Metastatic bone disease presents significant morbidity to patients and cost to the healthcare system, accounting for an estimated 17% of cancer-related cost burden in the USA [1]. The proximal femur is one of the most common sites of skeletal metastases in cancer patients, and as a weight bearing region subjected to high biomechanical forces, it is at elevated risk of fracture. It is estimated that pathologic fractures occur in 10–30% of cancer patients, a significant number of which occur in the proximal femur, resulting in substantial morbidity [2, 3]. Approximately 50% of metastatic proximal femoral lesions occur in the intertrochanteric or subtrochanteric region, with the other 50% located in the femoral neck [4, 5].

Currently, the mainstay of treatment internationally for proximal femur bone metastases that involve the intertrochanteric or subtrochanteric region is prophylactic internal fixation, most commonly with intramedullary nailing [6,7,8]. This has a number of advantages, including protection of the entire bone, minimal dissection of soft tissue, low cost, simplicity of procedure, and low infection rate [9, 10]. However, prophylactic fixation carries the risk of disease progression and/or progression and subsequent implant failure [4, 11,12,13,14].

Alternatively, an increasing number of surgeons are using endoprosthetic resection and reconstruction as a surgical technique to address metastatic bone disease of the proximal femur, particularly in patients with extensive intertrochanteric and subtrochanteric bone loss [4, 15]. This carries the advantage of immediate stability without the need for bone healing, as well as resection of all local disease, reducing risk of local recurrence. However, these procedures are more complex and costly, involve larger areas of soft tissue dissection and greater blood loss, and carry their own set of complications, such as periprosthetic infection and hip dislocation, making this procedure less appropriate for palliative surgery [13, 14, 16, 17].

Historically, the median survival for patients with bone metastases has been relatively short but varies by cancer primary diagnosis. However, with advancing treatments, patients may now live years after their cancer diagnosis [2, 3]. Thus, an increasing percentage of patients who would historically be treated with an intramedullary nail may be more appropriately treated with resection and reconstruction. A study by the Royal College of Surgeons estimated a nail breakage rate of up to 16% in patients with pathologic fractures, with a mean time to breakage of 10 months [18]. Longer life expectancy in cancer patients with advances in oncologic treatment may lead to a greater number of patients “outliving” their intramedullary fixation. The clinical question of intramedullary nailing versus reconstruction for proximal femur metastases has been explored at multiple institutions around the world, including the USA, France, China, Japan, and the UK [7, 11,12,13,14,15, 19, 20]. While these studies form part of a growing body of evidence to suggest that resection and endoprosthetic reconstruction may have advantages over internal fixation in regard to disease-related and quality of life outcomes, they have all been retrospective in nature. Higher level of evidence with less systemic bias is needed to explore the potential advantages of moving towards resection and endoprosthetic reconstruction as a treatment option.

The Proximal FEmur Resection or Internal Fixation fOR Metastases (PERFORM) study is a proposed randomized control trial that aims to compare patient-centered outcomes following resection and endoprosthetic reconstruction with internal fixation in patients with metastatic bone disease of the proximal femur. In order to design a valid study protocol, a study population needs to be defined in order to establish a zone of clinical equipoise between the two proposed treatment arms. The aim of the current study was to survey orthopedic oncologists regarding their practices in the treatment of proximal femur bone metastases in order to understand which patients may be appropriate for randomization.