Pulmonary embolism secondary to after-fracture fixation in metastatic bone disease patients

SESSION TITLE: Lung Cancer Case Report Posters 9 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Metastatic bone disease (MBD) causes significant mortality and morbidity, which manifests as pain, pathologic fracture, decreased daily function, and quality of life. Preventing pathological fractures with prophylactic treatment (PT) appears to be reasonable. Studies indicated that compared to PT, after-fracture (AF) fixation is related to a lower rate of venous thromboembolism including pulmonary embolism (PE), but higher rates of blood loss, nosocomial infection, duration of surgery, and re-operation risk. Here we report a case of PE secondary to AF fixation. CASE PRESENTATION: A 77-year-old male with past medical histories of hypertension, coronary artery disease, and benign prostatic hypertrophy presented at the Emergency Department (ED) for progressive left thigh pain for two months. The pain was described as dull, 8/10, consistent, and non-radiating. The pain was worse with ambulating and better with lying still. Sometimes the pain woke the patient up at night.On arrival, the patient's vital signs were within normal limits. Physical examination was positive for left thigh tenderness; the range of movement of the left lower extremity was limited by pain. X-ray of the left proximal leg showed an ill-defined area of osseous destruction with a moth-eaten appearance involving the left proximal femoral metadiaphysis. The patient was admitted to the medical floor for further management. Pain medications were provided. CT of the chest revealed a 4.1cm spiculated right upper lobe mass. The patient's Mirels score indicated prophylactic fixation. On the next day, he developed a pathological left femoral fracture during physical therapy evaluation and underwent left femur intramedullary nailing. Pathology indicated metastatic carcinoma with extensive necrosis, positive for CK7, possible pulmonary origin. The patient received postoperative deep venous thrombosis prophylaxis with subcutaneous heparin. Two days later, the patient complained of difficulty breathing with oxygen saturation at 88% on room air. Due to worsened kidney function, a ventilation/perfusion scan was performed, revealing a possible lingual pulmonary embolism. Heparin drip was initiated, followed by the transition to apixaban. The patient's saturation and pain improved significantly. He was discharged to the short-term rehabilitation center to follow up with oncology, pulmonology, and orthopedic surgery. DISCUSSION: Postoperative anticoagulation is critical in all MBD patients to prevent thromboembolic events unless contraindications exist. MBD patients undergoing PT have lower 1-year mortality rates and better secondary outcomes as compared with patients undergoing AF fixation. Early peri-operative death and increased thromboembolic risk need to be considered when deciding on PT. Patient survival prediction tools and fracture risk scoring systems such as the Mirels scoring system are helpful for physicians in making clinical decisions. CONCLUSIONS: AF fixation in MBD patients has a lower risk of developing pulmonary embolism compared to PT. However, postoperative anticoagulation should be applied to all MBD patients unless there are contraindications. Identifying MBD patients that have impending pathological fractures is both challenging and important since PT reveals lower morbidity and mortality rates compared to AF fixation. Large-scale investigations of the techniques for predicting impending fracture and patient survival are necessary to conquer this challenge. REFERENCE #1: Aneja, A., Jiang, J. J., Cohen-Rosenblum, A., Luu, H. H., Peabody, T. D., Attar, S., Luo, T., & Haydon, R. C. (2017). Thromboembolic Disease in Patients with Metastatic Femoral Lesions: A Comparison Between Prophylactic Fixation and Fracture Fixation. Journal of Bone and Joint Surgery, American Volume, 99(4), 315–323. https://doi.org/10.2106/jbjs.16.0002 REFERENCE #2: Damron, T. A., & Mann, K. G. (2020). Fracture risk assessment and clinical decision making for patients with metastatic bone disease. Journal of Orthopaedic Research, 38(6), 1175–1190. https://doi.org/10.1002/jor.24660 REFERENCE #3: Groot, O. Q., Lans, A., Twining, P., Bongers, M. E., Kapoor, N. D., Verlaan, J., Gupta, S., Raskin, K. A., Lozano-Calderon, S. A., Janssen, S. J., & Schwab, J. H. (2021). Clinical Outcome Differences in the Treatment of Impending Versus Completed Pathological Long-Bone Fractures. Journal of Bone and Joint Surgery, American Volume, 104(4), 307–315. https://doi.org/10.2106/jbjs.21.00711 DISCLOSURES: No relevant relationships by Mohamed Elsheshtawi No relevant relationships by Can Jones No disclosure on file for Vijay Narendran No relevant relationships by Catherine Ostos No relevant relationships by Virginia Velez Quinones