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Original Article |
1 Department of Orthopaedic Surgery, Hebrew University, Hadassah Medical Center, P.O. Box 12000, Jerusalem, 91120, Israel
2 Department of Oncology, Hebrew University, Hadassah Medical Center, Jerusalem, Israel
Correspondence: Address correspondence and reprint requests to: Amos Peyser, MD; E-mail: peysera{at}hadassah.org.il
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Patients & Methods: Twenty-one consecutive patients with 24 humeri fractured secondary to metastatic disease were retrospectively reviewed. The primary tumors included carcinomas of breast (11), kidney (2), multiple myeloma (2), colon (2), prostate (1), thyroid (1), lymphoma (1) and unknown origin (1). All fractures were stabilized with antegrade unreamed humeral nailing. Cemented technique was performed in 5 procedures. The mean age was 64 (range, 40–86), male to female ratio 6:15.
Results: Blood loss was unremarkable in 19 patients (22 procedures). Two patients who underwent fixation of additional pathological fractures during the same operation were given a total of 3 units of PC perioperatively. Mean postoperative hospitalization period due to one UHN procedure alone was 3 days (range, 2–7 days). Two patients died of their disease within 3 weeks of surgery. The remaining 19 patients returned to nearly normal function within 6 weeks after nailing. One patient developed postoperative local wound cellulitis. Relief of pain was rated as good in all but one patient. Adjuvant therapy was given in 20 procedures. Bony union was achieved in 88% (15/17) of all the cases where the patient had survived a minimum of 3 months.
Conclusion: Unreamed humeral nailing of the pathological humeral shaft fractures provides immediate stability and pain relief, minimum morbidity and early return of function to the extremity.
Key Words: Pathological humeral shaft fractures • unreamed humeral nailing • perioperative morbidity • pain relief • function
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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The purpose of this study is to evaluate the role of unreamed humeral nailing (UHN) in the management of pathological humeral fractures due to metastatic disease. Little has been written to date on this management approach.11
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PATIENTS AND METHODS |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Of the 21 patients, 15 were women and 6 were men (Table 1
). In 11 patients right humerus, in 7 patients the left and in 3 both humeri were operated due to pathological fractures. The mean patient age was 64 years (range 40 to 86 years.)
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Eight patients underwent 13 operations due to additional metastatic lesions of the femur, acetabulum and the tibia. In two patients needing hemiarthroplasty of the hip and intramedullary nailing of the femur were performed during the same anesthesia session with the humeral nailing. In the remaining six patients, six procedures were performed before and five after the humeral nailing.
Adjuvant Treatment
Pre-operative radiation therapy was used in six humeri. Postoperatively, radiation therapy was applied in ten humeri. Chemotherapy was instituted in 2 cases and radioactive iodine 131 in 1 case with thyroid carcinoma. One patient with bilateral lesions received adjuvant therapy after the surgery of only one site. Four patients (four humeri) did not receive adjuvant treatment at all due to progressive deterioration in their general condition after the surgery (three patients) or due to non-compliance in oncology follow-up visits (one patient).
Pre-operative Embolization
Angiography with embolization of vascular metastatic lesions was performed in three cases. After selective injection of the contrast material to axillary artery, the major supplying branches of the hyper-vascular tumor mass were occluded with metallic coils or gelfoam. The primary diagnoses of these three cases were; thyroid carcinoma, renal cell carcinoma and unknown carcinoma (Fig. 1).
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Totally five patients had minimally open procedures in order to debulk the tumor mass through a bone window and to fill the large areas of bone destruction with methylmethacrylate cement (four cases) and also to perform open biopsy for primary histological diagnosis (one case). Sixteen patients with 19 humeri were operated by closed technique.
In all the procedures both the proximal and distal locking screws were used except two patients, one with lymphoma and the other with multiple myeloma of the proximal metaphysis where only proximal locking was performed.
Postoperative Period
Slings were applied as an external support during the early postoperative period and pendulum shoulder exercises were started under the supervision of physiotherapists. The patients were encouraged to use their arm immediately after the operation and those with additional surgeries of the lower limbs were instructed to learn how to use walking aids.
The patients were examined in the outpatient clinic by one of the senior surgeons of the musculoskeletal oncology unit. The clinical follow-up evaluation was done according to two criteria: gain of function and pain status. Physical examination and patient’s satisfaction constituted the basis of our follow-up assessment. Gain of extremity function was accepted satisfactory, if the patient was able to function normal or with no impairment in activities of daily living. Extremity function was rated as fair, when there was some limitation in use of the extremity in activities of daily living. The function was rated as poor if the patient was unable to use the extremity postoperatively.
Postoperative pain status specific to humerus was rated as excellent if pain was completely resolved; good, if the decrease in pain was remarkable; fair, when there was continued pain although allowing for improved function. Pain relief was rated as poor if there was no difference or increase in pain. We did not consider analgesic use as a valid measure of humerus specific pain relief as almost all the patients in our series had other bony metastasis for which analgesia was required.10
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RESULTS |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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A total of three units of packed cells were given to these two patients.
Length of Post-Op Hospital Stay
The longest durations of postoperative hospitalization occurred in three patients where multiple extremities were stabilized in one surgical setting; humerus and neck of femur-16 days (Case 6), bilateral humeri-9 days (Case 8), humerus and distal femur-8 days (Case 7). For the rest of our study group where we performed single UHN procedures during admission, the mean duration of hospitalization after surgery was 3 days with a range of 2–7 days.
Pain Relief and Gain of Function
Pain relief and function was significantly improved immediately after surgery. By 6 weeks, relief of pain was rated as good in all patients except one where the pain relief was rated as fair due to continuous pain around the shoulder. In all patients who survived, there was a satisfactory return to full use of the limb for activities of daily living within 6 weeks.
Complications
No intraoperative or early postoperative complications related to stress of the procedure or to anesthesia were observed. The only complication was a case of superficial wound cellulitis 2 months after the operation which was treated successfully by intravenous antibiotics. This was the patient who had only a fair relief of postoperative pain as noted above.
Union and Re-operation
Excluding the 6 patients who did not survive until 3 months, bony union was achieved in 88% (15–17) of the procedures. Non-union was reported in two (Fig. 2). One case (Case 10) of non-union occurred in a patient with breast carcinoma which required revision with plating 2 years after original surgery due to nail breakage. The second patient (Case 14) underwent embolization and revision de-bulking surgery with an additional distal locking screw insertion 1 year after the primary operation due to local recurrence of the hypernephroma at the fracture site.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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There are two techniques for surgical fixation of pathological humeral shaft fractures: plating and intramedullary nailing. In their study, Dijkstra et al.4 reported more blood loss and local complications with plate fixation in comparison to nailing. In our series, none of the patients who underwent unreamed humeral nailing alone due to their pathological fractures of humerus received blood products peri-operatively. Damron et al.3 showed that the proximally and distally locked intramedullary nail have biomechanical advantages over plate or Rush rod fixation in a cadaveric model for middle-third impending fractures. Locking screw insertion with unreamed humeral nailing allows for rotational and axial control. Whereas, if using Rush rods, Lewallen et al.9 reported that augmentation with polymethyl-methacrylate is beneficial in order to achieve better stability.
Disadvantages of plate fixation include the potential for radial nerve injury, and inability to protect as much humeral length compared to intramedullary nailing. In our study, we had no neuro-vascular complications.
Intramedullary nail fixation has become the most popular method used for humeral shaft lesions. The major advantage of intramedullary nail fixation is that it can protect a long segment of the humerus. When augmented with methylmethacrylate, it can also provide rigid fixation of a long segment of diseased bone. Other advantages include a low risk of implant failure and the fact that the nail can be placed in a closed manner. In the current series, there was no additional pathological impending or actual fractures of the same humerus. The only fixation failure we observed was in a patient with breast carcinoma where the nail was broken due to non-union 2 years after the operation. This particular patient was not operated by cemented technique primarily and functioned very well until the nail breakage. The major disadvantage of antegrade intramedullary nailing is the mandatory incision and repair of the rotator cuff which may cause residual rotator cuff tendinitis and weakness.7 However, the postoperative expectations in elderly and fragile metastatic cancer patients are much different compared to younger trauma patient group where the rotator cuff symptoms may become more disturbing during recovery. Primary aim of surgical treatment in an oncology patient should be a speedy return to activities of daily living and decrease in pain around fracture site with the least invasive method.
Closed nailing is the preferred technique for both impending and actual fractures when the bony destruction is not severe. However, if the lesion involves cortices over a length of 3–6 cm. or located in metadiaphyseal region, open nailing with curettage and augmentation with methylmethacrylate should be considered to supplement the fixation.
To obtain better mechanical benefit, we suggest cementation especially in radio-resistant tumors like hypernephroma and thyroid carcinoma since surgical de-bulking is the only option to achieve decrease in tumor mass around the fracture site in these patients. The only tumor recurrence at the previous fracture site in our series was in a patient with hypernephroma where open de-bulking and cementation was not performed during primary nailing.
Major blood loss can be anticipated during surgical fixation in patients suffering from metastatic hyper-vascular tumors like hypernephroma, thyroid carcinoma and multiple myeloma. To perform angio-embolization prior to surgery is highly recommended for these patients in order to minimize intraoperative blood loss especially when a thorough curettage of a large metastatic lesion is indicated.1,12
Redmond et al.11 mentioned the obviation of the need for cement by the intramedullary nail fixation provided by the locking screws. We used cement, together with locking screw fixation after debulking of large metastatic lesions to re-fill the defect and to augment the fixation and stability.
The present study had limitations that need to be taken into consideration. This was a retrospective study with terminal oncology patients that speedily deteriorate and lost to follow-up. Collecting information retrospectively from such patient group brings extra difficulties to perform validated outcome measurements. Due to this reason, pain and function in our study were not assessed by validated scoring systems.
Metastatic involvement of the humerus generally occurs late in the course of the disease and operative treatment should be considered in patients with a life expectancy of minimum 6 weeks. Although in our series, we considered this time period as a landmark for the extremity function and pain status assessment; we witnessed a very fast recovery in extremity function and pain even during the first couple of days after the operation. From the current series, even the patients with additional pathological fractures of the femur that were operated together with UHN during the same surgical session; did not develop any complications and were satisfied with the intervention. From our point of view, they recovered quickly mostly due to the possibility of early postoperative ambulation by the use of walking aids.
As a conclusion, unreamed humeral nailing is a very effective treatment method with fast recovery in pain and extremity function. It demonstrated high satisfactory rate and should be considered as palliative treatment for the patients with pathological humeral shaft fractures due to metastatic disease.
Received for publication August 15, 2006. Accepted for publication October 4, 2006.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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This article has been cited by other articles:
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  J. Bickels, S. Dadia, and Z. Lidar Surgical Management of Metastatic Bone Disease J. Bone Joint Surg. Am., June 1, 2009; 91(6): 1503 - 1516. [Abstract] [Full Text] [PDF]
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