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75 (); 46-56
doi:
10.1016/j.jor.2026.02.005

Comparative complication rates of titanium vs carbon fiber intramedullary nails in pathologic long bone fractures: A systematic review and meta-analysis

, , , ,
a Rowan-Virtua School of Osteopathic Medicine, Stratford, NJ, USA
b Texas College of Osteopathic Medicine, Fort Worth, TX, USA
c Lake Erie College of Osteopathic Medicine, Erie, PA, USA
d Futures Forward Research Institute, Toms River, NJ, USA

⁎Corresponding author: Joseph D. Giacalone. giacal85@rowan.edu

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

Carbon fiber (CF) intramedullary (IM) nails have emerged as a promising alternative to titanium (TI) implants for managing pathologic long bone fractures, offering advantages such as radiolucency for improved imaging, reduced artifact during surveillance, and minimal attenuation of therapeutic radiation. Although early studies suggest comparable complication rates between CF and TI constructs, existing evidence remains limited by small sample sizes and a lack of direct, high-quality comparisons of complication profiles. This study aimed to systematically compare complication rates between CF and TI IM nails for the treatment of pathologic long-bone disease secondary to malignancy.

A systematic review and meta-analysis were conducted in accordance with the PRISMA 2020 guidelines to evaluate the complication profiles of CF versus TI IM nails in patients with impending or completed pathologic long-bone fractures secondary to malignancy. Eligible studies reported on postoperative outcomes, including revision surgery, nonunion, periprosthetic fracture, implant failure, and overall complication rates. Data were analyzed using single-proportion meta-analysis and subgroup analysis in RStudio v4.5.1.

Five retrospective cohort studies comprising 361 patients (194 treated with TI nails and 167 with CF nails) met the inclusion criteria. There were no statistically significant differences between cohorts in rates of nonunion (p = 0.876), periprosthetic fracture (p = 0.834), revision surgery (p = 0.757), or total complication rates (p = 0.617). However, implant failure occurred at a higher rate in the CF group (p = 0.016), based on a limited number of events.

CF IM nails appear to demonstrate complication rates comparable to traditional TI implants in the fixation of pathologic long bone fractures secondary to bone tumors, although they may be associated with a higher observed risk of implant failure. Given the low to very low quality of available evidence and the relatively small pooled sample size of this review, these findings should be considered exploratory. Future large-scale, prospective randomized studies are warranted to confirm these findings and enhance their generalizability across diverse oncologic populations.

Abstract

Highlights of the Paper

•First systematic review and meta-analysis comparing complication rates of carbon fiber vs titanium intramedullary nails.•Carbon fiber nails had complication rates comparable to titanium, including nonunion, revision, and overall complications.•Implant failure occurred more often with carbon fiber, indicating the need for further biomechanical and tumor-related study.

Keywords

Carbon fiber
Intramedullary nail
Titanium
Pathologic fracture
Metastatic bone disease
Orthopedic oncology
Systematic review
Meta-analysis
1

1 Introduction

Pathologic fractures of the long bones, whether due to primary bone tumors or more commonly metastatic disease, are a frequent and debilitating complication in oncology patients. These fractures not only impair mobility and correlate with reduced survival but also significantly reduce quality of life and often require surgical intervention.1–3 Among patients with long bone metastases, up to 28% may develop a pathologic fracture,4 and can develop in 5 - 10 % of those with primary bone tumors.5

Surgical management of long bone pathologic fractures secondary to malignancy depends on several factors, including tumor location, expected patient survival, and extent of local bone destruction.6–9 In this setting, the primary goals are to relieve pain and elicit prompt restoration of mobility.10 Surgical intervention is typically considered for lesions >2.5 cm or >50% cortical involvement, or when factors like Mirels score, prognosis, or tumor responsiveness to adjuvant therapy warrant operative management.7,11,12

Broadly, treatment strategies fall into three categories: resection with endoprosthetic reconstruction, internal fixation using plate and screw constructs, or stabilization with intramedullary (IM) nailing. IM nailing is most commonly indicated for meta-diaphyseal or diaphyseal lesions, particularly in patients with limited life expectancies, or where immediate weight bearing is warranted.6,9,13–15 In particular, it is recommended for the nail chosen to be of sufficient length to protect against future recurrence or distal metastases along with interlocking screws both proximally and distally.12,16

Traditionally, intramedullary implants are composed of titanium alloy (TI) due to its high tensile strength, corrosion resistance, and clinical familiarity. However, carbon fiber (CI) implants have emerged as a promising alternative, offering several unique advantages. These implants have radiolucent properties, which ultimately enhance postoperative imaging by minimizing artifacts on CT and MRI. This can lead to improved detection of local recurrence and help facilitate radiation planning.17–20 Additionally, CF constructs exhibit lower attenuation during radiotherapy, allowing for more accurate and effective dose delivery to target tissues.21–24

Beyond imaging and adjuvant therapy advantages, carbon fiber implants also offer a lower weight-to-strength ratio, high biocompatibility, and a modulus of elasticity closer to that of native bone.25–27 These properties collectively reduce stress shielding and may enhance implant integration by promoting bone remodeling.28,29 As such, CF nails may be particularly attractive in patients with pathologic fractures that are difficult to heal or require long-term radiographic surveillance.

While initial comparative studies suggest that carbon fiber nails perform similarly to titanium nails with respect to short-term complications, current evidence remains limited by small sample sizes and a lack of direct, high-quality comparisons of complication profiles.30–34 To address these limitations, we conducted a systematic review and meta-analysis comparing postoperative complication rates between titanium and carbon fiber intramedullary nails in the treatment of pathologic long bone disease.

2

2 Methods

A systematic search of the literature was conducted in August 2025 across five databases - PubMed, EMBASE, Web of Science, Scopus, and the Cochrane Library - in accordance with PRISMA 2020 guidelines.35 A standardized Boolean search string was used to screen for articles using the following search term: “carbon fiber” OR “radiolucent implant” OR “carbon fibre” OR “CF-PEEK” OR “PEEK” OR “CFR-PEEK” OR “carbon fiber reinforced”) AND (“fixation” OR “nail” OR “intramedullary” OR “intramedullary nail” OR “intramedullary nailing”) AND (“metastatic disease” OR “metastasis” OR “cancer” OR “metastatic bone disease” OR “bone tumor” OR “orthopaedic oncology” OR “tumor” OR “Orthopedic oncology").

2.1

2.1 Screening

An initial search across all databases yielded 391 articles, of which 197 duplicates were removed, leaving 194 unique studies for screening. Two reviewers (JG and SS) jointly screened titles, abstracts, and full texts for eligibility. Any discrepancies were resolved through thorough discussion and consensus; if needed, another author (TD) acted as a tie breaker. Ultimately, fourteen full-text articles were assessed for eligibility (Fig. 1).

PRISMA 2020 flow diagram outlining the study selection process.
Fig. 1 PRISMA 2020 flow diagram outlining the study selection process.
2.2

2.2 Inclusion & exclusion criteria

Studies were included if they1 compared CF and TI IM nails for impending or completed pathologic fractures of long bones secondary to malignancy, and2 reported sufficient postoperative complication outcomes such as nonunion, periprosthetic fracture, implant failure, revision surgery, or total complication rates. Studies that included vertebral tumors, lacked a titanium comparison group, or did not report complication outcomes were excluded.

2.3

2.3 Outcome measured

Outcomes of interest included operative time, fluoroscopy time, intraoperative blood loss, and length of hospital stay, as well as 90d postoperative complications: revision surgery, nonunion, implant failure, periprosthetic fracture, intraoperative fracture, tumor progression, periprosthetic infection, wound infection, other complications (e.g., delirium, venous thromboembolism, urinary tract infection, pneumonia, seroma, hematoma, chronic pain, and nerve deficits) and total complications. Total complications were defined as the cumulative occurrence of nonunion, implant failure, periprosthetic fracture, intraoperative fracture, tumor progression, periprosthetic infection, wound infection, and other complications. Additional outcomes included 90-day and 1-year mortality rates and overall survival, when reported.

2.4

2.4 Data collection & statistical analysis

For each included study, the following data were extracted: study design, number of patients, number of bones treated, patient demographics (age, sex, BMI), lesion characteristics (tumor type, lesion location, fracture status), median or mean follow-up duration, and receipt of neoadjuvant or adjuvant chemotherapy and/or radiotherapy. Descriptive statistics were calculated for baseline characteristics, and comparisons between the TI and CF nail groups were performed using appropriate statistical tests. Continuous variables, including age and BMI, were compared using Welch's t-test, while categorical variables, such as sex, fracture type (impending vs complete), and lesion location (humerus, femur, tibia), were compared using chi-square tests. A p-value of <0.05 was considered statistically significant.

Following data collection, meta-analysis was performed to pool complication rates using a single-proportion random effects model, with separate subgroup analyses for TI and CF intramedullary nails. For quantitative synthesis, we included complications that were consistently reported across at least three studies. Pooled event rates and corresponding 95% confidence intervals (CI) were calculated using inverse variance weighting.

Heterogeneity was assessed using the I2 statistic, with thresholds of 25%, 50%, and 75% representing low, moderate, and high heterogeneity, respectively. Between-study variance (τ2) was also calculated. Subgroup differences were assessed using chi-squared tests for interaction. All analyses were performed using R-Studio 4.5.1. with the meta and metafor packages. Forest plots were generated to visually display pooled proportions and confidence intervals for each outcome.

2.5

2.5 Risk of bias & certainty of evidence

Study quality was independently assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria,36 which provides a maximum score of 24 for comparative studies. Each study was reviewed and scored by two reviewers (JG and KS), with discrepancies resolved through consensus. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) analysis was performed to evaluate the certainty of evidence for the outcomes assessed for the study, following Cochrane Guidelines.

3

3 Results

A total of five studies encompassing 361 patients (TI = 194, nails, CF = 167) were included in the final analysis.14–18 All included studies were retrospective in design, evaluating outcomes among patients treated with TI or CF intramedullary nails for pathological fractures either due to metastatic disease or primary bone tumors (Table 1). Notably, Bhashyam et al. described cases only as “bone tumors” without subtype specification, while Yeung et al. reported “pathologic fracture due to sarcoma or metastatic bone disease” without providing further histologic detail.

Table 1 Summary of the five retrospective studies comparing titanium and carbon fiber intramedullary nails for treatment of bone metastases or primary bone tumors.
Author Study Type Number of Bones Treated Intervention (N) Tumor Type Outcomes Assessed Conclusion
Bhashyam et al. (2023) Retrospective 81 TI (54)CF (27) Bone tumors Post Operative Complications, Revision Surgery Rates Fixation failure was rare overall, with only 3 CF nails and 1 titanium nail requiring revision, suggesting comparable performance between implants except in cases with large segmental resections and minimal residual bone
Yeung et al. (2022) Retrospective 72 TI (26)CF (26) Sarcoma + Metastatic bone disease Operating time, Estimated blood loss, Fluoroscopic time, complications While the CF group presented with higher blood loss and increased fluoroscopy time, they had lower complications, suggesting non-inferiority to TI nails.
Pala et al. (2022) Retrospective 52 TI (27)CF (25) Breast cancer (n = 13), lung cancer (n = 9), multiple myeloma (n = 6), renal cancer (n = 6), urothelial cancer (n = 3), hepatocarcinoma (n = 2), gastrointestinal cancer (n = 2), endometrial cancer (n = 1), prostate cancer (n = 1), pancreatic cancer (n = 1), Merkel's cell carcinoma (n = 1), and cholangiocarcinoma (n = 1) Healing time, Fluoroscopic time, Operative time, Complications No difference between CF & TI nails for surgical time and fluoroscopic times. Healing time was shorter among the CF group.
Herzog et al. (2021) Retrospective 100 TI (47)CF (53) Multiple myeloma (n = 29), breast cancer (n = 18), renal cell carcinoma (n = 13), and lung cancer (n = 11), lymphoma (n = 4), prostate (n = 2) + Miscellaneous (n = 22) Postoperative complications, implant type, pathology, indication, cost, adjuvant therapy No significant differences were observed between the two groups across all the outcomes except for the lower cost associated with TI nails.
Kazzam et al. (2024) Retrospective 56 TI (30)CF (26) Multiple myeloma (n = 21), lung cancer (n = 10), breast cancer (n = 9), prostate cancer (n = 2), other (n = 8) Survival, implant failure rates, disease progression on post-operative CT/MRI, and post-operative radiotherapy dose CF nails and titanium nails showed similar survival and zero implant failure rates in metastatic bone disease, with CF offering improved postoperative imaging but limited additional clinical benefit except for patients needing long-term surveillance.
3.1

3.1 Summary of included studies

Paragragh

3.2

3.2 Group demographics

Across the five included studies, patients treated with TI nails (n = 194) and CF nails (n = 167) had comparable mean ages (65.8 vs. 65.6 years, p = 0.79), indicating no significant difference. However, the mean BMI was significantly higher in the TI group (26.6 vs. 25.1 kg/m2, p < 0.0001). The proportion of female patients was significantly greater in the CF group (45.8% vs. 34.7%, p = 0.0075), while male proportions were similar (p = 0.67).

Completed pathologic fractures were more common in the TI group (31.9% vs. 18.0%, p = 0.0002), whereas impending pathologic fractures were more frequent in the CF group (27.7% vs. 22.4%, p = 0.0009). Anatomically, humeral fixation was more common in the TI group (25.2% vs. 15.0%, p = 0.0068), while femoral fixation was more common in the CF group (22.4% vs. 18.8%, p = 0.0131). Tibial involvement was equivalent between groups (1.4%, p = 1.0) (Table 2).

Table 2 Baseline demographic and clinical characteristics of patients treated with titanium versus carbon fiber intramedullary nails. Welch's t-test was used for variables indicated by an asterisk (∗), and chi-square tests were used for variables indicated by a dagger (†). Statistically significant differences (p < 0.05) between groups were observed for BMI, female sex, pathologic and impending fractures, and humeral and femoral lesion locations.
Variables Titanium nail (n = 194) Carbon fiber nail (n = 167) p-value
Mean Age (SD) 65.8 (6.7) 65.6 (7.0) 0.79∗
Mean BMI (SD) 26.6 (0.91) 25.1 (1.2) <0.0001∗
Female sex, % (n) 34.7 (50) 45.8 (66) 0.0075†
Male sex, % (n) 36.9 (53) 34.7 (50) 0.6651†
Pathologic fracture, % (n) 31.9 (115) 18 (65) 0.0002†
Impending fracture, % (n) 22.4 (81) 27.7 (100) 0.0009†
Humerus, % (n) 25.2 (91) 15.0 (54) 0.0068†
Femur, % (n) 18.8 (68) 22.4 (81) 0.0131†
Tibia, % (n) 1.4 (5) 1.4 (5) 1.0†
3.3

3.3 Effect of intervention

Implant failure rates were analyzed across the 5 included studies for both interventions. The Titanium group had 0% implant failures, compared to 4.19% in the Carbon Fiber group, yielding statistical significance when compared using a Freeman-Tukey Double arcsine Test for meta-proportions (p value = 0.016, <0.05). Heterogeneity analysis values I2 = 28.4%, τ2 = 0, p-value = 0.183, yielded little variance, while portraying no significant difference between the two groups, p-value >0.05 (Fig. 2).

Pooled and weighted meta-analysis of implant failure rates.
Fig. 2 Pooled and weighted meta-analysis of implant failure rates.
Pooled and weighted meta-analysis of nonunion rates.
Fig. 3 Pooled and weighted meta-analysis of nonunion rates.
Pooled and weighted meta-analysis of periprosthetic fracture rates.
Fig. 4 Pooled and weighted meta-analysis of periprosthetic fracture rates.
Pooled and weighted meta-analysis of revision surgery rates.
Fig. 5 Pooled and weighted meta-analysis of revision surgery rates.
Pooled and weighted meta-analysis of other complication rates. Other complications were defined a priori in the Methods section.
Fig. 6 Pooled and weighted meta-analysis of other complication rates. Other complications were defined a priori in the Methods section.
Pooled and weighted meta-analysis of total complication rates. Total complications were defined a priori in the Methods section.
Fig. 7 Pooled and weighted meta-analysis of total complication rates. Total complications were defined a priori in the Methods section.

Nonunion rates, when compared between the two groups across the studies, showed no significant difference (p-value = 0.876, >0.05). The TI group had 3 incidents among 164 participants, whereas CF had 2 cases among 141 participants in the analysis. Heterogeneity analysis yielded I2 = 0.0%, τ2 = 0, p-value = 0.533, portraying no significant difference between the two groups (Fig. 3).

Comparing the periprosthetic fracture rates showed no difference between the two groups. Among the 5 studies included, the fracture rate was 2.06% & 1.79% in the TI and CF groups, respectively. Heterogeneity analysis yielded I2 = 32.4%, τ2 = 0.003, p-value = 0.149, showing no significant difference between the two groups (Fig. 4).

Revision rates among the two groups for the 4 included studies: 5 patients needed revision in both the Titanium and Carbon Fiber groups, portraying no difference (p-value = 0.757, >0.05). Among the included studies, heterogeneity was high in both groups, but not significant (I2 = 58.9%, τ2 = 0.0124, p-value = 0.0562) (Fig. 5).

Other complication rates, when compared, yielded no significant difference between the TI and CF groups, p-value = 0.612, >0.05. With rates of 7.18% and 4.25% among TI and CF groups, while significant heterogeneity was observed, p-value 0.0183, <0.05. (I2 = 58.5%, τ2 = 0.0089) (Fig. 6).

Total complication rates among the 2 procedures showed no significant difference (p-value 0.617, >0.05); a total of 33 complications were observed among the 194 participants included in the Titanium groups. 28 complications were seen in the Carbon Fiber group for the 167 participants included. Significant heterogeneity existed among the included studies for the subgroup analysis, I2 = 67.5%, τ2 = 0.0155, p-value = 0.0011 (Fig. 7).

3.4

3.4 Quality assessment

Methodological quality of the five included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria.19 Total scores ranged from 14 to 18 out of 24, indicating moderate overall study quality. Bhashyam et al. and Yeung et al. achieved the highest scores (18/24), demonstrating strong performance in clearly stated aims, consecutive patient inclusion, follow-up adequacy, and statistical analysis. Herzog et al. followed with a score of 17, while Pala et al. and Kazzam et al. scored 16 and 14, respectively, due to limitations in blinding, follow-up, and lack of prospective design elements. No included studies conducted a prospective sample size calculation or employed blinded outcome assessment (Table 3).

Table 3 Methodological quality assessment of included studies using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Each item was scored as 0 (not reported), 1 (reported but inadequate), or 2 (reported and adequate), for a maximum score of 24 for comparative studies.
Study Clearly Stated Aim Inclusion of Consecutive Patients Prospective Data Collection Appropriate Endpoints Unbiased Endpoint Assessment Adequate Follow-Up Loss to Follow-Up <5% Prospective Size Calculation Control Group Contemporary Group Baseline Equivalence Adequate Statistical Analyses Total Score
Bhashyam et al., 2023 2 2 0 2 0 2 2 0 2 2 2 2 18
Yeung et al., 2022 2 2 0 2 0 2 2 0 2 2 2 2 18
Kazzam et al., 2024 2 2 0 2 0 0 2 0 2 2 0 2 14
Herzog et al., 2022 2 2 0 2 0 2 2 0 2 2 1 2 17
Pala et al., 2022 2 2 0 2 0 2 2 0 2 2 1 1 16

A GRADE assessment was conducted for the six outcomes analyzed in this study. Four outcomes were rated as having “Low” quality of evidence, while two outcomes - other complications and total complications - were rated as “Very Low.” The lower GRADE for these two measures was primarily due to high heterogeneity (inconsistency) and wide 95% confidence intervals (imprecision), which reduced the overall certainty of the evidence (Table 4).

Table 4 Summary of the Modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria for included studies assessing the quality of evidence across analyzed outcomes comparing carbon fiber and titanium intramedullary nails in pathologic long bone lesions.
Modified Grading of Recommendations Assessment, Development, and Evaluation Criteria for Included Articles
Outcomes Risk of Bias Inconsistency Indirectness Imprecision Publication Bias Other Factors Final Grade
Implant Failure Ratesa Not Serious Not Serious Not Serious Not Serious N/A N/A Low
Non-Union Ratesa Not Serious Not Serious Not Serious Not Serious N/A N/A Low
Periposthetic Fracture Ratesa Not Serious Not Serious Not Serious Not Serious N/A N/A Low
Revision Surgery Ratesa Not Serious Not Serious Not Serious Not Serious N/A N/A Low
Other Complicationsa Not Serious Serious Not Serious Not Serious N/A N/A Very Low
Total Complicationsa Not Serious Serious Not Serious Serious N/A N/A Very Low
a Included studies are non-RCT, resulting in an overall starting GRADE of “Low".
4

4 Discussion

CF IM nails have garnered growing interest in orthopedic oncology due to their unique material properties and imaging advantages. As their use continues to expand, it is critical for orthopedic oncology surgeons to understand how this intervention affects patient outcomes and complication profiles. This study represents the first systematic review and meta-analysis to compare complication rates between CF and TI intramedullary nails in the treatment of pathologic fractures secondary to bone malignancy.

Across 361 patients, CF nails were associated with complication rates comparable to TI nails, with no statistically significant differences observed in rates of nonunion, periprosthetic fracture, revision surgery, or overall complications. However, CF nails were associated with a statistically higher rate of implant failure, based on a limited number of events, warranting further investigation. Notably, the overall quality of evidence was low to very low, as assessed by GRADE (Table 4), with the available literature being limited by retrospective study design, baseline heterogeneity, and methodological constraints reflected in moderate MINORS scores (Table 3). As such, these findings should be viewed as exploratory, highlighting the need for higher-quality prospective studies.

Given the comparable complication rates, it appears that CF nails may achieve clinical outcomes similar to TI constructs, while offering several unique advantages in the oncologic setting. Their radiolucent composition reduces scatter and attenuation, permitting more precise and effective radiation dosing, potentially resulting in better control of the progression of the tumor.21,37 This property also enhances postoperative imaging, allowing for clearer visualization of fracture healing and detection of local recurrence. However, radiolucency can also pose intraoperative challenges, as fluoroscopic visualization of implant positioning and alignment may be more difficult.37

Consistent with these observations, Gonzalez et al. conducted a retrospective, propensity-matched study of 207 patients with metastatic bone disease and reported no significant differences in PROMIS physical, mental, or pain scores between CF and TI cohorts at 6 months and 1 year postoperatively.38 These findings suggest that, despite potential mechanical or cost-related limitations, CF implants may not compromise functional recovery or quality of life, potentially supporting their role as a viable alternative to TI nails.

In our analysis, CF IM nails demonstrated a higher observed rate of implant failure compared with TI nails. However, this finding is based on a small number of events (TI = 0, CF = 7; Fig. 2) and should therefore be interpreted cautiously. This observed difference may nonetheless stem from inherent material properties and load distribution within long bones. Mugnai et al. reported that carbon fiber-reinforced polyetheretherketone volar locking plates exhibited a lower load to failure threshold, along with little tolerance to plastic deformation. CF also demonstrated reduced resistance to bending deformation, potentially predisposing it to mechanical failure. Although this study evaluated plates rather than nails, it highlights potential material-level limitations of CF constructs that may also be relevant to intramedullary applications.39

Limited studies report implant-related complications and failure rates with CF nails. Fragomen et al. performed a retrospective review of 12 patients (16 limbs) treated with carbon-fiber-reinforced polymer intramedullary nails, reporting nonunion in 5 of 16 limbs and hardware failure in 2 cases.40 Additionally, Piccioli et al. conducted a cohort study of 53 oncology patients treated with CF nails and observed intraoperative complications in 13.2% of cases and early postoperative complications in 7.52%.41 Although sample sizes were small, these studies suggest that implant-related mechanical issues, while infrequent, may occur with CF constructs.

Implant failure may also be explained by tumor location and local disease progression. Lozano-Calderon et al. found that metastatic involvement at or near the surgical site had a higher risk of complications, including implant failure.37 Given the nature of our study, radiographic variables such as tumor proximity and cortical destruction could not be assessed, leaving open the possibility that baseline differences in tumor burden contributed to failure outcomes. Additionally, none of the included studies reported whether the tumor was surgically removed or left in situ at the time of fixation, which may have influenced local mechanical stability and postoperative progression. Unresected or residual tumor tissue may have weakened bone integrity and increased susceptibility to implant failure, whereas cases involving tumor excision would be expected to demonstrate lower failure rates.

The elastic modulus of CF implants offers another possible explanation. Although this property is often regarded as beneficial for promoting load sharing and osteogenesis, it may paradoxically increase micromotion at the fracture site, potentially compromising stability. Fragomen et al. observed higher complication rates with CF constructs, attributing this to their greater elasticity and the resultant subtle motion that can delay or prevent union.40 In contrast, Zarian et al. reported faster fracture healing times in patients treated with CF nails compared to TI nails at all follow-up intervals.42 Similarly, Kojic et al. found that CF nails achieved clinical outcomes comparable to titanium, crediting this to their closer modulus match to cortical bone.43 Collectively, these findings illustrate that despite theoretical advantages, current evidence remains conflicting, with our results suggesting a possible association between CF nails and higher observed rates of implant failure.

Apart from a potential increase in implant failure, an additional limitation of CF implants remains their higher cost.44–46 Among the included studies, only Kazzam et al. and Herzog et al. reported cost data. Kazzam et al. noted that CF nails were approximately 92% more expensive than titanium nails within their institution,34 while Herzog et al. reported a $400 higher cost for a CarboFix CF nail ($2030) compared with a Synthes titanium nail ($1643), representing a difference of roughly 24%.33 CarboFix Orthopedics Ltd. was identified as the CF nail manufacturer in both Herzog et al. and Kazzam et al. whereas the remaining included studies did not specify implant manufacturer or perform formal cost analyses. This limited reporting precluded comparison of costs across included studies. Furthermore, the available cost estimates were derived from individual institutions and were not generated using standardized economic methodologies. Accordingly, no conclusions regarding cost-effectiveness could be drawn from the available data, and any potential economic implications of CF implants should be interpreted cautiously until validated by standardized cost analyses.

4.1

4.1 Limitations

The present systematic review is not without limitations. The analysis was based on a relatively small pooled sample size (n = 361) derived from five retrospective cohort studies, which inherently limits the overall strength and generalizability of the findings. In addition, the GRADE assessment demonstrated an overall low to very low level of evidence across analyzed outcomes, reflecting the limited methodological rigor of the available literature (Table 4). Consistent with this, the methodological quality of the included studies was only moderate overall, as assessed by the MINORS criteria (Table 3).

Although several studies reported baseline distributions of fracture type, tumor type, and anatomic location, complication outcomes were not stratified by these variables and were instead reported in aggregate at the implant level. As a result, outcome-level attribution was not possible, rendering subgroup analyses or meta-regression infeasible. Differences in baseline characteristics between cohorts, including disease burden, fracture status, and anatomic site, therefore represent an important limitation, as these factors could not be accounted for and may have influenced the pooled complication rates observed. In alignment with this, heterogeneity varied across outcomes, with low heterogeneity observed for some endpoints and moderate to substantial heterogeneity for others. As a result, pooled estimates for these outcomes may reflect underlying differences between studies rather than effects attributable solely to implant material and should be interpreted with caution.

A formal cost analysis was also not feasible due to sparse and inconsistent reporting of implant pricing, with only a minority of included studies providing cost data (n = 2) and none employing standardized health economic methodologies. Finally, none of the included studies provided consistent or detailed data on time to implant failure, preventing assessment of implant longevity or time-dependent risk.

5

5 Conclusion

Carbon fiber intramedullary nails appear to demonstrate complication rates comparable to traditional titanium implants in the fixation of pathologic long bone fractures secondary to bone tumors, although they may be associated with a higher risk of implant failure. Given the low to very low quality of available evidence and the relatively small pooled sample size of this review, these findings should be considered exploratory. Future large-scale, prospective randomized studies are warranted to confirm these findings and enhance their generalizability across diverse oncologic populations.

Institutional ethical committee approval

Not applicable. This study is a systematic review of previously published literature and did not require ethical approval.

Authors’ contributions

Joseph D. Giacalone: Conceptualization, Data curation, Formal analysis, Writing - original draft, Writing - review & editing.

Kunal Shah: Formal analysis, Methodology, Writing - original draft, Writing - review & editing.

Taylor Davis: Data curation, Methodology, Writing - original draft, Writing - review & editing.

Sanjana Subramanyam: Data curation, Methodology, Writing - review & editing.

James C. Wittig: Supervision, Project administration, Writing - review & editing.

Ethical statement

This study did not involve human subjects or identifiable data and was therefore exempt from Institutional Review Board (IRB) approval.

Guardian_Patients consent statement

Not applicable. This study did not involve active human participants, identifiable data, or minors requiring guardian consent.

Funding/sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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