Prophylactic Stabilization of Impending Fracture Improves Survival in Patients With Long Bone Metastases

Prophylactic surgery is often considered for patients who have a long bone metastatic lesion at substantial risk of fracture because fixation of an impending fracture may be technically easier than trying to stabilize a completed fracture. The number of surgical options is typically greater and the procedure can be scheduled around systemic therapy.

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Researchers at Massachusetts General Hospital conducted the first propensity score–matched study that compared outcomes of surgery for impending versus completed pathological fracture in cancer patients. They observed significantly longer one-year survival with prophylactic surgery, along with reductions in blood loss, transfusions, procedure time and reoperation risk.

Olivier Q. Groot, MD, research fellow in the Department of Orthopaedic Surgery at Massachusetts General Hospital, Joseph H. Schwab MD, chief of the Orthopaedic Spine Center and director of Spine Oncology at Mass General, and co-director of the Stephan L. Harris Chordoma Center at Mass General Cancer Center, and colleagues report the details in the Journal of Bone & Joint Surgery.

Study Methods

The researchers began by reviewing data on 1,064 consecutive adults who underwent surgery between 1999 and 2017 for an impending pathological or completed pathological fracture due to long bone metastasis, excluding sarcoma metastasis. In general, prophylactic fixation was recommended for patients with a Mirels score ≥8.

Patients were matched on 22 variables known to be associated with survival after long bone metastases, and those who could not be paired were excluded. That left 270 patients with impending fractures and 270 matched patients with completed fractures.

Primary Outcomes

• 90-day survival—73% for impending fractures vs. 71% for completed fractures (HR=1.13; P=0.48)
• 1-year survival—46% vs. 38% (HR=1.28; P=0.03)

Secondary Outcomes

• Median intraoperative blood loss—0.2 L for impending fractures vs. 0.3 L for completed fractures (P=0.03)
• Median number of perioperative blood transfusions—0 vs. 1 (P=0.01)
• Anesthesia time—2.8 vs. 3.1 hours (P=0.04)
• Reoperation rate—3.3% vs. 6.7% (OR=2.50; P=0.049)

The duration of hospitalization and 30-day rate of systemic postoperative complications did not differ between the two groups.

Applying the Findings

In light of the demonstrated benefits of prophylactic surgical stabilization, radiation oncologists, medical oncologists and orthopedic oncologists should work together to identify patients with long bone metastases who are good candidates. These patients' limited survival must be considered when helping them make decisions about the surgery.

A poster summarizing this research was honored with the "Clinical and Outcome Research Award" at the 2021 Mass General Clinical Research Day. The research was selected from a pool of 253 abstracts submitted by Mass General researchers.

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