**4.4. Closed intramedullary (IM) nailing with percutaneous cement augmentation**

The rigid IM nailing is widely used for metadiaphyseal lesions of the long bones and for trochanteric and subtrochanteric lesions of the femur in particular. Immediate bony stability and pain relief may be achieved with low morbidity. IM nailing may be undertaken using an open or closed technique. Closed IM nailing tends to be used when there are minimal bone destruction and displacement of the fragments. It may combine with percutaneous cement augmentation. Closed nailing with cement augmentation has many advantages over only closed nailing. First, intra- and post-operative bleeding is reduced as cement fills the space around the nail. Second, the cement gives early mechanical stability by preventing further destruction of bone and supporting the bone that remains; this results in further relief of pain. Third, filling the canal with cement at the time of nailing may limit the intramedullary spread of tumor [10]. Its operative procedures are shown in **Figure 12**.

**Figure 12.** The combined percutaneous bone cement injection with the conventional intramedullary nailing leads more effective in the symptom relief and local tumor suppression.
