INTRAMEDULLARY NAILING FOR METASTATIC HUMERAL LESIONS AND FRACTURES

Abstract

Introduction: Intramedullary humeral nailing (IMHN) is appropriate for metastatic lesions and fractures as it stabilizes the whole bone and allows immediate mobilization. We report the results of a patient cohort with metastatic lesions/fractures treated by IMHN.

Methods: We included patients who were treated with IMHN between June 2001 and December 2007 for metastatic lesions/fractures. We noted the source of referrals, site of fracture/lesion, primary lesion, metastasis elsewhere, operative complications, post-operative patient satisfaction and pain control, fracture healing and post-operative survivorship.

Results: We identified 38 patients. The median age was 71 years (50–87). Four patients presented with lytic lesions involving more than 50% of cortical diameter while 34 patients had a fracture. 10 patients had pain in their arm for at least 2 weeks before presentation. Primary malignancies were breast (9), Non-Hodgkins B-cell Lymphoma (4), prostate (4), kidney (5), myeloma and lung (2 each), bladder, leiomyosarcoma and oesophagus (1 each) and unknown (9). There were 22 proximal, 13 midshaft and 3 distal humeral lesions. All had metastasis elsewhere in addition to the humerus except six. 12 patients were without co-morbidities. Senior grade surgeons operated on all the patients. There were no intra-operative complications. Post-operative complications included sepsis (2), frozen shoulder(1), elbow stiff-ness(1), pneumonia(2), and transient radial nerve palsy (2). Three patients developed a second fracture distal to the first one and had revision surgery. Post-operative pain control was satisfactory in 34 and unsatisfactory in 3 patients. Difficulty in pain assessment occurred in 1 patient with brain metastasis. 36 patients died, with median survival from date of surgery of 12 weeks (range 1 – 62 weeks). Two patients are alive 2.5 and 1.7 years after surgery. The median follow-up period by the orthopaedic outpatient department was 2 months (1–26.5) for 33 patients as 5 patients died with in two weeks of operation. At follow up; 9 fractures had healed, 17 were healing, 2 had not united, and 5 patients did not have x-ray at follow up.

5 Out of 8 patients, who died with in 4 weeks of surgery, had a combination of at least one co morbidity, one area of metastasis other than the humerus and were in - patients. There was no co relation between mortality and sex, age, type of tumour, or presence of metastasis.

Conclusion: IMHN for metastatic lesions and fractures is effective for pain relief and fracture healing. However a long IM nail should be used and the whole arm should be radiated. Deviations from these principles lead to 3 surgical revisions in our cohort of patients. Also one group of patient had a high mortality rate and in this specific group non-operative treatment should be thought about.