Retrospective review finds similar risks in single and multiple nailings

In patients with metastatic skeletal lesions, many surgeons are hesitant to perform simultaneous nailing of multiple pathologic and impending fractures. This caution is primarily related to the risk of pulmonary compromise and mortality due to fat and tumor emboli generated during nailing. The belief that this risk would be greater when multiple sites are nailed has led some authors to advise against simultaneous nailing and to promote a staged approach, especially for impending fractures.

A study presented at the 2010 annual meeting of the Musculoskeletal Tumor Society suggests that these concerns may be overstated and that nailing of multiple fractures in appropriately selected patients may be performed safely.

According to Bryan S. Moon, MD, who presented the results, recommendations against multiple nailing “are supported by many and intuitively seem sound, but very little data actually exist to support the staging of stabilization of multiple impending or pathologic fractures.”

The retrospective review examined the medical charts of 16 patients (10 men and 6 women) who underwent simultaneous intramedullary nailing of various impending or pathologic fractures over a 17-year period for the occurrence of perioperative mortality and signs or symptoms of pulmonary compromise (Table 1). Patients had a mean age of 60 years (range 40–78).

Results
Of the three patients who died prior to discharge, two—including one who died intraoperatively—had acute pulmonary complications related to the simultaneous nailing procedures. The patients who died had a mean postoperative survival rate of 13.6 days (range 0–26).

Three of the 13 patients who survived beyond discharge experienced pulmonary complications. Eleven patients had documented dates of death; the mean postoperative survival time for patients who were discharged home was 43.8 weeks (range 2–271 weeks).

None of the five patients who were treated for impending fractures was among the intraoperative or perioperative deaths. One of these patients had impending fractures of both femurs; the remaining four had impending fractures of the humerus and femur.

Data vs. intuition
In reviewing the literature, the authors found that the many reports cautioning against simultaneous nailing of metastatic lesions are “based upon a relatively small number of patients who were typically intermingled with reports of single nailing. From these few scattered reports the recommendation for performing multiple nailings in a staged fashion and the use of unreamed nails has developed.”

Although an intuitive expectation would be that patients with more advanced disease would be less medically fit than those requiring only a single nailing, the 18.7 percent perioperative mortality rate in this series, while seemingly high, “is in keeping with the perioperative mortality rate reported in other series that were predominately single nailings,” wrote the authors. Rates in those series range from zero to 17 percent.

Furthermore, because perioperative deaths can result from “a multitude of causes,” the authors state that the intraoperative death rate may be a “better gauge for evaluating the risk of an acute embolic event during simultaneous nailings.” The intraoperative death rate of 6.25 percent in this series is comparable to the range of zero to 6.6 percent found in reports of single nailings for impending and pathologic fractures.

One of the most noteworthy findings of this study, the authors say, concerns patients treated for impending fractures. This group “would presumably have the highest risk because no fracture is present that could act as an exhaust for reaming products and aid in decompression of the intramedullary space.” Although these patients have previously been characterized as having the highest risk of intraoperative death, this series had an intraoperative and perioperative mortality rate of zero for the five patients with impending fractures.

The two deaths in this study that were directly attributable to pulmonary compromise reinforce the importance of careful patient selection, the authors note. However, they state that both of those cases “appear to be outliers” in comparison with the patients who survived. They also suggest that “there may be a threshold beyond two simultaneous nailings that may increase the likelihood of complications from fat embolism.”

Although this retrospective Level IV series was small and lacked a control group, the authors note that “the need for simultaneous nailing is an uncommon event.” They also state that selection bias was not only unavoidable, because only patients who were more medically fit and better able to withstand the inevitable production of emboli were selected, but “is likely a major contributor to a successful outcome and should not necessarily be considered a weakness of the study.”

In conclusion, simultaneous nailing “can be done safely,” say the authors, but patient selection is a critical factor. “Our findings do not support previous recommendations of using unreamed nails or the mandatory staging of multiple nailings.”

Coauthors of the study are Patrick P. Lin, MD; Robert L. Satcher Jr., MD, PhD; and Valerae O. Lewis, MD.

Disclosure information: Drs. Moon and Satcher—no conflicts; Dr. Lin—Pfizer; Dr. Lewis—AAOS Now, Stryker, Hindawi Publishing. Institutional support was received from Stryker.

Terry Stanton is senior science writer for AAOS Now. He can be reached at tstanton@aaos.org