Cardiac arrest during intramedullary nailing for femoral metastases

157

161

Background The proximal femur is the most common site of surgery for bone metastases, and stabilization may be achieved through intramedullary fixation (IMN) or endoprosthetic reconstruction (EPR). Intramedullary devices are less expensive, less invasive, and may yield improved function over endoprostheses. However, it is unclear which, if either, has any advantages. Questions/purposes We determined whether function, complications, and survivorship differed between the two approaches. Methods We retrospectively reviewed 158 patients with 159 proximal femur metastatic lesions treated with surgical stabilization. Forty-six were stabilized with IMN and 113 were treated with EPR. The minimum followup was 0.25 months (mean, 16 months; median, 17 months; range, 0.25-86 months). Results The mean Musculoskeletal Tumor Society score was 24 of 30 (80%) after IMN and 21 of 30 (70%) after EPR. There were 12 complications (26%) in the IMN group, including 10 nonunions, six of which went on to mechanical failure. There were complications in 20 of 113 (18%) of the EPR group, which consisted of 10 dislocations (9%) and 10 infections (9%). There were no mechanical failures with EPR. Both implants remained functional for the limited lifespan of these patients in each group at all time intervals. EPRs were associated with increased implant longevity compared with IMNs (100% versus 85% 5-year survival, respectively) and a decreased rate of mechanical failure (0% versus 11%, respectively) when compared with the intramedullary devices. Conclusions Patients with metastatic disease to the proximal femur may live for long periods of time, and these patients may undergo stabilization with either IMN or EPR with comparable functional scores and the implant survivorship exceeding patient survivorship at all time intervals. Endoprostheses demonstrate a lower mechanical failure rate and a higher rate of implant survivorship without mechanical failure than IMN devices.

Section: Discussionsupporting

confidence: 43%

“…The MSTS functional scores were similar (p = [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27], respectively.…”

Section: Resultsmentioning

confidence: 99%

Endoprostheses Last Longer Than Intramedullary Devices in Proximal Femur Metastases

Harvey

Ahlmann

Allison

et al. 2012

157

161

“…As these patients are subject to a higher volume of fat and tumor emboli, the risk of pulmonary compromise and mortality theoretically would be correspondingly greater. The risk is believed to be so great that some authors advocate avoiding simultaneous nailing and recommend a staged approach especially for impending fractures [3,[7][8][9][10].…”

Section: Introductionmentioning

confidence: 99%

Simultaneous Nailing of Skeletal Metastases: Is the Mortality Really that High?

Moon

Lin

Satcher

et al. 2011

Introduction The risk of death during simultaneous nailing of pathologic and impending fractures in patients with metastatic disease is believed to be so high that some authors have advocated a staged approach, especially for impending fractures. However, there are limited data to either support or refute the appropriateness of staging of multiple impending or pathologic fractures. Questions/purposes We therefore determined the rate of pulmonary mortality and morbidity in patients who underwent simultaneous nailing for metastatic disease of the skeleton. Methods We retrospectively reviewed 16 patients who underwent simultaneous intramedullary nailing of impending or pathologic fractures between 1993 and 2009. There were 10 men and six women with a mean age of 60 years (range, 40-78 years). The intramedullary nailings included 15 femurs, 17 humeri, and one tibia. Thirty-one nails were reamed and two were unreamed.

“…It has long been stated that the whole bone should be protected, although there is unease regarding the cardiopulmonary risks of prophylactic intramedullary fixation [2,4,5].We believe the article raises some important points that the main feature was not required to emphasize.We previously reported on two patients who had new metastases develop at the tip of an intramedullary nail. The nail subsequently fractured, resulting in complex revision surgery [3].…”

mentioning

confidence: 96%

“…It has long been stated that the whole bone should be protected, although there is unease regarding the cardiopulmonary risks of prophylactic intramedullary fixation [2,4,5].…”

mentioning

confidence: 99%

Letter to the Editor: Prophylactic Stabilization For Bone Metastases, Myeloma, or Lymphoma: Do We Need to Protect the Entire Bone?

Ashford

Esler

2013

We read the article by Alvi and Damron regarding the need for prophylactic stabilization of the whole bone in bone metastases, myeloma and lymphoma [1] with interest. It has long been stated that the whole bone should be protected, although there is unease regarding the cardiopulmonary risks of prophylactic intramedullary fixation [2,4,5].We believe the article raises some important points that the main feature was not required to emphasize.We previously reported on two patients who had new metastases develop at the tip of an intramedullary nail. The nail subsequently fractured, resulting in complex revision surgery [3]. These would represent Type 3 lesions in the classification by Alvi and Damron.We believe there are two points that require additional emphasis. First, the article only briefly mentioned the role of radiotherapy. We strongly believe that patients with a tumor not removed en bloc should have radiotherapy, especially in radiosensitive tumors such as lymphoma and myeloma. Preoperative irradiation of a lesion is sufficient, unless there is clear evidence that the tumor is growing despite radiotherapy. If the radiotherapy is postoperative, the whole bone should be irradiated, as there would be seeding throughout the medullary cavity.Second, an orthopaedic surgeon followed up clinically and radiographically all patients, enabling detection of disease progression or impending implant failure. This allowed for early intervention, which hopefully reduces morbidity. This approach is essential to the management of metastatic lesions, although it often is neglected.We congratulate Alvi and Damron on their thoughtprovoking paper.