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Patients with metastases to proximal femur, who are evaluated fr the risk of pathologic fracture in order to decide on preventive fixation vs follow-up constitute the study population. The patients will be randomized in two arms. First arm - the decision of treatment will rely on conventional decision algorithm including specialist judgement and Mirels' score. Second arm- the decision on treatment will be supported by CTFEA analysis of bone structure and quantitative simulation-based estimate of fracture risk, in addition to the conventional decision algorithm. Operation rates, pathologic fracture rates and additional secondary outcomes will be compared between the two study arms.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| CTFEA | Experimental | Decision on preventive surgery vs follow-up will be based on expert judgement, Mirels' score and CTFEA |
|
| Mirels | Other | Decision on preventive surgery vs follow-up will be based on expert judgement and Mirels' score |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| CTFEA | Diagnostic Test | CT scans are used to generate a finite element model of patient-specific long bones. The bone model is loaded in stance position. Load based on patient's weight and the mechanical response, including the risk of fracture, is computed. |
| Measure | Description | Time Frame |
|---|---|---|
| Primary efficacy hypothesis | To compare proportion of patients undergoing surgery in the treatment group vs the control group. | four years |
| Measure | Description | Time Frame |
|---|---|---|
| Composite endpoint | pathological fracture during 4 months of follow up OR death within 30 days after prophylactic surgery in patients who underwent surgery OR surgical complications within 4 months of follow up: infection, re-operation, mechanical failure | 4 months |
| Measure | Description | Time Frame |
|---|---|---|
| All-cause mortality | All-cause mortality | 4 years |
| Number of patients who became unable to ambulate | Number of patients who became unable to ambulate for any reason. Inability to ambulate will be determined by an orthopedic surgeon from anamnesis and physical examination. |
Inclusion Criteria:
Exclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Haggai Schermann, MD | Contact | 0528771014 | +972 | sheralmi@bu.edu |
| Amir Sternheim, MD | Contact | amirst@tlvmc.gov.il |
| Name | Affiliation | Role |
|---|---|---|
| Amir Sternheim, MD | Tel-Aviv Sourasky Medical Center | Principal Investigator |
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| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 19487532 | Background | Bickels J, Dadia S, Lidar Z. Surgical management of metastatic bone disease. J Bone Joint Surg Am. 2009 Jun;91(6):1503-16. doi: 10.2106/JBJS.H.00175. | |
| 2684463 | Background | Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res. 1989 Dec;(249):256-64. |
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The individual participant data will remain in TLVMC and will not be shared
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Patients will be randomized to two arms and followed prospectively
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|
| Conventional decision algorithm | Other | Decision on surgery vs follow-up will be based on expert opinion and Mirels' score |
|
|
| 4 years |
| Number of participants who sustained a pathological fracture | Number of participants who sustained a pathological fracture. Diagnosis of pathological fracture will be determined by an orthopedic surgeon based on imaging. | 4 months |
| Death | Death within 30 days after prophylactic surgery | 30 days |
| Surgical complications | Infection, re-operation, mechanical failure within 4 months of follow up | 4 months |
| Number of surgeries avoided | The number of surgeries "avoided" - presented only in the group of Intervention and only in patients without the safety endpoint within 4 months of follow up. Specifically, number of patients without the safety endpoint in whom a physician changed his/her decision to operate based on the CT-based FE analysis. | 4 months |
| Agreement of two measures of fracture risk | Agreement between the pathological fracture risk estimated using Mirels' scale and the pathological fracture risk CT-based FE simulation analysis. Risk levels determined by either of the estimates: low, medium, high | One week |
| Patients who denied surgery | Number of patients who did not undergo a prophylactic surgery, in whom the CT-based FE analysis showed a risk above moderate for fractures in future and who developed a fracture during the 4 months of follow-up - calculated in both study groups. | 4 months |
| Complications that could be prevented by CTFEA | Number of patients who underwent a prophylactic surgery, in whom the CT-based FE analysis showed a mild-moderate risk of a fracture and who devel-oped a complication (as defined in a composite safety endpoint) - calculated in both study groups | One month |
| 25761000 | Background | Goodheart JR, Cleary RJ, Damron TA, Mann KA. Simulating activities of daily living with finite element analysis improves fracture prediction for patients with metastatic femoral lesions. J Orthop Res. 2015 Aug;33(8):1226-34. doi: 10.1002/jor.22887. Epub 2015 May 21. |
| 17706228 | Background | Yosibash Z, Trabelsi N, Milgrom C. Reliable simulations of the human proximal femur by high-order finite element analysis validated by experimental observations. J Biomech. 2007;40(16):3688-99. doi: 10.1016/j.jbiomech.2007.06.017. Epub 2007 Aug 13. |
| 21497354 | Background | Trabelsi N, Yosibash Z, Wutte C, Augat P, Eberle S. Patient-specific finite element analysis of the human femur--a double-blinded biomechanical validation. J Biomech. 2011 Jun 3;44(9):1666-72. doi: 10.1016/j.jbiomech.2011.03.024. Epub 2011 Apr 15. |
| 25284156 | Background | Yosibash Z, Plitman Mayo R, Dahan G, Trabelsi N, Amir G, Milgrom C. Predicting the stiffness and strength of human femurs with real metastatic tumors. Bone. 2014 Dec;69:180-90. doi: 10.1016/j.bone.2014.09.022. Epub 2014 Oct 2. |
| 28326347 | Background | Benca E, Patsch JM, Mayr W, Pahr DH, Windhager R. The insufficiencies of risk analysis of impending pathological fractures in patients with femoral metastases: A literature review. Bone Rep. 2016 Mar 2;5:51-56. doi: 10.1016/j.bonr.2016.02.003. eCollection 2016 Dec. |
| 25724521 | Background | Nazarian A, Entezari V, Zurakowski D, Calderon N, Hipp JA, Villa-Camacho JC, Lin PP, Cheung FH, Aboulafia AJ, Turcotte R, Anderson ME, Gebhardt MC, Cheng EY, Terek RM, Yaszemski M, Damron TA, Snyder BD. Treatment Planning and Fracture Prediction in Patients with Skeletal Metastasis with CT-Based Rigidity Analysis. Clin Cancer Res. 2015 Jun 1;21(11):2514-9. doi: 10.1158/1078-0432.CCR-14-2668. Epub 2015 Feb 27. |
| ID | Term |
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| D004194 | Disease |
| D009140 | Musculoskeletal Diseases |
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| D010335 | Pathologic Processes |
| D013568 | Pathological Conditions, Signs and Symptoms |
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| D003226 | Congresses as Topic |
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| D009938 | Organizations |
| D004472 | Health Care Economics and Organizations |
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