What Is the Adverse Event Profile After Prophylactic Treatment of Femoral Shaft or Distal Femur Metastases?

Abstract

Background Prophylactic surgical treatment of the femur is commonly offered to patients with metastatic disease who have a high risk of impending pathologic fracture. Prophylactic fixation is associated with improved functional outcomes in appropriate patients selected based on established criteria, but the perioperative complication profile has received little attention. Given the substantial comorbidity in this population, it is important to characterize surgical risks for surgeons and patients to improve treatment decisions. Questions/purposes (1) What is the incidence of postoperative adverse events after prophylactic surgical stabilization of metastatic lesions of the femoral shaft or distal femur? (2) How does this complication profile compare with stabilization of pathologic fractures adjusted for differences in patient demographics and comorbidity? Methods We performed a retrospective study using the National Surgical Quality Improvement Program (NSQIP) database. We identified patients undergoing prophylactic treatment of the femoral shaft or distal femur by Current Procedural Terminology (CPT) codes. Patients undergoing treatment of a pathologic fracture were identified by CPT code for femur fracture fixation as well as an International Classification of Diseases code indicating neoplasm or pathologic fracture. We tracked adverse events, operative time, blood transfusion, hospital length of stay, andThe institution of one or more of the authors (RPM) has received, during the study period, funding from the James G. Hirsch, MD, Endowed Medical Student Fellowship at Yale University (New Haven, CT, USA) in an amount less than USD 10,000. One of the authors (JNG) certifies that he, or a member of his immediate family, has received or may receive payments or benefits, during the study period, an amount of less than USD 10,000 from Andante Medical Services (White Plains, NY, USA); an amount of less than USD 10,000 from Vertex (Boston, MA, USA); an amount of less than USD 10,000 from Bioventus (Durham, NC, USA); an amount of USD 10,000 to USD 100,000 from Stryker (Kalamazoo, MI, USA); and an amount of less than USD 10,000 from the Orthopaedic Trauma Association (Rosemont, IL, USA), none related to this study. Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use. Each author certifies that his institution waived approval for the reporting of this investigation and that all investigations were conducted in conformity with ethical principles of research.

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

“…However, as was highlighted in research by McLynn et al, the perioperative complication profile has received little attention. 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].…”

Trends in the surgical treatment of pathological proximal femur fractures in the United States

“…Consistent with previous methods, patients with PPFFs were identified by using International Classification of Diseases (ICD) codes for pathologic fracture (ICD‐9: 733.1X or ICD‐10: M84.4/5X) that were surgically treated with Common Procedural Terminology (CPT) codes for hip hemiarthroplasty (27125/27236), total hip arthroplasty (27130), fixation of proximal femur fracture with plate/screw construct (27244), or fixation of proximal femur fracture with intramedullary implant (27245) . Patients with femoral shaft and distal femur fractures were not included in this study to provide a relatively uniform population of PPFFs.…”

CORR Insights®: What Is the Adverse Event Profile After Prophylactic Treatment of Femoral Shaft or Distal Femur Metastases?

“…They found that when controlled for differences in patient characteristics, patients who underwent prophylactic stabilization benefited only in terms of a lower likelihood of transfusion compared to patients treated after a pathologic fracture occurred. The high overall complication (18%), major complication (14%), and death rates (7%) of the prophylactically treated group showed that the risks of prophylactic stabilization are not worse than that of treatment after fracture, and that the advantages are minimal [4]. Obviously, there are some situations where, owing to debilitating pain or failure of other treatments, prophylactic treatment is reasonable even with an equivalent risk compared to postfracture treatment.…”

“…Moreover, the risk of treatment complications, as illustrated in the current study [4], should be considered to ensure that prophylactic treatment is at the least not worse than treating the fracture after the fact. In the current study, McLynn and colleagues [4] present their National Surgical Quality Improvement Program (NSQIP)-based complication analysis for the femoral shaft and more distal femur.…”

“…Moreover, the risk of treatment complications, as illustrated in the current study [4], should be considered to ensure that prophylactic treatment is at the least not worse than treating the fracture after the fact. In the current study, McLynn and colleagues [4] present their National Surgical Quality Improvement Program (NSQIP)-based complication analysis for the femoral shaft and more distal femur. They found that when controlled for differences in patient characteristics, patients who underwent prophylactic stabilization benefited only in terms of a lower likelihood of transfusion compared to patients treated after a pathologic fracture occurred.…”