Safety and Efficacy of a Single-Stage versus Two-Stage Intramedullary Nailing for Synchronous Impending or Pathologic Fractures of Bilateral Femur for Oncologic Indications: A Systematic Review

SIMPLE SUMMARY: For patients with advanced cancer presenting with synchronous bilateral femur impending and/or complete pathologic fractures requiring placement of intramedullary nails (IMN), the optimal timing of bone fixation—whether in single-stage (SS) or two-stage (TS)—is still highly debatable. In this study, we systemically reviewed and compared the existing literature for perioperative outcomes such as complications, survival, same-admission mortality, length of stay, and start of rehabilitation and adjuvants between the SS and TS groups. Contrary to old literature, our findings revealed that SS IMN in select patients does not increase their risk of perioperative complications and same-admission mortality. However, limited comparative data exist on other proposed benefits of SS IMN including length of stay, earlier start of rehabilitation and adjuvant therapy, functional scores, and cost. Our results support SS bilateral femur IMN as a safe and efficient strategy for select patients. ABSTRACT: Although intramedullary nail (IMN) fixation is the standard of care for most impending and/or complete pathologic fractures of the femur, the optimal timing/sequence of the IMN in cases of synchronous bilateral femoral disease in advanced cancer is not well established. Thus, we compared the outcomes of single-stage (SS) vs. two-stage (TS) IMN of the bilateral femur with a systematic review of the literature on this topic. Bilateral SS and TS IMN cases were identified from 14 studies extracted from four databases according to PRISMA guidelines. Safety (complications, reoperations, mortality, survival, blood loss, and transfusion) and efficacy (length of stay [LOS], time to start rehabilitation and adjuvant therapy, functional scores, and cost) were compared between the groups. A total of 156 IMNs in 78 patients (36 SS and 42 TS) were analyzed. There were one surgical (infection in TS requiring reoperation; p = 0.860) and fifteen medical complications (five in SS, ten in TS; p = 0.045), with SS being associated with lower rates of total and medical complications. Survival, intraoperative mortality, and postoperative same-admission mortality were similar. No cases of implant failure were reported. Data on LOS, rehabilitation, and adjuvant therapy were scarcely reported, although one study favored SS over TS. No study compared cost or functional scores. Our study is the largest and most comprehensive of its kind in supporting the safety and efficacy of a SS bilateral femur IMN approach in these select patients. Further investigations with higher levels of evidence are warranted to optimize treatment protocols for this clinical scenario.