Internal fixation of radiation-induced pathological fractures of the femur has a high rate of failure

Abstract

We investigated the clinical outcome of internal fixation for pathological fracture of the femur after primary excision of a soft-tissue sarcoma that had been treated with adjuvant radiotherapy. A review of our database identified 22 radiation-induced fractures of the femur in 22 patients (seven men, 15 women). We noted the mechanism of injury, fracture pattern and any complications after internal fixation, including nonunion, hardware failure, secondary fracture or deep infection. The mean age of the patients at primary excision of the tumour was 58.3 years (39 to 86). The mean time from primary excision to fracture was 73.2 months (2 to 195). The mean follow-up after fracture fixation was 65.9 months (12 to 205). Complications occurred in 19 patients (86%). Nonunion developed in 18 patients (82%), of whom 11 had a radiological nonunion at 12 months, five a nonunion and hardware failure and two an infected nonunion. One patient developed a second radiation-associated fracture of the femur after internal fixation and union of the initial fracture. A total of 13 patients (59%) underwent 24 revision operations. Internal fixation of a pathological fracture of the femur after radiotherapy for a soft-tissue sarcoma has an extremely high rate of complication and requires specialist attention.

Management of soft-tissue sarcomas; treatment strategies, staging, and outcomes

“…Radiation-related fractures most commonly affect the femur and are significantly more frequent following postoperative radiation, likely due to the combination of higher radiation dose and larger treatment field [47–49]. High-risk patients can be identified using patient and treatment variables which have been combined into a nomogram (Table 2) [50], as well as specific bone radiation-avoidance principles [48].…”

Fertility, Cardiac, and Orthopedic Challenges in Survivors of Adult and Childhood Sarcoma

“…Infection is the most common method of failure for any long-bone reconstruction after sarcoma surgery. [57][58][59][60][61][62][63][64][65] Patients with a bone sarcoma typically undergo resection and reconstruction in combination after chemotherapy and are accordingly at risk for infection while immunosuppressed. Large surgical wounds are at particular risk for wound-healing complications.…”

“…The large bone defect left after resecting implants or allografts often precludes limb-salvage surgery and thus results in amputation. 58,59,64 All methods of reconstruction are subject to failure-ofconstruct. In the setting of allograft, autograft and arthrodesis, failure of the allograft to heal to the host bone will allow the hardware to fail over time.…”

“…Radiation to large, deep, high-grade sarcomas can also contribute to radiation necrosis, with short-or longterm effects, including bone fractures requiring intramedullary fixation and the need to remove necrotic bone. 64 Once the bone has become necrotic, attempts to support bone healing without resection are fraught with complications, including multiple surgical procedures, pain, and unsatisfactory results. 67…”

Can OP-1 stimulate union in a rat model of pathological fracture post treatment for soft tissue sarcoma?

“…Pathologic fracture is estimated to occur at a rate of 2–10% in this patient population, with a mean time to fracture of approximately 5 years. Non‐union of these fractures has been observed to occur in up to 90% of cases despite appropriate surgical internal fixation . Currently, there exists no reliable biological solution for this incompletely understood problem.…”