LAUSR

The improving survival of patients with metastatic bone disease translates into increased disease prevalence that has resulted in a rising cost of care. Our goals as physicians should be to not only alleviate the burden on our patients but also to minimize any unnecessary burden on the healthcare system. In the United States, caring for the more than 250,000 patients who have metastatic bone disease comes at an annual cost of USD 12 billion [1]. Hence, as orthopaedic surgeons, when we consider surgical treatment of these patients, we must do so with an increasing eye on the precise indications for prophylactic fixation as well as the potential morbidity of any surgical intervention. We should strive to only operate prophylactically on patients who truly have impending fractures and on those who are likely to have a better result with prophylactic treatment compared to treating the fracture after the fact. One area of increased scrutiny during the last several years has been the delineation of precise imaging-based indications for prophylactic fixation of impending fractures. Newer techniques, such as CT-based structural rigidity analysis (CTRA), finite element modeling (FEM), and fluorodeoxyglucose positron emission tomography (FDG-PET) CT have been shown to be more accurate in predicting impending fractures than the traditional Harrington and Mirels methods [2, 3, 5-7]. But generally, these techniques are not financially feasible, which limit their availability. Of course, using imaging to identify bone lesions that are biomechanically impending fractures is only part of the equation. Other important variables include patient’s level of pain, disease prognosis, expected response to alternate therapies, comorbidities, and personal goals. Moreover, the risk of treatment complications, as illustrated in the current study [4], should be considered to ensure that prophylactic treatment is at the least not worse than treating the fracture after the fact. In the current study, McLynn and colleagues [4] present their National Surgical Quality Improvement Program (NSQIP)-based complication analysis for the femoral shaft and more distal femur. They found that when controlled for differences in patient characteristics, patients who underwent prophylactic stabilization benefited only in terms of a lower likelihood of transfusion compared to patients treated after a pathologic fracture occurred. The high overall complication (18%), major complication (14%), and death rates (7%) of the prophylactically treated group showed that the risks of prophylactic stabilization are not worse than that of treatment after fracture, and that the advantages are minimal [4]. Obviously, there are some situations where, owing to debilitating This CORR Insights is a commentary on the article “What Is the Adverse Event Profile After Prophylactic Treatment of Femoral Shaft or Distal Femur Metastases?” by McLynn and colleagues available at: DOI: 10.1097/CORR.0000000000000489. The institution of the author (TAD) has received, during the study period, funding from the Orthopaedic Research and Education Foundation, the Musculoskeletal Tumor Society, and the Carol Baldwin Breast Cancer Research Foundation. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. T. A. Damron MD (✉), Musculoskeletal Science Research Center, Institute for Human Performance, 505 Irving Avenue, Room 3117, Syracuse, NY 13210 USA, Email: [email protected]