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

2. 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?

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

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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)

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

13. 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

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

15. 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

16. 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

17. 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

18. 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

19. 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.

20. 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

21. 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?

22. Pathological Fracture after Radiation and Resection of Soft Tissue Sarcoma

23. 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.

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

25. Thank you