These are well established although clinical evidence suggests that they are still sometimes ignored. Load-bearing, rather than load-sharing, devices are preferred and in the diaphysis of long bones, intramedullary nailing is the procedure of choice with locking screws used when appropriate and major bone defects filled by methylmethacrylate. Apart from a solitary renal metastasis, the spread of tumour cells within the medulla by nailing is acceptable, but the entire bone should subsequently be included in postoperative radiotherapy. In the upper limb, particularly in the forearm where stresses are relatively low, plate fixation and augmentation with cement can be highly effective.
The management of fractures about the hip differs significantly from that of purely traumatic injuries. Speed of surgery is less important than preoperative planning and a full medical and radiological assessment should be made initially. There is no virtue in undue delay but these patients are almost always haemodynamically stable, and have not been subject to significant trauma. They can be nursed comfortably on bed rest or traction for several days while appropriate investigations are carried out. When destruction is limited to the femoral neck or head, a cemented hemi-arthroplasty or total joint replacement is recommended as a primary procedure. Devices such as the dynamic hip screw are rarely indicated as they have a high rate of failure. Radiographs of the entire femur must be obtained before operation to exclude more distant disease as far as possible and long-stemmed implants may be used to reduce the risk of subprosthetic fracture. Extensive proximal femoral destruction is only treatable by endoprosthetic replacement, while periacetabular lesions should be reconstructed using threaded rods, reinforcement rings, bone cement and other techniques, as described by Harrington.6Patients with a life expectancy of less than six weeks rarely gain useful benefit from major reconstructive surgery, but the decision regarding any individual case must be taken by the breast-care team.
Postoperative radiotherapy should be considered in all cases, once initial wound healing has occurred.