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

Outcomes of distal femoral replacement versus internal fixation for metastatic bone diseases of the distal femur

Background

In clinical practice, internal fixation (IF) is a commonly utilized technique for metastatic bone disease (MBD) to the distal femur. Additionally, distal femoral reconstruction (DFR) has shown to be an effective surgical technique for primary tumors and MBD in the distal femur. The existing body of research comparing these methods has not focused on MBD or pathological fractures and thus does not guide surgical approach in the case of distal femoral MBD.

Methods

A multi-institutional retrospective review of musculoskeletal oncology patients treated surgically with IF (n = 29) or DFR (n = 34) for distal femoral MBD between 2005 and 2023. Overall survival, revision risk, and functional status were assessed.

Results

5-year patient overall survival was 47.9 % (CI, 29.5-77.6 %) and 46.6 % (CI, 31.5-68.8 %), for DFR and IF, respectively (p = 0.91). After competing risk analysis, the 5-year risk of implant revision for DFR was 18 % (95 % CI: 5.1-37 %) and 11 % for IF (95 % CI: 2.4-28 %) (p = 0.3). DFR had longer operative times (p = 0.002), higher blood loss (p < 0.001), and greater postoperative (p = 0.006) complications than IF. In addition, patients undergoing DFR had more distal lesions than patients who received IF (p = 0.003).

Conclusion

Despite similar overall survival and revision rates, IF may be preferable for patients due to its shorter operative time and lower rates of complication than DFR. However, specific anatomic location in the distal femur must be considered prior to deciding which procedure is optimal.

Computed tomography-derived structural analysis for the likelihood of pathologic fracture in canine antebrachial osteosarcoma

Determining the risk of pathologic fracture in dogs with a primary bone tumor would aid in case selection for in-situ treatment options. Prior research found strong relationships between in vitro strength of canine antebrachii with primary bone tumors and CT-derived metrics. This study assesses the prognosis for pathologic fracture in dogs with distal radial bone tumors using CT-derived structural analysis metrics. CT images of the antebrachium in dogs with aggressive osseous lesions of the radius were used to calculate structural rigidity and failure forces, including axial rigidity (AR), craniocaudal bending rigidity (BR), torsional rigidity (TR), and failure forces for a slightly-curved/asymmetric beam (Fs) or a curved beam (Fc). Metrics were compared with the clinical outcome of radial fracture. Eight of 19 dogs with CT-derived metrics developed a radial fracture. The prognostic potential of the metrics to discriminate fractured and nonfractured bones was analyzed using receiver operating characteristic curves (area under the curve), stepwise logistic regression, and classification regression (CART) analyses. Fc was the most sensitive and specific metric for prognosing fracture occurrence (AUC = 0.864). When dog body weight (BW) was included, all five metrics had AUC > 0.705. Fc was the best predictor of fracture using stepwise logistic regression and CART analysis, followed by BR. An indication of fracture probability can be determined by normalizing Fc or BR with dog BW or by using the logistic regression equation of either metric with dog BW. Results warrant further analysis of a larger cohort to evaluate fracture likelihood in dogs with antebrachial bone neoplasia.

Response rate specific to bone metastasis of various cancers for immune checkpoint inhibitors: a systematic review

PURPOSE

Immune checkpoint inhibitors (ICIs) have improved the prognosis of patients with cancer, such as melanoma, renal cell carcinoma, head and neck cancer, non-small cell lung cancer (NSCLC), and urothelial carcinoma. The extension of life expectancy has led to an increased incidence of bone metastases (BM) among patients with cancer. BM result in skeletal-related events, including severe pain, pathological fractures, and nerve palsy. Surgery is typically required for the treatment of BM in patients with an impending fracture; however, it may be avoided in those who respond to ICIs. We systematically reviewed studies analyzing BM responses to treatment with ICIs.

METHODS

This study was conducted in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 statement and registered in the UMIN Clinical Trials Registry (ID: UMIN000053707). Studies reporting response rates based on the Response Evaluation Criteria in Solid Tumors (RECIST) or the MD Anderson Cancer Center (MDA) criteria specific for BM in patients treated with ICIs were included; reports of fewer than five cases and review articles were excluded. Studies involving humans, published in English and Japanese, were searched. The PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched. Ultimately, nine studies were analyzed. The Risk of Bias Assessment tool for Non-randomized Studies was used to assess the quality of studies.

RESULTS

Based on the MDA criteria, complete response (CR) or partial response (PR) was observed in 44-78% and 62% patients treated with ICIs plus denosumab for NSCLC and melanoma, respectively. According to the RECIST, CR or PR was recorded in 5% and 7-28% of patients treated with ICIs for renal cell carcinoma and urothelial carcinoma, respectively.

CONCLUSION

Although response rates to ICIs for BM are poor, patients treated with ICI plus denosumab for bone metastases with impending fractures from NSCLC and melanoma are likely to avoid surgery to prevent fractures.

Reoperation after surgery for bone metastasis of renal cell carcinoma

BACKGROUND AND OBJECTIVE

The prognosis of metastatic renal cell carcinoma (RCC) has markedly improved with the advent of molecular targeted therapies and immune checkpoint inhibitors. However, the therapeutic response in patients with bone metastasis remains low; therefore, surgery still plays a significant role in treatment of bone metastasis. It is important to maintain quality of life for patients with bone metastasis from RCC and avoid reoperation after surgery for bone metastasis. Therefore, we investigated the risk factors for reoperation after surgery in patients with bone metastasis from RCC.

METHODS

We retrospectively studied 103 bones of 97 patients who underwent surgery for bone metastasis of RCC from 2001 to 2023 at our institutions.

RESULTS

Reoperation was performed in 10 (9.7%) of 103 bones. There was no correlation between reoperation-free survival and any of the following variables: preoperative and postoperative radiotherapy, site of bone metastasis, indication for surgery (solitary bone metastasis or impending or pathologic fractures), surgical method (intramedullary nailing fixation, curettage, or en bloc resection), preoperative embolization, or survival.

CONCLUSION

The risk of reoperation for bone metastasis of RCC does not appear to be based on the surgical method.

Clinical efficacy of customized modular prosthesis in the treatment of femoral shaft metastases

Purpose

To examine clinical outcomes of a specialized modular prosthesis used to fill a bone deficiency following removal of femoral shaft metastases.

Methods

Eighteen patients with femoral shaft metastases who underwent en bloc resection and implantation of a personalized modular prosthesis between December 2014 and December 2019 were retrospectively analyzed. Pain, limb function, and quality of life were evaluated using the visual analog scale (VAS), Musculoskeletal Tumor Society (MSTS) scale, International Society of Limb Salvage (ISOLS) scoring system, Karnofsky Performance Status (KPS) scale, and Nottingham Health Profile (NHP) scale. The Kaplan–Meier technique was used to analyze patient survival.

Results

The operation duration was 90–150 min (mean, 115 min), and the osteotomy length was 9–16 cm (mean, 11.72 cm). The patients were followed for 12–62 months (mean, 25.28 months). The VAS and NHP ratings were lower at 3, 6, and 12 months after surgery than before surgery, while the MSTS, ISOLS, and KPS scores were higher after surgery than they had been before. These differences were statistically significant (P&lt;0.05). The survival period was between 7 and 62 months (mean, 20.89 months), and the rates of survival at 1-year and 2-year were 72.22% and 27.78%, respectively. Except for two patients with aseptic prosthesis loosening during the follow-up period, there were no problems.

Conclusion

En bloc excision and implantation of a personalized modular prosthesis can reduce pain and improve the ability of patients with femoral shaft metastases to perform daily activities, thereby improving their quality of life.

Modification to Mirels scoring system location component improves fracture prediction for metastatic disease of the proximal femur

BACKGROUND

Correctly identifying patients at risk of femoral fracture due to metastatic bone disease remains a clinical challenge. Mirels criteria remains the most widely referenced method with the advantage of being easily calculated but it suffers from poor specificity. The purpose of this study was to develop and evaluate a modified Mirels scoring system through scoring modification of the original Mirels location component within the proximal femur.

METHODS

Computational (finite element) experiments were performed to quantify strength reduction in the proximal femur caused by simulated lytic lesions at defined locations. Virtual spherical defects representing lytic lesions were placed at 32 defined locations based on axial (4 axial positions: neck, intertrochanteric, subtrochanteric or diaphyseal) and circumferential (8 circumferential: 45-degree intervals) positions. Finite element meshes were created, material property assignment was based on CT mineral density, and femoral head/greater trochanter loading consistent with stair ascent was applied. The strength of each femur with a simulated lesion divided by the strength of the intact femur was used to calculate the Location-Based Strength Fraction (LBSF). A modified Mirels location score was next defined for each of the 32 lesion locations with an assignment of 1 (LBSF > 75%), 2 (LBSF: 51-75%), and 3 (LBSF: 0-50%). To test the new scoring system, data from 48 patients with metastatic disease to the femur, previously enrolled in a Musculoskeletal Tumor Society (MSTS) cross-sectional study was used. The lesion location was identified for each case based on axial and circumferential location from the CT images and assigned an original (2 or 3) and modified (1,2, or 3) Mirels location score. The total score for each was then calculated. Eight patients had a fracture of the femur and 40 did not over a 4-month follow-up period. Logistic regression and decision curve analysis were used to explore relationships between clinical outcome (Fracture/No Fracture) and the two Mirels scoring methods.

RESULTS

The location-based strength fraction (LBSF) was lowest for lesions in the subtrochanteric and diaphyseal regions on the lateral side of the femur; lesions in these regions would be at greatest risk of fracture. Neck lesions located at the anterior and antero-medial positions were at the lowest risk of fracture. When grouped, neck lesions had the highest LBSF (83%), followed by intertrochanteric (72%), with subtrochanteric (50%) and diaphyseal lesions (49%) having the lowest LBSF. There was a significant difference (p < 0.0001) in LBSF between each axial location, except subtrochanteric and diaphyseal which were not different from each other (p = 0.96). The area under the receiver operator characteristic (ROC) curve using logistic regression was greatest for modified Mirels Score using site specific location of the lesion (Modified Mirels-ss, AUC = 0.950), followed by a modified Mirels Score using axial location of lesion (Modified Mirels-ax, AUC = 0.941). Both were an improvement over the original Mirels score (AUC = 0.853). Decision curve analysis was used to quantify the relative risks of identifying patients that would fracture (TP, true positives) and those erroneously predicted to fracture (FP, false positives) for the original and modified Mirels scoring systems. The net benefit of the scoring system weighed the benefits (TP) and harms (FP) on the same scale. At a threshold probability of fracture of 10%, use of the modified Mirels scoring reduced the number of false positives by 17-20% compared to Mirels scoring.

CONCLUSIONS

A modified Mirels scoring system, informed by detailed analysis of the influence of lesion location, improved the ability to predict impending pathological fractures of the proximal femur for patients with metastatic bone disease. Decision curve analysis is a useful tool to weigh costs and benefits concerning fracture risk and could be combined with other patient/clinical factors that contribute to clinical decision making.

Management of Pathologic Fractures around the Knee: Part 1-Distal Femur

Pathologic fractures secondary to metastatic disease are an increasingly prevalent problem. Such patients require multidisciplinary collaboration to optimize clinical outcomes. An established algorithm for clinical, laboratory, and radiographic work-up will ensure that each patient achieves the best outcome while avoiding catastrophic complications. Metastatic disease to the region of the knee is less commonly encountered than in other regions of the body, but it presents unique difficulties that merit discussion. Part one of this two-part article series will discuss the appropriate work-up of patients with suspected or impending pathologic fracture of the distal femur, highlight biopsy principles, address perioperative nonsurgical treatments that will optimize patient outcomes, and discuss available surgical treatment modalities.

Prophylactic surgical treatment using CT-based rigidity analysis vs. after the fact fracture treatment of pathologic femoral lesions

Background

Accurate comparison of prophylactic surgical treatment (PST) to after fracture treatment (AF) of patients with femoral metastatic disease requires more accurately identifying patients for impending fracture, such as with CT-based structural rigidity analysis (CTRA). This study compares a more accurately defined PST group (of impending fractures defined by CTRA) to AF for metastatic femoral disease.

Methods

PST patients were enrolled and treated by the PI in a longitudinal multicenter study of impending pathologic fractures evaluated for accuracy by CTRA. The AF patients were also treated by the senior author and were identified by retrospective chart review. Fifty-five patients were treated surgically for metastatic femoral lesions and were divided into three groups for the purpose of this study: Group I (AF), Group II (PST-high), and Group III (PST-low). Demographic information, comorbidities, and clinical variables of interest were collected by retrospective chart review; cost data was collected by collaboration with our hospital financial personnel (office of the Chief Financial Officer).

Results

Survival showed statistically significant differences favoring Group II. Transfusions in Group I were nearly twice those of Groups II and III, but there was no statistically significant (NS) difference between groups. Estimated blood loss (EBL) was generally with NS difference. Similarly, there were NS differences in LOS between groups. Discharge disposition showed statistically significant differences between groups (P=0.012, global). Discharge to home was highest in Group II (76%) and lowest in Group I (27%). Discharge to rehab was lowest in Group II (24%) and highest in Group I (47%). There were no discharges to hospice or morgue in Group II, while both occurred in Group I. Mean direct and total costs were highest in Group I ($18,837 and $31,997, respectively) and lowest in Group II ($16,094 and $27,357) but the differences were NS.

Conclusions

This study shows benefits of PST over AF in a group of PST patients more accurately defined to have impending pathologic fractures by CTRA definition.

Clinical Outcome Differences in the Treatment of Impending Versus Completed Pathological Long-Bone Fractures

BACKGROUND

The outcome differences following surgery for an impending versus a completed pathological fracture have not been clearly defined. The purpose of the present study was to assess differences in outcomes following the surgical treatment of impending versus completed pathological fractures in patients with long-bone metastases in terms of (1) 90-day and 1-year survival and (2) intraoperative blood loss, perioperative blood transfusion, anesthesia time, duration of hospitalization, 30-day postoperative systemic complications, and reoperations.

METHODS

We retrospectively performed a matched cohort study utilizing a database of 1,064 patients who had undergone operative treatment for 462 impending and 602 completed metastatic long-bone fractures. After matching on 22 variables, including primary tumor, visceral metastases, and surgical treatment, 270 impending pathological fractures were matched to 270 completed pathological fractures. The primary outcome was assessed with the Cox proportional hazard model. The secondary outcomes were assessed with the McNemar test and the Wilcoxon signed-rank test.

RESULTS

The 90-day survival rate did not differ between the groups (HR, 1.13 [95% CI, 0.81 to 1.56]; p = 0.48), but the 1-year survival rate was worse for completed pathological fractures (46% versus 38%) (HR, 1.28 [95% CI, 1.02 to 1.61]; p = 0.03). With regard to secondary outcomes, completed pathological fractures were associated with higher intraoperative estimated blood loss (p = 0.03), a higher rate of perioperative blood transfusions (p = 0.01), longer anesthesia time (p = 0.04), and more reoperations (OR, 2.50 [95% CI, 1.92 to 7.86]; p = 0.03); no differences were found in terms of the rate of 30-day postoperative complications or the duration of hospitalization.

CONCLUSIONS

Patients undergoing surgery for impending pathological fractures had lower 1-year mortality rates and better secondary outcomes as compared with patients undergoing surgery for completed pathological fractures when accounting for 22 covariates through propensity matching. Patients with an impending pathological fracture appear to benefit from prophylactic stabilization as stabilizing a completed pathological fracture seems to be associated with increased mortality, blood loss, rate of blood transfusions, duration of surgery, and reoperation risk.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Current Overview of Treatment for Metastatic Bone Disease

The number of patients with bone metastasis increases as medical management and surgery improve the overall survival of patients with cancer. Bone metastasis can cause skeletal complications, including bone pain, pathological fractures, spinal cord or nerve root compression, and hypercalcemia. Before initiation of treatment for bone metastasis, it is important to exclude primary bone malignancy, which would require a completely different therapeutic approach. It is essential to select surgical methods considering the patient’s prognosis, quality of life, postoperative function, and risk of postoperative complications. Therefore, bone metastasis treatment requires a multidisciplinary team approach, including radiologists, oncologists, and orthopedic surgeons. Recently, many novel palliative treatment options have emerged for bone metastases, such as stereotactic body radiation therapy, radiopharmaceuticals, vertebroplasty, minimally invasive spine stabilization with percutaneous pedicle screws, acetabuloplasty, embolization, thermal ablation techniques, electrochemotherapy, and high-intensity focused ultrasound. These techniques are beneficial for patients who may not benefit from surgery or radiotherapy.

Bone Metastatic Breast Cancer: Advances in Cell Signaling and Autophagy Related Mechanisms

Bone metastasis is a frequent complication of breast cancer with nearly 70% of metastatic breast cancer patients developing bone metastasis during the course of their disease. The bone represents a dynamic microenvironment which provides a fertile soil for disseminated tumor cells, however, the mechanisms which regulate the interactions between a metastatic tumor and the bone microenvironment remain poorly understood. Recent studies indicate that during the metastatic process a bidirectional relationship between metastatic tumor cells and the bone microenvironment begins to develop. Metastatic cells display aberrant expression of genes typically reserved for skeletal development and alter the activity of resident cells within the bone microenvironment to promote tumor development, resulting in the severe bone loss. While transcriptional regulation of the metastatic process has been well established, recent findings from our and other research groups highlight the role of the autophagy and secretory pathways in interactions between resident and tumor cells during bone metastatic tumor growth. These reports show high levels of autophagy-related markers, regulatory factors of the autophagy pathway, and autophagy-mediated secretion of matrix metalloproteinases (MMP's), receptor activator of nuclear factor kappa B ligand (RANKL), parathyroid hormone related protein (PTHrP), as well as WNT5A in bone metastatic breast cancer cells. In this review, we discuss the recently elucidated mechanisms and their crosstalk with signaling pathways, and potential therapeutic targets for bone metastatic disease.

Complications after intramedullary nail fixation of pathological versus non-pathological femoral shaft fractures: a retrospective cohort study in 233 patients

BACKGROUND

Postoperative adverse events after intramedullary nailing have been reported in patients with metastatic pathological and non-pathological femoral fractures. Other consequences to be considered are readmission and reoperation. Few studies have compared the risks of postoperative adverse events, reoperation, and readmission after intramedullary nailing of pathological and non-pathological femur fractures. This study was designed to test the hypothesis that patients with pathological femoral fractures had more adverse events, readmission, and reoperation following surgical fixation than non-pathological femoral fractures.

METHODS

This was a retrospective observational cohort study, conducted at an academic medical center in Thailand. The data from patients with femoral shaft fractures undergoing long intramedullary nailing, from June 1, 2006, to June 30, 2020, were included. Patients who had a pathological fracture from a primary bone tumor, metabolic bone disease, or inadequate/missing information were excluded. Patients with pathological fractures from metastatic bone disease were assigned to be the pathological group whereas those with traumatic fractures were assigned to be the non-pathological group. The primary outcome was the risk of inpatient adverse events as compared between the two groups. The secondary outcome was the risk of consequences after discharge as compared between the two groups. Outcomes were analyzed by using multivariate logistic regression analysis.

RESULTS

The total number of patients was 48 in the pathological fracture group and 185 in the non-pathological group. There were significantly higher rates of surgical and medical adverse events in patients with pathological fractures compared to patients with non-pathological fractures. After adjusting for potential confounding factors in multivariate regression analysis, patients with pathological fractures had higher odds of both adverse surgical (adjusted OR 2.43, 95 % CI 1.15-5.13) and medical adverse events (adjusted OR 2.81, 95 % CI 1.13-7.03).

CONCLUSIONS

Patients with metastatic pathological femoral shaft fractures undergoing intramedullary nailing were more likely to experience postoperative adverse events than patients with non-pathological fractures.

Skeletal Survey in Multiple Myeloma: Role of Imaging

Bone disease is the hallmark of multiple myeloma. Skeletal lesions are evaluated to establish the diagnosis, to choose the therapies and also to assess the response to treatments. Due to this, imaging procedures play a key role in the management of multiple myeloma. For decades, conventional radiography has been the standard imaging modality. Subsequently, advances in the treatment of multiple myeloma have increased the need for an accurate evaluation of skeletal disease. The introduction of new high performant imaging tools, such as whole-body lowdose computed tomography, different types of magnetic resonance imaging studies, and 18F-fluorodeoxyglucose positron emission tomography, replaced the conventional radiography. In this review, we analyze the diagnostic potentials, indications of use, and applications of the imaging tools nowadays available. Whole-body low-dose CT should be considered as the imaging modality of choice for the initial assessment of multiple myeloma lytic bone lesions. MRI is the gold-standard for the detection of bone marrow involvement, while PET/CT is the preferred technique in the assessment of response to therapy. Both MRI and PET/CT are able to provide prognostic information.

A pituitary cup biopsy is more accurate than reamings for histological diagnosis of intramedullary lesions during nailing of impending and pathologic fractures: a retrospective matched cohort analysis

INTRODUCTION

Histologic diagnosis of the lesion is important while intramedullary nailing of a pathologic or impending fracture of a long bone. A biopsy can be performed extramedullary using a targeted sampling device such as a pituitary rongeur or intramedullary from the bone removed from the reamer during preparation of the intramedullary canal. The purpose of this study is to compare a cup pituitary rongeur vs. a reaming biopsy from the intramedullary canal during the treatment of pathologic bone lesions with an intramedullary nail.

METHODS

An IRB approved retrospective case control study was performed on 46 consecutive patients who underwent an IMN for pathologic fracture or impending pathologic fracture with an obvious lytic lesion with a known metastatic primary. A laryngeal cup pituitary forceps' rongeur was used in 25 patients and the intramedullary reamer as it passed the lesion was used in 21 patients. Histopathology reports were assessed for (1) adequacy of bone sample (defined as containing sufficient bone and marrow-derived tissue to allow complete histological analysis) and (2) tumor tissue diagnosis. A standard approach for IMN was used.

RESULTS

Twenty-three of 25 cup biopsy cases (92%) had positive pathology that corresponded to the primary cancer. Eleven of 21 reaming cases (52.4%) had positive pathology that corresponded to the primary cancer (p = 0.0117).

CONCLUSION

The use of an intramedullary cup biopsy forceps is better than reamings to diagnose pathological lesions of impending and pathological fractures in long bones caused by metastatic lesions.

Surgical management of proximal femoral metastasis: Fixation or hip replacement? A 309 case series

INTRODUCTION

The proximal femur is the most frequent operative site for metastasis, but there is no consensus between internal fixation and hip replacement. The present multicenter retrospective observational study sought: (1) to compare early clinical results between internal fixation and hip replacement for proximal femoral metastasis (PFM), and (2) to assess events affecting survival.

HYPOTHESIS

The study hypothesis was that internal fixation and hip replacement give comparable clinical results, operative site complications rates and survival.

MATERIAL AND METHODS

The series comprised 309 cases, 10 of which were bilateral, in 182 females and 117 males, with a mean age of 67.2±11.5 years and 62.5±13.2 years, respectively. Primaries were mainly breast (118; 38.2%), lung (85; 25.5%) or kidney (40; 12.9%). PFM was revelatory in 114 cases (36.9%). There was visceral involvement in 142 patients (46%), multiple peripheral bone involvement in 212 (68.6%), and spinal involvement in 134 (43.4%). There were 124 pathologic fractures (40%), 51 of which were revelatory. Metastases were cervicocephalic in 135 cases (43.7%), metaphyseal in 166 (53.7%) and both in 8 (2.6%). PFM was osteolytic in 90% of cases, managed by hip replacement in 161 cases and internal fixation in 148 (12 screwed plates, 136 nails). Seventy-seven patients had postoperative radiation therapy.

RESULTS

After hip replacement (n=144), walking was normal in 35 cases (24.3%), impaired but unassisted in 53 (36.8%), with 1 forearm crutch in 24 (16.6%), 2 crutches or a frame in 26 (18%), and impossible in 6 (4.1%). After nailing (n=125), results were respectively 38 (30.4%), 47 (37.6%), 15 (12%), 18 (14.4) and 7 (5.6%). Recovery of normal walking capacity did not significantly differ according to technique (p=0.162); nor did pain or function. Recovery of normal walking capacity was better after preventive surgery (p<0.001). Perioperative complications comprised: 10 cases of severe blood loss, 7 pulmonary embolisms, 6 digestive hemorrhages, and 5 lung infections. Secondarily, there were 11 infections (7 after hip replacement, 2 after nailing, 2 after plate fixation), 7 progressive osteolyses and 5 fractures. Complications rates were significantly higher with plate fixation, with no difference between nailing and hip replacement. Survival did not significantly differ between hip replacement (12 months [95% CI: 7-19]), nailing (7 months [95% CI: 6-11]) and plate fixation (16 months [95% CI: 6-not calculable]).

CONCLUSIONS

Clinical results and survival were comparable between hip replacement and nailing, confirming the study hypothesis, in agreement with the literature. Each technique has its indications. Patients with severely impaired walking capacity benefited greatly from surgery. The importance of preventive surgery was highlighted.

LEVEL OF EVIDENCE

IV, retrospective study.

When and where do patients with bone metastases actually break their femurs?

AIMS

Accurate estimations of the risk of fracture due to metastatic bone disease in the femur is essential in order to avoid both under-treatment and over-treatment of patients with an impending pathological fracture. The purpose of the current retrospective in vivo study was to use CT-based finite element analyses (CTFEA) to identify a clear quantitative differentiating factor between patients who are at imminent risk of fracturing their femur and those who are not, and to identify the exact location of maximal weakness where the fracture is most likely to occur.

METHODS

Data were collected on 82 patients with femoral metastatic bone disease, 41 of whom did not undergo prophylactic fixation. A total of 15 had a pathological fracture within six months following the CT scan, and 26 were fracture-free during the five months following the scan. The Mirels score and strain fold ratio (SFR) based on CTFEA was computed for all patients. A SFR value of 1.48 was used as the threshold for a pathological fracture. The sensitivity, specificity, positive, and negative predicted values for Mirels score and SFR predictions were computed for nine patients who fractured and 24 who did not, as well as a comparison of areas under the receiver operating characteristic curves (AUC of the ROC curves).

RESULTS

The sensitivity of SFR was 100% compared with 88% for the Mirels score, and the specificity of SFR was 67% compared with 38% for the Mirels score. The AUC was 0.905 for SFR compared with 0.578 for the Mirels score (p = 0.008).

CONCLUSION

All the patients who sustained a pathological fracture of the femur had an SFR of > 1.48. CTFEA was far better at predicting the risk of fracture and its location accurately compared with the Mirels score. CTFEA is quick and automated and can be incorporated into the protocol of CT scanners. Cite this article: Bone Joint J 2020;102-B(5):638-645.

Pathologic Versus Native Hip Fractures: Comparing 30-day Mortality and Short-term Complication Profiles

BACKGROUND

A large body of research on native hip fractures has resulted in several evidence-based guidelines aimed at improving postsurgical care for these patients. In contrast, there is a paucity of data on pathologic hip fractures, and whether native hip fracture protocols are generalizable to this population is unknown. The purpose of this study was to compare mortality rates and complication profiles between patients with pathologic and native hip fractures.

METHODS

Using the American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) database, we identified patients who underwent surgical treatment for pathologic and native hip fractures from 2007 to 2017 and 2601 matched pairs were identified using propensity scoring. Baseline covariates were controlled for, and rates of 30-day postoperative complications and mortality were compared using McNemar's test.

RESULTS

Pathologic hip fracture patients experienced significantly higher rates of death (6.3% vs 4.3%, P < .001), serious adverse events (17.3% vs 13.5%, P < .001), minor complications (34.3% vs 29.1%, P < .001), extended postoperative lengths of stay (30.2% vs 25.9%, P < .001), readmissions (11.9% vs 8.4%, P < .001), thromboembolic complications (3.0% vs 1.6%, P < .001), and perioperative transfusions (31.5% vs 26.4%, P < .001) compared to native hip fracture patients.

CONCLUSION

Pathologic hip fractures result in significantly higher complication rates than native hip fractures after surgical treatment, suggesting that guidelines for native hip fractures may not be generalizable for pathologic hip fractures. Orthopedic surgeons should closely monitor these patients for deep vein thrombosis, utilize blood sparing techniques, and employ a multidisciplinary approach to help manage and prevent a more heterogenous profile of postsurgical complications.

Is Delayed Time to Surgery Associated with Increased Short-term Complications in Patients with Pathologic Hip Fractures?

BACKGROUND

Delayed time to surgery of at least 2 days after hospital arrival is well known to be associated with increased complications after standard hip fracture surgery; whether this association is present for pathologic hip fractures, however, is unknown.

QUESTIONS/PURPOSES

(1) After controlling for differences in patient characteristics, is delayed time to surgery (at least 2 days) for patients with pathologic hip fractures independently associated with increased complications compared with early surgery (fewer than 2 days)? (2) What preoperative factors are independently associated with major complications and mortality after surgery for pathologic hip fractures?

METHODS

A retrospective study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database of pathologic hip fractures (including femoral neck, trochanteric, and subtrochanteric fractures) from 2007 to 2017. This database was chosen over other databases given the high-quality preoperative medical history and postoperative complication (including readmissions, reoperations, and mortality) data collected from patient medical records through the thirtieth postoperative day. Patients were identified using Common Procedural Terminology codes for hip fracture treatment (THA, hemiarthroplasty, proximal femur replacement, intramedullary nail, and plate and screw fixation) with associated operative diagnoses for pathologic fractures as identified with International Classification of Diseases codes. A total of 2627 patients with pathologic hip fractures were included in this study; 65% (1714) had surgery within 2 days and 35% (913) had surgery after that time. Patient demographics, hospitalization information, and 30-day postoperative complications were recorded. Differences in characteristics between patients who underwent surgery in the early and delayed time periods were assessed with chi-square tests for categorical variables and t-tests for continuous variables. Delayed-surgery patients were more medically complex at the time of admission than early-surgery patients, including having higher American Society of Anesthesiologists classification (mean ± SD 3.18 ± 0.61 versus 2.94 ± 0.60; p < 0.001) and prevalence of advanced, "disseminated" cancer (53% versus 39%; p < 0.001). Propensity-adjusted multivariable logistic regression analyses were performed to assess the effect of delayed time to surgery alone on the various outcome measures. Additional independent risk factors for major complications and mortality were identified using backwards stepwise regressions.

RESULTS

After controlling for baseline factors, the only outcome associated with delayed surgery was extended postoperative length of stay (odds ratio 1.94 [95% CI 1.62 to 2.33]; p < 0.001). Delayed surgery was not associated with any postoperative complications, including major complications (OR 1.23 [95% CI 0.94 to 1.6]; p = 0.13), pulmonary complications (OR 1.24 [95% CI 0.83 to 1.86]; p = 0.29), and mortality (OR 1.26 [95% CI 0.91 to 1.76]; p = 0.16). Histories of chronic obstructive pulmonary disease (OR 2.48), congestive heart failure (OR 2.64), and disseminated cancer (OR 1.68) were associated with an increased risk of major complications, while dependent functional status (OR 2.27), advanced American Society of Anesthesiologists class (IV+ versus I-II, OR 4.81), and disseminated cancer were associated with an increased risk of mortality (OR 2.2; p ≤ 0.002 for all).

CONCLUSIONS

After controlling for baseline patient factors, delayed time to surgery was not independently associated with increased 30-day complications after surgical treatment of pathologic hip fractures. These results are in contrast to the traditional dogma for standard hip fractures that surgery within 2 days of hospital arrival is associated with reduced complications. Although surgery should not be delayed needlessly, if the surgeon feels that additional time could benefit the patient, the results of this study suggest surgeons should not expedite surgery because of the risk of surgical delay observed for standard hip fractures.

LEVEL OF EVIDENCE

Level III, therapeutic study.

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

A 62-year-old woman presented with a pathologic femoral fracture. She underwent bilateral femoral intramedullary nailing (IMN) fixation, and her postoperative course was complicated by worsening lower extremity weakness and foot drop. Lumbar imaging identified vertebral compression fractures with foraminal encroachment. The patient was thereafter started on a radiotherapy regimen and discharged home. Pathologic fractures most commonly occur in the proximal femur. In some patients, contralateral weakness suggests an additional fracture, though it may represent spinal involvement. This case explores multiple current treatment options for pathologic fractures of the femur and spine and suggests that prophylactic endoprostheses may have greater selective benefit than IMN fixation.

Short-Term Morbidity and Mortality After Hemiarthroplasty and Total Hip Arthroplasty for Pathologic Proximal Femur Fractures

BACKGROUND

As oncology patients have increasing life expectancies, total hip arthroplasty (THA) may become an important treatment option for pathologic proximal femur fractures (PPFFs). Although THA and hemiarthroplasty (HA) have been compared for native hip fracture treatment, no data on short-term morbidity and mortality are available in the pathologic setting. The purpose of this study is to compare short-term morbidity and mortality of HA vs THA for PPFFs.

METHODS

The National Surgical Quality Improvement Program database was queried from 2007 to 2017 for patients with PPFFs treated with HA or THA. Propensity-adjusted logistic regressions were implemented to compare 30-day morbidity and mortality between procedures. Backwards stepwise regression was then used to determine independent predictors of treatment with HA compared to THA.

RESULTS

In adjusted analysis, THA was associated with longer operative times (120.3 ± 5.6 vs 98.7 ± 4.9 minutes, P < .001); however, there were no differences between THA and HA with regard to 30-day rates of major complications (P = .3), minor complications (P = .77), reoperations (P = .99), readmissions (P = .35), or deaths (P = .63). Older age (P < .001), dependent functional status (P = .02), and the presence of disseminated cancer (P = .049) were predictive of undergoing HA compared to THA.

CONCLUSION

As patients with metastatic cancer continue to live longer with their disease, the durability of surgical reconstruction to treat PPFFs is becoming increasingly important. This study demonstrated no significant differences in 30-day complications between PPFF patients treated with THA or HA after controlling for underlying confounders. These results suggest that THA can be utilized to treat certain patients with PPFFs, and future work is warranted to examine long-term functional outcomes.

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

BACKGROUND AND OBJECTIVES

Large scale data on the treatment of pathologic proximal femur fractures (PPFFs) are lacking. The purpose of this study was to evaluate trends in patient demographics, complication rates, and relative utilization rates of various techniques associated with PPFFs.

METHODS

The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) database was queried for PPFFs from 2009 to 2017. Patient demographics, 30-day complications, and utilization rates were recorded. Trends in these variables were determined over the study period.

RESULTS

Most patient demographics did not change during the study period. There were no trends toward decreasing rates of major complications (P = .82), reoperations (P = .65), non-home discharges (P = .17), readmissions (P = .07), or deaths (P = .75); transfusion rates significantly decreased (P < .001). Rates of hemiarthroplasty decreased (P = .03) and rates of intramedullary nailing increased (P = .001).

DISCUSSION

Despite advances in cancer therapeutics, the average PPFF patient has not significantly changed over the past decade. Similarly, most short-term outcomes after PPFF surgery have not improved, demonstrating a need for improved perioperative protocols. Finally, rates of IMN fixation are increasing while rates of HA are falling at NSQIP hospitals. Given that orthopedic oncologists favor endoprosthetic reconstruction in most cases, there may be a need for increased communication between orthopedic oncologists and other members of the orthopedic community treating PPFFs.