgical site infection were assessed for any association with the occurrence of sepsis. RESULTS: A total of 44 patients (3.0%) had an episode of sepsis within 30 days after surgery. Independent pre-operative factors significantly associated with the occurrence of sepsis were history of prior systemic inflammatory response syndrome (SIRS) (OR 2.89 [95% CI 1.3-6.2]), presence of Insulin-dependent Diabetes Mellitus (IDDM) (OR 3.52 [95% CI 1.4-8.7] and a length of stay>8 days (OR 2.5 [95% CI 1.0-6.2]). Independent infectious sources associated with occurrence of sepsis were surgical site infection (SSI) (OR 23.3 [95% CI 8.6-63.7]), pneumonia (OR 5.8 [95% CI 2.2-15.2]) and urinary tract infection (UTI) (OR 14.7 [95% CI 5.96-36.1]). Up to 52% of the cases of sepsis were associated with at least one source of infection (UTI, pneumonia or SSI) with UTI being the most common (29.5%) followed by pneumonia (22.7%) and SSI (18%). CONCLUSION: Three percent of patients following surgery for spinal tumor experience an episode of sepsis within 30 days. The most likely sources of sepsis include UTI, pneumonia and SSI. Pre- and post-operative targeted interventions in these high risk patients will be most beneficial in reducing the incidence, morbidity and mortality from sepsis after surgery for spinal tumors.

Perioperative Allogeneic Red Blood-Cell Transfusion Associated with Surgical Site Infection After Total Hip and Knee Arthroplasty.

BACKGROUND: Perioperative allogeneic red blood-cell transfusion is a suspected risk factor for surgical site infection (SSI) after total joint arthroplasty (TJA), but the interrelationships among SSI risk, transfusion dose, preoperative anemia, and the presence of coagulopathies have not been well described. METHODS: Data on SSI within 1 year after surgery as well as on transfusion with blood products within 30 days after surgery were obtained for 6,788 patients who had undergone primary or revision total hip or knee arthroplasty from 2000 to 2011 in a single hospital system. Multivariate logistic regression modeling was used to determine the independent association between allogeneic red blood-cell transfusion and SSI. RESULTS: There was a dose-dependent association between allogeneic red blood-cell transfusion and SSI, with the infection rate increasing as the transfusion dose increased from 1 unit (odds ratio [OR] = 1.97; 95% confidence interval [CI] = 1.38, 2.79; p < 0.001), to 2 units (OR = 2.20; CI = 1.37, 3.44; p = 0.002), to 3 units (OR = 3.66; CI = 1.72, 7.16; p = 0.001), and to >3 units (OR = 7.40; CI = 4.91, 11.03; p < 0.001) after controlling for medical comorbidities, planned procedure, preoperative anemia, and preexisting coagulopathies. A preexisting bleeding disorder (OR = 2.09; CI = 1.57, 2.80; p < 0.001) and clotting disorder (OR = 1.37; CI = 1.14, 1.64; p = 0.001) and preoperative anemia (OR = 3.90; CI = 3.31, 4.61; p < 0.001) were all independent risk factors for transfusion after adjusting for the planned procedure. CONCLUSIONS: We found a dose-dependent relationship between allogeneic red blood-cell transfusion and SSI risk after total hip or knee arthroplasty. Additionally, preoperative anemia or a known bleeding or clotting disorder were risk factors for the need for allogeneic red blood-cell transfusion. Our findings underscore the need for preoperative risk assessment, methods to limit surgical tissue injury, and optimized blood conservation strategies. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

When is hemiarthroplasty preferable to intramedullary prophylactic fixation of malignant lesions of the proximal femur?

BACKGROUND: Malignant hip lesions can be managed operatively by intramedullary (IM) nail fixation and hemiarthroplasty. METHODS: A retrospective review was performed on 86 patients who underwent hemiarthroplasty (n = 22) or IM nail fixation (n = 64) for prophylactic treatment of impending pathologic fracture due to malignant lesions of the hip. Cox proportional hazards and logistic regression modeling were performed to determine risk of death, fixation failure, pain relief, and return to ambulation without gait aids. RESULTS: Median survival time after surgery was 8.8 months (with no difference in survival between hemiarthroplasty and IM nail [adjusted Hazard Ratio 1.40, CI 0.72, 2.53; P = 0.31]). Hemiarthroplasty was associated with lower risk of pathologic fracture, fixation failure, or reoperation (adjusted HR 0.02, CI < 0.001, 0.48; P = 0.01). Hemiarthroplasty did not increase odds of unassisted ambulation compared to IM nail fixation (adjusted Odds Ratio [OR] 2.23, CI 0.56, 9.71; P = 0.26). The strongest predictor of postoperative ambulation was preoperative ambulation without aids (adjusted OR 28.9, CI 7.37, 161; P < 0.001). CONCLUSIONS: There is no difference in survival or likelihood of unassisted ambulation after prophylactic femoral fixation with IM nails versus hemiarthroplasty in patients with metastatic disease of proximal femur.