Is There an Association Between Prophylactic Femur Stabilization and Survival in Patients with Metastatic Bone Disease?

Philipp, Travis; Mikula, Jacob D.; Doung, Yee Cheen; Gundle, Kenneth R.

doi:10.1097/corr.0000000000000803

Cited by 46 publications

(30 citation statements)

References 37 publications

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“… 18 , 19 Prophylactically stabilizing a metastatic lesion (compared with the fixation of a completed pathological fracture) is cost-effective, lessens the burden on the healthcare system, and is associated with an improvement in overall survival. 4 , 20 , 21 Furthermore, these surgeries tend to be less morbid with shorter hospital stays and higher likelihood of discharge to home rather than a facility.…”

Section: Conclusion and Discussionmentioning

confidence: 99%

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Mirels Scores in Patients Undergoing Prophylactic Stabilization for Femoral Metastatic Bone Disease in the Veterans Administration Healthcare System

et al. 2020

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Introduction: A retrospective review was performed for patients in the Veterans Administration Healthcare System who underwent prophylactic stabilization of the femur for metastatic disease. The goal was to evaluate indications for prophylactic stabilization through Mirels criteria. Methods: All veterans who underwent inpatient prophylactic femoral stabilization between October 2010 and September 2015 were identified. Procedure and demographic variables were collected by using chart review. Provider notes and radiographs were reviewed to calculate Mirels scores. Results: Ninety-two patients underwent confirmed prophylactic stabilization for metastatic bone disease. Lung cancer and multiple myeloma accounted for most lesions. The mean Mirels score was 10.3 (range 7 to 12). 3.2% of patients had a score of 7, and 6.5% had a score of 8. Most lesions were peritrochanteric (66%) and lytic (85%). There was more variability in size (mean 2.3), with 15% being under one third of bony width and 38% between one and two-thirds. The mean pain score was 2.5; 73% reported functional pain. Of lytic and peritrochanteric lesions (53% of all cases), 55% were less than two-thirds the cortical width and 31% lacked functional pain. Conclusion: This retrospective study of prophylactically stabilized metastatic lesions revealed that more than 90% of patients had Mirels scores greater than 8, suggesting a substantial risk of pathologic fracture. Over half of all stabilized lesions were peritrochanteric and lytic. These criteria alone achieve a minimum Mirels score of 8; however, one-third of these lacked functional pain. Notably, Mirels' original paper found location and type criteria to be the least predictive of impending fracture. Contrariwise, functional pain was the most accurate predictor. Multiple studies have found poor specificity of the Mirels criteria. The high scores achievable by the location and type criteria may represent an overrepresentation of their contribution to fracture risk. Reconsideration of the relative weights of each criterion warrants further examination.

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Section: Conclusion and Discussionmentioning

confidence: 99%

“… 1 - 3 Metastatic lesions put patients at risk for pathological fracture, leading to substantial morbidity associated with hospital admission, pain, worsening quality of life, and perhaps decreased overall survival. 4 The femur is the most common site of metastatic disease and pathologic fracture in the appendicular skeleton. 5 …”

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Mirels Scores in Patients Undergoing Prophylactic Stabilization for Femoral Metastatic Bone Disease in the Veterans Administration Healthcare System

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“…In the study by Phillipp et al, for example, we expect their estimates of survival are probably overestimates. 17 …”

Section: Discussionmentioning

confidence: 99%

“… 10 , 11 However, most studies on metastatic bone disease are small, single-center studies 12 13 14 15 16 or use larger databases with limitations that stem from retrospective design, low granularity, and lack of statistical control. 17 Some studies have used the CPT and ICD codes to define cohorts of patients with metastatic disease of the femur, 17 whereas others do not explicitly state the criteria or methodology that were used to identify patient cohorts. 12 13 14 15 16 , 18 - 20 Efforts to produce studies with larger sample sizes will likely rely on structured data to identify patient cohorts.…”

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Utility of the Current Procedural Terminology Codes for Prophylactic Stabilization for Defining Metastatic Femur Disease

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Introduction: Cohorts from the electronic health record are often defined by the Current Procedural Terminology (CPT) codes. The error prevalence of CPT codes for patients receiving surgical treatment of metastatic disease of the femur has not been investigated, and the predictive value of coding ontologies to identify patients with metastatic disease of the femur has not been adequately discussed. Methods: All surgical cases at a single academic tertiary institution from 2010 through 2015 involving prophylactic stabilization of the femur or fixation of a pathologic fracture of the femur were identified using the CPT and International Classification of Disease (ICD) codes. A detailed chart review was conducted to determine the procedure performed as documented in the surgical note and the patient diagnosis as documented in the pathology report, surgical note, and/or office visit notes. Results: We identified 7 CPT code errors of 171 prophylactic operations (4.1%) and one error of 71 pathologic fracture fixation s(1.4%). Of the 164 prophylactic operations that were coded correctly, 87 (53.0%) had metastatic disease. Of the 70 pathologic operations that were coded correctly, 41 (58%) had metastatic disease. Discussion: The error prevalence was low in both prophylactic stabilization and pathologic fixation groups (4.1% and 1%, respectively). The structured data (CPT and ICD-9 codes) had a positive predictive value for patients having metastatic disease of 53% for patients in the prophylactic stabilization group and 58% for patients in the pathologic fixation group. The CPT codes and ICD codes assessed in this analysis do provide a useful tool for defining a population in which a moderate proportion of individuals have metastatic disease in the femur at an academic medical center. However, verification is necessary.

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“…Philipp et al found that patients with femoral metastases who underwent prophylactic internal fixation had a lower mortality rate than patients treated for pathologic femur fractures ( p = 0.002) [ 60 ]. El Abiad et al reinforced this data and reported that prophylactic fixation was related to a lower risk of complications ( p = 0.02) and shorter hospital stay ( p = 0.01) than post-fracture stabilization [ 61 ].…”

Section: Main Textmentioning

confidence: 99%

What’s new in musculoskeletal oncology

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Mavrogenis

Tsukamoto

2021

BMC Musculoskelet Disord

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We reviewed the recent literature related to primary musculoskeletal tumors and metastatic bone tumors. With regard to primary bone tumors, computer navigation systems and three-dimensional-printed prostheses seem to be new treatment options, especially in challenging anatomical locations, such as the sacrum and pelvis. Regarding the treatment of giant cell tumor of bone, recent studies have suggested that denosumab administration is related to a higher local recurrence rate following curettage, but a lower local recurrence rate following en bloc resection. In addition, there was no difference in the local recurrence rate at five years after surgery between short-term and long-term denosumab therapy. With regard to soft tissue tumors, percutaneous cryoablation appears to be a new treatment option for extra-abdominal desmoid tumors, with encouraging results. Regarding soft tissue sarcomas, a negative surgical margin of < 1 mm is sufficient to control local recurrence. Pexidartinib seems to be a promising systemic therapy for the treatment of tenosynovial giant cell tumors for which surgery is not expected to improve the function of the affected limb. Finally, the life expectancy of patients is the most important factor in determining the optimal surgical procedure for patients with impending or pathological fractures of the long bone due to metastatic bone tumors. Elevated C-reactive protein level was found to be an independent poor prognostic factor at 1 year after surgery for long bone metastases.

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Is There an Association Between Prophylactic Femur Stabilization and Survival in Patients with Metastatic Bone Disease?

Cited by 46 publications

References 37 publications

Mirels Scores in Patients Undergoing Prophylactic Stabilization for Femoral Metastatic Bone Disease in the Veterans Administration Healthcare System

Mirels Scores in Patients Undergoing Prophylactic Stabilization for Femoral Metastatic Bone Disease in the Veterans Administration Healthcare System

Utility of the Current Procedural Terminology Codes for Prophylactic Stabilization for Defining Metastatic Femur Disease

What’s new in musculoskeletal oncology

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