Unreamed intramedullary nailing for minimal invasive palliative stabilization of pathological fractures and osteolyses in long bones

The life expectancy of patients with malignant tumours and the incidence of osseous metastases have increased over the last decades. Operations for skeletal metastases of the extremities represent the most frequent surgery in orthopaedic oncology. The purpose of this study was to evaluate and compare the different operative treatment options for patients with pathologic fractures of the humerus and femur in terms of complications, postoperative recovery, and survival.From 2000 to 2005, 109 patients were surgically treated for pathologic fractures of the humerus (n=19) or femur (n=90). The study group consisted of 60 women and 43 men, with a mean age of 67 years (13-88). Breast carcinoma (36%) was the most common primary tumour, followed by kidney (17%) and bronchial (16%) carcinoma. Of all patients, 75 (73%) had numerous skeletal metastases, and 38 (37%) had visceral metastases.Wide or marginal resection was performed in seven fractures of the humerus and 14 fractures of the femur; intralesional resection was done in seven humeral and 73 femoral fractures; and stabilisation alone was done in five fractures of the humerus and three fractures of the femur. The median survival time for all patients was 6 months (0-102). The survival rate at 1 year was 25% (25% for both humeral and femoral fractures), 15% at 2 years (17% for humeral and 15% for femoral fractures), and 8% at 3 years (16% for humeral and 7% for femoral fractures). The overall complication rate was 11%, and revision surgeries were performed in seven patients (6.4%). The majority of patients (n=65; 60%), especially those with fractures close to the articular joint, were successfully treated with endoprosthetic replacement. Patients with fractures stabilised by intramedullary nails had shorter operating times, a shorter hospital stay, and fewer complications than patients treated with plating systems. Therefore, we recommend intralesional resection of the metastasis and stabilisation with intramedullary devices, supported by bone cement, as the treatment of choice for pathologic fractures of the diaphysis and metaphysis of the humerus and femur. Wide resection should be reserved for selected cases, such as solitary bone metastasis of kidney carcinoma.

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