Do Full-Length Femoral Radiographs Influence Fixation Method in Proximal Femur Fractures in Patients With a Co-existent History of Malignancy?

Purpose In patients admitted with extracapsular proximal femur fractures (PFFs) and a co-existent history of malignancy, pre-operative full-length femoral radiographs (FLF-XRs) should be obtained to exclude bony metastases and select the appropriate fixation method. It is unclear whether such radiographs influence the surgeon's chosen fixation method, even when no metastases are identified. Our primary aim was to identify whether FLF-XRs influenced the fixation method in this cohort. Methods We performed a retrospective analysis of all patients with PFFs who underwent surgical fixation at a major London teaching hospital over a three-year period (2018-20) using a search of electronic patient records. Data including history of any malignancy, FLF-XR status, fixation method (intramedullary nail (IMN) or sliding hip screw (SHS)), and one-year morbidity and mortality were collected. Results Our results showed that of the 306 extracapsular PFFs admitted during this time period, 23% (n = 69) had a history of malignancy, and of these, 55% (n = 38) had undergone FLF-XRs. Breast cancer was the most common primary source of co-existing malignancy. After excluding all subtrochanteric fractures (which structurally necessitate IMN fixation), there was no significant difference in fixation method resulting from the presence (or absence) of FLF-XRs in neither the co-existent malignancy PFF group (p = 0.09) nor the without malignancy PFF group (p = 0.84). Within the one-year post-operative follow-up period, none of the PFF patients with co-existent malignancy subsequently re-presented to the study hospital with complications relating to their fracture or surgical fixation. The one-year mortality rate was 28% (n = 19) amongst this group. Conclusion Excluding fracture patterns that necessitate a specific fixation method (subtrochanteric PFFs), the presence of FLF-XRs does not influence the chosen method of fixation (between IMN and SHS). We concur with existing literature that pre-operative FLF-XRs in PFF patients with co-existent malignancy are a low-value investigation and should not delay surgery beyond 36 hours from admission.