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Ante-grade intramedullary nailing for the treatment of humeral shaft metastatic bone tumor.

Byline: Jiang-Long. Chen, Tsu-Te. Yeh, Ru-Yu. Pan, Chia-Chun. Wu

Background: The surgical treatment of humeral fractures is controversial, and conservative therapy of pathologic fractures is not recommended. Materials and Methods: We performed a retrospective study of eight patients who had pathological humeral shaft fractures. All fractures were stabilized with ante-grade intramedullary nailing and wide resection of the tumor. Bone defects were filled with polymethylmethacrylate cement augmentation. Results: The mean operative time for the procedure was 160 min (range, 120-190 min), and the mean duration of hospitalization was 10.5 days (range, 5-15 days). Relief of pain was rated as good to excellent. There were no wound problems, deep infections, nerve palsies, or implant failures observed. X-ray studies demonstrated the improved stability of the humerus. Conclusion: Interlocking intramedullary nailing for pathological humeral shaft fractures provides immediate stability and can be accomplished with wide resection of tumor and bone defect augmentation with cement. Early return of functional status and pain relief greatly improved the patient's quality of life.


Pathological fractures caused by metastatic malignant disease have generated increasing interest in recent years. The humerus is the second most frequently involved bone, accounting for 16-39% of cases with actual or impending pathological fractures of the long bones. [sup][1],[2],[3],[4] Pathological fractures are not life-threatening, but pain and loss of arm function may have devastating effects on the patient's quality of life. In contrast to the treatment of nonpathological fractures of the humerus, surgical treatment of a pathological fracture is indicated when the high incidence of nonunion and the inadequate relief of pain. Rapid functional recovery with pain relief is the main goal of surgical intervention. One technique for internal fixation of humeral fractures involves the use of an intramedullary locking nail with adjunctive bone cement. [sup][5],[6] This technique has shown the benefits of the early painless restoration of limb function. There has been a remarkable revival of intramedullary fixation techniques in recent years because of its biomechanical and technical advantages in the treatment of actual and impending pathological fractures. [sup][7],[8],[9] The purpose of this retrospective study was to analyze the results of treatment with intramedullary locking nails in combination with adjunctive bone cement for humeral shaft fractures due to bone metastases, with particular emphasis on complications, restoration of function, and relief of pain. [sup][10],[11]

Materials and Methods

Between 2008 and 2012, we collected eight consecutive patients with pathological fractures of the humeral shaft. All patients were followed-up for at least 6 months or until death. Conventional anteroposterior and lateral radiographs were routinely taken of the entire humeral length. The indication for surgery was a pathological fracture or impending pathological fracture of the diaphysis of the humerus. An impending fracture was defined as a painful lesion with 50% cortical bone destruction or over a length of bone >2 cortical diameters. Advanced age or limited life expectancy was not considered contraindications for surgery. Mirels' scoring system that is based on four parameters (site, radiographic appearance, size, and related pain) was used to predict the risk of fracture and as an indication for surgical intervention [Figure 1].{Figure 1}

All surgical procedures were performed under general anesthesia. The beach-chair position was used in all patients. Open exposure was required in lesions with considerable bone destruction; this included exposure of the tumor site with a large cortical window. We used curettage, drilling with a high-speed burr, and occasionally resection of the affected bone segment to accomplish tumor removal. Biopsies were taken for both frozen and permanent sections.

A deltoid-splitting incision was used at the anterior aspect of the acromioclavicular joint and was extended about 3 cm. The site of entry for the nail into the humerus was in the sulcus between the greater tuberosity and the articular surface of the humeral head. The supraspinatus tendon was divided parallel to its fiber lines. The intramedullary canal was prepared with a guide wire. [sup][12] After the proper positioning and length were verified, the appropriate-sized titanium intramedullary nail (Zimmer Corporation, USA) was driven into the canal first, and then the entire tumor cavity was filled as completely as possible with polymethylmethacrylate (PMMA). Proximal interlocking screw was accomplished with the assistance of a nail-mounted drill-guide. Distal interlocking screws were performed by the free-hand technique. No reaming procedure and other adjuvant treatment was done.

We used visual analog scale scores (VAS) to evaluate pain intensity. [sup][13],[14],[15] The functional outcome was assessed using the Constant-Murley score and the American Shoulder and Elbow Surgeons (ASES) score for shoulders, and the Mayo Elbow Performance Score for elbows at the time of 1 month after operation. [sup][16],[17],[18],[19],[20],[21] Active forward flexion and abduction range of motion were recorded by a single physiotherapist.


The mean follow-up period was 11.7 months (range, 2-27 months). All patients were assessed using the VAS score for pain (range, 0-100). The mean VAS score improved from 92.5 preoperatively to 13.75 postoperatively. The mean age was 73 years (range, 59-87). There were three male and five female patients. We also assessed the return to full use of the affected limb for daily activities in patients who survived at least 3 months. In the majority of these patients, there was a satisfactory return to daily activities.

With regard to functional outcome, the average range of shoulder motion in active forward elevation and active abduction was 50[degrees] (range, 30-90[degrees]) and 51.8[degrees] (range, 20-70[degrees]), respectively. The mean improvement of shoulder motion in forward elevation and active abduction was 45[degrees] (range, 25-90[degrees]) and 50[degrees] (range, 30-90[degrees]). The mean Constant-Murley score was 71.4 (range, 55-80), and the mean ASES score was 82.5 (range, 65-95). Regarding elbow functional outcome, the average range of elbow motion was 88.1[degrees] (range, 60-110[degrees]). The Mayo Elbow Performance Score was 79.4 (range, 70-85).

The mean hospital stay was 10.5 days (range, 5-15 days). None of the reported patient deaths were related to the humeral nailing procedure. The mean postoperative survival time was 11.7 months (range, 2-27 months). There were no deaths in the immediate postoperative period; however, one patient survived <3 months after the intramedullary nailing procedure.

No local complications related to the surgical procedure were reported (radial nerve injuries, stiffness, infection, or heterotrophic ossifications) and the average operative time for the humeral nailing procedure was 161 min (range, 121-198 min) [Figure 2] and [Figure 3].{Figure 2}{Figure 3}


The success of intramedullary nailing techniques for lower limb fractures in the 1980s provoked an interest in the use of this technique for humeral fractures. The reported advantages included minimal surgical invasion, avoidance of the fracture exposure, preservation of the vasculature, and reduced risk of infection.

Due to the possibility of tumor spread and the poor bone quality adjacent to pathological fractures, we did not perform any reaming of the medullary canal. This not only reduces the operative time, but also avoids thermal injury to the surrounding soft tissue. Reaming of the medullary canal has been shown to increase intramedullary pressure and causes intravasation of bone marrow and fat into the venous blood system. This can lead to acute respiratory distress syndrome, fat embolism syndrome, and rarely sudden death.

During the procedure, tumor removal requires adequate exposure that may be associated with an increased risk of infection, increased blood loss, and local tumor seeding. These risks should be considered when local tumor progression cannot be controlled by nonoperative means and operative treatment is planned. Selective arterial embolization within 24 h prior to the operation is recommended for patients who have metastatic renal cell or thyroid carcinoma since surgical manipulation of these hypervascular tumors may cause extensive bleeding.

The introduction of PMMA into the defects created by extensive osteolysis and bone destruction was reported. This technique allowed for immediate weight bearing in the lower limbs and improved postoperative stability, and it has resulted in a significantly decreased incidence of subsequent fractures and other complications. The exposure of the fracture site could affect wound healing and thus might jeopardize important postoperative radiotherapy. Newer intramedullary devices allow the surgeon to lock the nail with less of a need for PMMA. In our study, we had no fracture site wound infections, no pulmonary embolism or other pulmonary complications and no nerve palsies distal to the fracture repair. Therefore, we believe that the open surgery at the fracture site can be undertaken with a lower risk of complications than has previously been assumed. The PMMA cement may also help extend the area of tumor cell death beyond the area of curettage through a thermal effect. Furthermore, potential benefits such as reduced intramedullary tumor burden, greater rigidity of the fracture repair, reduction of local tumor mass, and slower progression of the tumor also need to be considered. Intramedullary fixation devices are preferable for pathological fractures because of their superior ability to withstand mechanical loads; they support the entire length of the affected bone even in the absence of normal bone healing.

However, it should be noted that the device used for distal fixation was technically challenging, and the surgeon needs to remain aware of the potential for radial nerve injury. It is also important to maintain proper alignment to prevent rotation deformity of the humerus. Additionally, possible impairment of shoulder function may occur because of nail protrusion proximally or local rotator cuff damage occurring during insertion. Fortunately, none of our patients experienced these complications, and we were able to provide our patients with immediate mechanical stability of the arm.

Patient with pathological fracture often had poor life quality due to pain and the state of illness. Ante-grade intramedullary nailing for the treatment of pathological humeral shaft fractures offered less wound exposure and efficient operation time. The treatment is not to cure the disease, but provide mechanical stability. Besides, the function recovery is subjective. Thus, we conclude the VAS scores, ASES, Constant-Murley, and Mayo Elbow Performance scores to provide objective information about pain, shoulder and elbow function, respectively. All patients had much reducing of pain condition. According to the evaluation of the Constant-Murley and Mayo Elbow Performance scores, the shoulder and elbow function had significant improvement than preoperative status. Although it still had some impairment to arm function, but rapid recovery of arm brought great satisfaction to the patient in such illness status.

We should also consider the different operator, the size of the lesion and the short follow-up time as the limitation of these series. Besides, we put emphasis on the treatment of humerus diaphysis. In the future, we could use this method to the treatment of proximal or distal humeral pathological fracture.


The aims of operative management of bone metastases are relief of pain and restoration of function by achieving local tumor control and immediate mechanical stability. The advantage of early mobilization supports surgical stabilization of pathological fractures of humeral shaft. We believed ante-grade intramedullary nailing with adjuvant bone cement augmentation could provide immediate surgical stabilization and early range of motion. Although processing tumor invasion may destroy the rest of bone substance, the intramedullary nail could offer support after all. With adjuvant bone cement augmentation, the stability of arm function improved. Nonunion or mal-union could put into secondary priority. Ante-grade intramedullary nailing is a safe and efficient way to treat humeral shaft pathological fracture.


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Title Annotation:Original Article
Author:Chen, Jiang-Long; Yeh, Tsu-Te; Pan, Ru-Yu; Wu, Chia-Chun
Publication:Journal of Medical Sciences
Article Type:Report
Geographic Code:1USA
Date:Nov 1, 2014
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