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Predicting Risk of 30-day Postoperative Morbidity Using the Pathologic Fracture Mortality Index
Ashish Vankara1, Christopher R Leland, Ridge Maxson
1From the Department of Orthopaedic Surgery, Division of Orthopaedic Oncology, The Johns Hopkins Hospital, Baltimore, MD (Vankara, Leland, Maxson, Raad, Sabharwal, and Levin), Orthopaedic Surgery Service, Memorial Sloan-Kettering Cancer Center, New York, NY (Morris).
Introduction:
The purpose of this study was to evaluate the ability of the Pathologic Fracture Mortality Index (PFMI) to predict the risk of 30-day morbidity after pathologic fracture fixation and compare its efficacy with those of the American Society of Anesthesiologists (ASA) physical status, modified Charlson Comorbidity Index (mCCI), and modified frailty index (mFI-5).
Methods:
Cohorts of 1,723 patients in the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2020 and 159 patients from a tertiary cancer referral center who underwent fixation for impending or completed pathologic fractures of long bones were retrospectively analyzed. National Surgical Quality Improvement Program morbidity variables were categorized into medical, surgical, utilization, and all-cause. PFMI, ASA, mCCI, and mFI-5 scores were calculated for each patient. Area under the curve (AUC) was used to compare efficacies.
Results:
AUCs predicting all-cause morbidity were 0.62, 0.54, and 0.56 for the PFMI, ASA, and mFI-5, respectively. The PFMI outperformed the ASA and mFI-5 in predicting all-cause ( P < 0.01), medical ( P = 0.01), and utilization ( P < 0.01) morbidities. In the 2005 to 2012 subset, the PFMI outperformed the ASA, mFI-5, and mCCI in predicting all-cause ( P = 0.01), medical ( P = 0.03), and surgical ( P = 0.05) morbidities but performed similarly to utilization morbidity ( P = 0.19). In our institutional cohort, the AUC for the PFMI in morbidity stratification was 0.68. The PFMI was associated with all-cause (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.12 to 1.51; P < 0.001), medical (OR, 1.19; 95% CI, 1.03 to 1.40; P = 0.046), and utilization (OR, 1.32; 95% CI, 1.14 to 1.52; P < 0.001) morbidities but not significantly associated with surgical morbidity (OR, 1.21; 95% CI, 0.98 to 1.49; P = 0.08) in this cohort.
Discussion:
The PFMI is an advancement in postoperative morbidity risk stratification of patients with pathologic fracture from metastatic disease.
Level Of Evidence:
III.
Insights
The Pathologic Fracture Mortality Index (PFMI) effectively predicts 30-day morbidity after fracture fixation, outperforming other common indices. This tool enhances risk stratification for patients with pathologic fractures.
Area of Science:
- Orthopedic Surgery
- Oncology
- Epidemiology
Background:
- Pathologic fractures, often due to metastatic disease, pose significant morbidity risks post-fixation.
- Accurate prediction of postoperative morbidity is crucial for patient management and resource allocation.
Purpose of the Study:
- To evaluate the Pathologic Fracture Mortality Index (PFMI) for predicting 30-day morbidity after pathologic fracture fixation.
- To compare the PFMI's predictive efficacy against the American Society of Anesthesiologists (ASA) physical status, modified Charlson Comorbidity Index (mCCI), and modified frailty index (mFI-5).
Main Methods:
- Retrospective analysis of 1,723 patients from the National Surgical Quality Improvement Program (NSQIP) database (2005-2020) and 159 patients from a tertiary cancer center.
- Calculation of PFMI, ASA, mCCI, and mFI-5 scores for each patient.
- Comparison of predictive performance using Area Under the Curve (AUC) for various morbidity outcomes (medical, surgical, utilization, all-cause).
Main Results:
- The PFMI demonstrated superior predictive ability for all-cause morbidity (AUC=0.62) compared to ASA (AUC=0.54) and mFI-5 (AUC=0.56).
- PFMI outperformed ASA, mFI-5, and mCCI in predicting all-cause, medical, and surgical morbidities in specific patient subsets.
- In the institutional cohort, PFMI was significantly associated with all-cause, medical, and utilization morbidities.
Conclusions:
- The Pathologic Fracture Mortality Index (PFMI) represents a significant advancement in stratifying postoperative morbidity risk for patients with pathologic fractures.
- PFMI offers improved accuracy in predicting adverse outcomes, aiding clinical decision-making in this vulnerable patient population.
