Failures after operation for skeletal metastatic lesions of long bones

This study was based on 192 patients treated surgically for 228 metastatic lesions of the long bones from 1986 through 1995. The survival rate was 0.3 at 1 year after surgery. The surgical treatment consisted of resection and reconstruction of the involved bone (18), intralesional curettage (133), or stabilization only (77). Reconstruction was achieved by an endoprosthesis in 54 cases, by an osteosynthetic device in 162, by cement only in 10. In two cases no reconstruction was performed. The local failure rate was 11% and the median time to failure was 8 months. Local failure was most frequent in patients with kidney cancer (24%) and in diaphyseal and distal femoral lesions (20%). Among 162 operations involving osteosynthetic devices, 22 (14%) were failures as compared with one of 54 (2%) endoprostheses. Sixty percent of the patients received preoperative or postoperative radiotherapy. Five of the six patients who had surgery for local tumor progression had not received radiotherapy. Eight of 10 nonunions and all five patients who developed a stress fracture had been treated with radiotherapy. It is concluded that endoprosthetic reconstructions are preferable to osteosynthetic devices. The skeletal complications associated with radiotherapy may be circumvented by the use of endoprostheses.     

Etiology and results of tumor endoprosthesis revision surgery in 64 patients

From December 1980 to December 1995, 278 patients underwent primary custom endoprosthesis replacements for neoplastic disease at the University of California, Los Angeles and have been followed up for a minimum of 2 years or to death. The endoprosthesis reconstruction failed in 64 patients, including 10 additional patients referred for revision of their replacements. Failure was defined as the complete removal of a prosthesis for any reason. The cause of failure were aseptic loosening (44%), fatigue fracture (16%), local recurrence (14%), infection (13%), and failure of the expansion mechanism (6%). Forty-eight of 64 failed endoprostheses were managed by endoprosthesis reconstruction with most being revised using the same type of prosthesis. Nine of these patients with failed replacements experienced a second failure and four went on to require an amputation. Aseptic loosening and mechanical failure accounted for most of the failures and they were revised successfully. Sixty percent of the infected cases were salvaged satisfactorily by endoprosthetic revision, whereas, 89% of the local recurrences resulted in amputation. Based on endoprosthesis survival the 7-year failure rates were 31% and 34% for primary and revision reconstructions, respectively. The functional results for the patients with endoprosthesis revisions either were better, unchanged, or on average only slightly lower than results of patients with a surviving endoprosthesis.     

Significance of a false-positive trisomy 18 multiple-marker screening test

We report our results in 24 children with malignant primary bone tumours of the distal femur treated with a Stanmore extendible endoprosthesis (SEER). This consists of a femoral component that can be lengthened, a constrained knee and an uncemented sliding tibial component which crosses the proximal tibial physeal plate perpendicularly. The average age of the patients at diagnosis was ten years and the mean follow-up was 4.7 years (2.5 to 7.9). The mean growth of the affected tibia was 76% (18 to 136) and of the fibula 83% (15 to 750) of the growth of the unaffected limb. Measurement of growth arrest lines showed that the mean growth of the proximal tibial physis on the affected side was 69% (43 to 100) of that of the normal side. The great variability in the growth of the physis cannot yet be explained.     

Treatment of ureteral stenosis complicated by endourethral prosthesis. Long-term results

OBJECTIVE: To evaluate the long-term results obtained in the treatment of urethral stenosis complicated with urethral endoprosthesis. MATERIAL AND METHODS: Between March 1991 and December 1996, 40 endourethral prosthesis were implanted in 36 patients; 2 prosthesis were placed in 4 patients. Of the 40 prosthesis implanted, 37 were UroLume and 3 Ultraflex. All, with the exception of 2, were patients with recurrent stenosis after earlier failures of prior internal urethrotomy and/or repeat urethral dilations. RESULTS: Immediate post-operative symptomatic relief was achieved in 97.2% patients. Only one patient required removal of the endoprosthesis. In 4 patients (11.1%) urethral restenosis develop distal or proximal to the endoprosthesis. No patient developed restenosis due to endoprosthetic fibrosis. CONCLUSIONS: The long-term results obtained in the treatment of bulbar urethral stenosis complicated with endoprosthesis demonstrate the efficacy and stability over time of this technique, which shows a low complications rate when patients are strictly selected.     

Primary endoprosthetic replacement for acute femoral neck fractures. A review of 150 cases

A review of 150 consecutive endoprosthetic replacements for acute displaced femoral neck fractures was undertaken to investigate the following serious criticisms of the method. The first is excessive hospital mortality and morbidity, especially in comparison to internal fixation procedures retaining the femoral head. The second is pain, derived from the "unphysiologic" nature of placing a metal prosthesis against otherwise normal acetabular cartilage. In the first instance the procedure is condemned as too major an operative procedure, poorly tolerated by elderly patients. In the second, it is a poor procedure if it requires revision in a patient incapable of withstanding more than one operation. A detailed follow-up shows that the in-hospital mortality in patients averaging 79.8 years of age, was 4%, lower than published mortality for either hemiarthroplasty or internal fixation. Close postoperative monitoring, antibiotic and antiembolic prophylaxis (2.0% infection, 6% embolic complications), and rapid mobilization contributed significantly to the increased survival. Painful endoprostheses, the most frequent complication, occurred in 16.7% of the 125 patients available for follow up at an average of 21 months. The causes of pain were considered technical problems judging prosthetic neck length, head size, sinking and loosening. Dissolution of the medial femoral neck was associated with a narrow stem prosthesis in five of six of these failures. The above statistics suggest that primary endoprosthetic replacement for displaced femoral neck fractures carries with it neither the excessive mortality and morbidity nor the pain induced potential for early reoperations that have been suggested by the recent literature.     

Keith Roberts Porter: a modern Malpighi

Biocompatible polymeric endoprostheses EFOS are offered for endoprosthetic reconstruction of the external acoustic meatus in atresia. Such endoprostheses are safe for the adjacent tissues. Moreover, such prostheses contain antibacterial drugs (quinoxidine, dioxidin) and substances promoting tissue regeneration (orotic acid derivatives). This provides good epithelization of the walls of the newly established external acoustic meatus and sufficient lumen of the organ. The removal of the endoprosthesis is recommended on the postoperative day 90-120 in the outpatient setting.     

Tumor endoprosthesis in malignant bone tumors

In the Department of Orthopedics at the University of Vienna, tumor endoprostheses have been implanted after resections of tumors of the upper extremities since 1974 and of the knee joint since 1976. For replacement of the humerus after tumor resection, a system of modular tumor endoprostheses was developed very early. Initially, it was ceramic and later on made of titanium alloys, which were also implanted in combination with custom-made prostheses with cementless stem-plate fixation in 57 patients until February 1990. In 43 of these patients (75.4%) adequate resection (2 radical and 41 wide) had been performed. Of 49 patients with a follow-up period of at least 24 months, 36 patients had a mean disease-free survival time of 106.1 months. Between 1976 and 1981, 16 custom-made endoprostheses were used after tumor resection of the knee joint. Since 1982 we have used a modular system of tumor endoprostheses suitable for replacement of the proximal and distal femur, proximal tibia, total femur and total knee joint. Of 75 patients who had been operated on up to February 1990, 67 patients (89.3%) had undergone adequate resection (2 radical and 65 wide). Out of 32 of these patients, 24 (75%) exhibited a disease-free survival time of at least 24 months (mean 48.2 months). Out of 213 patients with resection/reconstruction (160 endoprostheses), 77.8% had a survival time of at least 24 months, a results which is considerably better than in 146 patients with amputation in which case the respective value was 69.4%.(ABSTRACT TRUNCATED AT 250 WORDS)     

Soft tissue tumours

Any soft tissue swelling beneath the deep fascia should be considered a sarcoma until proven otherwise. As the most important factor in the primary treatment of these cancers is the adequacy of the primary surgical resection, it is vital to diagnose these malignant tumours pre-operatively. The modern treatment of soft tissue sarcomas may involve all modalities, but the most important aspect of treatment of a primary localised sarcoma is wide excisional surgery preserving limb function. Radiotherapy is a vital adjunct in high-grade tumours, or in tumours whose resectability is limited either by size or anatomical proximity to vital structures. Apart from a few chemosensitive sarcomas, the role of chemotherapy is limited to treatment of metastatic disease where documented response rates are no greater than 30%. As 50% of patients with high-grade sarcomas will die from metastatic disease, improvements in survival rates will only come from improvements in response to systemic therapy. No controlled trials have shown any survival benefit for adjuvant chemotherapy, although a recent meta-analysis of published data has shown a trend to increased survival at two years. Multicentre randomised trials are ongoing. The prognosis of these lesions is highly variable, but is intimately related to the anatomical site (i.e., resectability), and also the grade and size of the tumour.     

The epidemiology of Langerhans cell histiocytosis

PURPOSE: During recent years, more intensified systemic and local treatment regimens have increased the 5-year survival figures in localized Ewing's sarcoma to more than 60%. There is, however, concern about the risk of second malignancies (SM) in long-term survivors. We have analyzed the second malignancies in patients treated in the German Ewing's Sarcoma Studies CESS 81 and CESS 86. MATERIALS AND METHODS: From January 1981 through June 1991, 674 patients were registered in the two sequential multicentric Ewing's sarcoma trials CESS 81 (recruitment period 1981-1985) and CESS 86 (1986-1991). The systemic treatment in both studies consisted of a four-drug-regimen (VACA = vincristine, actinomycin D, cyclophosphamide, and adriamycin; or VAIA = vincristine, actinomycin D, ifosfamide, and adriamycin) and a total number of four courses, each lasting nine weeks, was recommended by the protocol. Local therapy in curative patients was either complete surgery (n = 162), surgery plus postoperative radiotherapy with 36-46Gy (n = 274), or definitive radiotherapy with 46-60Gy (n = 212). The median follow-up at the time of this analysis was 5.1 years, the maximum follow-up 16.5 years. RESULTS: The overall survival of all patients including metastatic patients was 55% after 5 years, 48% after 10 years, and 37% after 15 years. Eight out of 674 patients (1.2%) developed a SM. Five of these were acute myelogenic leukemias (n = 4) or MDS (n = 1), and three were sarcomas. The interval between diagnosis of Ewing's sarcoma and the diagnosis of the SM was 17-78 months for the four AMLs, 96 months for the MDS and 82-136 months for the three sarcomas. The cumulative risk of an SM was 0.7% after 5 years, 2.9% after 10 years, and 4.7% after 15 years. Out of five patients with AML/MDS, three died of rapid AML-progression, and two are living with disease. Local therapy (surgery vs. surgery plus postoperative irradiation vs. definitive radiotherapy) had no impact on the frequency of AML/MDS, but local therapy did influence the risk of secondary sarcomas. All three patients with secondary sarcomas had received radiotherapy; however, all three sarcomas were salvaged by subsequent treatment and are in clinical remission with a follow-up of 1 month, 4.3 years, and 7.5 years after the diagnosis of the secondary sarcoma. Thus far, SM contributed to less than 1 % (3/328) of all deaths in the CESS-studies. CONCLUSIONS: The risk of leukemia after treatment for Ewing's sarcoma is probably in the range of 2%. The risk of solid tumors also seems to be low within the first 10 years after treatment and remains in the range of 5 % after 15 years. In the CESS-studies, less than 1% of all deaths within the first 10 years after diagnosis were caused by SM. Effective salvage therapy for secondary sarcomas is feasible.     

Experimental findings and a new screw endoprosthesis of the hip joint

Based on his own experimental findings, the author provides strong evidence for negative consequences of the deranged vascular network of haversian systems while screwing the screw pedicles of hip joint endoprostheses into the endostalic margin of the cortical layer of the diaphysis. It is shown that it is not advisable to use a endoprosthetic assembly unit in the intertrochanteric area for biomechanical reasons. The latest endoprosthesis of the author's own design, which has a monolithic transition of the neck into the pedicle, is described, with emphasis on driving the endoprosthetic screw pedicle into the diaphysis rather than on its screwing. The prosthesis has a pedicle with a specific trapezoidal thread and a knock-down mobility unit.     

Is postmenopausal estrogen therapy associated with neuromuscular function or falling in elderly women? Study of Osteoporotic Fractures Research Group

Thirty-one cases of endoprosthetic proximal femoral reconstruction after resection for bone tumors are reported. The minimum follow-up period was 2 years (average, 63 months). There were two local recurrences, two deaths from pulmonary metastases, two postoperative infections (1 superficial and 1 deep), both responding to therapy, one postoperative dislocation of a bipolar endoprosthesis, and two cases of loosening of acetabular cups on the same patient. Clinical results (Enneking grade) showed 27% E, 56% G, 14% F, and 3% P. Diaphyseal remodeling results (Rizzoli grade) were 29% A, 6% B, 49% C, 10% D, and 6% E. Anchorage (International Society of Limb Salvage grade) was assessed as 97% E and 3% F, whereas interface (International Society of Limb Salvage grade) was 100% E. Hip (bipolar) articulation was graded as 30% E, 56% G, 11% F, and 3% P. Initial rigid stabilization of the stem with cross-fixation screws allows for excellent bone ingrowth, but presents the problem of proximal cortical atrophy. Bipolar hip components are easy to insert and offer greater inherent stability and so are to be recommended for use in tumor surgery. The results suggest good medium- to long-term results with respect to wear. A new radiographic grading system is presented for bipolar arthroplasty. Survivorship of the femoral component in this series is 100% at a maximum follow-up period of 8 years.     

Endoscopic palliation of malignant obstructive jaundice using resterilized accessories: an audit of success, complications, mortality and cost

OBJECTIVE: To assess the success, complications and cost of endoscopic endoprosthesis placement for palliation of obstructive jaundice caused by malignancy. METHODS: Four hundred and two consecutive patients with obstructive jaundice due to nonresectable malignancy undergoing endoscopic stenting were studied. Commercial or home-made 7F or 10F endoprostheses were placed using minor modifications of the standard technique. The accessories were sterilized and reused. RESULTS: Endoprosthesis placement was successful in 291 patients (72.4%, 95% CI 67.7-76.7)-241 in one attempt, 49 in two attempts, and one in three attempts. Fifty nine patients (14.6%, 95% CI 11.4-18.6) had procedure-related complications, including cholangitis (30), pancreatitis (15), perforation (3) and bleeding (11). The incidence of cholangitis was significantly higher in bifurcation blocks than in other lesions (17.6% vs 4.7%, p = 0.0005). The success rate did not differ between distal and proximal lesions (68.1% vs 72.9%). The procedural cost per patient could be reduced from Rs 14,850 to Rs 6565 by reusing accessories after sterilization, and using home-made stents. CONCLUSIONS: Endoscopic endoprosthesis placement is a safe and effective method for palliation of malignant obstructive jaundice. Preparation of indigenous stents and reuse of accessories can reduce the cost of the procedure by over 50%.     

Synovial sarcoma of childhood and adolescence. Report of the German CWS-81 study

BACKGROUND: Synovial sarcoma is the third most common pediatric soft tissue tumor. It requires an aggressive approach to achieve a cure. However, optimal treatment modalities adapted to disease extension and histologic variants have not been determined because there is little information about prospectively treated patients. METHODS: A multicenter trial for soft tissue sarcomas (Protocol CWS 81) was conducted in West Germany between 1981-1985, and 31 patients with synovial sarcoma were registered. Treatment included multiagent chemotherapy and irradiation after initial tumor excision or biopsy. The male-female ratio in this group was 1:1.6 with a median age of 14 years (range, 1-19 years). The median follow-up time after diagnosis was 101 months (range, 77-131 months). RESULTS: The overall event-free survival (EFS) for patients with synovial sarcoma was 74.2% at 5 years. Group I-II tumors had a significantly better prognosis than those in Group III-IV (EFS at 5 years 84.4% and 58.3%, respectively; P = 0.024). Small tumors (< 5 cm) responded better than larger tumors (> or = 5 cm; EFS, 93% versus 58%; P = 0.029). Synovial sarcoma involved the extremities in 28 patients who had a better outcome compared with those with extremity rhabdomyosarcoma in this study (EFS for Group I-IV was 82% versus 24%, P = 0.001). CONCLUSIONS: The results appeared superior to previous experience using radical surgery alone and suggested that after initial, nonmutilating surgery, adjuvant chemotherapy, and irradiation contributed to the improved long-term survival.     

Proximal and distal femoral centralizers in modern cemented hip arthroplasty

Third generation cementing techniques using intramedullary restrictors, low porosity cement with pressurization, lavage, and cement-stem bond enhancement do not prevent implant malalignment and inadequate cement mantle thickness. This has led to the development of modular proximal and distal centralizers to control the alignment of the femoral component and maintain an adequate thickness of the cement, thereby theoretically decreasing the rate of aseptic loosening. A retrospective analysis was performed of 100 primary cemented centralized femoral components. At an average followup of 5.7 years (range, 4-8 years), the average Harris Hip Score was 90. There were no cases of aseptic loosening, osteolysis, or impending failure. Ninety-one percent of femoral stems were implanted with satisfactory alignment with an optimal cement thickness. However, six distal centralizers and one proximal centralizer fractured at the time of insertion and voids frequently were seen in and around the distal centralizer. Although centralizers improve prosthesis alignment and cement mantle thickness, the long term effects of centralizer fracture and distal cement voids need to be observed to determine if centralizers improve previous implant survival.     

Angiosarcomas associated with bone infarcts

OBJECTIVE: A bone infarct may occasionally dedifferentiate to osteogenic sarcoma, fibrosarcoma or malignant fibrous histiocytoma. However, the association of an angiosarcoma with a bone infarct is extremely rare. Such an association is presented in three patients. Their clinical course is compared with that of patients with bone infarcts associated with other sarcomas. DESIGN AND PATIENTS: The three patients were men with a mean age of 43 years. Cases 1 and 3 presented with a pathological fracture at the site of the angiosarcoma. Plain radiography was done in the three patients, computed tomography (CT) was performed in cases 1 and 3 and magnetic resonance imaging (MRI) in case 3. The femur was the site of the three tumors: midshaft in cases 1 and 3 and distal shaft in case 2. On the basis of the radiographic findings, and clinical examination, an open biopsy was performed for the three men, which confirmed the diagnosis of a high-grade angiosarcoma associated with a bone infarct. RESULTS: Case 1 was treated with high-above knee amputation and is still alive after 18 months from the time of operation. Segmental resection of the distal femur with adjuvant chemotherapy and local irradiation was the treatment for case 2, who is still alive with no tumor recurrence on metastatic disease 3 years from the operation. Intramedullary rodding was done for case 3 who died 6 months later. CONCLUSION: The association of an angiosarcoma with a bone infarct has been established in only five cases. Although the number of such associations is small, it seems that such an association may be prognostically more or less the same as in those cases in which a bone infarct is associated with either osteosarcoma, fibrosarcoma or malignant fibrous histiocytoma, where the survival rate is unfavorable. A cause-and-effect relationship may exist between a bone infarct and subsequent development of a bone sarcoma.     

Resectability of retroperitoneal sarcomas: a matter of surgical technique?

The management of retroperitoneal sarcomas has been hampered by the difficulty in complete resection, the resectability rate in the literature being about 53%. In a review of the last 88 consecutive patients with retroperitoneal sarcomas the resectability rate was 95%. At a mean follow-up of 48 months, the local recurrence rate was 17% following wide resection and 59% following local excision (P = 0.0002). For patients with minimum follow-up of 5 years, the local recurrence rate was 39% for those with primary tumours and 57% for those referred with local recurrence. Local recurrence diminished the rate of long-term survival. The 5- and 10-year survival rates for the primary retroperitoneal sarcomas (n = 55) were 66% and 57% and for those referred with locally recurrent sarcoma (n = 33) 57% and 26%, respectively. The 5-year survival rate varied significantly with the grade of the tumour, from 88% for Grade I to 44% for Grade III tumours (P = 0.006). In conclusion, with modern surgical techniques the resectability rate of retroperitoneal sarcomas is about 95%, and the survival rate of the primary tumours approximates that of the primary soft tissue sarcomas of the extremities.     

Infrainguinal arterial reconstruction for claudication: is it worth the risk? An analysis of 409 procedures

PURPOSE: Infrainguinal reconstruction traditionally has been reserved for patients with limb-threatening ischemia. Surgery for debilitating claudication, however, has been discouraged as a result of the perceived fear of bypass graft failure, limb loss, and significant perioperative complications that may be worse than the natural history of the disease. In this study, the results of infrainguinal reconstructions for claudication performed during the past 10 years were evaluated for bypass graft patency, limb loss, and long-term survival rates. METHODS: Data were collected and reviewed from the vascular registry, the office charts, and the hospital records for patients who underwent infrainguinal bypass grafting for claudication. RESULTS: From 1987 to 1997, 409 infrainguinal reconstructions were performed for claudication (9% of all infrainguinal reconstructions in our unit). The patient population had the following demographics: 73% men, 28% with diabetes, 54% smokers, and an average age of 64 years (range, 24 to 91 years). Inflow was from the following arteries: iliac artery/graft, 10%; common femoral artery, 52%; superficial femoral artery, 19%; profunda femoris artery, 16%; and popliteal artery, 2%. The outflow vessels were the following arteries: 165 above-knee popliteal arteries (40%), 150 below-knee popliteal arteries (37%), and 94 tibial vessels (23%). The operative mortality rate was 0%, and one limb was lost in the series from distal embolization. The primary patency rates were 62%, 77%, and 86% for above-knee popliteal artery, below-knee popliteal artery, and tibial vessel reconstructions at 4 years, and the secondary patency rates were 64%, 81%, and 90%, respectively. Cumulative patient survival rates were 93% and 80% at 4 and 6 years as compared with 65% and 52%, respectively, for infrainguinal reconstructions performed for limb salvage. CONCLUSION: Infrainguinal arterial reconstruction for disabling claudication is a safe and durable procedure in selected patients. These data indicate that concern for limb loss, death, and limited life span of the patients with this disease may not be warranted.     

Childhood soft tissue sarcoma: a 20-year experience

PURPOSE: To evaluate the disease-free and overall survival of pediatric patients with nonrhabdomyosarcoma soft-tissue sarcomas. METHODS: We retrospectively analyzed the records of 67 pediatric patients with a diagnosis of nonrhabdomyosarcoma soft tissue sarcoma treated with curative intent between 1970 and 1992. Median follow-up time for the 52 survivors was 120 months (range, 7 to 277 months). Fifty-nine patients received external beam radiotherapy, in a median dose of 5400 cGy (range, 1800 to 6660 cGy.) All patients underwent an initial surgical procedure. Eighteen patients had gross residual disease, and 15 had gross total excision with microscopic residual disease or positive margins. Adjuvant chemotherapy was administered to 44 patients (65%). RESULTS: The actuarial 10-year freedom from progression or recurrence and overall survival rates were 76% and 75%, and the 20-year rates were the same. Of 18 patients with gross residual disease, 9 (50%) had local progression and 6 died of local-only disease. By contrast, only one patient with microscopic residual disease who received postoperative radiotherapy had a local recurrence. The disease-free survival rate also correlated with histologic grade. CONCLUSIONS: As with adult soft tissue sarcomas, gross residual disease predicts local failure. Our results suggest that pediatric patients with soft tissue sarcomas treated with surgery and postoperative radiotherapy generally have a favorable overall survival rate.     

Intraepiphyseal resection of the proximal tibia and its impact on lower limb growth

From 1989 through 1996, 10 children affected by high grade bone tumors of the proximal tibia underwent an intraepiphyseal intercalary resection. The residual epiphyseal bone segment measured less than 2 cm in thickness in all cases and reconstruction always was performed using the combination of a vascularized fibular autograft and a massive bone allograft. The proximal epiphyseal osteosynthesis was fixed by small fragment screws. The aim of this study was to report the growth pattern of the residual proximal tibial epiphysis and to evaluate any possible lower limb discrepancy and/or deformity after the end of skeletal maturity. At current followup six patients were available for the final evaluation. Radiographic documentation included computed tomography scan of both knees before surgery, a panoramic radiographic view and a computed tomography scan of both lower limbs after the end of skeletal growth. The length of both femurs and tibias, the size of the tibial plateau and of the opposite distal femur, and any possible deformity of femur or tibia were measured and compared with the preoperative data. No patient had a limb length discrepancy greater than 3.5 cm. In all cases the ipsilateral femur had a valgus deformity of the hip develop. In two patients this deformity was associated with an elongation of the femur, partially compensating for the shortening of the tibia. The tibial plateau close to reconstruction grew less than the contralateral one (range 2%-8%) but maintained its normal relationship with the distal femur. None of these patients reported any restriction in recreational activities. They could walk, run, and jump. Their functional result according the International Society of Limb Salvage functional grading system was satisfactory in all cases.     

The retrograde intramedullary supracondylar nail: an alternative in the treatment of distal femoral fractures in the elderly?

To find out whether retrograde nailing of distal femoral fractures is beneficial for the aged patient, we performed a prospective study of consecutive patients 65 years or older with distal femoral fracture treated with a retrograde femoral nail between 1 March 1993 and 30 April 1996 in our department. In total, 26 patients with unilateral distal femoral fractures had been treated in our department, and 24 patients had been followed up for more than 12 months. All fractures had healed. Six patients did not walk before the injury. According to the Neerscore we counted 10/18 excellent results (> or = 85 points), 6/18 good results (> or = 70 points), 2/18 fair results (> or = 55 points) and no failures (< 55 points). Retrograde intramedullary nailing makes a biological osteosynthesis of distal femoral fractures possible. Even in our aged patients good functional results could be obtained. Poor hold of the distal interlocking screws and difficult proximal locking are the two major technical problems encountered with this implant. Early weight-bearing is not advisable.