Comparison of carbon fibre and titanium intramedullary nails in orthopaedic oncology

Palliative Care Needs of Patients with Musculoskeletal Malignancies

PURPOSE OF REVIEW

This review aims to assess the literature regarding current treatment options for the palliative care of patients with advanced musculoskeletal malignancies whether primary or metastatic.

RECENT FINDINGS

The inclusion of specialized palliative care physicians, in conjunction with surgeons, medical oncologists, radiation oncologists, interventional radiologists, and mental health professionals, results in better control of end-of-life symptoms in both children and adults with terminal musculoskeletal malignancies. The palliative care of patients with musculoskeletal malignancies requires a multi-disciplinary team and benefits from specialized palliative care physicians. The unique impacts of musculoskeletal malignancies on ambulation and independence creates additional mental and physical burdens on patients and care-takers alike. Palliative care should focus on preserving ambulatory function and patient independence, in addition to managing chronic pain and other end-of-life symptoms common to these malignancies.

Patient-Reported Outcomes After Intramedullary Nailing of Oncologic Impending or Pathologic Fractures With Carbon Fiber or Titanium Implant

INTRODUCTION

Despite the benefits of intramedullary nailing (IMN) of impending or pathologic fractures in oncologic patients, literature on patient-reported outcomes (PROs) is scarce in patients treated with carbon fiber (CF) nails. Our study compared postoperative PROs after IMN with CF or titanium implants.

METHODS

We conducted a retrospective propensity score-matched cohort study of patients treated at our institution with CF or titanium nails for impending or pathologic fractures from metastatic bone disease. Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health Short Form (SF) Physical, Mental, and Physical Function 10a scores were collected. Pain was assessed using visual analog scale (VAS). Absolute and differential scores were compared between groups.

RESULTS

We included 207 patients, 51 treated with CF and 156 with titanium nails. One month postoperatively, patients had a one-point decrease in the pain VAS score while PROMIS scores did not improve. At 3 months, PROMIS SF Physical and SF 10a scores improved from preoperative values. Six months postoperatively, median PROMIS SF Physical, SF Mental, and SF 10a scores were higher than preoperative scores. Absolute and differential PROMIS and pain VAS scores were similar between groups at the 6-month and 1-year marks.

CONCLUSION

Patient-reported outcomes were similar after intramedullary nailing with either CF or titanium implants.

Carbon vs. Titanium Nails in the Treatment of Impending and Pathological Fractures: A Literature Review

Background: Long bones are commonly affected by musculoskeletal tumors, but they also represent one of the most frequent locations for metastases. The treatment is based on pain management and the prevention or stabilization of pathological fractures by intramedullary nailing. While titanium nails are probably the most used, carbon-fiber-reinforced (CFR) nails have emerged as a new option for oncological patients. The aim of this review is to compare titanium and CFR nails according to current findings. Methods: Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards were followed: a total of 1004 articles were identified and 10 were included. Results: Traditionally, titanium implants are highly valued for their optimal biomechanical properties and ease of insertion, facilitated by their radiopacity. However, the use of titanium poses challenges in radiotherapy due to interference with radiation dosage and the creation of ferromagnetic artifacts. Conversely, CFR implants have emerged as a recommended option for intramedullary fixation, due to their biomechanical and structural properties and their benefits during radiotherapy and follow-up monitoring X-ray. Conclusions: CFR nailing represents a promising advancement in the surgical management of oncological patients with long bone metastases. However, further studies are needed to increase surgeons' confidence in their use.

Outcomes of Long Bones Treated With Carbon-Fiber Nails for Oncologic Indications: International Multi-institutional Study

BACKGROUND

Intramedullary nail fixation is commonly used for prophylactic stabilization of impending and fixation of complete pathological fractures of the long bones. However, metallic artifacts complicate imaging evaluation for bone healing or tumor progression and postoperative radiation planning. Carbon-fiber implants have gained popularity as an alternative, given their radiolucency and superior axial bending. This study evaluates incidences of mechanical and nonmechanical complications.

METHODS

Adult patients (age 18 years and older) treated with carbon-fiber nails for impending/complete pathological long bone fractures secondary to metastases from 2013 to 2020 were analyzed for incidences and risk factors of mechanical and nonmechanical complications. Mechanical complications included aseptic screw loosening and structural failures of host bone and carbon-fiber implants. Deep infection and tumor progression were considered nonmechanical. Other complications/adverse events were also reported.

RESULTS

A total of 239 patients were included; 47% were male, and 53% were female, with a median age of 68 (IQR, 59 to 75) years. Most common secondary metastases were related to breast cancer (19%), lung cancer (19%), multiple myeloma (18%), and sarcoma (13%). In total, 17 of 30 patients with metastatic sarcoma received palliative intramedullary nail fixation for impending/complete pathological fractures, and 13 of 30 received prophylactic nail stabilization of bone radiated preoperatively to manage juxta-osseous soft-tissue sarcomas, where partial resection of the periosteum or bone was necessary for negative margin resection. 33 (14%) patients had complications. Mechanical failures included 4 (1.7%) structural host bone failures, 7 (2.9%) implant structural failures, and 1 (0.4%) aseptic loosening of distal locking screws. Nonmechanical failures included 8 (3.3%) peri-implant infections and 15 (6.3%) tumor progressions with implant contamination. The 90-day and 1-year mortalities were 28% (61/239) and 53% (53/102), respectively. The literature reported comparable failure and mortality rates with conventional titanium treatment.

CONCLUSIONS

Carbon-fiber implants might be an alternative for treating impending and sustained pathological fractures secondary to metastatic bone disease. The seemingly comparable complication profile warrants further cohort studies comparing carbon-fiber and titanium nail complications.

A PEEK into carbon fiber: A practical guide for high performance composite polymeric implants for orthopaedic oncology

Introduction

The use of carbon fiber implants in orthopaedic oncology has increased within recent years. The most widely used type of polymer is carbon fiber polyether ether ketone (CF-PEEK). Its radiolucency enables targeted radiotherapy and artifact-free tumor surveillance, which provides major advantages over metallic hardware. We aim to summarize the unique benefits within orthopaedic oncology, clinical pitfalls, and recent advancements.

Methods

Four representative patient cases from a single tertiary academic medical center were treated with carbon fiber implants (n = 2 nails, n = 2 plates) from 2021 to 2022.

Results

There were no adverse events noted during intraoperative implantation or postoperative follow up. All patients reported improvements in pain and no difficulties in ambulation. There were no instances of catastrophic failure or implant loosening.

Conclusion

CF implants offer a diverse array of advantages regarding its radiolucency, low scatter density, and bioinert profile. Nonetheless, further research is required to understand the long-term surgical outcomes and robustness of CF implants. Multi institutional trials could address important aspects of durability and stability over extended periods, feasibility and ease-of-use for different anatomical sites and bone quality, as well as cost-effectiveness in post-operative imaging, healthcare resource utilization, and revision rates. Providing orthopaedic surgeons with valuable insight will enable thorough clinically supported, informed decision making regarding optimal use of implants.

Titanium vs. carbon fiber-reinforced intramedullary nailing for humeral bone tumors

BACKGROUND

Multiple techniques have been described to treat humeral diaphyseal bone tumors requiring curettage or excision. Recent studies have suggested that carbon fiber-reinforced polyetheretherketone (CFR-PEEK) intramedullary nails (IMNs) may be preferable to titanium IMNs for patients with musculoskeletal tumors due to CFR-PEEK's high tensile strength, radiolucency, a modulus of elasticity closer to native bone, and improved postoperative surveillance/radiation dosing. In this study, we describe the rate of fixation failure for both CFR-PEEK and titanium humeral IMNs when used for humeral diaphyseal bone tumors requiring curettage or excision.

METHODS

This was a single-institution retrospective cohort study including 81 patients (27 CFR-PEEK and 54 titanium) treated for a humeral diaphyseal bone tumor using an IMN ± methylmethacrylate between January 2017 and December 2022. Primary outcome was revision surgery due to soft tissue complications, nonunions, structural complications such as periprosthetic fracture or IMN breakage, periprosthetic infection, tumor progression, and implant failure due to rejection or fatigue.

RESULTS

No failures were observed in either patients treated with titanium nails or patients treated with CFR-PEEK not requiring curettage. Fixation failure due to implant failure was observed in 2 cases-at 214 days and 469 days after surgery-where CFR-PEEK IMN was used for stabilization after a wide segmental resection for oncologic control with a cement spacer reconstruction. In both cases, the resection was larger than 6 cm, the remaining distal humerus was less than 5 cm, and failures occurred at the interface of the residual bone and spacer. Both patients were revised using a titanium distal posterolateral humeral plate fixed with screws and cables without any subsequent complications. One additional CFR-PEEK IMN required revision surgery after 744 days due to progression of the tumor and subsequent nonunion. One revision surgery was observed after 63 days for the titanium IMN because of nonunion and tumor progression.

CONCLUSIONS

Humeral diaphyseal bone tumors requiring large segmental resection with small residual bone and a large cement spacer may fail via tension due to bending forces at the distal portion. In this clinical scenario, the use of larger-diameter CFR-PEEK IMNs may be indicated when available. In the interim, use of intercalary allografts instead of cement spacers, additional fixation with a titanium plate distally, or the use of a titanium nail when using a cement spacer may be considered.

Carbon Fiber Implants in Orthopaedic Oncology

Carbon fiber offers numerous material benefits including reduced wear, high strength-to-weight ratio, a similar elastic modulus to that of bone, and high biocompatibility. Carbon fiber implants are increasingly used in multiple arenas within orthopaedic surgery, including spine, trauma, arthroplasty, and oncology. In the orthopaedic oncologic population, the radiolucency of carbon fiber facilitates post-operative imaging for tumor surveillance or recurrence, the monitoring of bony healing and union, and radiation mapping and delivery.