Prophylactic Versus Postfracture Stabilization for Metastatic Lesions of the Long Bones: A Comparison of 30-day Postoperative Outcomes

Abstract

Introduction: The goals of orthopaedic treatment for most patients with osseous metastases are to control pain, maintain function, and maximize quality of life and time at home. The aim of this study was to determine differences in 30-day postoperative morbidity and mortality between patients who underwent prophylactic versus postfracture stabilization for metastatic lesions of long bones. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent prophylactic fixation (n = 461) or postfracture stabilization (n = 856) for pathologic fractures because of metastatic lesions of long bones from 2006 to 2016. The groups were compared with respect to several potential confounders using Student t, Kruskal-Wallis, and χ2 tests. Logistic and Poisson regression models (inclusion threshold of P < 0.1) were used to assess the associations of functional status with outcomes. The alpha level was set at 0.05. Results: Prophylactic fixation was associated with a lower risk of major medical complications (odds ratio = 0.64; 95% confidence interval [CI], 0.45 to 0.93; P = 0.02), discharge to a care facility rather than home (odds ratio = 0.48; 95% CI, 0.36 to 0.63; P < 0.01), and lower risk of a longer hospital stay (incidence risk ratio = 0.86; 95% CI, 0.74 to 0.96; P = 0.01) compared with postfracture stabilization. No significant difference was found in the risk of unplanned revision surgery or 30-day postoperative mortality between the two groups. Conclusion: Although prevention of pathologic fractures caused by metastatic disease may not always be possible, patients who underwent prophylactic stabilization had a lower risk of major complications within 30 days postoperatively and shorter hospital stays compared with patients who underwent postfracture stabilization. Level of Evidence: Level IV, retrospective cohort

Predicting Pathologic Bone Lesions Using Scout Computed Tomography (CT) Imaging

“…In addition, the mean length of stay was eight days after complete fracture fixation versus only four days for an impending fracture prophylactic fixation [16]. [18]. While the literature supports the early treatment of impending fractures to lower the risk of complications, shorten hospital stays, and lower overall health costs, identifying at-risk lesions is challenging.…”

“…Similarly, prophylactic fixation had a decreased length of stay and total charges (−3,405 USD, p =0.001) compared to acute fracture treatment [ 17 ]. A 2019 article by El Abiad et al used the American College of Surgeons National Surgical Quality Improvement Program database to compare 30-day postoperative outcomes in prophylactic versus postfracture stabilization for metastatic lesions of the long bones and found lower risk of discharge to a facility other than home (OR 0.48, p =0.02), shorter length of hospital stay (IRR = 0.86, p =0.01), and lower risk of major medical complications (OR = 0.64, p < 0.01) compared with postfracture stabilization [ 18 ]. While the literature supports the early treatment of impending fractures to lower the risk of complications, shorten hospital stays, and lower overall health costs, identifying at-risk lesions is challenging.…”

A Case of Lower Extremity Weakness with Foot Drop Following Intramedullary Nailing of a Pathologic Femoral Fracture

“…In their retrospective study of 332 cases of prophylactic femoral fixation and 288 cases of pathologic fracture fixation, they report that when controlling for disseminated cancer, the odds of experiencing an adverse event (major or minor), death, or prolonged hospital stay were no greater in prophylactic fixation than in fracture fixation for up to 30 days [4]. Recent data further suggest that patients who undergo prophylactic stabilization have a lower risk of major complications within 30 days postoperatively, and shorter hospital stays when compared to patients who underwent postfracture stabilization [5]. Despite positive short-term outcomes for both prophylactic and corrective fixation, however, nonunion and/or tumor progression may lead to long-term hardware failure.…”

Diagnosis and referral of adults with suspected bony metastases

“…However, reactive fixation can be more difficult technically to undertake, and may lead to a poorer outcome in terms of patient quality of life 3041. Studies comparing prophylactic and reactive metastatic lesion fixation are retrospective in nature with no randomised controlled trials available; however, cohorts are of moderate-large size with adequate follow-up, given the poor survival in this patient group 4243. The principles of orthopaedic management are summarised in box 1.…”

“…Irrespective of prognosis, symptomatic metastases are usually treated with surgery as a palliative procedure. In frail patients with a short prognosis (1-6 months), prophylactic “damage control” surgery (eg, with an intramedullary nail or plate, fig 4a, 4b) can prevent fracture, relieve pain, and improve likelihood of discharge to the patient’s own home 42434748. Patients most likely to benefit from this approach include those with multiple metastases, an expected survival of 1-6 months,1249 or symptoms such as severe pain or difficulty mobilising 13.…”