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 (p= 0.0078) at two-week postoperative follow-up and 2.0 points (p= 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即将发生或已发生的病理性股骨骨折，常采用从股骨近端至远端置入髓内钉的治疗方法。在穿过癌变骨组织置入髓内钉后，残留的化疗和/或放疗抵抗性肿瘤可能继续进展。溶骨性病变的进展可能导致未来髓内钉失效或发生病理性骨折。本研究评估了仅涉及股骨的队列中髓内钉置入后癌症进展的发生率，并描述了一种经皮保留髓内钉的挽救性技术。 本研究为单中心回顾性研究，纳入了2016年至2023年间因股骨溶骨性病变导致完全性或即将发生的髓内钉失效而接受髓内钉固定术的成年患者。癌症进展定义为X线片上原有病灶扩大和/或出现新病灶。通过结合疼痛和功能评分评估手术结果。 共有113名患者（中位年龄66.8岁，四分位距=16.4；中位随访时间6.0个月，四分位距=14.5）接受了髓内钉固定术。其中16名患者（14.2%）在术后出现癌症进展。术前和术后的放疗及化疗并未降低癌症进展的几率。3名患者接受了初次开放性挽救手术，包括股骨近端置换关节成形术；6名患者因手术条件不佳或患者选择而未接受挽救治疗。 7名患者（中位随访时间10.7个月，四分位距=12.9）接受了经皮挽救治疗。在该组患者中，术后两周随访时疼痛和功能评分改善了4.0分（p=0.0078），最近一次随访时（平均随访时间13.0±9.4个月）改善了2.0分（p=0.0312）。所有3名术前无法行走的患者术后恢复了行走能力，6名患者能够在不使用助行器的情况下独立行走。术后30天内未报告重大并发症。 股骨溶骨性转移可能在髓内钉固定术后发生进展。需要对整个股骨进行持续监测，以维持改善的功能状态，并防止原有病灶的灾难性进展或新病灶的出现。对于仅存在更近端转移的患者，应重新考虑从股骨近端至远端干骺端置入长钉的常规做法。此外，在导丝插入、扩髓以及通过癌变骨组织向无癌远端骨置入髓内钉的过程中，存在癌细胞机械性转移的风险。
肿瘤(癌症)患者之家