Authors: Walid Ebeid, MD; Sherif Amin, MD; Amr Abdelmegid, MD

Abstract

Background: Little is known about oncologic outcomes of patients with primary bone tumors complicated by a pathologic fracture and treated by limb salvage.
Methods: Our study included 17 men and 14 women aged 6 to 61 years (average age 17 years). All 31 patients had primary bone tumors complicated by a pathologic fracture. Diagnoses included osteosarcoma (17 patients), Ewing's sarcoma (10), malignant fibrous histiocytoma (3), and lymphoma (1). All received preoperative chemotherapy. The distal femur was affected in 13 patients, the proximal femur in 6, mid shaft femur in 4, the proximal humerus in 4, the proximal tibia in 3, and the fibula in 1. All patients underwent limb salvage and achieved a wide resection margin.
Results: The average follow-up period was 18 months (range 8 to 51 months). Two patients required amputation due to local recurrence. Six patients developed pulmonary metastases and eventually died.
Conclusions: A pathologic fracture of primary bone tumor is not always a contraindication for limb salvage since the oncologic outcome appears acceptable.

Introduction

The principal goal in the management of patients who have a primary bone sarcoma is prolonging their survival. Primary bone sarcomas that require surgical resection can be treated by either amputation or limb salvage. Most studies comparing limb salvage and amputation reported that limb salvage had no adverse effect on the long-term survival of patients.[1]

Several contraindications to limb salvage have been developed to ensure that this treatment does not result in an inferior oncologic outcome.[2] Pathologic fracture of a primary bone sarcoma is considered a contraindication to limb salvage for two reasons: (1) the fracture results in a local hematoma with dissemination of tumor cells into adjacent tissues and adjacent joints, and (2) damage to the microcirculation may facilitate metastases.[3] On the other hand, several factors support limb salvage for primary bone sarcoma complicated by pathologic fractures.[4] These factors include the efficacy of neoadjuvant chemotherapy, healing of the fracture during the preoperative chemotherapy, thus facilitating manipulation during surgery, and the use of reconstructive modalities (eg, joint fusion and rotationplasty) that do not require functioning muscles after wide surgical resections.

This study evaluates the oncologic outcomes of limb salvage procedures that were used for 31 patients with primary bone sarcoma complicated by a pathologic fracture.