Tips on surgery and fracture management from the MSTS
Radiotherapy is a valuable adjunct to surgery in treatment of soft-tissue sarcomas, but the late effects of radiation can be significant (Fig. 1), according to H. Thomas Temple, MD, professor of orthopaedics and pathology at the University of Miami School of Medicine. Speaking at the Musculoskeletal Tumor Society (MSTS) 2011 Specialty Day Program, Dr. Temple explained that patients’ responses to radiation are unpredictable due to tumor heterogeneity, variability of normal tissue response, and individual patient variability.
The biologic late effects of radiation are underestimated and largely unreported, he added. “In some patients, chronic irradiated soft tissue is indurated and fibrotic, predisposing it to joint stiffness and contracture. The skin is prone to cellulitis; the affected extremities are often edematous, which, if severe and left untreated, can lead to ulceration and deep infection. The underlying bone may be damaged, limiting its capacity to remodel and increasing the risk of fracture. Irradiated joints are also at risk for osteonecrosis and arthrosis,” Dr. Temple said.
Surgery in the irradiated field
Performing surgery in an irradiated field requires meticulous technique and soft-tissue handling; the liberal use of drains, antibiotics, and free flaps; and prophylactic bone fixation for periosteal stripping. Anecdotal evidence also supports the use of hyperbaric oxygen before and/or after surgery.
“Patients with moderate to severe chronic radiation damage are at high risk for surgical complications,” he said. “Soft-tissue planes are distorted or obliterated, which exposes blood vessels and nerves to possible damage. It may be difficult to achieve adequate exposure. Because small vessels may be fragile, the risk of bleeding and fluid collection is increased. Consequently, wound healing may be delayed; deep infection may result in potential amputation.”
Dr. Temple noted that although wound complications are more significant in patients who have preoperative radiotherapy compared to those who receive postoperative radiotherapy, the timing of radiotherapy has no significant impact on local recurrence, overall survival, or disease-free survival rates, according to the literature.
Preventing late effects of radiation
Late effects of radiation are directly related to the dose as well as the mode of radiation delivery, explained Dr. Temple. “To avoid these effects we need to narrow our indications for external beam radiotherapy (EBRT),” he said. “We should also look at biologic markers to potentially identify patients who are at risk for late-term complications, and segregate chemotherapy responders—patients who respond well to chemotherapy may not require radiotherapy.”
He added that radiotherapy treatment time should be limited and the radiation dose maximized where it is needed most. Dr. Temple believes it is too soon, however, to make changes to the radiotherapy treatment protocol for soft-tissue sarcomas. He recommends examining multi-institutional retrospective studies to further define the scope of the problem and “developing prospective trials that compare other novel strategies with the basic tenets of surgery and EBRT.
“At some point in the future, we may rely on systemic and targeted radiotherapy treatment strategies to control both local and distant disease,” he said. “In the meantime, we may be able to mitigate many of the late effects of radiation that affect overall function and outcomes by limiting radiotherapy treatment time and fields and maximizing the dose where it is needed most.”
Fracture management of irradiated bone
Radiation can damage bone, increasing the risk for fracture. According to fellow MSTS presenter Ginger E. Holt, MD, director of the musculoskeletal oncology division at Vanderbilt Orthopaedic Institute, the following are additional risk factors for fracture in irradiated bone:
- female sex
- age older than 55 years
- periosteal stripping during resection
- neoadjuvant chemotherapy
- tumor in the anterior thigh compartment
- radiation to the entire bone
- use of glucocorticoids
She added that fractures are most often associated with radiation greater than 50 Gy, and that the average occurrence of fracture is 4 years following radiation.
Fractures in irradiated bone can be difficult to treat and few treatment guidelines exist. Although nonsurgical management is an option, most of these fractures need to be treated surgically—and aggressively, Dr. Holt said.
“Intramedullary (IM) nailing is often the first line of treatment for radiation-associated diaphyseal fractures. IM nails are load sharing and provide maximal fixation with minimal disruption to soft tissue,” she explained. “At best, however, only about half of these fractures will heal.”
Radiation-associated long-bone fractures can also be treated with a bone graft or vascular fibula graft (VFG). A VFG is used “to bridge, or go outside, the irradiated field to create a union above and below the fracture; the fracture itself doesn’t necessarily heal,” she said.
An endoprosthesis is another option for bypassing the bone. “In some patients, an endoprosthesis may actually be a better first line of treatment—you really have to look at it case by case,” said Dr. Holt. “For example, a standard hip replacement can be very successful in patients with osteonecrosis or disease of the acetabulum.”
Some bones—such as the clavicle—can be resected without reconstruction, making them easier to treat, according to Dr. Holt. Claviculectomy, either total or partial, is a definitive treatment with a low complication rate and good pain relief.
Dr. Holt also addressed prophylactic open reduction internal fixation (ORIF)/IM nailing at the time of index surgery. She cautioned that this not only increases operating room time, but may also promote infection. “The IM nail devascularizes the IM canal, and by stripping the bone both externally and internally, we’ve eliminated the one chance that it has to heal,” she added.
Dr. Holt does, however, advocate prophylactic fixation in cases where the cortex is resected or breached. “When a piece of bone is removed, some type of fixation or prophylaxis in the remaining bone needs to occur,” she explained. “However, even the best plans to treat a patient prophylactically may not be enough.”
Fracture management of irradiated bone needs to be appropriate and aggressive, based on individual patient factors and the surgeon’s skill set, Dr. Holt concluded. “It is a hostile environment—irradiated bone does not heal. The more we can bypass it and be definitive in our treatment, the better.”
Disclosure information: Dr. Temple—Stryker; Dr. Holt—Ruth Jackson Orthopaedic Society
- Patients with moderate to severe chronic radiation damage are at high risk for surgical complications, and fractures in radiated bone are difficult to treat.
- Because irradiated bone does not heal well, fracture management must be aggressive and employ techniques that “bypass the bone.”
- IM nailing, endoprostheses, grafts, resection without reconstruction, and prophylactic fixation are among the techniques that can be used.
Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at email@example.com