**7. Conclusion**

Very recently, the multihole injection nail (SOLCO, Seoul, Korea) has developed into a hollow titanium flexible nail with the tip of multiple side holes. The bone cement could be injected deeply in the course of a percutaneous fixation without adding bone cortex holes. The advantages of this new implant include immediate achievement of stable fixation and effective pain relief, deeper injection of drugs or bone cements, a short recovery time, and high emotional satisfaction from simple operation [9]. The use of the multihole injection nail is

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

of tumor [10]. Its operative procedures are shown in **Figure 12**.

effective in the symptom relief and local tumor suppression.

**5. Chemotherapeutic agent-loaded bone cement**

control but also decreases the number of distant metastases [11].

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

**Figure 12.** The combined percutaneous bone cement injection with the conventional intramedullary nailing leads more

Beyond the injection of bone cement only, there is growing interest on therapeutic effects on mixture of bone cement and chemotherapeutic agents. Many studies suggested that antineo‐ plastic agent–loaded bone cement not only prevents tumor recurrences with better local tumor

According to the literature, percutaneous injection with a mixture of gemcitabine and PMMA bone cement was applied to two patients of femoral neck metastasis from lung cancer [7]. In vitro test reported that the antineoplastic agents, such as cisplatin laden bone cement, hinder

shown in **Figure 11**.

138 Tumor Metastasis

The metastatic bone cancer takes the highest frequency of more than 95% of malignant bone tumors and has adverse influences on quality of life in patient with advanced disease. Moreover, metastatic bone tumor usually reveals in multiple areas. An optimal customized surgical option according to patient's circumstances should be planned, in order to achieve durable skeletal stability, effective pain relief, least surgical morbidity, less hospital stay, and local tumor suppression.
