Simultaneous nailing of skeletal metastases: Is the mortality really that high?

Introduction: The risk of death during simultaneous nailing of pathologic and impending fractures in patients with metastatic disease is believed to be so high that some authors have advocated a staged approach, especially for impending fractures. However, there are limited data to either support or refute the appropriateness of staging of multiple impending or pathologic fractures. Questions/purposes: We therefore determined the rate of pulmonary mortality and morbidity in patients who underwent simultaneous nailing for metastatic disease of the skeleton. Methods: We retrospectively reviewed 16 patients who underwent simultaneous intramedullary nailing of impending or pathologic fractures between 1993 and 2009. There were 10 men and six women with a mean age of 60 years (range, 40-78 years). The intramedullary nailings included 15 femurs, 17 humeri, and one tibia. Thirty-one nails were reamed and two were unreamed. Results: Three of 16 patients died before discharge; two of these deaths were presumed to be the direct result of acute pulmonary complications related to simultaneous nailing and one was intraoperative. For the 13 patients who survived after discharge, there were three pulmonary complications. There were no intraoperative or perioperative deaths in the prophylactic nailing group. Conclusions: Simultaneous nailing of impending and pathologic fractures can be performed with lower mortality rates than previously reported. Patients with impending fractures did not appear to be at higher risk than patients with pathologic fractures. Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of level of evidence.