Surgical decision-making for long bone metastases

Appendicular bone metastastases are most frequent in the femur and the humerus. These lesions can weaken the bone and often lead to pathological fractures. An increase in the number of patients with bone metastatic disease and pathological fractures is expected. Pathological fractures negatively impact quality of life, function, and survival. Surgical intervention is often indicated to treat a pathological fracture and aims to optimize quality of life by providing a stable construct that outlives the patient. This thesis aims to develop tools for better patient selection for surgery and improve implant selection based on patient- and tumor characteristics. Endoprosthetic reconstruction and intramedullary nailing are preferred over open reduction and internal fixation for proximal femoral metastasis. Implant-specific reasons for reoperation should be considered when deciding between these techniques for proximal femoral metastasis. A CT-scan based algorithm can be useful for predicting occurrence of a pathological fracture through a femoral metastasis and could inform the decision whether or not to operate. For humeral metastasis, several implant options seem reasonable. Treatment variation seems to be driven by subspecialty training, tumor type, life expectancy, and location of the humeral metastasis. Patient reported outcome have been scarcely reported after surgery for long bone metastases and should be a focus for future study with the tools provided. Survival probabilities can be estimated using several methods of which a nomogram seems to be most appropriate. Specific patient populations might benefit from metastasectomy. These findings and tools could aid surgical decision making for patients with long bone metastases.