IM Nailing and Endoprosthetic Reconstruction Show Comparable Outcomes With Distinct Timing Benefits for Bone Metastases

Findings from a meta-analysis of outcomes with intramedullary (IM) nailing vs endoprosthetic (EP) reconstruction showed that both options are effective for surgical management of femoral metastases suggesting that the choice between these techniques should be guided by individual prognosis and multidisciplinary consensus, according to R. Lor Randall, MD, FACS.¹

Across 10 studies (n = 1,047), IM nailing demonstrated lower rates of superficial infection, deep infection, and early reoperation vs EP reconstruction. However, beyond the 6-month mark, EP reconstruction showed superior mechanical longevity vs IM nailing. Despite specific temporal advantages for each surgical method, the meta-analysis found comparable implant failure rates; no statistically significant difference in overall outcomes between groups was observed.

“What we are really seeing is a timing effect,” Randall stated in an interview with OncLive®. “IM nailing can be advantageous early; if the prognosis for a patient is particularly grim, IM nails may be preferred. [However], endoprosthetics are more durable, so if a patient has a better prognosis and can handle that upfront recovery, that may be the way to go. This reinforces how we think about these patients in practice: it is not a one-size-fits-all approach.”

In addition to sharing findings from the meta-analysis, Randall discussed the potential influence of emerging systemic agents on surgical morbidity and bone stability and the importance of involving orthopedic oncologists in treatment planning to ensure long-term skeletal integrity.

Randall is the David Linn Endowed Chair for Orthopedic Surgery, the chair of the Department of Orthopedic Surgery, and a professor at the University of California Davis Comprehensive Cancer Center in Sacramento.

OncLive: What was the clinical impetus for comparing outcomes with IM nailing and EP reconstruction, and why is this research relevant to medical oncologists?

Randall: As systemic therapies continue to improve and patients live longer with skeletally related events—which represent [approximately] 20% of the United States cancer care economy—we are seeing a growing incidence of femoral metastases. The real challenge, from a structural standpoint, is choosing the right surgical strategy when a patient has either an impending or realized fracture. We want to impart functionality to the patient, minimize complications, and align treatment with the patient's overall prognosis.

This meta-analysis was performed at Mayo Clinic; it is a systematic review comparing two primary approaches to metastatic disease of the femur: IM nailing and EP reconstruction. To many medical oncologists, this may not be of particular interest, but these are very disparate surgical procedures, and the recoveries are meaningfully different for patients. It is good to be familiar with this.

What methodology was employed in this systematic review?

In the study, [the investigators] looked at over 1,000 patients across multiple studies and examined meaningful outcomes such as infection, implant failure, and reoperation in patients with advanced metastatic disease. [Outcomes were evaluated before and after a 6-month period]. It is particularly important to note that this study isn't trying to declare a single best approach, but it helps us clarify the trade-offs between these 2 strategies. Both techniques perform well, and there is no clear overall winner, but the details matter.

What were the short- and long-term advantages of IM nailing vs EP reconstruction, according to this analysis?

When we look closely, some important patterns emerged in the short term, specifically within the first 6 months of intervention. IM nailing tends to have lower rates of deep infection and lower rates of reoperation, and the complication [rate] is quite minimal. There are real advantages to using intramedullary fixation. However, when you look beyond 6 months, EP reconstruction shows a trend toward fewer reoperations, suggesting better durability over time. IM nails, however, continue to show a lower infection rate.

Based on these findings, when would you gravitate towards IM nailing over EP reconstruction and vice versa?

In general, IM nails are the right choice for patients with a more limited life expectancy, where you want a less invasive operation and quicker recovery. Endoprosthetics tend to be better suited for patients with longer expected survival, more extensive bone loss, or joint involvement, where durability and immediate stability matter more.

Both IM nails and EP reconstructions are highly effective tools. The key is selecting the right operation for the right patient, balancing short-term safety with long-term durability based on the patient in front of us. Importantly, this decision is best made in a multidisciplinary setting, incorporating our medical oncology partners, our radiologists, and, of course, the patient’s goals.

How might emerging systemic therapies, bone-targeted agents, and next-generation immunomodulators influence surgical morbidity and long-term skeletal integrity?

This is an interesting and evolving area. We are starting to [explore new adjuvant platforms], such as polymethyl methacrylate cements, with specific agents that can be delivered [locally]. There are oncologic agents that can be delivered locally, such as bisphosphonates or denosumab [Prolia], which could potentially help with bone stability in the tumor microenvironment. There is also a [phase 3], prospective randomized controlled trial [(NCT03295981)] investigating whether the local delivery of bisphosphonate as a surgical adjuvant can decrease recurrence rates in giant cell tumor of [the bone] that is starting to ramp up.²

These agents have proved to be efficacious, but not definitively so. Many of these agents, particularly those readily available now like denosumab and bisphosphonates, do not necessarily completely attenuate the process, and they can also cause a little bit of bone pain. A salient point for medical oncologists is that if a patient is on these agents, do not necessarily attribute pain to the agent itself. It may be that these patients are progressing and going on to realize fractures. It is important to keep orthopedic oncologists on board, because realized fractures can still occur with these treatments.

References

1. Bulut H, Sullivan MH, Rose PS. Comparative evaluation of treatment strategies for femoral metastases: endoprosthesis reconstruction versus intramedullary nailing. Eur J Orthop Surg Traumatol. 2025;35(1):273. doi:10.1007/s00590-025-04395-1
2. Local bisphosphonate effect on recurrence rate in extremity giant cell tumor of bone. ClinicalTrials.gov. Updated October 15, 2025. Accessed April 9, 2026. https://clinicaltrials.gov/study/NCT03295981

References

1. Bulut H, Sullivan MH, Rose PS. Comparative evaluation of treatment strategies for femoral metastases: endoprosthesis reconstruction versus intramedullary nailing. Eur J Orthop Surg Traumatol. 2025;35(1):273. doi:10.1007/s00590-025-04395-1
2. Local bisphosphonate effect on recurrence rate in extremity giant cell tumor of bone. ClinicalTrials.gov. Updated October 15, 2025. Accessed April 9, 2026. https://clinicaltrials.gov/study/NCT03295981