Authors: Nahhas, Mohammed, and Isler, Marc Pathological Fracture after Radiation and Surgical Resection of Soft Tissue Sarcomas Authors: Nahhas, Mohammed, and Isler, Marc

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Introduction the combination of high dose radiation and resection of soft tissue sarcomas in the long bones predisposes to pathological fracture, particularly when associated with periosteal stripping some authors suggest prophylactic fixation is this justified?

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Risk factors Periosteal stripping Radiation Chemotherapy Female Anterior compartment resection

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Scarborough,CORR,389,2001 periosteal stripping increases the rate of fracture by removing the intramembranous reparative mechanism (the periosteum) and disruption of the vascular supply to the bone.

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Materials and methods Retrospective review of a prospective database known risk factors incidence of fracture, type of trauma success of fracture treatment

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Inclusion criteria Soft tissue sarcoma of thigh and leg limb-sparing surgical resection & >50gy RT age 18 and older Fracture site in field of radiation

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Exclusion criteria Superficial sarcoma ( completely above deep fascia) or upper limb sarcomas Bone lesions, or soft tissue sarcomas requiring osseous resection benign soft tissue tumors

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Results 1990 to 2003 245 lower extremity sarcomas of soft tissue were resected before (or after) radiation therapy

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Results 9 fractures in 245 patients (4%) 5 Females/ 4 Males No prior infections mean latency of 29.6 months only minimal trauma (e.g. fall from standing height)

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Results of fracture treatment intramedullary nailing 2 cases (22%) developed nonunion no infections

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Discussion reported incidence of 6% to 25% Butler MS, Clin Orthop 251, 1990 Stinson SF, Int Radiat Oncol Biol Phys 21,1991 Wall JE, Orthopedics, 19, 1996

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Scarborough,CORR,389,2001 Rate of fracture 5.6 % Rate of nonunion 45 %

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Scarborough,CORR,389,2001 Periosteal stripping and anterior compartment involvement were identified as significant risk factors for the femur fracture after en bloc excision and irradiation for treatment of soft tissue sarcomas of the thigh

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Scarborough,CORR,389,2001 16 % fracture rate if anterior compartment 15-fold increase in risk

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Lin PP,Cancer 47,1998 Periosteal stripping a risk factor for fracture after surgical excision and radiation of the extremity tumors

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Lin PP,Clin Orthop 352,1998 Also reported 75% nonunion or delayed union advocated intramedullary fixation and bone grafting

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Bell RS, Clin Orthop, 271, 1991 Concluded that long bones have a diminished capacity to remodel according to stress after radiation therapy.

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Discussion rate of fracture compatible with lower end of reported range rate of non union lower than most reports

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Discussion lower radiation dose (most cases treated preoperatively to 50gy with only close or positive margins boosted to 63gy); is this an explanation for lower nonunion rate? avg 54Gy our pts vs avg 59gy Scarborough study; is this significant?

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Conclusion Based on this series, the small number and low morbidity associated with pathological fractures in the context of irradiated and resected soft tissue sarcoma does not warrant prophylactic intramedullary fixation of the femur/tibia at the time of sarcoma resection.

Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma Conclusion individualized decision morbidity vs benefit bone resection

Thank you