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Takeuchi A, Tsuchiya H, Setsu N, Gokita T, Tome Y, Asano N, Minami Y, Kawashima H, Fukushima S, Takenaka S, Outani H, Nakamura T, Tsukushi S, Kawamoto T, Kidani T, Kito M, Kobayashi H, Morii T, Akiyama T, Torigoe T, Hiraoka K, Nagano A, Kakunaga S, Hashimoto K, Emori M, Aiba H, Tanzawa Y, Ueda T, Kawano H. What Are the Complications, Function, and Survival of Tumor-devitalized Autografts Used in Patients With Limb-sparing Surgery for Bone and Soft Tissue Tumors? A Japanese Musculoskeletal Oncology Group Multi-institutional Study. Clin Orthop Relat Res 2023; 481:2110-2124. [PMID: 37314384 PMCID: PMC10566762 DOI: 10.1097/corr.0000000000002720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 02/28/2023] [Accepted: 05/08/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Tumor-devitalized autografts treated with deep freezing, pasteurization, and irradiation are biological reconstruction methods after tumor excision for aggressive or malignant bone or soft tissue tumors that involve a major long bone. Tumor-devitalized autografts do not require a bone bank, they carry no risk of viral or bacterial disease transmission, they are associated with a smaller immunologic response, and they have a better shape and size match to the site in which they are implanted. However, they are associated with disadvantages as well; it is not possible to assess margins and tumor necrosis, the devitalized bone is not normal and has limited healing potential, and the biomechanical strength is decreased owing to processing and tumor-related bone loss. Because this technique is not used in many countries, there are few reports on the results of this procedure such as complications, graft survival, and limb function. QUESTIONS/PURPOSES (1) What was the rate of complications such as fracture, nonunion, infection, or recurrence in a tumor-devitalized autograft treated with deep freezing, pasteurization, and irradiation, and what factors were associated with the complication? (2) What were the 5-year and 10-year grafted bone survival (free from graft bone removal) of the three methods used to devitalize a tumor-containing autograft, and what factors were associated with grafted bone survival? (3) What was the proportion of patients with union of the tumor-devitalized autograft and what factors were associated with union of the graft-host bone junction? (4) What was the limb function after the tumor-devitalized autograft, and what factors were related to favorable limb function? METHODS This was a retrospective, multicenter, observational study that included data from 26 tertiary sarcoma centers affiliated with the Japanese Musculoskeletal Oncology Group. From January 1993 to December 2018, 494 patients with benign or malignant tumors of the long bones were treated with tumor-devitalized autografts (using deep freezing, pasteurization, or irradiation techniques). Patients who were treated with intercalary or composite (an osteoarticular autograft with a total joint arthroplasty) tumor-devitalized autografts and followed for at least 2 years were considered eligible for inclusion. Accordingly, 7% (37 of 494) of the patients were excluded because they died within 2 years; in 19% (96), an osteoarticular graft was used, and another 10% (51) were lost to follow-up or had incomplete datasets. We did not collect information on those who died or were lost to follow-up. Considering this, 63% of the patients (310 of 494) were included in the analysis. The median follow-up was 92 months (range 24 to 348 months), the median age was 27 years (range 4 to 84), and 48% (148 of 310) were female; freezing was performed for 47% (147) of patients, pasteurization for 29% (89), and irradiation for 24% (74). The primary endpoints of this study were the cumulative incidence rate of complications and the cumulative survival of grafted bone, assessed by the Kaplan-Meier method. We used the classification of complications and graft failures proposed by the International Society of Limb Salvage. Factors relating to complications and grafted autograft removal were analyzed. The secondary endpoints were the proportion of bony union and better limb function, evaluated by the Musculoskeletal Tumor Society score. Factors relating to bony union and limb function were also analyzed. Data were investigated in each center by a record review and transferred to Kanazawa University. RESULTS The cumulative incidence rate of any complication was 42% at 5 years and 51% at 10 years. The most frequent complications were nonunion in 36 patients and infection in 34 patients. Long resection (≥ 15 cm) was associated with an increased risk of any complication based on the multivariate analyses (RR 1.8 [95% CI 1.3 to 2.5]; p < 0.01). There was no difference in the rate of complications among the three devitalizing methods. The cumulative graft survival rates were 87% at 5 years and 81% at 10 years. After controlling for potential confounding variables including sex, resection length, reconstruction type, procedure type, and chemotherapy, we found that long resection (≥ 15 cm) and composite reconstruction were associated with an increased risk of grafted autograft removal (RR 2.5 [95% CI 1.4 to 4.5]; p < 0.01 and RR 2.3 [95% CI 1.3 to 4.1]; p < 0.01). The pedicle freezing procedure showed better graft survival than the extracorporeal devitalizing procedures (94% versus 85% in 5 years; RR 3.1 [95% CI 1.1 to 9.0]; p = 0.03). No difference was observed in graft survival among the three devitalizing methods. Further, 78% (156 of 200 patients) of patients in the intercalary group and 87% (39 of 45 patients) of those in the composite group achieved primary union within 2 years. Male sex and the use of nonvascularized grafts were associated with an increased risk of nonunion (RR 2.8 [95% CI 1.3 to 6.1]; p < 0.01 and 0.28 [95% CI 0.1 to 1.0]; p = 0.04, respectively) in the intercalary group after controlling for confounding variables, including sex, site, chemotherapy, resection length, graft type, operation time, and fixation type. The median Musculoskeletal Tumor Society score was 83% (range 12% to 100%). After controlling for confounding variables including age, site, resection length, event occurrence, and graft removal, age younger than 40 years (RR 2.0 [95% CI 1.1 to 3.7]; p = 0.03), tibia (RR 6.9 [95% CI 2.7 to 17.5]; p < 0.01), femur (RR 4.8 [95% CI 1.9 to 11.7]; p < 0.01), no event (RR 2.2 [95% CI 1.1 to 4.5]; p = 0.03), and no graft removal (RR 2.9 [95% CI 1.2 to 7.3]; p = 0.03) were associated with an increased limb function. The composite graft was associated with decreased limb function (RR 0.4 [95% CI 0.2 to 0.7]; p < 0.01). CONCLUSION This multicenter study revealed that frozen, irradiated, and pasteurized tumor-bearing autografts had similar rates of complications and graft survival and all resulted in similar limb function. The recurrence rate was 10%; however, no tumor recurred with the devitalized autograft. The pedicle freezing procedure reduces the osteotomy site, which may contribute to better graft survival. Furthermore, tumor-devitalized autografts had reasonable survival and favorable limb function, which are comparable to findings reported for bone allografts. Overall, tumor-devitalized autografts are a useful option for biological reconstruction and are suitable for osteoblastic tumors or osteolytic tumors without severe loss of mechanical bone strength. Tumor-devitalized autografts could be considered when obtaining allografts is difficult and when a patient is unwilling to have a tumor prosthesis and allograft for various reasons such as cost or socioreligious reasons. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Akihiko Takeuchi
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Nokitaka Setsu
- Department of Orthopaedic Surgery, Kyushu University, Fukuoka, Japan
| | - Tabu Gokita
- Department of Orthopaedic Surgery, Saitama Prefectural Cancer Center, Saitama, Japan
| | - Yasunori Tome
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Naofumi Asano
- Department of Orthopaedic Surgery, Keio University, Tokyo, Japan
| | - Yusuke Minami
- Department of Orthopedic Surgical Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiroyuki Kawashima
- Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Suguru Fukushima
- Department of Musculoskeletal Oncology and Rehabilitation, National Cancer Center Hospital, Tokyo, Japan
| | - Satoshi Takenaka
- Department of Orthopaedic Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Hidetatsu Outani
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tomoki Nakamura
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Satoshi Tsukushi
- Department of Orthopaedic Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Teruya Kawamoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Teruki Kidani
- Department of Orthopaedic Surgery, Ehime University, School of Medicine, Toon, Japan
| | - Munehisa Kito
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroshi Kobayashi
- Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Takeshi Morii
- Department of Orthopaedic Surgery, Kyorin University, School of Medicine, Tokyo, Japan
| | - Toru Akiyama
- Department of Orthopaedic Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Tomoaki Torigoe
- Department of Orthopaedic Oncology and Surgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Koji Hiraoka
- Department of Orthopaedic Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Akihito Nagano
- Department of Orthopaedic Surgery, Gifu University, School of Medicine, Gifu, Japan
| | - Shigeki Kakunaga
- Department of Orthopaedic Surgery, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Kazuhiko Hashimoto
- Department of Orthopaedic Surgery, Kinki University School of Medicine, Osaka-sayama, Japan
| | - Makoto Emori
- Department of Orthopaedic Surgery, Sapporo Medical University, Sapporo, Japan
| | - Hisaki Aiba
- Department of Orthopaedic Surgery, Nagoya City University Medical School, Nagoya, Japan
| | - Yoshikazu Tanzawa
- Department of Orthopaedic Surgery, School of Medicine, Tokai University, Isehara, Japan
| | - Takafumi Ueda
- Department of Orthopaedic Surgery, Kodama Hospital, Takarazuka, Japan
| | - Hirotaka Kawano
- Department of Orthopaedic Surgery, Teikyo University, Tokyo, Japan
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Wisanuyotin T, Paholpak P, Sirichativapee W, Sirichativapee W, Kosuwon W. Effect of bone cement augmentation with different configurations of the dual locking plate for femoral allograft fixation: finite element analysis and biomechanical study. J Orthop Surg Res 2023; 18:405. [PMID: 37270556 DOI: 10.1186/s13018-023-03894-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/30/2023] [Indexed: 06/05/2023] Open
Abstract
AIMS Implant failure in allograft reconstruction is one of the most common problems after treating a large bone defect for a primary bone tumor. The study aimed to investigate the effect of bone cement augmentation with different configurations of dual locking plates used for femoral allograft fixation. METHODS Four finite element (FE) models of the femur with a 1-mm bone gap were developed at the midshaft with different configurations of the 10-hole fixation dual locking plate (LP) with and without intramedullary bone cement augmentation. Model 1 was the dual LP at the lateral and medial aspect of the femur. Model 2 was Model 1 with bone cement augmentation. Model 3 was the dual LP at the anterior and lateral aspect of the femur. Finally, Model 4 was Model 3 with bone cement augmentation. All models were tested for stiffness under axial compression as well as torsional, lateral-medial, and anterior-posterior bending. In addition, the FE analyses were validated using biomechanical testing on a cadaveric femur. RESULTS Model 2 had the greatest axial compression stiffness, followed by Models 1, 4, and 3. Bone cement augmentation in Models 2 and 4 had 3.5% and 2.4% greater axial stiffness than the non-augmentation Models 1 and 3, respectively. In the bone cement augmentation models, Model 2 had 11.9% greater axial compression stiffness than Model 4. CONCLUSION The effect of bone cement augmentation increases construct stiffness less than the effect of the dual LP configuration. A dual lateral-medial LP with bone cement augmentation provides the strongest fixation of the femur in terms of axial compression and lateral bending stiffness.
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Affiliation(s)
- Taweechok Wisanuyotin
- Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand.
| | - Permsak Paholpak
- Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Winai Sirichativapee
- Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Wilasinee Sirichativapee
- Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Weerachai Kosuwon
- Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
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Biomechanical evaluation on a novel design of biodegradable embossed locking compression plate for orthopaedic applications using finite element analysis. Biomech Model Mechanobiol 2022; 21:1371-1392. [PMID: 35717547 DOI: 10.1007/s10237-022-01596-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 05/19/2022] [Indexed: 11/02/2022]
Abstract
In orthopaedics, conventional implant plates such as locking compression plate (LCP) made from non-biodegradable materials play a vital role in the fixation to support bone fractures, but also create a complication such as stress shielding. These again require a painful surgery to remove/replace after they have healed as it does not degrade into the physiological environment (PE). Currently, there has already been enough discovery of biodegradable materials that, despite being mechanically inefficient compared to non-biodegradable materials, can completely be biodegraded in PE during and after healing to avoid such problems. While there has been insufficient research on the design of biodegradable implant plates, the implementation of which may help achieve the goal with an effort of high mechanical strength. A novel design of biodegradable embossed locking compression plate (BELCP) is designed for biodegradable materials to approach superior mechanical performance and complete degradation over time, considering all such parameters and factors. For biomechanical evaluation, four-point bending test (4PBT), axial compressive and tensile test (ACTT) and torsion test (TT) have been performed on LCP, BELCP and its continuously degraded forms made of biodegradable material (Mg-alloy) using finite element method. BELCP has found 50%, 100% and 100% higher mechanical performance and safer in 4PBT, ACTT and TT, respectively, than LCP. Moreover, BELCP has also observed safe during continuous degradation up to 6 months after implantation under these three tests, considering an approximate sustained degradation rate of about 4 mm/year. Even Mg-alloy made BELCP can be sufficient and safer to support fractured bone than SS-alloy made LCP, but not Ti-alloy made LCP. BELCP can be a successful biodegradable bone implant plate after human/animal trials in the future.
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