CORR Insights ®: Intramedullary nailing of femoral diaphyseal metastases: is it necessary to protect the femoral neck?

M ore than 1.5 million patients are diagnosed with cancer annually in the US, and more than half a million die each year from metastases [2]. Bone metastases to the femur are common; in fact, the femur is the most common site of osseous metastatic disease resulting in orthopaedic intervention. As such, most general orthopaedic surgeons are likely to encounter this problem. The goal in stabilizing these lesions is to allow the patient to regain mobility and maintain a high quality of life. Experience has shown fixation with intramedullary devices is superior to using plates and screws [3], although this may not apply for periprosthetic femoral bone metastases, where plate fixation may be the treatment of choice. When choosing an intramedullary implant, the conventional wisdom has been to use locked cephalomedullary nails. Locking the nails makes sense because of the inherent instability of the femur when a metastatic lesion is present. The rationale for cephalomedullary nails instead of conventional nails is to prevent femoral neck fractures if a lesion were to develop in this region during the remaining lifespan of the patient, but this theory is supported only by anecdotal evidence. The use of a cephalomedullary nail adds a degree of difficulty to the surgical procedure due to technical aspects of implanting screws in the femoral neck. The additional steps take more surgical time, and entail the use of more fluoroscopy with resultant radiation exposure to the patient, surgeon and staff. Additionally, current high-quality imaging has greatly improved the detection of occult bone lesions, and occult femoral neck lesions seem unlikely to be missed with careful imaging. The use of bisphosphonates for patients with skeletal metastases also has substantially reduced the number of skeletal events requiring surgical intervention [4]. In addition, there is no evidence available to suggest that even if a metastatic bone lesion developed in the femoral neck, that a cephalomedullary nail would be sufficient to prevent a pathologic fracture or the need for surgical revision. Finally, patients with metastatic disease in general have a limited lifespan, with the majority dying in the This CORR Insights is a commentary on the article ‘‘Intramedullary Nailing of Femoral Diaphyseal Metastases: Is it Necessary to Protect the Femoral Neck?’’ by Moon and colleagues available at: DOI: 10.1007/ s11999-014-4064-1. The author certifies that he, or any member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or the Association of Bone and Joint Surgeons. This CORR Insights comment refers to the article available at DOI: 10.1007/s11999014-4064-1. M. T. Scarborough MD (&) Department of Orthopaedics and Rehabilitation, University of Florida, PO Box 112727, Gainesville, FL 32611, USA e-mail: scarbmt@ortho.ufl.edu CORR Insights Published online: 24 December 2014 The Association of Bone and Joint Surgeons1 2014