Jiang Will, Latich Igor, Lindskog Dieter, Friedlaender Gary, Lee Francis Y
Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, New Haven, CT 06510, USA.
Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT 06510, USA.
Cancers (Basel). 2024 Aug 10;16(16):2812. doi: 10.3390/cancers16162812.
Intramedullary nailing insertion from the proximal-to-distal femur is frequently performed for impending and complete pathological femur fractures due to osteolytic metastases. After nailing through cancer-laden bone, residual chemotherapy- and/or radiation-resistant tumor may progress. Progression of osteolysis risks future nail failure or pathological fractures. This study assesses the incidence of cancer progression following intramedullary nailing in a femur-only cohort and describes a percutaneous rod-retaining salvage technique. A single-institution, retrospective study was conducted to identify adult patients who underwent intramedullary nailing for femoral osteolytic lesions for complete or impending nail failure from 2016 to 2023. Progression was defined as enlargement of the pre-existing lesion and/or appearance of new lesions on radiographs. Surgical outcomes were assessed with a combined pain and functional score. A total of 113 patients (median age 66.8 years (IQR = 16.4); median follow-up 6.0 months (IQR = 14.5)) underwent intramedullary nailing. Sixteen patients (14.2%) exhibited post-nailing cancer progression. Pre- and postoperative radiation and chemotherapy did not decrease the odds of cancer progression. Three patients underwent initial open surgical salvage consisting of proximal femur replacement arthroplasty, and six patients did not receive salvage due to poor surgical candidacy or patient choice. Seven patients (median follow-up 10.7 months (IQR = 12.9)) received percutaneous salvage. In this group, pain and functional scores improved by 4.0 points ( = 0.0078) at two-week postoperative follow-up and 2.0 points ( = 0.0312) at the most recent follow-up (mean follow-up 13.0 ± 9.4 months). All three nonambulatory patients became ambulatory, and six patients were able to ambulate independently without walking aids. No major complications were reported 30 days postoperatively. Progression of femoral osteolytic metastases may occur following intramedullary nailing. Continued monitoring of the entire femur is needed to maintain improved functional status and to prevent catastrophic progression of pre-existing lesions or appearance of new lesions. In patients with more proximal metastases only, the customary practice of bringing a long nail from the proximal femur to distal metaphysis should be reconsidered. Furthermore, there is concern of mechanical transport of cancer cells during guide wire insertion, reaming, and rod insertion through cancer laden bone to cancer free distal bone.
对于因溶骨性转移导致的股骨即将发生和已完全发生的病理性骨折，常采用从股骨近端向远端插入髓内钉的方法。在通过充满癌细胞的骨组织插入髓内钉后，残留的对化疗和/或放疗耐药的肿瘤可能会进展。骨质溶解的进展会增加未来髓内钉失效或病理性骨折的风险。本研究评估了仅针对股骨进行髓内钉固定后癌症进展的发生率，并描述了一种经皮保留棒的挽救技术。进行了一项单机构回顾性研究，以确定2016年至2023年期间因股骨溶骨性病变接受髓内钉固定以治疗完全或即将发生的髓内钉失效的成年患者。进展被定义为在X线片上原有病变扩大和/或出现新病变。通过疼痛和功能综合评分评估手术结果。共有113例患者（中位年龄66.8岁（四分位间距 = 16.4）；中位随访时间6.0个月（四分位间距 = 14.5））接受了髓内钉固定。16例患者（14.2%）出现钉后癌症进展。术前和术后的放疗和化疗并未降低癌症进展的几率。3例患者最初接受了包括股骨近端置换关节成形术在内的开放手术挽救，6例患者因手术候选资格差或患者选择而未接受挽救。7例患者（中位随访时间10.7个月（四分位间距 = 12.9））接受了经皮挽救。在该组中，术后两周随访时疼痛和功能评分提高了4.0分（P = 0.0078），最近一次随访时提高了2.0分（P = 0.0312）（平均随访时间13.0±9.4个月）。所有3例不能行走的患者都能够行走，6例患者能够独立行走而无需辅助器具。术后30天未报告重大并发症。股骨溶骨性转移在髓内钉固定后可能会发生进展。需要持续监测整个股骨，以维持改善的功能状态，并防止原有病变的灾难性进展或新病变的出现。对于仅近端有转移的患者，应重新考虑从股骨近端向远端干骺端置入长髓内钉的常规做法。此外，人们担心在导丝插入、扩髓以及通过充满癌细胞的骨组织向无癌的远端骨组织插入髓内钉的过程中癌细胞的机械转移。
