Les auteurs rapportent leur expérience de l'enclouage fémoral alésé ou non en cas de métastase fémorale fragilisante ou fracturaire. L'indication opératoire était posée grâce à l'utilisation du score de Tokuhashi, score prédictif évaluant le pronostic selon 5 critères liés statistiquement à la survie : l'état général du patient, l'étiologie du cancer, l'existence de métastases viscérales, le nombre de métastases osseuses, le caractère fracturaire ou non de la métastase. L'étude rétrospective menée entre 1997 et 2000 portait sur 24 patients. Ces métastases touchaient le tiers proximal du fémur (massif trochantérien ou région sous-trochantérienne) dans 22 cas. Ces métastases fracturaires ou fragilisantes ont été traitées par enclouage de reconstruction (20 patients) ou clou centromédullaire standard (4 patients). La moitié des patients opérés a présenté une complication médicale. Le quart des patients est décédé dans le trimestre suivant l'intervention, tous ayant présenté une complication médicale. Aucune embolie graisseuse ou pulmonaire n'a pu être formellement diagnostiquée. La survie était égale à 2 mois si le score était inférieur à 3, de 17 mois si celui-ci était supérieur à 6.

Pluridisciplinary management of patients with metastasis to the femur is well defined, but the choice between palliative surgery or abstention must be decided on the basis of a few evaluated prognostic criteria. We report a series of 24 cases of metastasis to the weakened or fractured femur which was evaluated with the Tokuhashi score and treated by surgery.

Sixteen women and eight men, mean age 71 years (58-89) underwent centromedullary nailing of the femur. These patients had metastases from breast cancer (n = 13 of the 16 women). Twenty of the 24 patients also had other metastases. The Tokuhasi score was > 6 in 16/24 patients. Fourteen patients had pain which did not respond to morphine. Thirteen had fractures and eleven weakened femurs. Time to surgery was six days (1-15). A full nail was inserted in four patients and a reconstruction nail in twenty.

Operative time was 93 minutes (57-123). Blood loss was 200 ml (150-350). There were no intraoperative complications (fat embolism) excepting increased comminution. Hospital stay was 23 days (8-55). Survival was 148 days (8-510) for patients with fractures and 272 days (12-730) for patients with weakened femurs. Eight patients with a fractured femur died (six within the first three postoperative weeks), two among those with preventive nailing. On average, weight bearing among the surviving patients with nailing for fracture was achieved on the 57^th postoperative day (30-90). Only six patients required morphine early after surgery. Centromedullary nailing successfully relieved pain in all patients with an isolated metastasis. Mean survival in patients with a Tokuhashi score ≪ 3 was 2.1 months. It was 17 months in those whose score was > 6.

Centromedullary nailing for fractured or weakened femur due to metastasis is a useful therapeutic solution for patients with short life expectancy. With this technique, antalgesics can be reduced while preserving independence as long as possible. The Tokuhashi score is easy to establish. If it is less than 3, centromedullary nailing should not be attempted due to the short expected survival.