CORR Insights®: Is There an Association Between Prophylactic Femur Stabilization and Survival in Patients with Metastatic Bone Disease?

Abstract

Prophylactic stabilization is a topic of interest both to general orthopaedic surgeons and orthopaedic oncologists. The benefits of prophylactic stabilization compared to treatment after the pathologic fracture occurs remain poorly substantiated. Yet, it is widely assumed that “orthopaedic surgeons know it is best to stabilize lesions in the femoral neck prior to fracture.” Unfortunately, this presumption is largely unsupported by evidence. Indeed, few articles speak to this topic, and robust data supporting prophylactic fixation are sparse. According to the Nationwide Inpatient Sample (NIS), pathologic fractures have been associated with increased morbidity and mortality [2]. Decreasing that morbidity and mortality would obviously be desirable. As such, a comparison using the NIS database between patients treated with pathologic bone lesions before and after fracture suggests advantages for prophylactic stabilization in terms of blood transfusion, risk of urinary tract infection, and discharge to home. However, these advantages come at the expense of a higher likelihood of venous thromboembolic disease in the group that received prophylactic surgery [1]. According to the National Surgical Quality Improvement Program, prophylactic stabilization is associated with a lower rate of blood transfusion compared to pathologic fracture treatment after controlling for patient differences [10]. Additionally, compared to pathologic fracture treatment, prophylactic stabilization resulted in less blood loss, shorter hospital stay, higher percentage discharge to home, higher resumption of supportfree ambulation, and greater ability to avoid endoprosthetic reconstruction [16]. One study showed reduced direct costs and length of stay in those treated prophylactically compared to after fracture [4]. The current paper by Phillip and colleagues [17] may now be added to the knowledge base purporting a benefit to prophylactic stabilization. In this case, the purported benefit is survival.