title: 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.
  
  
  OBJECTIVE
  We asked whether patients undergoing prosthetic replacement at index surgery for radiation-related 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.
authors.affiliation: Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA. hanjokimmd@gmail.com
authors.forename: Han Jo
authors.initials: HJ
authors.lastname: Kim
authors.forename: John H
authors.initials: JH
authors.lastname: Healey
authors.forename: Carol D
authors.initials: CD
authors.lastname: Morris
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: Boland
mesh_terms: D000368:Aged; D002370:Casts, Surgical; D005260:Female; D005264:Femoral Fractures / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D005593:Fracture Fixation, Internal / Q000009:adverse effects; D017102:Fracture Healing; D005599:Fractures, Ununited / Q000209:etiology / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D009519:New York City; D019637:Orthopedic Procedures; D019919:Prosthesis Implantation / Q000009:adverse effects; D011829:Radiation Dosage; D011832:Radiation Injuries / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D018714:Radiotherapy, Adjuvant / Q000009:adverse effects; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012509:Sarcoma / Q000532:radiotherapy* / Q000601:surgery*; D012983:Soft Tissue Neoplasms / Q000532:radiotherapy* / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome