Single-Stage versus Multi-Stage Intramedullary Nailing for Multiple Synchronous Long Bone Impending and Pathologic Fractures in Metastatic Bone Disease and Multiple Myeloma

Simple Summary For patients with advanced metastatic disease presenting with synchronous multiple long bone impending and complete fractures requiring placement of intramedullary nails (IMN), the optimal timing of bone fixation-whether in a single or multiple stages-is still highly debatable. In this work, we compared perioperative outcomes like overall complications, survival, in-hospital death, and postoperative length of stay among others between patients who have undergone single or multi-stage intramedullary nailing procedures for oncological indications. Our findings revealed that single-stage intramedullary nailing synchronous long-bone metastases in select patients does not increase their risk of perioperative complications and in-hospital mortality but leads to earlier postoperative discharge and initiation of rehabilitation. Thus, our results support single-stage multiple nailing as an efficient and viable therapeutic strategy for select patients with multiple long-bone metastases. Purpose: Determine whether perioperative outcomes differ between patients who have undergone single or multi-stage IMN procedures for impending or completed pathologic fractures. Methods: Patients were classified into single-stage single-bone (SSSB), single-stage multiple-bone (SSMB), and multi-stage multiple-bone (MSMB) based on procedure timing and number of bones involved. Outcome variables compared included length of stay (LOS), in-hospital mortality and survival, initiation of rehabilitation and adjuvant therapy, and perioperative complications. Results: There were 272 IMNs placed in 181 patients (100 males, 81 females, 55.2% and 44.8%, respectively) with a mean age of 66.3 +/- 12.1 years. MSMB had significantly longer LOS (24.3 +/- 14.2 days) and rehabilitation initiation (3.4 +/- 2.5 days) compared to SSSB (8.5 +/- 7.7 and 1.8 +/- 1.6 days) and SSMB (11.5 +/- 7.6 and 2.0 +/- 1.6 days) subjects, respectively (both; p < 0.01). Although total perioperative complication rates in SSMB and MSMB were comparable (33.3% vs. 36.0%), they were significantly higher than SSSB (18%) (p = 0.038). MSMB had significantly more (20%) cardiopulmonary complications than SSMB (11.1%) and SSSB (4.5%) (p = 0.027). All groups exhibited comparative survivorship (8.1 +/- 8.6, 7.1 +/- 7.2, and 11.4 +/- 11.8 months) and in-hospital mortality (4.5%, 8.9%, and 4.0%) (all; p > 0.05). Conclusion: In comparison to MSMB, SSMB intramedullary nailing did not result in higher perioperative complication or in-hospital mortality rates in select patients with synchronous long-bone metastases but led to earlier postoperative discharge and initiation of rehabilitation.