Intramedullary nailing has sufficient durability for metastatic femoral fractures

Abstract

BackgroundSurgical treatment options of femoral metastases include intramedullary nailing (IMN) and endoprosthetic reconstruction (EPR). Previous studies have demonstrated functional and oncological advantages of EPR over IMN. The purpose of this study was to (1) report the durability of IMN and (2) establish the indication of IMN for femoral metastases.MethodsIn 2003–2013, among 186 surgically treated femoral metastasis cases, we retrospectively reviewed 80 consecutive IMN cases in 75 patients, including 14 pathological and 66 impending fractures. For the decision of surgical procedure (IMN, EPR, or plating), the following factors are considered: (1) fracture pattern (impending or pathological fracture), (2) Mirels’ score (≥8 or <8), (3) fracture site (femoral head, neck, intertrochanter, subtrochanter, diaphysis, or distal), (4) number of metastases (solitary or multiple), and (5) patient’s estimated prognosis. Patient demographics, postoperative survival, implant survival, and early postoperative mortality were reviewed.ResultsThe patients were 37 males and 38 females, with a mean age of 60.1 (20–84) years. Average follow-up period was 11.4 (1–77) months. The most common fracture site was the subtrochanter (46/80), followed by the diaphysis (26/80) and the intertrochanter (8/80). The most common primary tumor was lung cancer (24/80, 32 %), followed by breast cancer (24 %) and melanoma (15 %). With the exception of six cases, all patients underwent postoperative radiotherapy to the affected whole femur. The postoperative patient survival was 14.2 and 8.4 % at 2 and 3 years from surgery, respectively, while the implant survival rate remained 94.0 % at both 2 and 3 years. Three out of 46 subtrochanteric cases required revision surgeries because of proximal breakage of implant 4–50 months after initial surgery for femoral metastases, but all were replaced by mega-prosthesis and did not need further operation until their death. Early postoperative fatal complications were observed in three patients, all of which were pulmonary dysfunction.ConclusionsThe performance of IMN in this study was satisfactory although a large portion of sub- and intertrochanter metastases were included. Broader indication including these parts should be considered, for IMN has advantages such as lower cost and less invasiveness and even an implant failure can be revised by mega-prosthetic reconstruction.

Multimodal Treatment of Bone Metastasis—A Surgical Perspective

“…They concluded that intramedullary nailing for femoral metastases is an adequate fixation method and allows for a less invasive method of fixation at a lower cost. They also emphasized that in the event of implant failure, endoprosthetic replacement is a viable salvage option ( 54 ).…”

What Factors Are Associated With Implant Breakage and Revision After Intramedullary Nailing for Femoral Metastases?

“…Intramedullary (IM) nails are commonly used to treat actual and impending pathologic fractures of the femur because of the smaller surgical exposure, which may result in less blood loss and surgical time, perhaps enabling more rapid postoperative rehabilitation. In general, no extensive muscle releases are used and immediate weightbearing is possible [23]. Furthermore, the construct provides prophylactic protection of the long bone against future fractures in other regions as a result of its mechanical support over the entire length.…”

Surgical management of metastatic lesions of the proximal femur with pathological fractures using intramedullary nailing or endoprosthetic replacement

“…EPR is a radical resection, however it has excessive cost compared with IMN. Surgical decisions are not only based on medical characters, but also health economics (14), particularly in China. Patients with extremely limited lifespan will not benefit from major surgery and trauma as such procedures require longer recovery.…”

“…Surgical modalities are widely regarded as effective, most of which include endoprosthetic reconstruction (EPR) (1,3,7,8,(10)(11)(12)(13), intramedullary nailing (IMN) and open reduction-internal fixation (4,5,9,10,14). Although these surgical strategies are usually palliative, consensus of the optimal surgical procedure has not been reached.…”

“…Multiple factors regarding the primary tumor, fracture displacement, health status, estimated survival and anatomic region of involvement are of marked importance when choosing appropriate surgical approaches. However, the focus of surgical preferences is generally concentrated on the durability of the implants in previous literatures (4,5,14) and functional outcomes; however, a constant functional follow-up has rarely been analyzed in previous research. The present retrospective study was performed to analyze clinical, functional and oncological outcomes in patients following EPR or IMN in order to investigate the indications for each surgical treatment.…”