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Minor Complications Associated with Increased Mortality Risk After Surgery for Metastases in Long Bones

Key findings

  • In a retrospective cohort of 1,090 patients with metastatic bone disease who had surgery for a pathologic fracture or impending fracture in a long bone, the 30-day rate of postoperative complications was 31%
  • Factors associated with 30-day postoperative complications were rapidly growing primary tumors, multiple bone metastases, pathologic fracture, surgery of the lower extremities, hypoalbuminemia, hyponatremia and high white blood cell count
  • The risk of death within one year was substantially increased in patients with minor complications as well as those with major complications
  • Patients at high risk of postoperative complications should be considered for nonoperative treatment or be monitored closely after surgery

Cancer patients with metastases in the long bones usually are in poor physical condition and have a poor prognosis. Some of these patients benefit from surgery as palliation, but surgery isn't always the best option because of the risk of postoperative complications. Several studies have quantified that risk, but none has systematically assessed the different kinds of complications that occur or their consequences.

In a retrospective study, Bas Bindels, researcher in the Skeletal Oncology Research Group at the Mass General Cancer CenterJoseph H. Schwab MD, chief of the Orthopaedic Spine Center at Massachusetts General Hospital, director of Spine Oncology and co-director of the Stephan L. Harris Chordoma Center at the Mass General Cancer Center, and colleagues identified a high rate of postoperative complications in patients with metastases in the long bones, which was associated with increased mortality. The findings are published in Clinical Orthopaedics and Related Research.

Study Details

The research team reviewed 1,090 adults who underwent surgery for a pathologic fracture or impending fracture in a long bone between January 1999 and December 2016 and had a diagnosis of metastatic disease in the treated bone. The median follow-up time after surgery was 216 days.

Postoperative complications were classified according to the Clavien–Dindo system published in Annals of Surgery:

  • Grade I — deviation from the postoperative course without intervention (disregarded)
  • Grade II — pharmacologic intervention
  • Grade III — surgical, endoscopic or radiologic intervention
  • Grade IV — intensive care unit management
  • Grade V — death

Incidence of Complications

  • Within 30 days, 333 patients (31%) had at least one complication
  • 118 patients (11% of all patients and 35% of those with complications) had at least one major complication (grade III–V)
  • 231 patients (69% of those with complications) had only one complication, 77 (23%) had two complications and 25 (7.5%) had more than two
  • The most common complications were urinary tract infection (9.4%), pneumonia (6.8%), delirium (6.5%), pulmonary embolism (3.4%) and atrial fibrillation (3.0%)

Predisposing Factors

In multivariate analysis, seven factors were independently associated with increased risk of complications within 30 days:

  • Rapidly growing primary tumor (OR, 1.6)
  • Multiple bone metastases (OR, 1.6)
  • Pathologic fracture (OR, 1.5)
  • Lower-extremity surgery (OR, 2.2)
  • Albumin level < 3.5 g/dL (OR, 1.7)
  • Sodium level < 135 mmol/L (OR, 1.5)
  • White blood cell count > 1 × 1,000/mm3 (OR, 1.7)

Survival

Both minor and major complications within 30 days after surgery were associated with an increased risk of death within one year:

  • Grade II — HR, 1.6; 95% CI, 1.3–1.8; P < .001
  • Grades III–IV — HR, 3.4; 95% CI, 2.8–4.2; P < .001

At all time points during the first year after surgery, the probability of death was highest for patients who had major complications and lowest for patients with no complications.

Takeaways

When considering whether a cancer patient with metastasis in a long bone will benefit from operative treatment, orthopedic surgeons should carefully assess disease status. Rapid-growing primary tumors such as lung and esophageal cancer, the presence of multiple bone metastases, the presence of a pathologic fracture and surgery of the lower extremities all increase the risk of postoperative complications.

Albumin level, sodium level and white blood cell count also predispose the patient to complications and should be part of the standard preoperative work-up. Patients with an increased risk of postoperative complications should be considered for nonoperative treatment. However, negative consequences of nonoperative treatment, including pain, loss of function and loss of mobility, should be considered as well.

Knowledge about postoperative complications should be used to counsel patients about possible adverse events and to monitor high-risk patients closely to allow early treatment in case of a complication.

31%
of patients with metastasis in a long bone had a postoperative complication

11%
of patients with metastasis in a long bone had a major postoperative complication

3x
increased risk of death at 1 year in patients with metastasis in a long bone who had a major postoperative complication

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