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• W2968579849 abstract "Where Are We Now? 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 support-free 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. Where Do We Need To Go? In order to understand and accurately document a benefit for prophylactic stabilization, it is important to understand whether the patients treated prophylactically really were at risk of fracture. Without the assurance that we are comparing prophylactic stabilization of actual impending pathologic fractures to treatment after fracture, we risk simply showing that treatment of patients without increased risk is better than those after fracture. If the latter were the case, it would likely be easy to demonstrate a benefit in terms of numerous endpoints, but it could also potentially lead to adding unnecessary risk to patients who may not need surgery at all. That is a danger we should strive to avoid. Moving forward, we need to more precisely refine the definition of impending pathologic fractures and include this in documentation of fracture risk assessment. A working definition used for impending pathologic fracture decision-making in our documentation and analysis could provide provide better understanding of the data presented as well as better scientific validation of what most orthopedic surgeons believe to be obvious benefits of prophylactic stabilization. Numerous techniques for defining impending fractures are available. However, none are sufficiently accurate. Traditionally, surgeons use the Harrington criteria or numerous other plain film-based assessments, but they have been largely shown to be poorly predictive [5, 9, 19]. Frequently used modern techniques include Mirels criteria, L-cort, and Carnesale’s definition, but each of these, while sensitive, are not specific enough [5, 7, 19]. Promising newer techniques such as CT-based structural rigidity analysis (CTRA), finite element modeling (FEM), positron emission tomography–CT (PET-CT), Single-photon emission-CT (SPECT-CT), and/or machine learning may help us to improve our specificity and positive predictive value for impending fractures [11-15]. However, these techniques are yet to be widely available and continue to be laborious, time-consuming, and generally impractical for current clinical practice. Regardless, further study of these evolving approaches and their inclusion in documentation of the definition of impending pathologic fracture is needed to improve support for the current clinical practice of prophylactic stabilization. How Do We Get There? First, more attention needs to be paid to patients receiving prophylactic stabilization. Do those patients truly need to be fixed or are we “cherry picking” the easiest ones with the better prognoses? While the intent of Phillip and colleagues [17] and prior studies [1, 2, 4, 10] was to control for differences in patient variables, poor or non-existent definitions of impending fractures in those populations limits our ability to assess validity of their conclusions. Moving forward, studies comparing impending to actual pathologic fractures should include specific definitions of what was considered an impending fracture when possible. Second, while Mirels, L-cort, and Carnesale are not perfect tools to predict fracture, they do provide highly sensitive and clinically practical tests [5, 7, 19]. Attempts to improve upon these tests with newer approaches (CTRA, FEM, PET-CT, SPECT-CT, and/or machine learning) have led to variable improvement in specificity and positive predictive value, but often at the expense of decreased sensitivity and negative predictive value [11-15]. Hence, simpler screening tools will probably continue to play a role either alone or in combination with newer approaches until the validity and accessibility of the latter improve. Screening tools like CTRA and FEM will require development through small business models such as the NIH Small Business Innovation Research grant program. All new techniques require strong positive documentation to support insurance authorization, and since PET-CT and SPECT-CT are already utilized in the oncology realm, they may more easily gain approval for prospective multi-institutional studies in the future. Machine learning would need to incorporate not only clinical and radiographic variables, but also bone structural and physical properties that are not typically gathered routinely [15]. Ultimately, there is no one approach that is likely to stand alone as a means of predicting metastatic fracture risk because none consider all possible variables that go into the equation of when a patient will fracture. This is a complex problem that will likely require a multi-factorial approach. Already, the finding that combining FEM and Mirels improves specificity and positive predictive value while maintaining high sensitivity suggests combining engineering and clinical information may improve fracture risk prediction [11-15]. This is similar to the World Health Organization’s Fracture Risk Assessment (FRAX) instrument used for predicting fracture risk in osteoporosis, which combines bone mineral density and clinical factors [6, 8, 13]. There are several variables not considered by established or newer pathologic fracture prediction tools that may be important, such as: Age, gender, race, height, weight, BMI, history of fragility fracture, family history of osteoporosis, current smoking and corticosteroid use, primary cancer, patient activity level and capacity, comorbidities, rheumatoid arthritis, causes for secondary osteoporosis, alcohol use, and patient expectations. Many of these variables are considered in the FRAX tool [18]. Development of the FRAX tool for osteoporosis resulted from multi-institutional international cooperation through multiple national organizations and a series of meta-analyses of risk factors [18]. A similar approach to pathologic fractures would potentially lead to development of a valuable pathologic fracture risk assessment tool. Finally, net benefit analysis is another means by which we should approach this problem [3]. Net benefit analysis is a decision analytic measure that weighs the benefits and risks of testing. While potential benefits of fracture risk testing have been the focus of the majority of the published literature, the potential risks have not. The biggest risk for the patient with a false-positive predictive result leading to unnecessary surgery is the risk of surgery. If net benefit decision curve analysis showed that risks outweigh the benefits, a test for determining impending fracture would be contraindicated. Conversely, if the analysis showed that benefits outweigh the risks, the test would be considered acceptable [3]." @default.
• W2968579849 created "2019-08-22" @default.
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• W2968579849 date "2019-07-31" @default.
• W2968579849 modified "2023-09-27" @default.
• W2968579849 title "CORR Insights®: Is There an Association Between Prophylactic Femur Stabilization and Survival in Patients with Metastatic Bone Disease?" @default.
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