The epidemiology of cancer patients with proximal femoral lesions and evaluation of surgical decision tools: A prospective cohort study

Introduction This study evaluated the outcomes of orthopaedic oncological surgical decisions in cancer patients with proximal femoral lesions and the accuracy of fracture prediction tools. Methods Patients with proximal femur metastatic cancer or multiple myeloma lesions presenting for prophylactic surgical evaluation between March 2018 and July 2023 were recruited with follow-up until March 2026. Femoral fracture risk was evaluated using CT finite element analysis (CTFEA) and Mirels' score. Patients were randomized, enabling 2/3 of their surgeons to receive the results of their CTFEA. Results One hundred and ten patients completed the study. The patient 36-month patient survival rate from the time of orthopaedic oncology referral was 44%, with no difference in the survival estimates of patients who underwent prophylactic surgery and patients with no surgery ( P = 0.8. Four patients fractured. CTFEA predicted fracture in all and Mirels' score in two. There was no statistically significant difference between the sensitivity (100% vs 50%), specificity (72% vs 70%), positive prediction value (27% vs 13%), and negative prediction value (100% vs 94%) between CTFEA and the Mirels' score. CTFEA advised surgery in 57% (36/63) patients, but in only 27/36, was the clinical decision surgery. Conclusion Compared to publications prior to modern therapy, patient survival improved. Having prophylactic proximal femur surgery because of metastasis was not found to affect survival time. While CTFEA correctly identified all four fracture patients, following its prophylactic surgery recommendations would have led to unnecessary surgeries. Orthopaedic oncologists disregarded the CTFEA recommendation to perform surgery in 25% of patients.