Venting during prophylactic nailing for femoral metastases: current orthopedic practice.
BACKGROUND
Reamed intramedullary nailing, recommended for impending fracture of a femur weakened by bone metastases, causes a rise in intramedullary pressure and increases the risk of a fat embolism syndrome. The pressure can be equalized by the technique of venting--drilling a hole into the distal cortex of the femur. Our objective was to study the current practice of orthopedic surgeons in Ontario with respect to venting during prophylactic intramedullary nailing for an impending femoral fracture due to bone metastases.


METHODS
We mailed a questionnaire to all orthopedic surgeons from the Province of Ontario listed in the 1999 Canadian Medical Directory or on the Canadian Orthopaedic Association membership list, asking if they vent when prophylactically nailing an impending pathologic femoral fracture. The responses were modelled as a function of surgeon volume and year of graduation.


RESULTS
Of the 415 surveys mailed, 223 (54%) surgeons responded. Of these, 81% reported having prophylactically treated a femoral metastatic lesion during the previous year; 67% treated 1 to 3 metastatic lesions and 14% treated more than 3; 19% did not treat a metastatic femoral lesion prophylactically. Over two-thirds of surgeons had never considered venting, whereas one-third always or sometimes vented the femoral canal. More recent graduates were 3 times more likely to vent than earlier (before 1980) graduates (odds ratio [OR] = 3.2, 95% confidence interval [CI] 1.6-6.5) as were those who treat a greater number of impending fractures (OR = 1.4, 95% CI 1.1-1.7).


CONCLUSIONS
Although there is a theoretical rationale for routine venting, there is disagreement among Ontario orthopedic surgeons regarding the use of this technique during prophylactic nailing for femoral metastatic lesions. Prospective evidence will be required to warrant a change in the standard of care.
Dalgorf
Dustin
D
University of Toronto, Division of Orthopaedics, Sunnybrook & Women's College Health Sciences Centre, Toronto, Ont.
Borkhoff
Cornelia M
CM
Stephen
David J G
DJ
Finkelstein
Joel
J
Kreder
Hans J
HJ
D001291:Attitude of Health Personnel; D004620:Embolism, Fat / Q000209:etiology / Q000517:prevention & control*; D019317:Evidence-Based Medicine; D005264:Femoral Fractures / Q000209:etiology / Q000517:prevention & control*; D005266:Femoral Neoplasms / Q000150:complications / Q000556:secondary / Q000601:surgery*; D005594:Fracture Fixation, Intramedullary / Q000009:adverse effects / Q000379:methods* / Q000706:statistics & numerical data; D005598:Fractures, Spontaneous / Q000209:etiology / Q000517:prevention & control*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D016015:Logistic Models; D009864:Ontario; D009985:Orthopedics / Q000193:education / Q000379:methods / Q000706:statistics & numerical data; D010027:Osteotomy / Q000379:methods* / Q000706:statistics & numerical data; D010820:Physicians / Q000523:psychology; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011312:Pressure; D012307:Risk Factors; D011795:Surveys and Questionnaires