Cephalomedullary Nailing
In the absence of reliable evidence, it is the opinion of the workgroup that there is no advantage to routine use of cephalomedullary nails for diaphyseal metastatic lesions as there does not appear to be a high frequency of new femoral neck lesions following intramedullary nailing.


Rationale

The lack of relevant and high-quality evidence regarding this topic led to a consensus level recommendation. Though it did not meet the strict inclusion criteria for this CPG, one study examined the occurrence of femoral neck metastases posterior to intramedullary nail fixation performed for a femoral diaphyseal metastatic lesion (Moon, 2015). The study reported no new femoral neck secondary lesions occurring subsequent to the aforementioned procedure.

Benefits/Harms of Implementation

Failure to diagnose a femoral neck lesion prior to implanting an intramedullary nail, increases the risks of adverse outcomes such as implant failure and the need for additional surgery. Efforts should be made to assess the entire bone length prior to decision making. Other risks are equal to those of any intramedullary nailing procedure in a cancer patient, which should be assessed on an individual basis.

The benefits of implementing this recommendation, when correctly indicated, will be the decrease in surgical time and radiation exposure to the surgeon and operating room personnel. This has implications on cost savings to society.

Future Research

Further studies would be beneficial with appropriately randomized samples, power, and follow up times, examining the intramedullary nail revision rate due to the occurrence of new femoral neck lesions in the setting of metastatic disease and pathological fractures due to diaphyseal lesions.


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