100 eral medical condition of the patient, and expected survival time. Surgery may be chosen if the patient is healthy enough and life expectancy is sufficiently long to benefit from pain relief, improved mobility, and care. If there is no expectation that the survival may be long enough for the patient to recover and truly benefit from surgical procedures, other palliative therapies may be chosen instead. However, this may restrict the patients involved to bed or chair. New therapies have been introduced to improve the survival of patients with lung cancer (Giaccone et al. 2006, Sandler et al. 2006). The median survival of patients with advanced lung cancer has increased from 6 months to 12 months with the introduction of new treatment regimens such as chemotherapy in combination with a monoclonal antibody, which acts as an angiogenesis inhibitor (Rosen et al. 2003, Sandler et al. 2006). However, the efficacy of promising new agents in lung cancer patients concerning treatment of metastases in bone, which is one of the most common metastatic sites, is unknown (Langer and Hirsh 2010). Some authors have stated that a life expectancy of at least 2 months is usually required for meaningful surgery of limb metastases (Harrington et al. 1976), and of 3 to 6 months for spinal lesions (Cybulski et al. 1987, Atanasiu et al. 1993, Tomita et al. 1994). We think that stabilization of long-bone fractures is almost always justified unless the patient has reached a terminal stage. However, we must raise the question of whether spinal surgery would be justified in our cohort with a median survival time of barely 2 months. Decision making regarding the management of pathological fractures is complex, balancing tumor biology, biomechan- ics, and functional outcome goals. We believe that surgery for vertebral metastases may be the best alternative in patients who are expected to live for at least another 2–3 months if surgery leads to a substantial difference, i.e. if the patient can avoid being bedridden or can retain the ability to ambulate independently. More than half of our patients with spine disease improved considerably, i.e. at least 1 Frankel grade. Still, a 2-month survival will be necessary in most cases to gain real benefit from the procedure, considering postoperative pain, surgical complications, and sometimes slow neurological recovery. Today, we are more cautious with patient selection for surgery because of the short survival rate in combination with a high complication rate in this cohort. We identified low preoperative hemoglobin levels as a neg- ative predictor of survival. Hemoglobin has been used as a prognostic factor in metastatic prostate cancer (Matzkin et al. 1993) and in heterogeneous groups of cancer patients (Hansen et al. 2004, Nathan et al. 2005). In the multivariate analysis, we could show that complete pathological fractures had an unfavorable prognosis for survival, as described by other authors (Sugiura et al. 2008). Almost all of the patients (14/16) with humeral metastases had complete fractures. This is probably because impending Acta Orthopaedica 2011; 82 (1): 96–101 fractures in non-weight bearing bones frequently escape diag- nosis due to the relative absence of load-related pain. We found a complication rate of 20%. The total failure rate leading to reoperation of previously operated metastatic sites was 15%. We have previously reported a reoperation rate of 12% in skeletal breast cancer metastases (Wedin et al. 2001) and a failure rate of 11% in patients treated for metastatic lesions of the long bones (Wedin et al. 1999). Nathan et al. (2005) described a similar reoperation rate (11%) after surgery in patients with different types of cancer. Failures are often due to local tumor progression, stress fracture, implant failure due to nonunion, or poor fixation of osteosynthetic devices in insuf- ficient bone stock. They appear equally often in the extremities and in the spine (Yazawa et al. 1990, Bono et al. 1991), as in our series. The high reoperation rate in our study may also be partly explained by the fact that during the 20-year time frame, many orthopedic surgeons—not all sub-specialized in ortho- pedic oncology—performed the operations. Our study was limited by confounding factors. Changes in diagnostics, in selection of patients, in perioperative treat- ment, in indications for surgery, and in methods of fixation during the 20-year study period may have influenced the results. To address the question of whether or not to operate on lung cancer patients with bone metastases, one would want to know the survival prognosis for all patients—not only the ones who (historically) have undergone surgery—as they rep- resent a selected group of patients. This could not be investi- gated, however, as our register covers only surgically-treated cancer patients. Despite its shortcomings, the present work represents the largest follow-up study of lung cancer patients after surgery for skeletal metastases. Most studies have analyzed hetero- geneous populations of patients with bone metastasis. Most analyses on indications for surgery have been based on the treatment of breast and prostate cancer, which is not necessar- ily applicable to lung cancer patients. In conclusion, our findings highlight the fact that surgical treatment of bone metastases in lung cancer patients is asso- ciated with high morbidity and mortality. Thus, the selection process for the (probably) few lung cancer patients who will benefit from surgical treatment is important, especially those with spinal cord compression. Both authors contributed to the planning of the study, interpretation of the results, and editing of the manuscript. RJW performed the data analysis and wrote the manuscript. RW collected the data. The study was supported by grants from Karolinska Institutet and Stockholm County Council. No competing interests declared.