Site-dependent Replacement or Internal Fixation for Postradiation Femur Fractures After Soft Tissue Sarcoma Resection

Abstract

Background High-dose radiation retards bone healing, compromising the surgical results of radiation-induced fractures. Prosthetic replacement has traditionally been reserved as a salvage option but may best achieve the clinical goals of eliminating pain, restoring function and avoiding complications. Questions/purposes We asked whether patients undergoing prosthetic replacement at index surgery for radiationrelated subtrochanteric or diaphyseal fractures of the femur had fewer complications than those undergoing open reduction internal fixation at index operation. Methods We retrospectively reviewed records from 1045 patients with soft tissue sarcomas treated with surgical resection and high-dose radiation therapy between 1982 and 2009 and identified 37 patients with 39 fractures. We recorded patient demographics, diagnosis, type of surgical resection, total radiation dose, fracture location and pattern, years after radiation the fracture occurred, type of surgical fixation, and associated complications. Results Patients undergoing prosthetic replacement at index surgery had a lower number of major complications and revision surgeries than those undergoing index open reduction internal fixation. Patients undergoing open reduction internal fixation at index surgery had a nonunion rate of 63% (19 of 30). Fractures located in the metaphysis were more likely to heal than those located in the subtrochanteric or diaphyseal regions. Conclusions Radiation-induced fractures have poor healing potential. Our data suggest an aggressive approach to fracture treatment with a prosthetic replacement can minimize complications and the need for revision surgery.

Study on Fracture Healing with Small-Splint-Fixation Therapy by Near-Infrared Raman Spectroscopy

“…e maturation of the mineral in bone is indicated by the changes in the phosphate and carbonate modes. is change of carbonate-to-phosphate ratio is consistent with some studies such as bone tissue maturation [28] and mineralization of developing bone [29]. Meanwhile, this result indicated that an increase in carbonate occurs with increasing mineralization in bone tissue [1].…”

Effects of radiation and surgery on healing of femoral fractures in a rat model

“…In the clinical situation, prophylactic intramedullary nailing of the femur is often carried out to prevent fracture in sarcoma patients who are at risk. However, fractures have been reported in patients who have prophylactic intramedullary nails in place, which reflects the significant biological effect of the radiation . Fractures that occur despite prophylactic nailing also indicates the importance of elucidating a biological mechanism and solution to this clinical problem.…”

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

“…Kim et al 13 reported on 36 fractures of the femur after surgical resection and radiotherapy. The authors compared 30 patients treated by internal fixation to a subgroup of six patients treated with a primary endoprosthesis; 19 of the 30 patients (63%) treated by internal fixation developed a nonunion.…”

“…11 When they occur in the femur they represent a major clinical problem as they are painful and debilitating: complications are common despite treatment by internal fixation. 10,13 The purpose of this study was to assess the clinical outcome of patients with a radiationinduced pathological fracture of the femur treated by internal fixation. Our hypothesis was that these fractures have an exceptionally low potential to heal and that many patients would develop a nonunion after internal fixation, requiring further surgery.…”