Intramedullary nailing of (impending) pathologic fractures

Does the Level and Complexity of Femur Fracture Determine Intramedullary Peak Pressures During Reamed Femoral Nailing? A Prospective Study

OBJECTIVES

To investigate femoral intramedullary (IM) pressures during reamed antegrade nailing and to determine whether fracture level and/or complexity affect peak pressures.

METHODS

DESIGN

Prospective, nonrandomized observational cohort.

SETTING

Single level I trauma center.

PATIENT SELECTION CRITERIA

Patients presenting with femur fractures (OTA/AO 31A3; 32A; 32B; 32C; 33A2; 33A3), requiring antegrade IM nail fixation, were included in this study. Excluded were minors and patients presenting with hemodynamic instability, a reduced level of consciousness and intoxication. Femurs were divided into thirds based on preoperative radiological measurements and allocated to 3 groups based on fracture location: Proximal (A), middle (B), and distal (C) third femur fractures. Fracture complexity was also documented.

OUTCOME MEASURES AND COMPARISONS

Peak IM pressures of proximal, middle, and distal third femoral fractures were compared during antegrade femoral IM nail fixation.

RESULTS

Twenty-two fractures in 21 patients were enrolled and treated over a 4-month period with a distribution of fracture locations of group A = 12, group B = 6, and group C = 4. Measured mean resting distal IM pressures were significantly higher ( P < 0.05) in proximal fractures (group A: 52.5 mm Hg) than in middle and distal third fractures (group B: 36.6 mm Hg and group C: 27.5 mm Hg). Greatest peak pressures were generated during the first ream in groups A and B, occurring distal to the fracture in all cases. Group A averaged 363.8 mm Hg (300-420), group B 174.2 mm Hg (160-200), and group C 98.8 mm Hg (90-100). There was a significant difference comparing group A with B and C combined ( P < 0.01) and group A with B ( P < 0.05) and C ( P < 0.05]) individually. Group A consisted of 6 comminuted and 6 simple fracture configurations. Mean peak pressures in these subgroups differed significantly: 329 mm Hg (300-370) versus 398 mm Hg (370-430), respectively ( P < 0.05). Complex fractures in study groups B and C did not have significantly different peak pressures compared with simple fractures ( P > 0.05).

CONCLUSIONS

Both the fracture location and comminution affect peak IM pressures during reamed antegrade femoral nailing. Proximal, simple fracture configurations resulted in significantly higher pressures when compared with more distal and comminuted fracture configurations.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pathologic Peri-Implant Proximal Femur Fracture: Takeaways from Our Experience

Pathologic fractures of the distal femur secondary to bone metastases are not as common as those in the proximal femur, and they are rarely reported on in the literature. Even in the absence of current metastatic lesions in the femoral neck, traditional orthopaedic teaching has stressed the importance of protecting the entire femur, while recent studies have shown that it may not be necessary to stabilize the entire femur in the event of future metastases. Thus, there is no consensus regarding optimal surgical treatment, making the choice of fixation often based on the experience of the surgeon. In this paper, we reported on a patient who presented with a pathologic fracture of the distal femur who was stabilized with a retrograde intramedullary nail and then subsequently suffered a pathologic fracture of the proximal femur. To our knowledge, there have been no cases reported on a peri-implant pathologic fracture proximal to a retrograde intramedullary nail in the setting of metastatic bone disease. We would like to share our experience on how to surgically manage this and discuss the literature around management of distal femoral bone metastases.

Evaluation of Intramedullary Methods with Polymethylmethacrylate for Fixation of Bone Lesions of the Extremities

Objective  To evaluate the better potential and functional results in pain control in the treatment of pathological fractures and prophylactic fixation with an intramedullary nail associated with polymethylmethacrylate, compared with the utilization of an intramedullary nail in long bone tumor lesions.

Methods  From January 2012 to September 2017, 38 patients with 42 pathological lesions (fractures or impending fractures according to the Mirels criteria) were treated surgically. Sixteen patients allocated to the control group underwent a locked intramedullary nail fixation, and 22 patients with pathological lesions were allocated to treatment with an intramedullary nail associated with polymethylmethacrylate. Postoperatively, the patients were submitted to the Musculoskeletal Tumor Society (MSTS) rating scale, radiographic assessment, and to the assessment of events and complications related to the treatment.

Results  The evaluation using the MSTS questionnaire showed better functional results in the group associated with polymethylmethacrylate, in comparison with the control group, which obtained an average score of 16.375 out of a maximum of 30 points (54.6%). The group studied with association with polymethylmethacrylate obtained a mean of 22.36 points (74.5%). The procedure proved to be safe, with similar complication and severity rates, and with no statistical difference in comparison with the standard treatment.

Conclusion  Stabilization of tumor lesions with an internal fixation associated with the polymethylmethacrylate demonstrated early rehabilitation and improved the quality of life, allowing rapid functional recovery. The use of polymethylmethacrylate has advantages such as reduced bleeding, tumor necrosis and higher mechanical stability.

Are piriformis reconstruction implants ideal for prophylactic femoral neck fixation?

OBJECTIVES

Prophylactic femoral neck fixation may be performed in the setting of geriatric diaphyseal femur fracture, pathologic or impending atypical femur fractures. Fixation constructs often utilize cephalomedullary implants with one or two proximal interlocking screws into the femoral head/neck. Variations in proximal femoral anatomy and implant design can interfere with the placement of two screws in the femoral head and neck. Our objective was to assess the strength of piriformis entry reconstruction implants with one versus two proximal interlock screws for prophylactic femoral neck fixation.

METHODS

Thirty fourth generation synthetic femur models were separated into 5 groups. The control group was an intact femur, and the second group was an intact femur with an entry hole in the piriformis fossa. The remaining groups had an intramedullary nail placed with either 0, 1, or 2 screws placed into the femoral head and neck. Each femur was mechanically loaded along the mechanical axis through the femoral head. Load to failure and failure displacement were recorded.

RESULTS

Mean load to failure was 5583 ± 543 N in the intact femur. Constructs with 2 screws had a significantly higher mean load to failure (3223 ± 474 N) compared to one screw constructs (2368 ± 280 N). All of the experimental groups remained significantly lower than the intact femur model (p < 0.05).

CONCLUSION

Our results demonstrate that piriformis entry reconstruction implants have a significantly lower load to failure compared to an intact femur irrespective of screw construct. Further studies are needed to investigate this potential iatrogenic weakening.

Updated Outcomes of Prophylactic Femoral Fixation

Despite an increasing number of patients with metastatic bone disease (MBD), minimal data exist regarding outcomes of patients undergoing prophylactic femoral fixation for MBD when compared with other frequently performed orthopedic operations, such as hemiarthroplasty of the femur. The authors performed a retrospective database review evaluating these procedures due to similar operative times and patient populations and also reviewed common comorbidities such as body mass index (BMI). The goal was to provide updated results of prophylactic femoral fixation and evaluate whether certain patient risk factors (eg, BMI) altered 30-day survival for patients with MBD. The authors reviewed 1849 patients with and without MBD treated by prophylactic fixation and hemiarthroplasty from 2006 to 2011 identified in the American College of Surgeons National Surgical Quality Improvement Program database. There were no significant differences in complications between patients undergoing surgical treatment for impending or actual femoral fracture. In addition, there were no differences between the 217 patients with MBD in either the hemiarthroplasty or prophylactic fixation groups because the rate of death within 30 days postoperatively was 5.56% and 3.30%, respectively (P=.526). When comparing BMI, obese patients had higher rates of wound infection, and underweight patients were more likely to develop pneumonia or die within 30 days postoperatively. Patients with impending femur fractures benefit from prophylactic fixation and perform as well in the short term as patients undergoing hemiarthroplasty. Certain BMI categories (underweight or obese) contributed to poorer outcomes. These findings provide updated information for discussing risks and benefits with surgical candidates.

The current status of prophylactic femoral intramedullary nailing for metastatic cancer

The most common site for cancer to spread is bone. At post-mortem, bony metastases have been found in 70% of patients dying from breast and prostate cancer. Due to the prevalence of cancer, bone metastasis and the associated management represents a huge burden on NHS resources. In patients with metastasis, around 56% of these involve the lower limb long bones. Due to the huge forces placed upon long bones during weight bearing, there is a high risk of fracture through areas of metastasis. It is reported that 23% of pathological fractures occur in the femoral subtrochanteric region. This area is subjected to forces up to four times the body weight, resulting in poor union rate for these fractures, and significant morbidity associated with difficulty in mobilising, and in patient nursing. As cancer treatments improve, the life expectancy in this subgroup of patients is likely to increase. Therefore medium-to-long-term management of these fractures, beyond the palliative, will become essential. We aim to evaluate the current management for metastatic malignant femoral disease, with particular focus on the prophylactic augmentation of diseased femorii using intramedullary nails.

Intramedullary nailing of femoral diaphyseal metastases: is it necessary to protect the femoral neck?

BACKGROUND

Intramedullary nailing is the accepted form of treatment for impending or pathologic fractures of the femoral diaphysis. Traditional teaching promotes the use of a cephalomedullary nail so that stabilization is provided for the femoral neck in the event that a future femoral neck metastasis develops. However, that approach may add cost, surgical time, blood loss, and added radiation exposure to staff members, and there is limited evidence in the literature that supports this practice.

QUESTIONS/PURPOSES

The purpose of our study was to evaluate the incidence of femoral neck metastases in patients who underwent femoral nailing of diaphyseal metastases.

PATIENTS AND METHODS

Retrospective analysis of our Musculoskeletal Oncology database identified 145 femoral nailings performed for metastatic disease, myeloma, or lymphoma of the femoral diaphysis between 2001 and 2011. Average patient age was 59 years. One hundred forty-one patients underwent 145 femoral nailings (four were bilateral). One hundred forty-four of the nails used were cephalomedullary implants and one was a flexible nail. Thirty-six (25%) femurs had sustained a pathologic fracture and 109 (75%) femurs were treated as impending fractures. Eighty-four patients received either preoperative or postoperative radiation therapy. Average radiographic followup was 13 months and average postoperative survival was 16 months. Of the 141 patients in this series, 121 (86%) are known to have died at a median of 9 months (range, 0.1-133 months) after surgery. The latest followup radiographs were obtained at a median of 5 months after the femoral nailing (range, 0-119 months). Of the 90 patients with documented dates of death and radiographic followup greater than zero months, 76 (84%) had radiographs available within a year of death. Thirty-one patients had zero months radiographic followup. The median survival for this group of patients was only 0.9 months (range, 0.1-12 months).

RESULTS

No patients (0%) in this series had femoral neck metastases develop postoperatively.

CONCLUSION

Despite traditional teaching that supports the use of cephalomedullary implants when treating metastatic disease of the femur, we were unable to identify a single patient who had femoral neck metastasis after surgery on the femur. Our findings do not support the use of cephalomedullary implants in this patient population for the sole purpose of prophylactic femoral neck stabilization; however, this series was relatively small, and the experiences of other centers will be needed to come to a more-complete sense of the frequency of what in all likelihood is a rare event.

Surgical management of bone metastases: quality of evidence and systematic review

BACKGROUND

Surgical management of metastatic bone disease (MBD) is typically reserved for lesions with the highest risk of fracture. However, the high risk of perioperative complications associated with surgery may outweigh the benefits of improved pain and/or function. The goal of this study was to (1) assess the quality of current evidence in this domain; (2) confirm that surgical management of metastases to the long bones and pelvis/acetabulum provides pain relief and improved function; and (3) assess perioperative morbidity and mortality rates.

METHODS

We conducted a systematic review of the literature for clinical studies that reported pain relief and function outcomes, as well as perioperative complications and mortality, in patients with MBD to the long bones and/or pelvis/acetabulum treated surgically. Multiple databases were searched up to January 2012. Pooled weighted proportions are reported.

RESULTS

Forty-five studies were included in the final analysis, with 807 patients. All included studies were level IV with 'moderate' overall quality of evidence using the Methodological Index for Non-Randomized Studies scale. Pain relief following surgical management of metastases was 93, 91, and 93 % in the humerus, femur, and pelvis/acetabulum, respectively. Maintained or improved function after surgery was seen in 94, 89, and 94 % in the humerus, femur, and pelvis/acetabulum, respectively. Perioperative complications and mortality were 17 and 4 %, respectively.

CONCLUSIONS

Despite the inherent limitations of the current evidence, a benefit for the surgical management of bone metastases to the long bones and pelvis/acetabulum is evident; however, there is still substantial risk of perioperative morbidity and mortality that should be considered.

Intramedullary nailing for treatment of pathologic femoral fractures due to metastases

Pathologic fractures of the femur because of bone metastases seriously affect the quality of life of cancer patients. Different surgical options are indicated to achieve a durable and solid fixation, depending on several clinical, prognostic and mechanical factors. Locked intramedullary nailing is currently used to treat pathologic femoral fractures in patients with multiple metastases when the trochanteric region or shaft is mainly involved. This study evaluates intramedullary nailing for treatment of patients with pathologic femoral fractures, focussing on complications, clinical and functional outcomes and survival rates. The series included 80 pathologic fractures treated with a titanium alloy Proximal Nail (Standard or Antirotation) or Lateral Anterograde Femoral Nail (PFN, PFNA or LAFN, Synthes) inserted in a locked static mode. Acrylic cement was used to fill the bone cavity after nail insertion in eight patients; percutaneous cementoplasty was simultaneously performed in 11 cases of severe ipsilateral acetabular osteolysis. Postoperative outcomes focussed on pain relief, postoperative mobility and quality of life and they were analysed retrospectively using QOL-ACD and ECOG. Eleven patients (13.75%) suffered from non-fatal DVT post-surgery, with no pulmonary embolism. Six patients (7.5%) developed superficial wound infections and two patients (2.5%) developed pnaeumonia. There was no loss of reduction, breakage, screw pull out, or hardware or implant failure that required component substitution or revision. Lung histotype and the contemporary presence of cerebral and visceral metastases appeared to be predisposing factors in reducing survival time. All patients attained satisfactory pain relief, early deambulation and a marked clinical improvement during the first 6-10 postoperative months, with gradual worsening thereafter from deterioration of their general condition due to cancer progression. The patients' survival rate was 40% at 1 year, 25% at 2 years and 15% at 3 years. Results confirm that multiple factors related to patients and primary cancer may affect survival rate after femoral fracture. Intramedullary nailing should be indicated for pathologic fractures at femoral diaphysis and metaphysis when cancer is in an advanced stage. This procedure offers good and durable stability, and enables pain relief, early postoperative mobilisation and weight-bearing, thus improving the quality of life of cancer patients.

Fixation of pathological humeral fractures by the cemented plate technique

Pathological fractures of the humerus are associated with pain, morbidity, loss of function and a diminished quality of life. We report our experience of stabilising these fractures using polymethylmethacrylate and non-locking plates. We undertook a retrospective review over 20 years of patients treated at a tertiary musculoskeletal oncology centre. Those who had undergone surgery for an impending or completed pathological humeral fracture with a diagnosis of metastatic disease or myeloma were identified from our database. There were 63 patients (43 men, 20 women) in the series with a mean age of 63 years (39 to 87). All had undergone intralesional curettage of the tumour followed by fixation with intramedullary polymethylmethacrylate and plating. Complications occurred in 14 patients (22.2%) and seven (11.1%) required re-operation. At the latest follow-up, 47 patients (74.6%) were deceased and 16 (25.4%) were living with a mean follow-up of 75 months (1 to 184). A total of 54 (86%) patients had no or mild pain and 50 (80%) required no or minimal assistance with activities of daily living. Of the 16 living patients none had pain and all could perform activities of daily living without assistance. Intralesional resection of the tumour, filling of the cavity with cement, and plate stabilisation of the pathological fracture gives immediate rigidity and allows an early return of function without the need for bony union. The patient's local disease burden is reduced, which may alleviate tumour-related pain and slow the progression of the disease. The cemented-plate technique provides a reliable option for the treatment of pathological fractures of the humerus.

Novel venting technique for intramedullary rod fixation of pathologic fractures

This article introduces a novel technique to vent the femur and potentially decrease the embolic load created by reaming during intramedullary rod fixation of impending pathologic femur fractures. We used readily available operating room equipment to create a distal femoral vent hole without interfering with standard intramedullary instrumentation and with minimal increase in surgical time. This technique can be used for the prophylactic intramedullary stabilization of impending pathologic femur fractures from metabolic bone disease, metastatic cancer, and bisphosphonate use.

Intramedullary nails for long bone metastases: why do they fail?

Metastatic disease to long bones is common and often requires stabilization to treat or prevent fracture. Intramedullary fixation is used in many metaphyseal and diaphyseal lesions. The goal of this study was to investigate the causes of and risk factors for reconstructive failure in intramedullary fixation of metastatic disease. We performed a retrospective review of 112 consecutive reconstructions for metastatic disease treated with an isolated intramedullary nail. There were 81 reconstructions in the femur, 25 in the humerus, and 6 in the tibia. All included patients were followed until death or reconstructive failure. All surviving patients had a minimum 2-year follow-up.Ten failures required construct revision. Median time to revision was 17.9 months (range, 3-93 months). The causes of failure included surgeon error, tumor progression, nonunion, and hardware failure. Patients with short survival times (P<.001) or a diagnosis of lung cancer (P=.029) were unlikely to fail. Revision was required in 6 solitary lesions (P=.012), 3 cases of lymphoma (P=.002), 3 cases of progressive renal cell carcinoma (P=.040), and 2 radiation-associated fractures (P=.007).Intramedullary stabilization is a successful operation for appropriate lesions. Failures may be minimized with proper implant selection and surgical technique, resection or curettage of renal cell carcinoma, avoidance of radiation-associated fractures, and overestimating patient survival.

Compound osteosynthesis for osteolyses and pathological fractures of the proximal femur

Due to improved oncological therapeutic procedures with longer survival times, the stabilization of osteolyses and pathological fractures is gaining importance. The proximal femur is often affected by metastases. As femoral stability can be compromised by such bone lesions, stabilization as a palliative measure is indicated to restore function and relieve pain. Besides intramedullary osteosynthesis and endoprosthetic reconstruction, compound osteosynthesis is an alternative method for stabilization of the proximal femur. Between 1994 and 2004, 34 compound osteosyntheses were performed for a tumor-caused lesion compromising mechanical stability of the proximal femur. Of those cases, 22 double-plate compound osteosyntheses and 12 single-plate compound osteosyntheses were performed for 9 pathological fractures and 25 osteolyses. Both techniques provided good primary stability. The average survival time after compound osteosynthesis was 14.2 months (range, 0-72 months). Double-plate compound osteosyntheses showed a lower mechanical failure rate than single-plate compound osteosyntheses (14.3% vs 33.3%) and a higher survival probability after 5 years (76.4% vs 38.6%). No surgical revision was required due to perioperative complications in any case. We conclude that reliable stabilization of extensive osteolyses and pathological fractures of the proximal femur can be achieved with compound osteosynthesis. Our data suggest that double-plate compound osteosyntheses is a more favorable technique than single-plate compound osteosyntheses based on a lower rate of mechanical failure and higher survival probability.

Metastatic malignant melanoma of the conjunctiva: a case report

Background

Malignant melanoma of the conjunctiva is an extremely rare non-cutaneous neoplasm with infrequent skeletal metastatic spread.

Case presentation

We present the case of a 54 year old female Caucasian patient with osseous metastases originating from a malignant melanoma of her right conjunctiva. Metastatic deposits were identified in the left humeral diaphysis and left tibial metaphysis. Clinical, radiological and scintigraphic evaluation necessitated prompt stabilisation of both long bones. Following reamed intramedullary nailing and post-operative radiotherapy she remains asymptomatic six months post-operatively.

Conclusion

This unusual pattern of metastatic spread to the appendicular skeleton of an extremely rare melanomatous lesion requires diagnostic vigilance as well as a multidisciplinary approach for accurate diagnosis, staging and management. Due to the poor prognosis, treatment goals should be directed to palliation of symptoms and prolongation of the quality of life.

Prophylactic stabilization of proximal femoral metastatic bone disease: reconstruction intramedullary nail fracture

Pathological fracture is an unfortunate manifestation of metastatic bone disease and whenever possible, prophylactic stabilization is preferable to fixation of fracture. The Russell-Taylor reconstruction intramedullary nail (Smith & Nephew Richards, Inc., Memphis, Tennessee) provides a stable construct for the prophylactic management of impending pathological fracture. Implant failure with this system typically involves distal locking screws. Cases of proximal screw cut-out and pullout have been reported as has breakage of both proximal locking screws. We present a case of failure of the Russell-Taylor delta reconstruction nail implant, just distal to the point of insertion of the proximal locking screws.

Surgery for metastatic lesions of the femur: good outcome after 245 operations in 216 patients

We report our experience with surgery for femoral metastatic lesions, based on 216 patients who underwent a total of 245 operations for femoral metastatic lesions. The median age was 66 (30-94) years, and the most common diagnosis breast cancer, followed by prostate cancer. All patients had pain on weight bearing, 196 had pain at rest, 147 were unable to walk preoperatively, and 148 were confined to a health-care facility. The patients were operated with bipolar hip prosthesis (n=7), total hip replacement (THR) with Harrington reconstruction of the acetabulum (n=42), ordinary THR (n=108), intramedullary nailing (n=55), and other techniques (n=33). All patients improved as regards pain at rest, pain on weight bearing, walking ability and social independence. The median survival for the 216 patients was 6 (0-123) months. All in all, 47 operations were followed by complications of any kind, where dislocations of hip prostheses and implant breakdown were the commonest, but pulmonary embolism the most serious. Patients with femoral metastatic lesions can be operated safely and with acceptable complication rates. Furthermore, large and long-standing gains as regards pain control and mobility can be expected.

Intramedullary nailing for pathological femoral fractures

PURPOSE

To evaluate whether the operating time correlates with the survival and outcome in patients who underwent intramedullary nailing for metastatic femoral fractures.

METHODS

Records of 10 men and 11 women aged 43 to 86 (mean, 66) years who underwent intramedullary nailing (4 bilaterally) for metastatic femoral fractures between 1999 and 2003 were reviewed. The patients were followed up for at least 2 years or until their death. The main outcome measure was the correlation between operating time and survival. Operating time was categorised into 5 groups from 60 to 210 minutes, with 30-minute increments.

RESULTS

Operating time does not correlate with survival and outcome. The mean survival period was 9.4 months. Pain relief was achieved in 90% of the patients. There was no implant failure, but one loss of reduction.

CONCLUSION

Intramedullary nailing appears safe and effective for treatment of metastatic bone disease, and confers good functional results, pain relief, and mobility.

Clinical evaluation of a true percutaneous technique for antegrade femoral nailing

From July 1997 to March 2001, 209 consecutive patients with 215 femoral shaft fractures amenable to antegrade femoral nailing were enrolled. A true percutaneous insertion technique was performed using a stab wound incision. One hundred ninety-seven (92%) fractures achieved primary union with anatomic or near anatomic alignment. Eighteen (8%) healing problems and two deep infections (1%) responded to repeat interventions. There was one iatrogenic complication related to an anterior starting point. External blood loss was minimal (generally <100 cc). Incisions averaged 16 mm and healed uneventfully. At one-year follow-up only 10% of patients had hip abductor pain. The percutaneous technique appears to be a safe and effective alternative to the standard technique. Hip pain at one year appears decreased compared to reports using a traditional approach.

Breast cancer bone metastasis in femur: surgical considerations and reconstruction with Long Gamma Nail

AIM

The femur is the most common long bone involved in metastatic breast cancer. Several studies have been published on the surgical management of metastatic disease of the femur. However, only few studies have been published specifically on the outcomes following reconstruction of femoral metastasis from breast cancer using a third generation intramedullary nail. The aim of this study is to review the outcomes after intramedullary surgical stabilization of femoral metastases from breast cancer. This is often associated with significant bone destruction.

METHODS

A retrospective study of 18 femoral metastatic lesions in 15 patients treated with a Long Gamma Nail over a 6-year period was carried out. Pain relief, mobilization status and implant related complications were the main outcome measures analyzed.

RESULTS

Thirteen out of 15 patients had complete pain relief and all patients regained their preoperative mobilization status with or without walking aids. There were no implant failures or perioperative deaths. Four (26%) patients developed minor complications. Ten patients died with an average survival of 9 months and five patients are alive with an average survival of 32 months.

CONCLUSION

Stabilization of femoral metastases due to breast cancer with Long Gamma Nail is a safe and effective method with acceptable risks.

Pressurization of the Metastatic Femur During Prophylactic Intramedullary Nail Fixation

BACKGROUND

Venting during prophylactic nailing of metastatic femoral lesions may decrease intramedullary pressures and the risk of fat and tumor embolization. This study aimed to quantify maximum intramedullary pressure levels and durations, and to examine tumor displacement during prophylactic reamed intramedullary nailing of vented and nonvented metastatically involved femora.

METHODS

Proximal metastatic defects were simulated in six pairs of cadaveric femora and prophylactically treated using reamed intramedullary nailing with or without proximal and distal vents. Maximum pressures, durations of pressure exceeding embolic threshold levels (25 and 200 mm Hg), and tumor displacement were recorded.

RESULTS

Maximum pressures and durations of pressure exceeding embolic thresholds decreased more than 50% with venting (p < 0.05). Distal pressures surpassed the 25-mm Hg threshold even with venting. Post-test sectioning showed increased tumor disbursement in vented specimens.

CONCLUSIONS

Venting reduces pressurization during prophylactic reamed intramedullary nailing of femoral metastases, but may increase the spread of tumor to extraskeletal tissue if vented tissue is not contained.

Retrograde removal of an incarcerated solid titanium femoral nail after subtrochanteric fracture

Intramedullary nailing with a solid titanium nail can result in significant bone ingrowth. Failure of an implant requires removal for replacement with another device. Previous methods have included use of extractors for cannulated nails. When extractors are not available or are inadequate, a simple retrograde push-out method can be used as described here.

Subtrochanteric metastatic lesions treated with the long gamma nail

From 1996 to 2002, 39 consecutive intramedullary reconstructions (three bilateral) in 36 patients were performed in a group of subtrochanteric femoral metastatic bone disease using the long gamma nail (LGN). Reconstruction was performed prophylactically in 28 femurs and, for actual fractures in 11. All patients achieved good functional results with pain relief and improved mobility. No major intraoperative complication or long-term mechanical failures were observed. Minor technical, medical and implant related complications were seen in 14 patients. The LGN is a valuable intramedullary reconstruction device with good functional outcome for the treatment of subtrochanteric femoral metastatic bone disease.

Biomechanical analysis of humeral diaphyseal segmental defect fixation

With disseminated malignancies, segmental defects of the humeral diaphysis may occur from surgical resection or as a complication of failed prior internal fixation. This study directly compared the biomechanical properties of a second generation titanium modular intercalary humeral spacer (segmental defect replacement prosthesis) with those of a modern locked humeral nail combined with methylmethacrylate (intramedullary nail) or with an intercalary allograft spacer (allograft nail composite) for fixation of segmental defects of the humeral diaphysis. Eighteen matched pairs (36 specimens) of fresh-frozen humeri were prepared in a standard fashion to create a 5-cm middiaphyseal defect and were divided randomly into three groups of 12 specimens each, using three different reconstructive methods. Specimens were tested in external torsion to failure on a Materials Testing System machine. The segmental defect replacement specimens had statistically greater peak torque (mean, 41.4 N-m) and stiffness (mean, 2.1 N-m/ degrees) than the intramedullary nail specimens (mean peak torque, 23.1 N-m) (mean stiffness, 1.6 N-m/ degrees) or the allograft nail composite specimens (mean peak torque, 12.4 N-m) (mean stiffness, 0.6 N-m/ degrees). The intramedullary nail specimens also had a statistically greater peak torque at failure and stiffness than the allograft nail composite specimens. For segmental defects of the humeral diaphysis, reconstruction with a cemented metallic intercalary spacer provides significantly greater immediate stability than interlocked intramedullary nail fixation supplemented with segmental methylmethacrylate or intercalary allograft reconstruction.

The treatment of impending and existing pathological femoral fractures using the long gamma nail

The subtrochanteric region of the femur accounts for one-third of all pathological fractures requiring surgical intervention. The large forces occurring in this region and the possible non-occurrence of bony consolidation constitute a difficult problem to the trauma surgeon. The medical records and X-rays of 25 consecutive patients treated with the long gamma nail (LGN) for pathological (impending or existing) fractures of the femur were analysed retrospectively. Our results in the use of the LGN for pathological fractures of the femur have been good. We recommend an aggressive approach to the early stabilisation of impending fractures and the use of distal locking.

Impending or completed pathologic femur fractures treated with intramedullary hip screws

This study examined the use of the long intramedullary hip screw in 13 consecutive patients with metastatic disease of the femur with impending or completed fractures. There were 6 impending and 7 completed fractures. Eleven of 13 patients had unreamed rods placed with an average operative time of 100 minutes and blood loss of 280 cc. Eleven of 12 patients who were able to ambulate preoperatively regained that status postoperatively. Postoperative complications included death (1), myocardial infarction (1), and urinary tract infection (2). These results indicate the long intramedullary hip screw is a safe and effective surgical device for treating metastatic disease of the femur.

Femoral nailing for metastatic disease of the femur: a comparison of reamed and unreamed femoral nailing

A total of 73 consecutive intramedullary femoral nails were inserted for metastatic disease of the femur; 43 were reamed and 30 were solid nails. The two groups were similar with regards to age, type of primary tumour, anatomical site, acute or 'impending' fracture and postoperative survival. The 'solid' nail offers a satisfactory alternative form of stabilisation for metastatic disease of the femur with rates of implant failure which are comparable with the reamed nail. In this series bilateral nailing was not associated with any increase in mortality. Contrary to other reports, imposing a delay in patients with pain and a short life expectancy seems unjustified. The use of the 'solid' femoral nail does not prevent sudden death due to massive fat embolism.

Multiple operations in patients with bony metastases and a prolonged course of disease

A retrospective study of 19 patients suffering from bone metastases with a survival time of more than 24 months, and having undergone at least three operations, is reported. Fourteen patients had to have multiple surgery because of local recurrences after internal fixation supported by bone cement (n = 12) or tumour resection alone (n = 2). Only five of 19 patients had several operations because of multiple-site bony metastases without any unnecessary surgery as a result of failed local tumour control with recurrences. A complete and extralesional resection of solitary bone metastases with a potentially poor response to radiotherapy, such as hypernephroma, could help to avoid additional surgery in patients with a shortened life expectancy.

Treatment of pathological fractures of the humeral shaft due to bone metastases: a comparison of intramedullary locking nail and plate osteosynthesis with adjunctive bone cement

In a retrospective study 37 patients were surgically treated for 38 fractures (27 actual and 11 impending) caused by metastatic lesions of the humerus shaft. A comparison between plate osteosynthesis with bone cement (20 cases) and intramedullary nailing (18 cases) was made. There was no mortality related to the surgical procedure. The patients' survival rate was 61% after 3 months and 44% after 6 months; six were alive after 1 year. Overall, a subjective and objective relief of pain was achieved in 92% and 79%, respectively. Restoration of arm function was improved in 95%. The operative course was complicated in six patients after plate osteosynthesis (three local and three systemic complications) and in four patients after intramedullary nailing (one local and three systemic complications). Fixation failed in four patients, instability developed twice after intramedullary fixation without bipolar static locking. No significant difference in survival rate, pain relief, restoration of function and complications were associated with methods of treatment, or with operation of actual or impending pathological fractures. Despite the poor life expectancy our results indicate that intramedullary nailing with bipolar static locking and post-operative irradiation or plate osteosynthesis with bone cement for treatment of pathological (impending) fractures of the humerus shaft are safe ways to restore arm function and improve quality of life.

Pathological fractures of the proximal femur treated with the Variwall reconstruction nail

Ten patients with pathological proximal femoral fractures were treated with the Variwall reconstruction nail. There were five intertrochanteric, one combined shaft and neck, and four subtrochanteric fractures fixed by this method. The mean age was 71 (54-90). The purpose of this study was to assess the use of a reconstruction nail in pathological fractures around the intertrochanteric region. The Variwall nail was found to be relatively easy to insert with no operative complications. Follow up was for a minimum 4 months. Most patients achieved our aim of good pain relief coupled with improved mobility and thus were easier to nurse. Even with extensive metastases in the femur, the nail provided sound stability to permit early weight bearing. There were no complications related to the nail.