Intercalary allografts following resection of a primary diaphyseal
tumour have high rates of complications and failures. At our institution
intercalary allografts are augmented with intramedullary cement
and fixed using compression plating. Our aim was to evaluate their
long-term outcomes. A total of 46 patients underwent reconstruction with an intercalary
allograft between 1989 and 2014. The patients had a mean age of
32.8 years (14 to 77). The most common diagnoses were osteosarcoma
(n = 16) and chondrosarcoma (n = 9). The location of the tumours
was in the femur in 21, the tibia in 16 and the humerus in nine. Function
was assessed using the Musculoskeletal Tumor Society (MSTS) scoring
system and the Toronto Extremity Salvage Score (TESS). The survival
of the graft and the overall survival were assessed using the Kaplan-Meier method.Aims
Patients and Methods
Biological reconstruction techniques after diaphyseal tumour resection have increased in popularity in recent years. High complication and failure rates have been reported with intercalary allografts, with recent studies questioning their role in limb-salvage surgery. We developed a technique in which large segment allografts are augmented with intramedullary cement and fixed using compression plating. The goal of this study was to evaluate the survivorship, complications and functional outcomes of these intercalary reconstructions. Forty-two patients who had reconstruction with an intercalary allograft following tumour resection between 1989 and 2010 were identified from our prospectively collected database. Allograft survival, local recurrence-free, disease-free and overall survival were assessed using the Kaplan-Meier method. Patient function was assessed using the Musculoskeletal Tumour Society (MSTS) scoring system and the Toronto Extremity Salvage Score (TESS). The 23 women and 19 men had a mean age of 33 years (14–77). The most common diagnoses were osteosarcoma (n=16) and chondrosarcoma (n=9). There were 9 humerus, 18 femur and 15 tibia reconstructions. At a mean follow-up of 95 months (5–288), 31 patients were alive without disease, 10 were dead of disease and 1 was deceased of other causes. There were 4 local recurrences and 11 patients developed metastatic disease. 5-year local recurrence free survival was 92%, 5-year disease-free survival was 70% and overall survival was 75%. Fourteen of 42 patients (33%) experienced complications: 5 wound healing complications, 4 infections, 2 non-unions, 2 fractures and 1 nerve palsy. Four allografts (9.5%) were revised for complications and 2 (5%) for local recurrence. Mean allograft survival was 85 months (4–288). Mean time to union was 8.2 (3–36) months for the proximal osteotomy site and 8.1 (3–23) months for the distal osteotomy site. The mean score for MSTS 87 was 29.4 (+/− 4.4), MSTS 93 was 83.7 (+/−14.8) and TESS was 81.6 (+/−16.9). An intercalary allograft augmented with intramedullary cement and compression plate fixation provides a reliable and durable method of reconstruction after tumour resection. Complication rates are comparable to the literature and are associated with high levels of patient function and satisfaction.
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. Cite this article:
Radiation induced pathologic fractures present a difficult problem for musculoskeletal oncologists. The purpose of this study was to determine the outcomes of management of radiation-induced pathologic fractures in a group of patients who had previously undergone combined management of extremity soft tissue sarcoma. A review of our retrospective database was undertaken. From 1986 to present, thirty-two patients with soft tissue sarcomas were found to have radiation induced pathologic fractures. The records of these patients were reviewed for patient demographics, tumour size and anatomic site, presence of periosteal stripping at time of surgery, radiation dose, time to fracture, fracture treatment and fracture outcome. There were twenty-three females and nine males with a mean age of sixty-three (range thirty-six to eighty-nine) years. Fractures occurred at a mean of forty-five months after resection of the sarcoma (range three to one hundred and fifty months). Anatomic distribution of fractures were : proximal femur(twelve), femoral diaphysis (eight), distal femur (two) tibia (five), acetabulum (two), metatarsal (two) and patella (one). Periosteal stripping was performed in half of the patients. Twenty-three patients had received high dose radiation (6600Gy). Seven fractures were managed conservatively while twenty-five were treated surgically. Only eleven of the thirty-two fractures united. Six patients underwent amputation, three for local recurrence and three for non-union of their fracture. Eight patients ultimately underwent arthroplasty, while seven patients have persistent non-unions. In the proximal femur, only three out of twelve fractures healed while six patients eventually underwent arthroplasty and three continue to have non-unions. Of eight femoral diaphyseal fractures, only one united. Patients who eventually underwent prosthetic replacement had good function and pain relief. Radiation induced pathologic fractures are a difficult clinical problem. In particular patients with fractures in the proximal femur often undergo multiple attempts at fixation before definitive management with resection and endoprosthetic replacement. Fractures of the femoral diaphysis rarely heal despite aggressive surgical management. Primary arthroplasty may be considered in some patients as an alternative to fixation in radiation-induced pathologic fractures of the femur in order to avoid long term morbidity and repeated operations.
