Internal fixation of radiation-induced fragility fractures of the pelvis: a case series.
Complication
Fragility fracture of the pelvis
Internal fixation
Operative
Radiation induced
Journal
Archives of orthopaedic and trauma surgery
ISSN: 1434-3916
Titre abrégé: Arch Orthop Trauma Surg
Pays: Germany
ID NLM: 9011043
Informations de publication
Date de publication:
Feb 2023
Feb 2023
Historique:
received:
20
06
2021
accepted:
14
01
2022
pubmed:
3
2
2022
medline:
16
2
2023
entrez:
2
2
2022
Statut:
ppublish
Résumé
The optimal treatment for radiation-induced fragility fractures of the pelvis (RI-FFP) is not well evaluated due to the rarity of the condition. The aim of this retrospective study was to assess the prevalence of RI-FFP, the radiological and clinical outcomes as well as the complications of patients treated with internal fixation. A retrospective review of our database was performed to identify all surgically treated patients with RI-FFP. Surgical stabilization was recommended for patients with FFP type III and FFP type IV. Surgical stabilization was also recommended after 5-7 days for patients with FFP type II in case of unsuccessful conservative treatment. Demographic data, fracture patterns according to the FFP classification of Rommens and Hofmann, type of treatment and surgery-related complications including nonunion, hardware failure, fracture progression (secondary fracture) or infection were documented. Among 500 patients with FFP, the prevalence of patients with RI-FFP was 1% (5/500): 5 patients with a median age of 79 years (76-79). The median time interval from radiation to fracture was 18 months (18-24). All of them underwent internal fixation. Two patients experienced surgery-related complications, one due to hardware failure and one due to fracture progression. At median follow-up of 27 months, all fractures had healed. Patients reached a good level of mobility with a median Parker Mobility Score of 7 and suffered moderate pain with a median value of 2.5 on the numeric rating scale. RI-FFP remains a rare injury (1%). In our experience, patients, who underwent surgical treatment, obtained a high level of mobility and a moderate pain score after 2 years of follow-up. Internal fixation can be recommended in RI-FFP. Because bone healing may be impaired due to previous irradiation, highly stable constructs are required to avoid fracture progression or revision surgery. III, retrospective study.
Sections du résumé
BACKGROUND
BACKGROUND
The optimal treatment for radiation-induced fragility fractures of the pelvis (RI-FFP) is not well evaluated due to the rarity of the condition.
PURPOSE
OBJECTIVE
The aim of this retrospective study was to assess the prevalence of RI-FFP, the radiological and clinical outcomes as well as the complications of patients treated with internal fixation.
METHODS
METHODS
A retrospective review of our database was performed to identify all surgically treated patients with RI-FFP. Surgical stabilization was recommended for patients with FFP type III and FFP type IV. Surgical stabilization was also recommended after 5-7 days for patients with FFP type II in case of unsuccessful conservative treatment. Demographic data, fracture patterns according to the FFP classification of Rommens and Hofmann, type of treatment and surgery-related complications including nonunion, hardware failure, fracture progression (secondary fracture) or infection were documented.
RESULTS
RESULTS
Among 500 patients with FFP, the prevalence of patients with RI-FFP was 1% (5/500): 5 patients with a median age of 79 years (76-79). The median time interval from radiation to fracture was 18 months (18-24). All of them underwent internal fixation. Two patients experienced surgery-related complications, one due to hardware failure and one due to fracture progression. At median follow-up of 27 months, all fractures had healed. Patients reached a good level of mobility with a median Parker Mobility Score of 7 and suffered moderate pain with a median value of 2.5 on the numeric rating scale.
CONCLUSION
CONCLUSIONS
RI-FFP remains a rare injury (1%). In our experience, patients, who underwent surgical treatment, obtained a high level of mobility and a moderate pain score after 2 years of follow-up. Internal fixation can be recommended in RI-FFP. Because bone healing may be impaired due to previous irradiation, highly stable constructs are required to avoid fracture progression or revision surgery.
LEVEL OF EVIDENCE
METHODS
III, retrospective study.
Identifiants
pubmed: 35107637
doi: 10.1007/s00402-022-04358-9
pii: 10.1007/s00402-022-04358-9
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
865-871Informations de copyright
© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.
Références
Higham CE, Faithfull S (2015) Bone health and pelvic radiotherapy. Clin Oncol (R Coll Radiol) 27:668–678. https://doi.org/10.1016/j.clon.2015.07.006
doi: 10.1016/j.clon.2015.07.006
pubmed: 26276560
Vitzthum LK, Park H, Zakeri K, Heide ES, Nalawade V, Mundt AJ, Vaida F, Murphy JD, Mell LK (2020) Risk of pelvic fracture with radiation therapy in older patients. Int J Radiat Oncol Biol Phys 106:485–492. https://doi.org/10.1016/j.ijrobp.2019.10.006
doi: 10.1016/j.ijrobp.2019.10.006
Nanninga GL, de Leur K, Panneman MJ, van der Elst M, Hartholt KA (2014) Increasing rates of pelvic fractures among older adults: the Netherlands, 1986–2011. Age Ageing 43:648–653. https://doi.org/10.1093/ageing/aft212
doi: 10.1093/ageing/aft212
Andrich S, Haastert B, Neuhaus E, Neidert K, Arend W, Ohmann C, Grebe J, Vogt A, Jungbluth P, Rösler G, Windolf J, Icks A (2015) Epidemiology of pelvic fractures in Germany: considerably high incidence rates among older people. PLoS ONE 10:e0139078. https://doi.org/10.1371/journal.pone.0139078
doi: 10.1371/journal.pone.0139078
Krappinger D, Kaser V, Merkel A, Neururer S, Lindtner RA (2021) An alphanumeric classification of osteoporotic pelvic ring injuries. Arch Orthop Trauma Surg 141(5):861–869. https://doi.org/10.1007/s00402-020-03546-9
doi: 10.1007/s00402-020-03546-9
Rommens PM, Hofmann A (2013) Comprehensive classification of fragility fractures of the pelvic ring: recommendations for surgical treatment. Injury 44:1733–1744. https://doi.org/10.1016/j.injury.2013.06.023
doi: 10.1016/j.injury.2013.06.023
Hotta K, Kobayashi T (2021) Functional treatment strategy for fragility fractures of the pelvis in geriatric patients. Eur J Trauma Emerg Surg 47(1):21–27. https://doi.org/10.1007/s00068-020-01484-0
doi: 10.1007/s00068-020-01484-0
Ueda Y, Inui T, Kurata Y, Tsuji H, Saito J, Shitan Y (2021) Prolonged pain in patients with fragility fractures of the pelvis ma. Eur J Trauma Emerg Surg 47(2):507–513. https://doi.org/10.1007/s00068-019-01150-0
doi: 10.1007/s00068-019-01150-0
Yoshida M, Tajima K, Saito Y, Sato K, Uenishi N, Iwata M (2020) Mobility and mortality of 340 patients with fragility fracture of the pelvis. Eur J Trauma Emerg Surg. https://doi.org/10.1007/s00068-020-01481-3
doi: 10.1007/s00068-020-01481-3
Benzinger P, Becker C, Kerse N, Bleibler F, Büchele G, Icks A, Rapp K (2013) Pelvic fracture rates in community-living people with and without disability and in residents of nursing homes. J Am Med Dir Assoc 14:673–678. https://doi.org/10.1016/j.jamda.2013.03.012
doi: 10.1016/j.jamda.2013.03.012
Marrinan S, Pearce MS, Jiang XY, Waters S, Shanshal Y (2015) Admission for osteoporotic pelvic fractures and predictors of length of hospital stay, mortality and loss of independence. Age Ageing 44:258–261. https://doi.org/10.1093/ageing/afu123
doi: 10.1093/ageing/afu123
Prieto-Alhambra D, Avilés FF, Judge A, Van Staa T, Nogués X, Arden NK, Díez-Pérez A, Cooper C, Javaid MK (2012) Burden of pelvis fracture: a population-based study of incidence, hospitalisation and mortality. Osteoporos Int 23:2797–2803. https://doi.org/10.1007/s00198-012-1907-z
doi: 10.1007/s00198-012-1907-z
Cannon CP, Lin PP, Lewis VO, Yasko AW (2008) Management of radiation-associated fractures. J Am Acad Orthop Surg 16:541–549
doi: 10.5435/00124635-200808000-00015
pubmed: 18768711
Sternheim A, Saidi K, Lochab J, O’Donnell PW, Eward WC, Griffin A, Wunder JS, Ferguson P (2013) Internal fixation of radiation-induced pathological fractures of the femur has a high rate of failure. Bone Jt J 95-B:1144–1148. https://doi.org/10.1302/0301-620X.95B8.31832
doi: 10.1302/0301-620X.95B8.31832
Urits I, Orhurhu V, Callan J, Maganty NV, Pousti S, Simopoulos T, Yazdi C, Kaye RJ, Eng LK, Kaye AD, Manchikanti L, Viswanath O (2020) Sacral insufficiency fractures: a review of risk factors, clinical presentation, and management. Curr Pain Headache Rep 24:10. https://doi.org/10.1007/s11916-020-0848-z
doi: 10.1007/s11916-020-0848-z
Frey ME, Warner C, Thomas SM, Johar K, Singh H, Mohammad MS et al (2017) Sacroplasty: a ten-year analysis of prospective patients treated with percutaneous sacroplasty: literature review and technical considerations. Pain Physician 20:E1063–E1072
Rommens PM, Ossendorf C, Pairon P, Dietz SO, Wagner D, Hofmann A (2015) Clinical pathways for fragility fractures of the pelvic ring: personal experience and review of the literature. J Orthop Sci 20:1–11. https://doi.org/10.1007/s00776-014-0653-9
doi: 10.1007/s00776-014-0653-9
Rommens PM, Boudissa M, Sven K, Kisilak M, Hofmann A, Wagner D (2021) Operative treatment of fragility fractures of the pelvis is connected with lower mortality. A single institution experience. PLoS ONE 9(16):e0253408. https://doi.org/10.1371/journal.pone.0253408
doi: 10.1371/journal.pone.0253408
Walker JB, Mitchell SM, Karr SD, Lowe JA, Jones CB (2018) Percutaneous transiliac–transsacral screw fixation of sacral fragility fractures improves pain, ambulation, and rate of disposition to home. J Orthop Trauma 32:452–456. https://doi.org/10.1097/BOT.0000000000001243
doi: 10.1097/BOT.0000000000001243
Eckardt H, Egger A, Hasler RM, Zech CJ, Vach W, Suhm N, Morgenstern M, Saxer F (2017) Good functional outcome in patients suffering fragility fractures of the pelvis treated with percutaneous screw stabilisation: assessment of complications. Injury 48:2717–2723. https://doi.org/10.1016/j.injury.2017.11.002
doi: 10.1016/j.injury.2017.11.002
Arduini M, Saturnino L, Piperno A, Iundusi R, Tarantino U (2015) Fragility fractures of the pelvis: treatment and preliminary results. Aging Clin Exp Res 27(Suppl 1):S61–S67. https://doi.org/10.1007/s40520-015-0430-4
doi: 10.1007/s40520-015-0430-4
Parker MJ, Palmer CR (1993) A new mobility score for predicting mortality after hip fracture. J Bone Jt Surg Br 75:797–798. https://doi.org/10.1302/0301-620X.75B5.8376443
doi: 10.1302/0301-620X.75B5.8376443
Rodriguez CS (2001) Pain measurement in the elderly: a review. Pain Manag Nurs 2:38–46. https://doi.org/10.1053/jpmn.2001.23746
doi: 10.1053/jpmn.2001.23746
Rommens PM, Wagner D, Hofmann A (2017) Fragility fractures of the pelvis. JBJS Rev 21(5):01874474-201703000–00004. https://doi.org/10.2106/JBJS.RVW.16.00057
doi: 10.2106/JBJS.RVW.16.00057
Matsumura S, Jikko A, Hiranuma H, Deguchi A, Fuchihata H (1996) Effect of X-ray irradiation on proliferation and differentiation of osteoblast. Calcif Tissue Int 59:307–308. https://doi.org/10.1007/s002239900129
doi: 10.1007/s002239900129
Sapienza LG, Salcedo MP, Ning MS, Jhingran A, Klopp AH, Calsavara VF, Schmeler KM, Leite Gomes MJ, de FreitasCarvalho E, Baiocchi G (2020) Pelvic insufficiency fractures after external beam radiation therapy for gynecologic cancers: a meta-analysis and meta-regression of 3929 patients. Int J Radiat Oncol Biol Phys 106:475–484. https://doi.org/10.1016/j.ijrobp.2019.09.012
doi: 10.1016/j.ijrobp.2019.09.012
Park SH, Kim JC, Lee JE, Park IK (2011) Pelvic insufficiency fracture after radiotherapy in patients with cervical cancer in the era of PET/CT. Radiat Oncol J 29:269–276. https://doi.org/10.3857/roj.2011.29.4.269
doi: 10.3857/roj.2011.29.4.269
Razavian N, Laucis A, Sun Y, Spratt DE, Owen D, Schonewolf C, Uppal S, Maturen KE, Jolly S (2020) Radiation-induced insufficiency fractures after pelvic irradiation for gynecologic malignancies: a systematic review. Int J Radiat Oncol Biol Phys 108:620–634. https://doi.org/10.1016/j.ijrobp.2020.05.013
doi: 10.1016/j.ijrobp.2020.05.013
Ikushima H, Osaki K, Furutani S, Yamashita K, Kishida Y, Kudoh T, Nishitani H (2006) Pelvic bone complications following radiation therapy of gynecologic malignancies: clinical evaluation of radiation-induced pelvic insufficiency fractures. Gynecol Oncol 103:1100–1104. https://doi.org/10.1016/j.ygyno.2006.06.038
doi: 10.1016/j.ygyno.2006.06.038
Tokumaru S, Toita T, Oguchi M, Ohno T, Kato S, Niibe Y, Kazumoto T, Kodaira T, Kataoka M, Shikama N, Kenjo M, Yamauchi C, Suzuki O, Sakurai H, Teshima T, Kagami Y, Nakano T, Hiraoka M, Mitsuhashi N, Kudo S (2012) Insufficiency fractures after pelvic radiation therapy for uterine cervical cancer: an analysis of subjects in a prospective multi-institutional trial, and cooperative study of the Japan Radiation Oncology Group (JAROG) and Japanese Radiation Oncology Study Group (JROSG). Int J Radiat Oncol Biol Phys 84:e195-200. https://doi.org/10.1016/j.ijrobp.2012.03.042
doi: 10.1016/j.ijrobp.2012.03.042
Mahmood B, Pasternack J, Razi A, Saleh A (2019) Safety and efficacy of percutaneous sacroplasty for treatment of sacral insufficiency fractures: a systematic review. J Spine Surg 5:365–371. https://doi.org/10.21037/jss.2019.06.05
doi: 10.21037/jss.2019.06.05
Gal TJ, Munoz-Antonia T, Muro-Cacho CA, Klotch DW (2000) Radiation effects on osteoblasts in vitro: a potential role in osteoradionecrosis. Arch Otolaryngol Head Neck Surg 126:1124–1128. https://doi.org/10.1001/archotol.126.9.1124
doi: 10.1001/archotol.126.9.1124
Barth HD, Zimmermann EA, Schaible E, Tang SY, Alliston T, Ritchie RO (2011) Characterization of the effects of x-ray irradiation on the hierarchical structure and mechanical properties of human cortical bone. Biomaterials 32:8892–8904. https://doi.org/10.1016/j.biomaterials.2011.08.013
doi: 10.1016/j.biomaterials.2011.08.013
Lapina O, Tiškevičius S (2014) Sacral insufficiency fracture after pelvic radiotherapy: a diagnostic challenge for a radiologist. Medicina (Kaunas) 50:249–254. https://doi.org/10.1016/j.medici.2014.09.006
doi: 10.1016/j.medici.2014.09.006
pubmed: 25458963
Meixel AJ, Hauswald H, Delorme S, Jobke B (2018) From radiation osteitis to osteoradionecrosis: incidence and MR morphology of radiation-induced sacral pathologies following pelvic radiotherapy. Eur Radiol 28:3550–3559. https://doi.org/10.1007/s00330-018-5325-2
doi: 10.1007/s00330-018-5325-2
Strobel K, Burger C, Seifert B, Husarik DB, Soyka JD, Hany TF (2007) Characterization of focal bone lesions in the axial skeleton: performance of planar bone scintigraphy compared with SPECT and SPECT fused with CT. AJR Am J Roentgenol 188:W467–W474. https://doi.org/10.2214/AJR.06.1215
doi: 10.2214/AJR.06.1215
Salavati A, Shah V, Wang ZJ, Yeh BM, Costouros NG, Coakley FV (2011) F-18 FDG PET/CT findings in postradiation pelvic insufficiency fracture. Clin Imaging 35:139–142. https://doi.org/10.1016/j.clinimag.2009.12.026
doi: 10.1016/j.clinimag.2009.12.026