title: Intramedullary nailing for treatment of pathologic femoral fractures due to metastases.
abstract: 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.
authors.affiliation: Unit of Orthopedic Oncology, University La Sapienza, Rome, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Piccioli
authors.affiliation: Department of Orthopedics, Catholic University, Rome, Italy. Electronic address: barbararossi82@yahoo.it.
authors.forename: Barbara
authors.initials: B
authors.lastname: Rossi
authors.affiliation: Unit of Spinal Surgery, Orthopedic Institute Galeazzi, Milan, Italy.
authors.forename: Laura
authors.initials: L
authors.lastname: Scaramuzzo
authors.affiliation: Department of Orthopedics, Catholic University, Rome, Italy.
authors.forename: Maria Silvia
authors.initials: MS
authors.lastname: Spinelli
authors.affiliation: Department of Orthopedics, Tumor Hospital of Yunnan Province, Kunming Medical University, Yunnan, China.
authors.forename: Zuozhang
authors.initials: Z
authors.lastname: Yang
authors.affiliation: Department of Orthopedics, Catholic University, Rome, Italy.
authors.forename: Giulio
authors.initials: G
authors.lastname: Maccauro
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001843:Bone Cements / Q000627:therapeutic use*; D001858:Bone Nails; D005260:Female; D005264:Femoral Fractures / Q000209:etiology / Q000473:pathology / Q000601:surgery*; D005594:Fracture Fixation, Intramedullary; D017102:Fracture Healing; D005598:Fractures, Spontaneous / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008124:Locomotion; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000150:complications / Q000473:pathology*; D010147:Pain Measurement; D011379:Prognosis; D011788:Quality of Life; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D015996:Survival Rate; D016896:Treatment Outcome; D016474:Weight-Bearing
chemical_list: D001843:Bone Cements
keywords: Femur; Intramedullary nailing; Metastases; Pathologic fractures; Prognostic factors