Abstract
The femur is a common site for skeletal metastases. The Gamma2 nail has proved effective in relieving pain and restoring function. Little data exists on the use of the Gamma3 Long Nail (GLN) in this condition. Improved instrumentation is suggested to reduce operative time and facilitate minimally invasive surgery. This study reports a series of patients treated in a District General Hospital.
A retrospective casenote review was performed of all patients treated with the GLN for femoral metastatic disease over a five year period. Patients were followed-up for a minimum of one year. Functional level was assessed using the Parker Mobility Score (PMS).
12 patients underwent 15 nailings. Mean age was 75.4 years (median 75.7, range 61-92). In bilateral cases, the operations were performed during the same hospital admission. There were seven prophylactic nailings for impending fracture from proximal femoral lesions, seven procedures for actual fractures distal to the intertrochanteric line, and one basicervical fracture associated with multiple femoral metastases. Primaries were four prostate, two breast, two lung, one bowel, one bladder, one renal, and one myeloma.
Average anaesthetic time for all procedures was 134 mins (median 125, range 90-210). Average peri-operative drop in serum haemoglobin was 2.3g/dL (median 2.1, range 0.6-4.8). Five patients with actual fracture and one patient with impending fracture required blood transfusion, receiving 2.2 units on average.
In-hospital mortality rate was 0.83%, with only one patient not surviving to discharge. One year mortality was 83.3%. Only two patients were alive one year post-operation. Of the remaining patients, average survival was 3.2 months (median 3, range 1-6). Patients spent an average of 17 days on an acute orthopaedic unit (median 14, range 4-80). Two patients required further convalescence in a rehabilitation unit.
There were three surgical complications. Two impending fractures became complete, One intra-operatively and one post-operatively. In the case of basi-cervical fracture, the proximal screw cut out of the femoral head, requiring revision to a long-stem bipolar hemiarthroplasty. This was the only re-operation required in this series.
Average pre-operative PMS was 5.2 (median 4, range 2-9). Average peri-operative drop in PMS was two points (median 1.5, range 0-6). Of the 11 patients who survived to discharge, 10 were independently mobile and returned to their pre-operation residence. Nine required a change in walking aids. Only one patient reported post-operative pain.
This small patient series suggests that the Gamma3 Long Nail is a suitable treatment option for impending and actual metastatic femoral fractures in the District General setting. Length of stay, in-hospital mortality and re-operation rates compare favourably with published data on the Gamma2. There was a significant drop in Parker Mobility Score but all patients bar one were independently mobile and returned to their home. Anaesthetic time was not lower than with the Gamma2, suggesting little tangible benefit of the new instrumentation.
