Intervention for impending pathological fractures at proximal femur is associated with lower mortality rates in patients with intermediate-to-high risk according to the Katagiri-New score

Intervention for impending pathological fractures at proximal femur is associated with lower mortality rates in patients with intermediate-to-high risk according to the Katagiri-New score | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Intervention for impending pathological fractures at proximal femur is associated with lower mortality rates in patients with intermediate-to-high risk according to the Katagiri-New score Toshiyuki Nishimoto, Hirokazu Shimizu, Masatake Matsuoka, Daisuke Takahashi, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4512443/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 Oct, 2024 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 11 You are reading this latest preprint version Abstract Background Prophylactic intervention for impending pathological fractures (IF) is associated with improved survival in patients with long-bone metastasis. However, information regarding whether the tumor burden and/or physical status are associated with survival benefits of intervention for IF is lacking. Methods This multicenter retrospective study investigated 121 patients who underwent surgery for 63 impending and 58 complete metastatic fractures of the proximal femur between 2008 and 2023. After matching for age, sex, body mass index, and Katagiri-New score, 42 patients with IF were compared with 42 patients with complete pathological fractures. The 1-year mortality rate was considered the primary outcome, and was compared and stratified by risk based on the Katagiri-New score. The 1-year mortality rate was evaluated according to the surgical method in the subgroup analysis of patients with IF. Results The 1-year mortality rate was significantly lower in patients with IF with intermediate-to-high risk(p = 0.04), whereas no difference was observed in patients with low-to-high risk. IF was associated with a significantly higher rate of home discharge (p < 0.01) and improved post-operative ambulatory function (p = 0.07). The subgroup analysis of patients with IF revealed no difference in the survival rate between nailing and hemiarthroplasty. Conclusion Patients with intermediate-to-high risk IF based on the Katagiri-New score had a lower mortality rate than those who underwent surgery for pathological fractures. A higher rate of home discharge was observed in patients with IF. Based on the Katagiri-New score, survival benefits can be obtained from prophylactic intervention for IF of the proximal femur in patients with intermediate-to high-risk. Impending fracture fracture at proximal femur mortality rate Katagiri score Figures Figure 1 Figure 2 BACKGROUND Pathological fractures can result in the loss of quality of life in patients with bone metastasis. Prophylactic intervention of impending pathological fracture (IF) is often recommended to prevent further morbidity and carry on ordinary daily activities in cases that a long bone is exposed at risk of pathological fracture[ 1 – 3 ]. Notably, the intervention is associated with not only high ambulatory function but low mortality rate compared to patients with completed pathological fracture[ 4 – 6 ]. However, physical statuses of patients with bone metastasis largely differ and their prognoses are dependent on tumor burden, other metastases and performance status[ 7 – 9 ]. Until now, it remains unclear what sort of patients with bone metastasis could have survival benefits when the patients have prophylactic intervention for IF. Preventive care also have been conducted for naïve fracture of the proximal femur[ 8 – 11 ]. Once it occurs, it is associated with morbidity and a 20–30% mortality rate during the first year [ 12 , 13 ]. Higher mortality rates are associated with systemic diseases (e.g., congestive heart failure and diabetes mellitus), poor physical status according to the American Society of Anesthesiologists physical status classification system, age, and delayed surgery [ 14 – 16 ]. Thus, postoperative mortality rates for proximal femur fractures are associated with systemic diseases and general conditions. The Katagiri-New score is frequently employed at the time of diagnosis of bone metastasis to evaluate and predict, respectively the risk and prognosis [ 17 – 19 ]. This scoring system contains items reflecting the tumor burden and general condition (primary cancer, visceral metastases, laboratory data, Eastern Cooperative Oncology Group Performance Status [ECOG PS], previous chemotherapy, and multiple skeletal metastases). Therefore, we hypothesized that high-risk patients would benefit from prophylactic interventions. This study aimed to compare the mortality rates of patients who underwent surgery for IF with those who underwent surgery for complete pathological fractures of the proximal femur. METHODS Study design This multicenter, retrospective study was approved by the local ethics committee of our hospital (022–0036). We enrolled 121 adult patients with the age of ≥ 18 who underwent surgery for 63 impending and 58 complete metastatic fracture of the proximal femur from January 2008 to April 2023 (Fig. 1 ). Patients with IF were defined as having a Mirels’ score ≥ 8 and who underwent prophylactic intervention. The patients who underwent surgery for complete pathological fractures were assigned to the control group. Patients with revision procedures and surgeries for multiple bone lesions were excluded. Variables and outcomes Patients with IF were matched to the controls using propensity-score matching (1:1) based on the following variables: age, sex, body mass index (BMI), and Katagiri-New score. The Katagiri-New score includes six prognostic factors: primary lesion, visceral or cerebral metastasis, abnormal laboratory data, poor performance status based on the ECOG PS, previous chemotherapy, and multiple skeletal metastases [ 17 ]. The rate of loss to follow-up was 5.1% (3/58) and 4.7% (3/63) in the IF and control groups, respectively. The primary outcome was 1-year mortality rate after surgery. The secondary outcomes were (1) rate of postoperative ambulatory function, (2) rate of home discharge. As perioperative information, surgical methods and surgery time were also evaluated. A subgroup analysis of the patients with IF was performed to evaluate the 1-year mortality after surgery based on the surgical procedures. Statistical analysis Categorical variables were evaluated using the chi-squared test for two or more groups, whereas continuous variables were analyzed using an independent t-test. Survival rates were visualized using the Kaplan–Meier method and differences were investigated using the log-rank test. The propensity score for each patient was calculated according to the age (± 10 years), sex, BMI (low:<19, moderate, high ≥ 25), and Katagiri-New score (A: 0–3, B: 4–6, and C: 7–10). We performed all the statistical analyses and matching with a 0.2 calliper width to create 1:1 (IF: controls) matched groups using JMP Pro version 14 (SAS Institute, Inc., Cary, NC, USA), with a significance level set at 0.05. RESULTS In the matched patients, the most frequent primary cancer sites were lung, breast, and kidney (Table 1 ). In the perioperative evaluation, the rate of hemiarthroplasty was significantly higher in patients with IF (18/42, 42.8%) than in the controls, at (9/42, 21.4%) (p = 0.03) (Table 2 ). The groups did not differ in terms of the surgical time. A tendency for a higher rate of postoperative ambulatory function was observed in patients with IF (38/42, 90.4%) compared to that in controls (32/42, 76.2%) (p = 0.07) (Table 2 ). The rate of home discharge was significantly higher in patients with IF (32/42, 76.2%) than that in the controls (22/42, 52.3%) (p < 0.01). Table 1 Demographic data in the matched patients Impending fracture (n = 42) Complete fracture (n = 42) P-value Age 64.3 ± 2.0 62.3 ± 2.1 0.58 Sex (female = 1) 17/42 15/42 0.65 BMI 21.4 ± 0.6 22.0 ± 0.6 0.50 Katagiri-New Score 0.67 A 7 6 B 21 25 C 14 11 Primary cancer 0.78 Lung 12 15 Breast 4 6 Kidney 6 5 Other 20 16 PS 0–2 35 34 0.82 3–4 7 8 Mean ± standard error, BMI: body mass index, PS: performance status Table 2 Perioperative outcomes Impending fracture (n = 42) Complete fracture (n = 42) P-value Waiting days before surgery, day N.A. 11.4 ± 1.1 Surgical method 0.03 Nailing 24 33 Hemiarthroplasty 18 9 Surgery Time (min) 158 ± 28 147 ± 17 0.56 Rate of postoperative ambulatory, % 90.4 (38/42) 76.1 (32/42) 0.07 Rate of home discharges, % 76.1 (32/42) 52.3 (22/42) < 0.01 Mean ± standard error, N.A.: not applicable Analysis of intermediate-to-high-risk patients according to the Katagiri-New score revealed that the 1-year mortality rate was lower in patients with IF than in the controls (p = 0.04) (Fig. 2 b). However, the groups demonstrated no significant difference when patients with low-to high-risk were included (Fig. 2 a). In the subgroup analysis of the enrolled patients with IF (n = 63), no significant differences were observed between the nailing and hemiarthroplasty groups for the following variables: age, BMI, and Katagiri-New score (Table 3 ). No difference in the 1-year mortality rates was observed between the two groups (Table 3 ). Table 3 Subgroup analysis of patients with impending fractures Nailing (n = 40) Hemiarthroplasty (n = 23) P-value Age 65.8 ± 2.4 67.4 ± 2.3 0.68 Female, % 62.5 (25/40) 39.1 (9/23) < 0.05 BMI 21.3 ± 0.58 21.83 ± 1.1 0.67 Katagiri-New score 0.38 A 6 2 B 21 14 C 13 7 Surgical time 96 ± 6 185 ± 12 < 0.001 1-year mortality rate, % 47.5 (19/40) 47.8 (11/23) 0.96 Mean ± standard error, BMI: body mass index DISCUSSION The present study revealed that patients with intermediate-to-high risk based on the Katagiri-new score who underwent prophylactic intervention for IF had a lower 1-year mortality rate than those who underwent surgery for a complete pathological fracture. Furthermore, there was a significantly high rate of home discharge in patients with IF. The subgroup analysis demonstrated that the association of the surgical methods with survival rate was negative. A high mortality rate is associated with systemic disease or poor physical status in patients undergoing surgery for naïve fractures of the proximal femur. The results of our study revealed that high-risk patients stratified by the Katagiri-New score were associated with lower mortality, which are consistent with the findings of previous studies [ 4 – 6 ]. Since the Katagiri-New score includes primary cancer, tumor burden, laboratory data, and physical status, it may reflect systemic status. Differences in postoperative mobility were also confirmed between patients with IF and those with complete pathological fractures. While multiple surgical options are available for patients undergoing prophylactic intervention than those with complete fractures[ 5 ], our results were consistent with this opinion. Notably, subgroup analyses of patients with IF revealed no significant difference in the mortality rates was observed between intramedullary nailing and hemiarthroplasty. A retrospective report demonstrated similar results [ 20 ]; nevertheless, further studies are warranted to determine the optimal surgical modality for managing metastatic lesions in the proximal femur. Our study had several limitations. First, it was a retrospective study. There might be a recall or selection bias. Second, surgical methods and were determined by surgeons and not randomized. Although our subgroup analysis demonstrated that the association of surgical methods with the mortality rate was negative, it might be an interaction factor. Third, it had a relatively small sample size; however, cohort studies have included and matched similar or fewer number of cases [ 21 – 24 ]. Although the propensity-score model allowed the comparison of two groups, adjusting for patients with bone metastasis diagnosed with fracture at the proximal femur is challenging. CONCLUSIONS Intervention for impending pathological fracture of the proximal femur was associated with lower mortality rates in patients with intermediate-to-high Katagiri scores. Thus, early surgical intervention should be considered in high-risk patients with femoral metastasis. Abbreviations IF impending pathological fracture ECOG PS Eastern Cooperative Oncology Group Performance Status BMI body mass index Declarations Ethics approval and consent to participate The study was approved by the local ethics committee at Hokkaido University Hospital (022-0036) and by a participating hospital, and all persons gave their informed consent prior to their inclusion. The guidelines of human ethics according to the Declaration of Helsinki were followed. Consent for publication Not applicable. Availability of data and materials The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding No funding for this research. Authors' contributions T.N. collected data, which was assisted by D.T., T.S. and T.S.. H.S. designed the study supervised by M.M.. H.S. wrote the manuscript, and illustrated the figures. H.H., N.I. and A.I. directed the entire study. Acknowledgements Not applicable. References Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res 1989(249):256–64. Amendola RL, Miller MA, Kaupp SM, Cleary RJ, Damron TA, Mann KA. Modification to Mirels scoring system location component improves fracture prediction for metastatic disease of the proximal femur. BMC Musculoskelet Disord. 2023;24(1):65. Jawad MU, Scully SP. In brief: classifications in brief: Mirels' classification: metastatic disease in long bones and impending pathologic fracture. Clin Orthop Relat Res. 2010;468(10):2825–7. Philipp TC, Mikula JD, Doung YC, Gundle KR. Is There an Association Between Prophylactic Femur Stabilization and Survival in Patients with Metastatic Bone Disease? Clin Orthop Relat Res. 2020;478(3):540–6. Groot OQ, Lans A, Twining PK, Bongers MER, Kapoor ND, Verlaan J-J, Newman ET, Raskin KA, Lozano-Calderon SA, Janssen SJ et al. Clinical Outcome Differences in the Treatment of Impending Versus Completed Pathological Long-Bone Fractures. JBJS 2022, 104(4). Yanagisawa S, Uchiyama Y, Tanzawa Y, Watanabe T, Wasai S, Suzuki T, Watanabe M. Comparison of the clinical outcomes of intramedullary nailing between impending and completed pathological fractures caused by metastatic femoral tumors from solid cancers. J Orthop Sci 2023. Svensson E, Christiansen CF, Ulrichsen SP, Rørth MR, Sørensen HT. Survival after bone metastasis by primary cancer type: a Danish population-based cohort study. BMJ Open. 2017;7(9):e016022. Mazzoli G, Cohen R, Lonardi S, Corti F, Elez E, Fakih M, Jayachandran P, Colle R, Shah AT, Salati M, et al. Prognostic impact of performance status on the outcomes of immune checkpoint inhibition strategies in patients with dMMR/MSI-H metastatic colorectal cancer. Eur J Cancer. 2022;172:171–81. Kodaira M, Takahashi S, Yamada S, Ueda K, Mishima Y, Takeuchi K, Yamamoto N, Ishikawa Y, Yokoyama M, Saotome T, et al. Bone metastasis and poor performance status are prognostic factors for survival of carcinoma of unknown primary site in patients treated with systematic chemotherapy. Ann Oncol. 2010;21(6):1163–7. Ishizu H, Shimizu T, Arita K, Sato K, Takahashi R, Kusunoki K, Shimodan S, Asano T, Iwasaki N. Secondary fracture and mortality risk with very high fracture risk osteoporosis and proximal femoral fracture. J Bone Miner Metab. 2024;42(2):196–206. Kling JM, Clarke BL, Sandhu NP. Osteoporosis prevention, screening, and treatment: a review. J Womens Health (Larchmt). 2014;23(7):563–72. Muñoz Vives JM, Jornet-Gibert M, Cámara-Cabrera J, Esteban PL, Brunet L, Delgado-Flores L, Camacho-Carrasco P, Torner P, Marcano-Fernández F. Mortality Rates of Patients with Proximal Femoral Fracture in a Worldwide Pandemic: Preliminary Results of the Spanish HIP-COVID Observational Study. J Bone Joint Surg Am. 2020;102(13):e69. Keene GS, Parker MJ, Pryor GA. Mortality and morbidity after hip fractures. BMJ. 1993;307(6914):1248–50. Baghdadi S, kiyani M, kalantar SH, Shiri S, Sohrabi O, Beheshti Fard S, Afzal S, Khabiri SS. Mortality following proximal femoral fractures in elderly patients: a large retrospective cohort study of incidence and risk factors. BMC Musculoskelet Disord. 2023;24(1):693. Postler A, Posten C, Schubert M, Beyer F, Lützner J, Vicent O, Kleber C, Goronzy J, Kamin K. Patients risk for mortality at 90 days after proximal femur fracture – a retrospective study in a tertiary care hospital. BMC Geriatr. 2024;24(1):130. Walter N, Szymski D, Kurtz S, Alt V, Lowenberg DW, Lau E, Rupp M. Factors associated with mortality after proximal femoral fracture. J Orthop Traumatol. 2023;24(1):31. Katagiri H, Okada R, Takagi T, Takahashi M, Murata H, Harada H, Nishimura T, Asakura H, Ogawa H. New prognostic factors and scoring system for patients with skeletal metastasis. Cancer Med. 2014;3(5):1359–67. Kobayashi K, Ando K, Nakashima H, Sato K, Kanemura T, Yoshihara H, Hirasawa A, Kato F, Ishiguro N, Imagama S. Prognostic Factors in the New Katagiri Scoring System After Palliative Surgery for Spinal Metastasis. Spine (Phila Pa 1976). 2020;45(13):E813–9. Kubota H, Soejima T, Sulaiman NS, Sekii S, Matsumoto Y, Ota Y, Tsujino K, Fujita I, Fujimoto T, Morishita M, et al. Predicting the survival of patients with bone metastases treated with radiation therapy: a validation study of the Katagiri scoring system. Radiat Oncol. 2019;14(1):13. Lin JS, Santiago-Torres JE, Everhart JS, Zayan NE, Mayerson JL, Scharschmidt TJ. When is hemiarthroplasty preferable to intramedullary prophylactic fixation of malignant lesions of the proximal femur? J Surg Oncol. 2017;116(8):1132–40. Ceccarelli G, Costa G, Ferraro V, De Rosa M, Rondelli F, Bugiantella W. Robotic or three-dimensional (3D) laparoscopy for right colectomy with complete mesocolic excision (CME) and intracorporeal anastomosis? A propensity score-matching study comparison. Surg Endosc. 2021;35(5):2039–48. Beletsky A, Naveen NB, Tauro T, Southworth TM, Chahla J, Verma NN, Yanke AB, Cole BJ. Microdrilling Demonstrates Superior Patient-Reported Outcomes and Lower Revision Rates Than Traditional Microfracture: A Matched Cohort Analysis. Arthrosc Sports Med Rehabil. 2021;3(3):e629–38. de'Angelis N, Notarnicola M, Martínez-Pérez A, Memeo R, Charpy C, Urciuoli I, Maroso F, Sommacale D, Amiot A, Canouï-Poitrine F, et al. Robotic Versus Laparoscopic Partial Mesorectal Excision for Cancer of the High Rectum: A Single-Center Study with Propensity Score Matching Analysis. World J Surg. 2020;44(11):3923–35. Chen CJ, Ding D, Wang TR, Buell TJ, Ilyas A, Ironside N, Lee CC, Kalani MY, Park MS, Liu KC, et al. Microsurgery Versus Stereotactic Radiosurgery for Brain Arteriovenous Malformations: A Matched Cohort Study. Neurosurgery. 2019;84(3):696–708. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 22 Oct, 2024 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 30 Jul, 2024 Reviews received at journal 26 Jul, 2024 Reviewers agreed at journal 21 Jul, 2024 Reviews received at journal 18 Jul, 2024 Reviewers agreed at journal 08 Jul, 2024 Reviewers agreed at journal 05 Jul, 2024 Reviewers invited by journal 05 Jul, 2024 Editor invited by journal 14 Jun, 2024 Editor assigned by journal 13 Jun, 2024 Submission checks completed at journal 13 Jun, 2024 First submitted to journal 01 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4512443","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":315108343,"identity":"a970ae30-c1f8-4caa-8e51-9e0336941718","order_by":0,"name":"Toshiyuki Nishimoto","email":"","orcid":"","institution":"Hokkaido University","correspondingAuthor":false,"prefix":"","firstName":"Toshiyuki","middleName":"","lastName":"Nishimoto","suffix":""},{"id":315108344,"identity":"83ba69c6-7216-4cf4-8e33-fafa3fa644e2","order_by":1,"name":"Hirokazu Shimizu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIie3PsUrDQBjA8e8oXJdKtnJF5F7hCx1E2oe5m/IG4iD1QjAuouuVvkRKoXNCoJPoGmmHZHHWRRyCeClxEJJIN5H7L98d3I+7A7DZ/mKMKBBmYg/ALAEcM14PIyNFfB13knoi1ARjIJ2EL4LrKC9TOO0fFYW+nMnVNvCDtxC4M2yGuEvCTAxSOAv6YzfaULneJb5KQnDnC9FMmDSEpYAppaOcDuQ6kze5IQK3zYTriuA3+WRypeX+llYCWUVETZYhyoj9QnBPYq8iPXd+J8Y6M+ThkbX+hWvv5fmjnAA+bUhx+z47uddeoS7Op9w5bnlY3ZX6sSWUNZ/rqDxY2Gw22//tC4z1aiuBHdyEAAAAAElFTkSuQmCC","orcid":"","institution":"Hokkaido University","correspondingAuthor":true,"prefix":"","firstName":"Hirokazu","middleName":"","lastName":"Shimizu","suffix":""},{"id":315108345,"identity":"c2a39bc3-a911-412b-aac6-7f19823db3f3","order_by":2,"name":"Masatake Matsuoka","email":"","orcid":"","institution":"Hokkaido University","correspondingAuthor":false,"prefix":"","firstName":"Masatake","middleName":"","lastName":"Matsuoka","suffix":""},{"id":315108346,"identity":"e96ac450-c8d3-4b44-bf77-62b0d170e747","order_by":3,"name":"Daisuke Takahashi","email":"","orcid":"","institution":"Hokkaido University","correspondingAuthor":false,"prefix":"","firstName":"Daisuke","middleName":"","lastName":"Takahashi","suffix":""},{"id":315108347,"identity":"886a2983-a53d-4c3e-90e8-800f3da49859","order_by":4,"name":"Tomohiro Shimizu","email":"","orcid":"","institution":"Hokkaido University","correspondingAuthor":false,"prefix":"","firstName":"Tomohiro","middleName":"","lastName":"Shimizu","suffix":""},{"id":315108349,"identity":"57bc7440-ec38-4c22-b7de-e85a58744d11","order_by":5,"name":"Norimasa Iwasaki","email":"","orcid":"","institution":"Hokkaido University","correspondingAuthor":false,"prefix":"","firstName":"Norimasa","middleName":"","lastName":"Iwasaki","suffix":""},{"id":315108354,"identity":"bd6f0d22-d5d5-41f6-aa10-cc155aa9b132","order_by":6,"name":"Tamotsu Soma","email":"","orcid":"","institution":"National Hospital Organization Hokkaido Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Tamotsu","middleName":"","lastName":"Soma","suffix":""},{"id":315108355,"identity":"6c3c2a4f-8a6e-4a5a-a92f-a7227e538ac3","order_by":7,"name":"Hiroaki Hiraga","email":"","orcid":"","institution":"National Hospital Organization Hokkaido Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Hiroaki","middleName":"","lastName":"Hiraga","suffix":""},{"id":315108356,"identity":"0b01763f-7d13-4dcd-a437-13ca6cf7f6a3","order_by":8,"name":"Akira Iwata","email":"","orcid":"","institution":"National Hospital Organization Hokkaido Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Akira","middleName":"","lastName":"Iwata","suffix":""}],"badges":[],"createdAt":"2024-06-01 07:23:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4512443/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4512443/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12891-024-07838-8","type":"published","date":"2024-10-22T15:57:07+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60185067,"identity":"988bbd30-ca69-438a-9240-97ceb43a95a1","added_by":"auto","created_at":"2024-07-12 18:40:26","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":699816,"visible":true,"origin":"","legend":"\u003cp\u003eStudy design\u003c/p\u003e","description":"","filename":"Figure1BMCNishimoto20240524.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4512443/v1/ce7121875d5b41a4ad7e55a9.jpg"},{"id":60185084,"identity":"0c782e0d-b619-402e-9d61-4ec3930daa6c","added_by":"auto","created_at":"2024-07-12 18:40:26","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":387956,"visible":true,"origin":"","legend":"\u003cp\u003e1-year mortality rate after surgery (A) Analysis of the patients with low-to-high risk based on the Katagiri-n=New score. (B) Analysis of the patients with intermediate-to-high risk based on the Katagiri-New score.\u003c/p\u003e","description":"","filename":"Figure2BMCNishimoto20240524.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4512443/v1/dcfe2d562ca9ae0e74d71426.jpg"},{"id":67682801,"identity":"c60b841e-b132-4468-b6a2-cafa4552e479","added_by":"auto","created_at":"2024-10-28 16:15:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1549766,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4512443/v1/a51f4117-3ff7-433d-b16d-2000b34cc473.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Intervention for impending pathological fractures at proximal femur is associated with lower mortality rates in patients with intermediate-to-high risk according to the Katagiri-New score","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003ePathological fractures can result in the loss of quality of life in patients with bone metastasis. Prophylactic intervention of impending pathological fracture (IF) is often recommended to prevent further morbidity and carry on ordinary daily activities in cases that a long bone is exposed at risk of pathological fracture[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Notably, the intervention is associated with not only high ambulatory function but low mortality rate compared to patients with completed pathological fracture[\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, physical statuses of patients with bone metastasis largely differ and their prognoses are dependent on tumor burden, other metastases and performance status[\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Until now, it remains unclear what sort of patients with bone metastasis could have survival benefits when the patients have prophylactic intervention for IF.\u003c/p\u003e \u003cp\u003ePreventive care also have been conducted for na\u0026iuml;ve fracture of the proximal femur[\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Once it occurs, it is associated with morbidity and a 20\u0026ndash;30% mortality rate during the first year [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Higher mortality rates are associated with systemic diseases (e.g., congestive heart failure and diabetes mellitus), poor physical status according to the American Society of Anesthesiologists physical status classification system, age, and delayed surgery [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Thus, postoperative mortality rates for proximal femur fractures are associated with systemic diseases and general conditions.\u003c/p\u003e \u003cp\u003eThe Katagiri-New score is frequently employed at the time of diagnosis of bone metastasis to evaluate and predict, respectively the risk and prognosis [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This scoring system contains items reflecting the tumor burden and general condition (primary cancer, visceral metastases, laboratory data, Eastern Cooperative Oncology Group Performance Status [ECOG PS], previous chemotherapy, and multiple skeletal metastases). Therefore, we hypothesized that high-risk patients would benefit from prophylactic interventions. This study aimed to compare the mortality rates of patients who underwent surgery for IF with those who underwent surgery for complete pathological fractures of the proximal femur.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003e This multicenter, retrospective study was approved by the local ethics committee of our hospital (022\u0026ndash;0036). We enrolled 121 adult patients with the age of \u0026ge;\u0026thinsp;18 who underwent surgery for 63 impending and 58 complete metastatic fracture of the proximal femur from January 2008 to April 2023 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Patients with IF were defined as having a Mirels\u0026rsquo; score\u0026thinsp;\u0026ge;\u0026thinsp;8 and who underwent prophylactic intervention. The patients who underwent surgery for complete pathological fractures were assigned to the control group. Patients with revision procedures and surgeries for multiple bone lesions were excluded.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eVariables and outcomes\u003c/h2\u003e \u003cp\u003ePatients with IF were matched to the controls using propensity-score matching (1:1) based on the following variables: age, sex, body mass index (BMI), and Katagiri-New score. The Katagiri-New score includes six prognostic factors: primary lesion, visceral or cerebral metastasis, abnormal laboratory data, poor performance status based on the ECOG PS, previous chemotherapy, and multiple skeletal metastases [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe rate of loss to follow-up was 5.1% (3/58) and 4.7% (3/63) in the IF and control groups, respectively. The primary outcome was 1-year mortality rate after surgery. The secondary outcomes were (1) rate of postoperative ambulatory function, (2) rate of home discharge. As perioperative information, surgical methods and surgery time were also evaluated. A subgroup analysis of the patients with IF was performed to evaluate the 1-year mortality after surgery based on the surgical procedures.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eCategorical variables were evaluated using the chi-squared test for two or more groups, whereas continuous variables were analyzed using an independent t-test. Survival rates were visualized using the Kaplan\u0026ndash;Meier method and differences were investigated using the log-rank test. The propensity score for each patient was calculated according to the age (\u0026plusmn;\u0026thinsp;10 years), sex, BMI (low:\u0026lt;19, moderate, high\u0026thinsp;\u0026ge;\u0026thinsp;25), and Katagiri-New score (A: 0\u0026ndash;3, B: 4\u0026ndash;6, and C: 7\u0026ndash;10). We performed all the statistical analyses and matching with a 0.2 calliper width to create 1:1 (IF: controls) matched groups using JMP Pro version 14 (SAS Institute, Inc., Cary, NC, USA), with a significance level set at 0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eIn the matched patients, the most frequent primary cancer sites were lung, breast, and kidney (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In the perioperative evaluation, the rate of hemiarthroplasty was significantly higher in patients with IF (18/42, 42.8%) than in the controls, at (9/42, 21.4%) (p\u0026thinsp;=\u0026thinsp;0.03) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The groups did not differ in terms of the surgical time. A tendency for a higher rate of postoperative ambulatory function was observed in patients with IF (38/42, 90.4%) compared to that in controls (32/42, 76.2%) (p\u0026thinsp;=\u0026thinsp;0.07) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The rate of home discharge was significantly higher in patients with IF (32/42, 76.2%) than that in the controls (22/42, 52.3%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic data in the matched patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImpending fracture\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eComplete fracture\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSex (female\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17/42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15/42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eKatagiri-New Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePrimary cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLung\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKidney\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard error, BMI: body mass index, PS: performance status\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerioperative outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImpending fracture\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComplete fracture\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWaiting days before surgery, day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN.A.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNailing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemiarthroplasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery Time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e158\u0026thinsp;\u0026plusmn;\u0026thinsp;28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e147\u0026thinsp;\u0026plusmn;\u0026thinsp;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRate of postoperative ambulatory, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90.4 (38/42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.1 (32/42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRate of home discharges, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76.1 (32/42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.3 (22/42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard error, N.A.: not applicable\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAnalysis of intermediate-to-high-risk patients according to the Katagiri-New score revealed that the 1-year mortality rate was lower in patients with IF than in the controls (p\u0026thinsp;=\u0026thinsp;0.04) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb). However, the groups demonstrated no significant difference when patients with low-to high-risk were included (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn the subgroup analysis of the enrolled patients with IF (n\u0026thinsp;=\u0026thinsp;63), no significant differences were observed between the nailing and hemiarthroplasty groups for the following variables: age, BMI, and Katagiri-New score (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). No difference in the 1-year mortality rates was observed between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSubgroup analysis of patients with impending fractures\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNailing\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHemiarthroplasty\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFemale, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.5 (25/40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.1 (9/23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKatagiri-New score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSurgical time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96\u0026thinsp;\u0026plusmn;\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e185\u0026thinsp;\u0026plusmn;\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e1-year mortality rate, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.5 (19/40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.8 (11/23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard error, BMI: body mass index\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe present study revealed that patients with intermediate-to-high risk based on the Katagiri-new score who underwent prophylactic intervention for IF had a lower 1-year mortality rate than those who underwent surgery for a complete pathological fracture. Furthermore, there was a significantly high rate of home discharge in patients with IF. The subgroup analysis demonstrated that the association of the surgical methods with survival rate was negative.\u003c/p\u003e \u003cp\u003eA high mortality rate is associated with systemic disease or poor physical status in patients undergoing surgery for na\u0026iuml;ve fractures of the proximal femur. The results of our study revealed that high-risk patients stratified by the Katagiri-New score were associated with lower mortality, which are consistent with the findings of previous studies [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Since the Katagiri-New score includes primary cancer, tumor burden, laboratory data, and physical status, it may reflect systemic status. Differences in postoperative mobility were also confirmed between patients with IF and those with complete pathological fractures.\u003c/p\u003e \u003cp\u003eWhile multiple surgical options are available for patients undergoing prophylactic intervention than those with complete fractures[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], our results were consistent with this opinion. Notably, subgroup analyses of patients with IF revealed no significant difference in the mortality rates was observed between intramedullary nailing and hemiarthroplasty. A retrospective report demonstrated similar results [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]; nevertheless, further studies are warranted to determine the optimal surgical modality for managing metastatic lesions in the proximal femur.\u003c/p\u003e \u003cp\u003eOur study had several limitations. First, it was a retrospective study. There might be a recall or selection bias. Second, surgical methods and were determined by surgeons and not randomized. Although our subgroup analysis demonstrated that the association of surgical methods with the mortality rate was negative, it might be an interaction factor. Third, it had a relatively small sample size; however, cohort studies have included and matched similar or fewer number of cases [\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Although the propensity-score model allowed the comparison of two groups, adjusting for patients with bone metastasis diagnosed with fracture at the proximal femur is challenging.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eIntervention for impending pathological fracture of the proximal femur was associated with lower mortality rates in patients with intermediate-to-high Katagiri scores. Thus, early surgical intervention should be considered in high-risk patients with femoral metastasis.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eimpending pathological fracture\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eECOG PS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEastern Cooperative Oncology Group Performance Status\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebody mass index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the local ethics committee at Hokkaido University Hospital (022-0036) and by a participating hospital, and all persons gave their informed consent prior to their inclusion. The guidelines of human ethics according to the Declaration of Helsinki were followed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding for this research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eT.N. collected data, which was assisted by D.T., T.S. and T.S.. \u0026nbsp;H.S. designed the study supervised by M.M..\u0026nbsp;\u0026nbsp;H.S. wrote the manuscript, and illustrated the figures. H.H., N.I. and A.I. directed the entire study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res 1989(249):256\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmendola RL, Miller MA, Kaupp SM, Cleary RJ, Damron TA, Mann KA. Modification to Mirels scoring system location component improves fracture prediction for metastatic disease of the proximal femur. BMC Musculoskelet Disord. 2023;24(1):65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJawad MU, Scully SP. In brief: classifications in brief: Mirels' classification: metastatic disease in long bones and impending pathologic fracture. Clin Orthop Relat Res. 2010;468(10):2825\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhilipp TC, Mikula JD, Doung YC, Gundle KR. Is There an Association Between Prophylactic Femur Stabilization and Survival in Patients with Metastatic Bone Disease? Clin Orthop Relat Res. 2020;478(3):540\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGroot OQ, Lans A, Twining PK, Bongers MER, Kapoor ND, Verlaan J-J, Newman ET, Raskin KA, Lozano-Calderon SA, Janssen SJ et al. Clinical Outcome Differences in the Treatment of Impending Versus Completed Pathological Long-Bone Fractures. \u003cem\u003eJBJS\u003c/em\u003e 2022, 104(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYanagisawa S, Uchiyama Y, Tanzawa Y, Watanabe T, Wasai S, Suzuki T, Watanabe M. Comparison of the clinical outcomes of intramedullary nailing between impending and completed pathological fractures caused by metastatic femoral tumors from solid cancers. J Orthop Sci 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSvensson E, Christiansen CF, Ulrichsen SP, R\u0026oslash;rth MR, S\u0026oslash;rensen HT. Survival after bone metastasis by primary cancer type: a Danish population-based cohort study. BMJ Open. 2017;7(9):e016022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMazzoli G, Cohen R, Lonardi S, Corti F, Elez E, Fakih M, Jayachandran P, Colle R, Shah AT, Salati M, et al. Prognostic impact of performance status on the outcomes of immune checkpoint inhibition strategies in patients with dMMR/MSI-H metastatic colorectal cancer. Eur J Cancer. 2022;172:171\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKodaira M, Takahashi S, Yamada S, Ueda K, Mishima Y, Takeuchi K, Yamamoto N, Ishikawa Y, Yokoyama M, Saotome T, et al. Bone metastasis and poor performance status are prognostic factors for survival of carcinoma of unknown primary site in patients treated with systematic chemotherapy. Ann Oncol. 2010;21(6):1163\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIshizu H, Shimizu T, Arita K, Sato K, Takahashi R, Kusunoki K, Shimodan S, Asano T, Iwasaki N. Secondary fracture and mortality risk with very high fracture risk osteoporosis and proximal femoral fracture. J Bone Miner Metab. 2024;42(2):196\u0026ndash;206.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKling JM, Clarke BL, Sandhu NP. Osteoporosis prevention, screening, and treatment: a review. J Womens Health (Larchmt). 2014;23(7):563\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMu\u0026ntilde;oz Vives JM, Jornet-Gibert M, C\u0026aacute;mara-Cabrera J, Esteban PL, Brunet L, Delgado-Flores L, Camacho-Carrasco P, Torner P, Marcano-Fern\u0026aacute;ndez F. Mortality Rates of Patients with Proximal Femoral Fracture in a Worldwide Pandemic: Preliminary Results of the Spanish HIP-COVID Observational Study. J Bone Joint Surg Am. 2020;102(13):e69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeene GS, Parker MJ, Pryor GA. Mortality and morbidity after hip fractures. BMJ. 1993;307(6914):1248\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaghdadi S, kiyani M, kalantar SH, Shiri S, Sohrabi O, Beheshti Fard S, Afzal S, Khabiri SS. Mortality following proximal femoral fractures in elderly patients: a large retrospective cohort study of incidence and risk factors. BMC Musculoskelet Disord. 2023;24(1):693.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePostler A, Posten C, Schubert M, Beyer F, L\u0026uuml;tzner J, Vicent O, Kleber C, Goronzy J, Kamin K. Patients risk for mortality at 90 days after proximal femur fracture \u0026ndash; a retrospective study in a tertiary care hospital. BMC Geriatr. 2024;24(1):130.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalter N, Szymski D, Kurtz S, Alt V, Lowenberg DW, Lau E, Rupp M. Factors associated with mortality after proximal femoral fracture. J Orthop Traumatol. 2023;24(1):31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatagiri H, Okada R, Takagi T, Takahashi M, Murata H, Harada H, Nishimura T, Asakura H, Ogawa H. New prognostic factors and scoring system for patients with skeletal metastasis. Cancer Med. 2014;3(5):1359\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKobayashi K, Ando K, Nakashima H, Sato K, Kanemura T, Yoshihara H, Hirasawa A, Kato F, Ishiguro N, Imagama S. Prognostic Factors in the New Katagiri Scoring System After Palliative Surgery for Spinal Metastasis. Spine (Phila Pa 1976). 2020;45(13):E813\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKubota H, Soejima T, Sulaiman NS, Sekii S, Matsumoto Y, Ota Y, Tsujino K, Fujita I, Fujimoto T, Morishita M, et al. Predicting the survival of patients with bone metastases treated with radiation therapy: a validation study of the Katagiri scoring system. Radiat Oncol. 2019;14(1):13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin JS, Santiago-Torres JE, Everhart JS, Zayan NE, Mayerson JL, Scharschmidt TJ. When is hemiarthroplasty preferable to intramedullary prophylactic fixation of malignant lesions of the proximal femur? J Surg Oncol. 2017;116(8):1132\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCeccarelli G, Costa G, Ferraro V, De Rosa M, Rondelli F, Bugiantella W. Robotic or three-dimensional (3D) laparoscopy for right colectomy with complete mesocolic excision (CME) and intracorporeal anastomosis? A propensity score-matching study comparison. Surg Endosc. 2021;35(5):2039\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeletsky A, Naveen NB, Tauro T, Southworth TM, Chahla J, Verma NN, Yanke AB, Cole BJ. Microdrilling Demonstrates Superior Patient-Reported Outcomes and Lower Revision Rates Than Traditional Microfracture: A Matched Cohort Analysis. Arthrosc Sports Med Rehabil. 2021;3(3):e629\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede'Angelis N, Notarnicola M, Mart\u0026iacute;nez-P\u0026eacute;rez A, Memeo R, Charpy C, Urciuoli I, Maroso F, Sommacale D, Amiot A, Canou\u0026iuml;-Poitrine F, et al. Robotic Versus Laparoscopic Partial Mesorectal Excision for Cancer of the High Rectum: A Single-Center Study with Propensity Score Matching Analysis. World J Surg. 2020;44(11):3923\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen CJ, Ding D, Wang TR, Buell TJ, Ilyas A, Ironside N, Lee CC, Kalani MY, Park MS, Liu KC, et al. Microsurgery Versus Stereotactic Radiosurgery for Brain Arteriovenous Malformations: A Matched Cohort Study. Neurosurgery. 2019;84(3):696\u0026ndash;708.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Impending fracture, fracture at proximal femur, mortality rate, Katagiri score","lastPublishedDoi":"10.21203/rs.3.rs-4512443/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4512443/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eProphylactic intervention for impending pathological fractures (IF) is associated with improved survival in patients with long-bone metastasis. However, information regarding whether the tumor burden and/or physical status are associated with survival benefits of intervention for IF is lacking.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis multicenter retrospective study investigated 121 patients who underwent surgery for 63 impending and 58 complete metastatic fractures of the proximal femur between 2008 and 2023. After matching for age, sex, body mass index, and Katagiri-New score, 42 patients with IF were compared with 42 patients with complete pathological fractures. The 1-year mortality rate was considered the primary outcome, and was compared and stratified by risk based on the Katagiri-New score. The 1-year mortality rate was evaluated according to the surgical method in the subgroup analysis of patients with IF.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe 1-year mortality rate was significantly lower in patients with IF with intermediate-to-high risk(p\u0026thinsp;=\u0026thinsp;0.04), whereas no difference was observed in patients with low-to-high risk. IF was associated with a significantly higher rate of home discharge (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and improved post-operative ambulatory function (p\u0026thinsp;=\u0026thinsp;0.07). The subgroup analysis of patients with IF revealed no difference in the survival rate between nailing and hemiarthroplasty.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePatients with intermediate-to-high risk IF based on the Katagiri-New score had a lower mortality rate than those who underwent surgery for pathological fractures. A higher rate of home discharge was observed in patients with IF. Based on the Katagiri-New score, survival benefits can be obtained from prophylactic intervention for IF of the proximal femur in patients with intermediate-to high-risk.\u003c/p\u003e","manuscriptTitle":"Intervention for impending pathological fractures at proximal femur is associated with lower mortality rates in patients with intermediate-to-high risk according to the Katagiri-New score","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-12 18:40:21","doi":"10.21203/rs.3.rs-4512443/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-30T08:51:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-26T17:40:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"303059085027955061155164287953755149565","date":"2024-07-21T05:53:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-18T14:23:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178924106052755191256391076117411506054","date":"2024-07-08T12:05:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"247270544787386931782769152883293191410","date":"2024-07-05T18:41:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-05T16:55:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-14T04:28:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-14T03:52:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-14T03:51:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2024-06-01T07:18:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d7878b9b-3b62-48ee-afce-ab4347914b54","owner":[],"postedDate":"July 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-28T16:12:09+00:00","versionOfRecord":{"articleIdentity":"rs-4512443","link":"https://doi.org/10.1186/s12891-024-07838-8","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2024-10-22 15:57:07","publishedOnDateReadable":"October 22nd, 2024"},"versionCreatedAt":"2024-07-12 18:40:21","video":"","vorDoi":"10.1186/s12891-024-07838-8","vorDoiUrl":"https://doi.org/10.1186/s12891-024-07838-8","workflowStages":[]},"version":"v1","identity":"rs-4512443","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4512443","identity":"rs-4512443","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}