title: Simultaneous nailing of skeletal metastases: is the mortality really that high?
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  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.
  
  
  RESULTS
  Three of 16 patients died before discharge; two of these deaths were presumed to be the direct result of acute pulmonary complications related to simultaneous nailing and one was intraoperative. For the 13 patients who survived after discharge, there were three pulmonary complications. There were no intraoperative or perioperative deaths in the prophylactic nailing group.
  
  
  CONCLUSIONS
  Simultaneous nailing of impending and pathologic fractures can be performed with lower mortality rates than previously reported. Patients with impending fractures did not appear to be at higher risk than patients with pathologic fractures.
  
  
  METHODS
  Level IV, therapeutic study. See the Guidelines for Authors for a complete description of level of evidence.
authors.affiliation: Department of Orthopaedic Oncology, MD Anderson Cancer Center, PO Box 301402, Houston, TX 77230-1402, USA. bsmoon@mdanderson.org
authors.forename: Bryan
authors.initials: B
authors.lastname: Moon
authors.forename: Patrick
authors.initials: P
authors.lastname: Lin
authors.forename: Robert
authors.initials: R
authors.lastname: Satcher
authors.forename: Valerae
authors.initials: V
authors.lastname: Lewis
mesh_terms: D000328:Adult; D000368:Aged; D001859:Bone Neoplasms / Q000453:epidemiology / Q000401:mortality / Q000556:secondary* / Q000601:surgery*; D015897:Comorbidity; D005260:Female; D005264:Femoral Fractures / Q000601:surgery*; D005594:Fracture Fixation, Intramedullary / Q000009:adverse effects; D005598:Fractures, Spontaneous / Q000453:epidemiology / Q000601:surgery*; D006801:Humans; D006810:Humeral Fractures / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures; D011655:Pulmonary Embolism / Q000453:epidemiology; D012189:Retrospective Studies; D013978:Tibial Fractures / Q000601:surgery