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. ABSTRACT: 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.