Humeral shaft fractures represent a significant number of all traumatic fractures, with an incidence of 13 per 100,000 fractures per year1 and with an estimated 149,300 cases occurring in the United States from 2002 to 2011.2 Although pathologic fractures in patients with metastatic cancer account for only a fraction of all humeral breaks, they cause significant morbidity and an increased rate of mortality in already fragile patients.3 The incidence of fracture differs with the type of bony disease, occurring in up to 43% of patients with multiple myeloma metastasis, 35% with breast cancer metastasis, and 17% with lung cancer metastasis.3
When surgical intervention is indicated for the management of humeral fractures, surgeons rely on open reduction and internal fixation (ORIF) or intramedullary nail (IMN) fixation. Recent studies in a healthy population showed that the use of IMN fixation is on the decline and that ORIF with any of a variety of plating techniques has become the gold standard for repair.2,4 The decline of IMN fixation in a healthy population is multifactorial; however, the possibility of postoperative shoulder pain from rotator cuff damage with an anterior approach and the higher cost compared with ORIF have been specifically identified as factors.4 In 2011, Schoch et al2 found that 60% of traumatic humeral shaft fractures were treated with ORIF compared with 8% treated with a different surgical procedure and 32% treated nonoperatively. The union rate achieved for operative fractures in a healthy population, regardless of fixation method, is adequate, with nonunion rates of 4% to 23%.5–9
The surgical treatment of pathologic fractures may differ from the treatment of humerus fractures in a healthy population. Although ORIF may allow fixation of specific regions of the humerus, such as the proximal and distal metaphyseal regions, major concerns are the lack of stabilization of the entire bone and the need for extensile approaches if a longer length of stabilization is desired.10 Therefore, the most widely accepted method of fixation for pathologic fractures of the humerus shaft is IMN fixation. In a study that included both femoral and humeral pathologic fractures, Hunt et al11 found that IMN fixation was associated with a significantly lower number of implant failures compared with ORIF with plates. In addition, IMN fixation is applicable to most bony segments and allows for immediate rigid stabilization of the whole bone.10,12 However, the nuances of the operative technique of IMN fixation in this patient population are not universally accepted.
Reamed IMN fixation of long bone fractures in a trauma setting has shown greater stability and a lower complication rate than unreamed IMN fixation.13 However, within the past decade, reamed vs unreamed IMN fixation in the treatment of pathologic fractures has been vastly understudied. To the authors' knowledge, no studies have exclusively examined humeral shaft fractures. Most studies comparing the 2 approaches are outdated and show data that may be skewed by inadequate follow-up because of short patient survival. Cole et al14 and Gibbons et al15 directly compared reamed vs unreamed procedures and found mean life span after surgery of 18 weeks and 9 weeks, respectively. The current study describes the outcomes of operative techniques in the age of modern cancer treatment algorithms that have lengthened many of the expected survival times for these unique patient populations.16,17 Additionally, many studies have included fixation of impending fractures along with complete fractures14,15,18–23 or only impending fractures.24,25 The current authors included only complete fractures and excluded patients who had impending fractures to fully examine the effect of reamed vs unreamed procedures on union and time to union.
Authors who have directly compared reamed vs unreamed femoral nails have been split in their conclusions; one study argued that the unreamed procedure leads to lower morbidity rates,14 whereas another showed no significant differences in morbidity or complication rates between the two modalities.15 Some studies that examined only a reamed technique showed effectiveness in treating pathologic fractures, providing adequate stability, enhancing quality of life, and providing pain relief, with negligible complications.26–28 Other studies have been proponents of an unreamed method, finding that such treatment provides immediate stability and pain relief, faster operative times, low intraoperative blood loss, minimum morbidity, and a low risk of implant failure.18–21,29,30 Finally, older studies focused on the use of solid nails,18,21 which are no longer used in the United States.
The goal of this study was to analyze the outcomes achieved by a single surgeon in the treatment of pathologic humeral shaft fractures with cannulated IMN fixation with both reamed and unreamed techniques in an era of longer patient survival.
Materials and Methods
This study used a retrospective medical record review. Before the study was initiated, institutional review board approval was obtained to gather demographic, clinical, and follow-up data on patients with pathologic humeral shaft fractures who underwent IMN fixation performed by a single surgeon (S.E.P.) at a Level I trauma center between 2009 and 2017. Patients were categorized according to whether they underwent IMN fixation with a reamed or an unreamed technique. The surgeon's preference for treatment of metastatic disease of the humeral shaft is the placement of an unreamed nail. Reaming was reserved for patients whose humeral canal would not allow for the safe placement of the smallest IMN or for patients who had mixed or blastic metastatic disease. Demographic characteristics included age, sex, race, ethnicity, body mass index, smoking status, and comorbid disease. Clinical characteristics included the type of cancer or bony lesion, site of involvement, chemoradiation therapy status, nail diameter, intraoperative blood loss, transfusion during acute hospital stay, length of acute hospital stay, and length of orthopedic follow-up. The follow-up data included evidence of union, time to union, complications, and reoperations. Sites of involvement were defined as the midshaft, the proximal third of the shaft, and the distal third of the shaft. Radiographic union was assessed by 2 separate reviewers (M.J.C., M.D.H.) and defined as the first date of healing on 3 of 4 cortices. Complications were defined as nonunion, delayed union, implant failure, periprosthetic fracture, or infection. Delayed union was defined as evidence of union longer than 8 months postoperatively. Exclusion criteria for the study were lack of radiographs to accurately determine union vs nonunion and lack of appropriate follow-up.
Statistical analyses were performed with mean and standard deviation for continuous variables and with frequency and percentage for categorical variables. Reamed and unreamed cohorts were compared with Student's t test for continuous variables and with the chi-square or Fisher's exact test for categorical variables. All comparative analyses were 2 tailed and used an alpha of 0.05.
From 2009 to 2017, a total of 25 patients underwent IMN fixation for pathologic humeral shaft fracture. Of those, 9 patients were excluded. Of the patients who were excluded, 6 were lost because of follow-up of less than 1 month and/or inadequate follow-up radiographs, and 3 were lost because of death within 1 month after the operative date. A total of 16 patients were included, and of these, 5 underwent a reamed procedure and 11 underwent an unreamed procedure (Table 1).
The reamed and unreamed cohorts showed no differences across demographic variables, including age at the time of surgery (reamed group, 65.4 years [95% confidence interval, 55.7–75.1]; unreamed group, 67 years [95% confidence interval, 60.1–73.9]), sex, race, ethnicity, body mass index (reamed group, 26.9 kg/m2 [95% confidence interval, 23.3–30.4]; unreamed group, 30 kg/m2 [95% confidence interval, 26.9–33.1]), smoking status, and comorbid disease (P>.05) (Table 2). The 2 cohorts also showed no difference in fracture location (P>.05). The reamed group included 3 midshaft fractures and 2 proximal shaft fractures. The unreamed group included 7 midshaft fractures, 3 proximal shaft fractures, and 1 distal shaft fracture (P>.05). Clinical data showed no statistically significant differences between the reamed and unreamed groups in the pathology of the bony lesion, chemoradiation status, and rate of blood transfusion during acute stay (P>.05). Mean length of follow-up for both groups was 51.5 weeks and was not different between the 2 groups, with a mean of 51.3 weeks in the reamed group (95% confidence interval, 13.7–88.9) and a mean of 51.6 weeks in the unreamed group (95% confidence interval, 7.1–110) (P>.05). No difference was found in average nail diameter, with a diameter of 8.4 mm in the unreamed group (95% confidence interval, 8–8.8) and a diameter of 8.8 mm in the reamed group (95% confidence interval, 8.1–9.5) (P>.05). No difference was found in average intraoperative blood loss between the groups, with loss of 148 mL in the unreamed cohort (95% confidence interval, 83.7–213) vs loss of 270 mL in the reamed cohort (95% confidence interval, 88–628) (P>.05). Finally, no difference was found in mean length of hospital stay, with 5 days for both the unreamed group (95% confidence interval, 2.1–7.9) and the reamed group (95% confidence interval, 1.3–8.7) (P>.05) (Table 2).
A total of 12 patients (75%) showed evidence of union, 4 in the reamed group (80%) and 8 in the unreamed group (72.7%) (P>.05). Figure 1 shows a healed unreamed fracture. Average time to union for the reamed cohort was 80.5 days (95% confidence interval, 45.6–115), whereas the average time to union for the unreamed cohort was 109.1 days (95% confidence interval, 81.2–137) (P>.05). Overall, 5 patients (31.3%) had complications, 2 (12.5%) of which were nonunion (Table 3). Of the patients who had complications, 1 (20%) underwent a reamed procedure and 4 (36.4%) underwent an unreamed procedure (P>.05). In the reamed group, 1 fracture (20%) progressed to nonunion but did not require reoperation (Figure 2). In the unreamed group, 1 fracture (9.1%) progressed to nonunion and required revision fixation (Figure 3), 1 fracture (9.1%) had delayed union, and 2 fractures (18.2%) had disease progression at the fracture site that required additional surgical treatment (Figure 4). No implant failures, periprosthetic fractures, or infections occurred in either group. A total of 3 patients (18.8%) underwent reoperation, all 3 (27.3%) in the unreamed group (none in the reamed group) (P>.05). In the unreamed cohort, 1 fracture (9.1%) required revision IMN fixation because of nonunion (Figure 3), 1 fracture (9.1%) was converted to another implant because of disease progression, and 1 fracture (9.1%) required amputation of the limb because of disease progression (Figure 4; Table 4).
Anteroposterior (A) and lateral (B) radiographs of a patient with pathologic fracture of the right humerus secondary to multiple myeloma metastasis. Anteroposterior (C) and lateral (D) radiographs with evidence of union on 3 of 4 cortices 48 days postoperatively after unreamed intramedullary nail fixation.
Data on the 5 Complications
Anteroposterior (A) and lateral (B) radiographs of a patient with pathologic fracture of the right humerus secondary to prostate carcinoma metastasis. Anteroposterior (C) and lateral (D) radiographs with evidence of nonunion 9 months after reamed intramedullary nail fixation that did not require reoperation.
Anteroposterior (A) and lateral (B) radiographs of a patient with pathologic fracture of the left humerus secondary to bladder carcinoma metastasis. Anteroposterior (C) and lateral (D) radiographs with anatomic alignment of the fracture site 2 weeks after treatment with unreamed intramedullary nail fixation. Anteroposterior (E) and lateral (F) radiographs with evidence of nonunion 9 months postoperatively, causing the distal locking screws to back out, which was managed with a revision intramedullary nail.
Anteroposterior (A) and lateral (B) radiographs of a patient with pathologic fracture of the right humerus secondary to renal cell carcinoma metastasis. Anteroposterior (C) and lateral (D) radiographs with anatomic alignment of the fracture site 2 weeks after treatment with an unreamed intramedullary nail. Anteroposterior (E) and lateral (F) radiographs with significant disease progression 7 months postoperatively, which was managed with amputation of the limb.
The reamed approach for IMN fixation of long bone fractures has become a standard method of treatment. A major benefit of this technique is the ability to use a larger nail diameter. In theory, a larger nail offers greater stabilization of the fracture site.13,31 Additionally, some authors have suggested that reaming is associated with lower nonunion rates in patients with trauma. In contrast, unreamed IMN fixation involves fewer steps, yields faster operative times, and minimizes intraoperative blood loss.32 Moreover, although some authors suggest that an unreamed approach does not eliminate the potential for fat emboli syndrome1,4,15,18 a known but rare complication of IMN fixation, the theoretical risk can be reduced with an unreamed procedure, as shown in previous studies.21,33–35 It is not readily apparent in these discussions whether these risk vs benefit calculations are readily applicable in the setting of humerus fractures secondary to neoplastic disease. The current study found a union rate of 75% for IMN fixation of pathologic humeral shaft fractures and a nonunion rate of 12.5%, which parallels the rates achieved in nonpathologic fractures.5–9 These findings did not show the superiority of either the reamed or the unreamed procedure. The 2 techniques yielded similar rates of union and time to union, with minimal complications and need for reoperation. Thus, the reamed technique provided no added benefit. The current findings also suggest that an unreamed technique may be associated with less intraoperative blood loss and shorter length of hospital stay, although the difference was not statistically significant. In congruence with the literature,18–21,29,30 the current study showed that an unreamed procedure adequately stabilized the fracture site and was associated with minimal morbidity and a complication rate comparable to that of a reamed procedure.
Additionally, although polymethylmethacrylate cement is a common additive to fixation constructs, in metastatic disease, it is employed much less in the setting of IMN fixation.36,37 In a multi-institutional study, Wedin et al37 noted that in 148 IMN fixations, there was no discernible benefit associated with the addition of cement for the 30% of cases in which it was used. As a result, they reserve its use for cases with large destructive lesions and substantial cortical bone loss. None of the patients in that review had a lesion that met this description.
In the current study, 81% of patients received radiation therapy, which presumably leads to an environment promoting nonunion as a result of fibrosis of the vasculature and impaired osteoblastic activity of the bone.38,39 This situation is similar to major trauma because open fractures that cause extensive soft tissue damage, periosteal stripping, and vasculature damage are associated with a greater risk of nonunion.40 However, the current study showed excellent rates of union, even in the setting of substantial radiation therapy. Although most of the patients in the current study received radiation therapy, 3 did not because of their pathology. Medical oncologists sometimes manage multiple myeloma and leukemia with systemic bisphosphonate chemotherapy alone.41,42 Only 1 patient who was not receiving radiation therapy had a complication in the form of delayed union. An interesting finding in the current study is that the length of follow-up was longer than the life expectancy reported by previous authors.14,15 In the current study, mean patient follow-up was 51 weeks, which is substantially longer than that in other studies that directly compared the 2 fixation methods in pathologic femoral fractures.14,15 This lengthened survival can be attributed to improvements in modern cancer screening and treatment. Thus, fixation of pathologic fractures should be considered to extend beyond acute palliative measures.
A limitation of this study was the sample size of patients who were treated for pathologic fracture. At the authors' institution, most pathologic bony lesions with impending fractures are fixated before a complete break occurs. Additionally, this study included only patients treated by a single surgeon. Although this group represents the vast majority of patients, it excludes those who presented during off-hours and were operated on by another surgeon. The sample size also was affected by the number of patients who were excluded from the study, although exclusion was caused primarily by patient death. This study also did not examine concurrent intralesional procedures or the use of cement to fill bony defects. Thus, the authors' conclusions are limited by potential confounding by these variables.
The use of IMN fixation of pathologic humeral shaft fractures achieves rates of union that are parallel to those seen with fixation by any method in a healthy population, regardless of the use of a reamed vs an unreamed technique and even with the use of standard perioperative radiation therapy. The authors consider this technique to be an excellent choice for the management of displaced pathologic humerus fractures in the setting of neoplastic disease. The authors also suggest that the clinical outcomes were not significantly different in patients who underwent placement of an unreamed nail. As the life expectancy of patients with metastatic bone cancer continues to lengthen, it is important to continue to evaluate treatment for both short-term stabilization and long-term function.
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- Changulani M, Jain UK, Keswani T. Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus: a randomised controlled study. Int Orthop. 2007;31(3):391–395. doi:10.1007/s00264-006-0200-1 [CrossRef] PMID:16900354
- Westrick E, Hamilton B, Toogood P, Henley B, Firoozabadi R. Humeral shaft fractures: results of operative and non-operative treatment. Int Orthop. 2017;41(2):385–395. doi:10.1007/s00264-016-3210-7 [CrossRef] PMID:27150488
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- Willeumier JJ, van der Linden YM, van de Sande MAJ, Dijkstra PDS. Treatment of pathological fractures of the long bones. EFORT Open Rev. 2017;1(5):136–145. doi:10.1302/2058-5241.1.000008 [CrossRef] PMID:28461940
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|Factor||No. of Patients|
|Total pathologic fractures||25|
|Excluded because of lack of follow-up or inadequate radiographs||6 (66.7%)|
|Excluded because of death <1 month after surgery||3 (33.3%)|
|Reamed intramedullary nail||5 (31.3%)|
|Unreamed intramedullary nail||11 (68.8%)|
|Characteristic||Overall (n=16)||Reamed (n=5)||Unreamed (n=11)||P|
|Patient age at time of surgery, mean±SD (range), y||66.5±11.1 (48–87)||65.4±11.1 (49–80)||67±11.6 (48–87)||.80|
|Sex, No. (%)||.1|
| Female||9 (56.3)||3 (60)||6 (54.6)|
| Male||7 (43.8)||2 (40)||5 (45.5)|
|Race, No. (%)||.54|
| White||14 (87.5)||5 (100)||9 (81.8)|
| Black||2 (12.5)||0 (0)||2 (18.2)|
| Other||0 (0)||0 (0)||0 (0)|
|Hispanic ethnicity, No. (%)||0 (0)||0 (0)||0 (0)||.1|
|BMI, mean±SD (range), kg/m2||29±5 (20.5–34.9)||26.9±4.1 (23.2–31.4)||30±5.3 (20.5–34.9)||.26|
|Comorbidity, No. (%)|
| Smoker (current or previous)||8 (50)||1 (20)||7 (63.6)||.28|
| Diabetes||6 (37.5)||1 (20)||5 (45.5)||.59|
| Hypertension||10 (62.5)||2 (40)||8 (72.7)||.30|
| Dyslipidemia||10 (62.5)||2 (40)||8 (72.7)||.30|
| CAD||2 (12.5)||2 (40)||0 (0)||.08|
| CHF||2 (12.5)||0 (0)||2 (18.2)||.54|
| COPD||5 (31.3)||1 (20)||4 (36.4)||.62|
| Chronic kidney disease||10 (62.5)||1 (20)||1 (9.1)||.1|
| Thyroid dysfunction||4 (25)||1 (20)||3 (27.3)||.1|
| Atrial fibrillation||3 (18.8)||1 (20)||2 (18.2)||.1|
| GERD||3 (18.8)||0 (0)||3 (27.3)||.51|
|Pathology, No. (%)|
| Breast carcinoma metastasis||3 (18.8)||2 (40)||1 (9.1)||.21|
| Multiple myeloma metastasis||4 (25)||0 (0)||4 (36.4)||.25|
| Renal cell carcinoma metastasis||3 (18.8)||1 (20)||2 (18.2)||.1|
| Lung carcinoma metastasis||1 (6.3)||0 (0)||1 (9.1)||.1|
| Other metastasis||4 (25)||2 (40)||2 (18.2)||.55|
| Primary bone disease||1 (6.3)||0 (0)||1 (9.1)||.1|
|Fracture location, No. (%)||.1|
| Shaft||10 (62.5)||3 (60)||7 (63.6)|
| Proximal||5 (31.3)||2 (40)||3 (27.3)|
| Distal||1 (6.3)||0 (0)||1 (9.1)|
|Radiation therapy, No. (%)|
| Adjuvant||11 (68.8)||4 (80)||7 (63.6)||.59|
| Neoadjuvant||1 (6.3)||0 (0)||1 (9.1)||.1|
| Adjuvant + neoadjuvant||1 (6.3)||1 (20)||0 (0)||.31|
| None||3 (18.8)||0 (0)||3 (27.3)||.25|
|Chemotherapy, No. (%)|
| Adjuvant||7 (43.8)||1 (20)||6 (54.6)|
| Neoadjuvant||1 (6.3)||0 (0)||1 (9.1)||.1|
| Adjuvant + neoadjuvant||5 (31.3)||2 (40)||3 (27.3)||.1|
| None||3 (18.8)||2 (40)||1 (9.1)||.21|
|Nail diameter, mean±SD (range), mm||8.5±0.7 (8–10)||8.8±0.8 (8–10)||8.4±0.7 (8–10)||.28|
|Intraoperative blood loss, mean±SD (range), mL||186.3±236.4 (5–1000)||270±408.7 (50–1000)||148.2±109.1 5–300)||.36|
|Received transfusion during acute stay, No. (%)||1 (6.3)||0 (0)||1 (9.1)||.1|
|Length of hospital stay, mean±SD (range), d||5±4.5 (1–13)||5±4.2 (1–10)||5±4.9 (1–13)||.1|
|Length of follow-up, mean±SD (range), wk||51.5±83.9 (5.5–347)||51.3±42.9 (5.5–121)||51.6±99.1 (7–347)||.1|
Data on the 5 Complications
|Complication||Site||Reamed or Unreamed||Outcome/Treatment||Radiation Therapy Status|
|Nonunion||Humerus||Unreamed||Revision intramedullary nail||Adjuvant|
|Disease progression||Humerus||Unreamed||Forequarter amputation||Adjuvant|
|Nonunion||Humerus||Reamed||Observation||Neoadjuvant + adjuvant|
|Outcome||Overall (n=16)||Reamed IMN Fixation (n=5)||Unreamed IMN Fixation (n=11)||P|
|Cases with evidence of union, No. (%)||12 (75)||4 (80)||8 (72.7)||.1|
|Time to union, mean±SD (range), d||99.6±45.3 (39–194)||80.5±39.8 (39–122)||109.1±47.3 (48–194)||.33|
|Total complication rate, No. (%)||5 (31.3)||1 (20)||4 (36.4)||.62|
| Nonunion||2 (12.5)||1 (20)||1 (9.1)||.1|
| Delayed union||1 (6.3)||0 (0)||1 (9.1)||.1|
| Disease progression||2 (12.5)||0 (0)||2 (18.2)||.54|
| Implant failure||0 (0)||0 (0)||0 (0)||.1|
| Infection||0 (0)||0 (0)||0 (0)||.1|
| Periprosthetic fracture||0 (0)||0 (0)||0 (0)||.1|
|Total reoperation rate, No. (%)||3 (18.8)||0 (0)||3 (27.3)||.51|
| Revision IMN fixation||1 (6.3)||0 (0)||1 (9.1)||.1|
| Conversion to another implant||1 (6.3)||0 (0)||1 (9.1)||.1|
| Amputation||1 (6.3)||0 (0)||1 (9.1)||.1|