Intercalary allograft augmented with intramedullary cement and plate fixation is a reliable solution after resection of a diaphyseal tumour

3D-printed modular prostheses for reconstruction of intercalary bone defects after joint-sparing limb salvage surgery for femoral diaphyseal tumours

Aims

The aim of this study was to investigate the safety and efficacy of 3D-printed modular prostheses in patients who underwent joint-sparing limb salvage surgery (JSLSS) for malignant femoral diaphyseal bone tumours.

Methods

We retrospectively reviewed 17 patients (13 males and four females) with femoral diaphyseal tumours who underwent JSLSS in our hospital.

Results

In all, 17 patients with locally aggressive bone tumours (Enneking stage IIB) located in the femoral shaft underwent JSLSS and reconstruction with 3D-printed modular prostheses between January 2020 and June 2022. The median surgical time was 153 minutes (interquartile range (IQR) 117 to 248), and the median estimated blood loss was 200ml (IQR 125 to 400). Osteosarcoma was the most common pathological type (n = 12; 70.6%). The mean osteotomy length was 197.53 mm (SD 12.34), and the median follow-up was 25 months (IQR 19 to 38). Two patients experienced local recurrence and three developed distant metastases. Postoperative complications included wound infection in one patient and screw loosening in another, both of which were treated successfully with revision surgery. The median Musculoskeletal Tumor Society score at the final follow-up was 28 (IQR 27 to 28).

Conclusion

The 3D-printed modular prosthesis is a reliable and feasible reconstruction option for patients with malignant femoral diaphyseal tumours. It helps to improve the limb salvage rate, restore limb function, and achieve better short-term effectiveness.

Intercalary Prosthetic Reconstruction with Three-Dimensional-Printed Custom-Made Porous Component for Defects of Long Bones with Short Residual Bone Segments After Tumor Resection

BACKGROUND

Intercalary reconstruction for patients with short residual bone segments remains challenging. Three-dimensional (3D)-printed custom-made porous implants are a promising technique for short-segment fixation in these patients. This study aims to evaluate the efficiency of 3D-printed custom-made porous components (3DCPCs) for short-segment fixation, focusing on prosthesis survivorship, radiographic results, and potential complications.

METHODS

This retrospective study involved 39 patients who underwent intercalary prosthetic reconstruction with 3DCPCs after tumor resection of the femur, tibia, or humerus from June 2015 to October 2020. Segment bone loss involved the femur (n = 15), tibia (n = 16), and humerus (n = 8), leaving 78 residual bone segments. There were 46 short segments requiring 46 3DCPCs and 32 segments with the ability to accommodate 32 off-the-shelf standard uncemented stems for prosthesis fixation. Clinical and functional outcomes were evaluated. Prosthesis-overall survivorship and prosthesis-specific survivorship were analyzed using Kaplan-Meier survival analysis. Radiographic results and modes of failure of using this technique were also examined.

RESULTS

The mean follow-up was 41 months. The prosthesis-overall survivorship was 87.2% and 84.6% at 2 and 5 years, respectively. The prosthesis-specific survivorship was 92.1% and 89.5% at 2 and 5 years, respectively. There was not a substantial difference in prosthesis survivorship among the femur, tibia, and humerus. The average MSTS score was 26.2, ranging from 22 to 28. The radiographic evaluation results revealed excellent or good interface (38/46) in most of the 46 porous components. A total of 38 of 46 bone segments' remolding demonstrated no change. In total, seven patients (16.3%) had complications requiring further surgery.

CONCLUSION

The prosthesis survivorship of using 3DCPCs for short-segment fixation is similar or better compared to other studies involving intercalary prosthetic reconstruction with short-segment fixation. Radiographic evaluation revealed good osteointegration and avoidance of stress shielding. Overall, intercalary prosthetic reconstruction with 3DCPC is a feasible modality for patients with short residual bone segments after tumor resection.

Outcomes of proximal humeral reconstruction with cemented osteoarticular allograft in pediatric patients: a retrospective cohort study

BACKGROUND

There is no agreement on the best choice of proximal humeral reconstruction following tumor resection in pediatric patients. We reviewed the functional outcomes, oncologic outcomes, and surgical complications in pediatric patients after proximal humeral reconstruction with cemented osteoarticular allograft.

METHODS

Eighteen patients aged 8-13 years who underwent proximal humeral osteoarticular allograft reconstruction following resection of primary bone sarcoma were included. The mean follow-up period was 88 ± 31.7 months. At the last follow-up assessment, limb function was evaluated based on shoulder range of motion, Musculoskeletal Tumor Society score, and Toronto Extremity Salvage Score. Tumor recurrence and postoperative complications were extracted from the patients' medical records.

RESULTS

Mean active forward flexion of the shoulder was 38° ± 18°. Mean active abduction was 48° ± 18°. Mean active external rotation was 23° ± 9°. The mean Musculoskeletal Tumor Society score was 73.4% ± 11.2%. The mean Toronto Extremity Salvage Score was 75.6% ± 12.9%. Local recurrence occurred in 1 patient. Metastasis developed after the operation in 2 additional patients. We recorded 6 postoperative complications in this series, including 1 superficial infection, 1 late-onset deep infection, 1 allograft fracture, 2 cases of nonunion, and 2 cases of shoulder instability. Two complications required allograft removal.

CONCLUSION

In pediatric patients, reconstruction of the proximal humerus with cemented osteoarticular allograft results in acceptable oncologic and functional outcomes while the postoperative complication rate seems to be lower than that of other available techniques.

Biological Prosthesis (Hollow 3D-Printed Titanium Custom-Made Prosthesis and Bone Graft) for Humeral Reconstruction in Pediatric Oncologic Patients: Surgical Indications and Results

This study presents the mid-term outcomes of a novel "biological prosthesis" for pediatric humerus reconstruction after major bone tumor removal. This approach involves a hollow 3D-printed titanium custom-made prosthesis combined with bone grafting. The primary aim was to preserve and revitalize the unaffected autologous proximal or distal humeral stump. Between 2017 and 2021, we treated five pediatric patients (mean age 11.2 years; range 7-17) with humeral bone sarcomas. A one-stage surgical procedure involved tumor resection and implanting a hollow 3D-printed custom-made prosthesis. In two cases, we preserved the proximal humerus; in two, the distal part; and in one, both. Graft materials included homologous bone chips in three cases and free vascularized fibular grafts in two cases. All patients were clinically and radiographically assessed after a mean follow-up of 32.2 months (range of 14-68). No significant complications were observed, and no implant revisions were needed. Osseointegration was evident in all cases within eight months post-surgery; vascular support for the remaining autologous stump was demonstrated in all cases. Our hollow 3D-printed custom-made prosthesis and bone grafting offer the potential for partial or complete articular surface preservation. This approach encourages revascularization of the epiphysis, leading to satisfactory outcomes in humerus reconstruction within the pediatric population.

Are Vascularized Fibula Autografts a Long-lasting Reconstruction After Intercalary Resection of the Humerus for Primary Bone Tumors?

BACKGROUND

A vascularized fibula graft (VFG) is the vascular autograft most frequently used to restore large segmental long bone defects, particularly in the upper limb. Because the use of a vascularized fibula involves an operation in an uninvolved extremity with potential morbidity, it is important to document that this type of reconstruction is successful in restoring function to the humerus. However, the long-term results of VFG after intercalary resection of the humeral diaphysis for bone tumors are still unknown.

QUESTIONS/PURPOSES

(1) What was the complication rate of reconstruction? (2) What was the functional result after surgical treatment, as assessed by the Musculoskeletal Tumor Society (MSTS) score, the American Shoulder and Elbow Society (ASES) score, and Constant score? (3) What was the survivorship of these grafts free from revision and graft removal at 5, 10, and 15 years?

METHODS

Between 1987 and 2021, 127 patients were treated at our institution with en bloc resection for a primary malignant or an aggressive benign bone tumor of the humerus; we excluded patients treated with extra-articular resection or amputation. Of those, 14% (18 of 127) were treated with intercalary resection of the humeral diaphysis for primary bone tumors and reconstruction with VFG, with or without a bulk allograft, and were analyzed in this retrospective study. Generally, our indications for reconstruction with VFG are intercalary resection of the humerus for primary malignant or aggressive benign bone tumors in patients with long life expectancy and high functional demands, in whom adequate bone stock of the proximal and distal epiphysis can be preserved. In 13 patients, VFG was used alone, whereas in five patients, a massive allograft was used. Our policy was to use VFG combined with a massive allograft in patients undergoing juxta-articular joint-sparing resections in which proximal osteotomy was performed close to the anatomic neck of the humerus to obtain more stable fixation and better tendinous reattachment of the rotator cuff and deltoid. All 18 patients who were treated with a VFG were available for follow-up at a minimum of 2 years (median follow-up 176 months, range 26 to 275 months), and although three have not been seen in the past 5 years and are not known to have died, they had 172, 163, and 236 months of follow-up, and were included. The median age at surgery was 25 years (range 2 to 63 years), the median humeral resection length was 15 cm (range 8 to 21 cm), and the median fibular length was 16 cm (range 12 to 23 cm). Complications and functional scores were ascertained by chart review that was performed by an individual not involved in patient care. Functional results were assessed with the MSTS score (range 0 to 30), the ASES score (range 0 to 100), and the Constant score (range 0% to 100%). Survivorship was estimated using a Kaplan-Meier survivorship estimator, which was suitable because there were few deaths in this series.

RESULTS

Seven patients underwent a revision procedure (one radial nerve transient palsy because of screw impingement, four nonunions in three patients with one humeral head avascular necrosis, treatment for screw-related pain in one patient, and two VFG fractures), and one patient underwent VFG removal. Donor site complications were observed in four patients (one ankle valgus deformity and three claw toes-the first toe in two patients and the other toes in the third). At the final clinical control, at a median follow-up of 176 months (range 26 to 275 months), the median MSTS score was 30 of 30 (range 28 to 30), the median ASES score was 98.3 (range 93 to 100), and the median Constant score was 93.5% (range 79% to 100%). Revision-free survival was 71% (95% CI 53% to 96%) at 5 years and 57% (95% CI 37% to 88%) at 10 and 15 years; VFG removal-free survival was 94% (95% CI 83% to 100%) at 5, 10, and 15 years.

CONCLUSION

VFG appears to be an effective reconstructive option after humeral intercalary resection for primary bone tumors. These are complex procedures and should be performed by an experienced team of surgeons who recognize that complications may occur frequently in the first years after the procedure. The frequency of mechanical complications observed in the first 5 years postoperatively may be lessened by using long spanning-plate fixation, and if successful, this reconstruction provides a long-term, durable reconstruction with excellent functional results.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Biological reconstruction of bone defect after resection of malignant bone tumor by allograft: a single-center retrospective cohort study

BACKGROUND

Allograft reconstruction following the resection of malignant bone tumors is associated with high rates of complications and failures. This study aimed to evaluate the efficacy and current problems of allograft reconstruction techniques to optimize treatment strategies at our center.

MATERIALS AND METHODS

Thirty-eight cases (16 men and 22 women), who were diagnosed with malignant bone tumors and had undergone allograft reconstruction, were recruited. Allograft was fixed by intramedullary nail, single steel plate, double plate, and intramedullary nail combined plate in 2, 4, 17, and 15 cases, respectively. Allograft union, local recurrence, and complications were assessed with clinical and radiological tests. Tumor grade was assessed using the Enneking staging of malignant bone tumors. Functional prognosis was evaluated by the Musculoskeletal Tumor Society (MSTS) scoring system.

RESULTS

Intercalary and osteoarticular reconstructions were performed in 32 and 6 cases, respectively. Six patients underwent reoperation related to allograft complications, four patients had local recurrence, and three patients with allograft fracture underwent allograft removal. A total of eight host-donor junctions showed nonunion, including seven cases (18.4%) in diaphysis and one case (3.1%) in metaphysis (p < 0.01). Host rejection and secondary osteoarthritis occurred in nine and two cases, respectively. No deep infection and internal fixation device fracture occurred. The overall allograft survival rate was 81.6%. Postoperative MSTS score of patients with allograft survival was 26.8 ± 2.9, indicating a significant improvement as compared to their preoperative function.

CONCLUSIONS

Allograft represents an excellent choice for intercalary bone defects after malignant bone tumor resection. Robust internal fixation protection across the whole length of the allograft is an important prerequisite for the survival of the allograft, while multidimensional osteotomy, intramedullary cement reinforcement, and pedicled muscle flap transfer can effectively improve the survival rate and healing rate of the allograft.

Surgical Fixation Method in Lower Extremity Intercalary Allograft Reconstruction After Oncologic Resection: A Comparison of Plates and Nails

INTRODUCTION

Fixation in intercalary allograft reconstruction includes plates and intramedullary nails. The purpose of this study was to examine rates of nonunion, fracture, the overall need for revision surgery, and allograft survival based on the surgical fixation method in lower extremity intercalary allografts.

METHODS

A retrospective chart review was performed on 51 patients with intercalary allograft reconstruction in the lower extremity. Fixation methods compared were intramedullary fixation with nails (IMN) and extramedullary fixation with plates (EMP). Complications compared were nonunion, fracture, and wound complications. The alpha was set at 0.05 for statistical analysis.

RESULTS

Nonunion incidence at all allograft-to-native bone junction sites was 21% (IMN) and 25% (EMP) (P = 0.8). Fracture incidence was 24% (IMN) and 32% (EMP) (P = 0.75). Median fracture-free allograft survival was 7.9 years (IMN) and 3.2 years (EMP) (P = 0.04). Infection was seen in 18% (IMN) and 12% (EMP) (P = 0.7). The overall need for revision surgery was 59% (IMN) and 71% (EMP) (P = 0.53). Allograft survival at the final follow-up was 82% (IMN) and 65% (EMP) (P = 0.33). When the EMP group was subdivided into single plate (SP) and multiple plate (MP) groups and compared with the IMN groups, fracture rates were 24% (IMN), 8% (SP), and 48% (MP) (P = 0.04). Rates of revision surgery were 59% (IMN), 46% (SP), and 86% (MP) (P = 0.04). Allograft survival at the final follow-up was 88% (IMN), 92% (SP), and 52% (MP) (P = 0.05).

DISCUSSION

Median fracture-free allograft survival was notably longer for the IMN group than the EMP group; otherwise, there were no notable differences between the intramedullary and extramedullary groups. When the EMP group was subdivided into the SP and MP groups, patients with MPs had higher rates of fracture, higher rates of revision surgery, and lower overall allograft survival.

LEVEL OF EVIDENCE

III, Therapeutic Study, Retrospective Comparative Study.

Effect of bone cement augmentation with different configurations of the dual locking plate for femoral allograft fixation: finite element analysis and biomechanical study

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.

Reconstructive Allograft Preparation for Long Bone Intercalary Segments After Tumor Resections: Toronto Sarcoma Protocol

Background

The Reconstructive Allograft Preparation by Toronto Sarcoma (RAPTORS) protocol is reliable and reproducible without substantially adding to the surgical reconstruction time or cost. Our technique includes clearance of debris, lavage of the medullary canal, pressurized filling of the medullary canal with antibiotic-laden cement for its mechanical and antimicrobial properties, and insertion of cancellous autograft at the allograft-host junctional ends prior to dual-plate compression to fix the allograft into the defect1-3. Our experience with large intercalary allograft reconstruction has demonstrated high rates of long-term success and addresses the most common causes of large allograft failure (infection, fracture, and nonunion)4, as shown in our long-term outcome study1.

Description

Once the tumor is resected, it is used as a template for cutting and shaping the allograft to fit the bone defect and to restore length and anatomy. The frozen allograft is thawed in a container with povidone iodine and bacitracin saline solution until it reaches room temperature. The allograft is size-matched, and clearance of its intramedullary marrow contents is performed with use of curets and intramedullary reamers7. If 1 end of the allograft includes the metaphysis and is covered by dense cancellous bone, we try not to ream through this end because maintaining this metaphyseal cancellous surface will expedite bone healing. The segment is then thoroughly lavaged with "triple wash" solutions to clear out any remaining marrow contents and to ensure sterilization of the allograft. This serial-wash technique involves the use of 3 discrete antiseptic modalities and has been utilized at our institution with low rates of allograft infection. These antiseptic modalities include 10% weight-per-volume povidone iodine diluted 1:1 with normal saline solution, 3% weight-per-volume hydrogen peroxide diluted 1:1 with normal saline solution, and 50,000 units of sterile bacitracin lyophilized powder dissolved in 500 mL of normal saline solution. Following the triple wash, the medullary canal is filled with antibiotic-laden methylmethacrylate bone cement. If both ends are open, the far end of the segment is first plugged with the surgeon's finger or with gauze, or if 1 end is covered with cancellous bone, then retrograde filling of the canal with cement is performed from the open end. The cement is then pressurized to ensure complete filling of the intramedullary space. Before it sets, 1 cm of cement is removed from each open end of the allograft to allow for packing of autograft bone cancellous chips and to ensure that cement does not impede anatomic reduction of the allograft-host bone junction. For this step, cancellous autograft from the iliac crest is harvested with use of a separate sterile surgical setup in order to prevent contamination of the autograft site by instruments used for tumor resection. The cancellous autograft is packed into the space created after recessing the cement at the end(s) of the allograft and, using a bone tamp, the autograft is compressed into this cavity and into the corresponding end of the host long bone in order to improve the healing potential at the allograft-host bone junction(s)8. Finally, a dual compression plate construct is utilized for upper as well as lower-extremity reconstructions in most cases. The cement in the allograft must be completely hardened before drilling into it. The allograft-host bone junctions are sequentially compressed at both the proximal and distal ends to allow for maximal apposition of the osseous surfaces. Only 1 or 2 unicortical screws are placed into the allograft to hold it in place and to facilitate maximal compression at both bone junctions. Patient compliance during postoperative rehabilitation is essential to optimize healing and provide reliable and durable outcomes. Postoperative care following the RAPTORS technique includes limited early rehabilitation and long periods of non-weight-bearing until radiographic union is noted across both bone junctions, followed by gradual resumption of weight-bearing and more aggressive physiotherapy. See the Appendix for further details regarding each step of the procedure.

Alternatives

Intercalary reconstruction alternatives include various biological or endoprosthetic constructs. The other biological reconstruction options include the use of a free vascularized bone graft, distraction osteogenesis, combined vascularized fibula and allograft (i.e., the Capanna technique), or recycled tumor bones. Intercalary prostheses offer another reconstruction option for diaphyseal defects, but their feasibility is more limited in cases of periarticular segments with very short residual medullary canals. In such cases, there may be inadequate stem length for fixation, or the segment may require a custom implant that takes time to design and manufacture, which can be associated with high costs5.

Rationale

Major factors limiting the widespread use of allografts include infection, graft fracture, graft nonunion, and, in some locations, availability4,6. Our technique of allograft preparation with dual compression plating and triple-washing to provide mechanical and antimicrobial protection as well as augmented healing has shown reproducible results with low complication rates compared with the literature.

Expected Outcomes

There have been high rates of long-term allograft survival (84.4%) following intercalary long-bone reconstruction at our institution, with lower complication rates than those presented in the literature.

Important Tips

Transverse osteotomies of the allograft, made perpendicular to the long axis of the diaphysis/anatomical axis, are important to replicate the resected host bone. Transverse osteotomies, while inherently less stable than step-cut ones, allow for adjusting the rotation of the allograft segment as needed for maximal contact and compression, as well as restoration of anatomical limb rotation.It is important to perform meticulous clearance of the intramedullary contents while preserving the endosteal bone and allograft integrity. We would utilize hand-reaming rather than a power drill device, in order to prevent overreaming or breaking through the allograft bone.Place as few unicortical screws as possible into the allograft-cement construct in order to maintain its structural strength and minimize potential sites for vascular ingrowth and bone resorption.

Acronyms & Abbreviations

K-wires = Kirschner wiresW/V = weight per volume.

Three-dimensional-printed porous prosthesis for the joint-sparing reconstruction of the proximal humeral tumorous defect

Background: Tumorous bone defect reconstructions of the proximal humerus with joint sparing is a challenge. Numerous reconstruction methods have been proposed but the proximal residual humerus is commonly sacrificed because of its extremely short length. To preserve the proximal humerus and improve clinical outcomes, we designed a three-dimensional (3D) printed uncemented prosthesis with a porous structure to treat tumorous bone defects of the proximal humerus. Methods: Our analysis included seven patients treated between March 2018 and July 2019. A 3D model was established, and related data were obtained, including the diameter of the humeral head, the resection length, and the residual length. A prosthesis was designed and fabricated based on these data. Functional and oncologic outcomes were recorded, and complications and osseointegration were evaluated. Results: The mean age of the patients was 20.3 years, and the median follow-up period was 26 months. The lengths of the residual proximal humerus were 17.9 mm on average. All the patients had preserved humeral heads and most of the rotator cuff was intact. The average postoperative range of motion (ROM) of the affected shoulder was 83.8°; flexion was 82.5°, extension was 43.8°, and adduction was 16.3°. The average Musculoskeletal Tumor Society score (MSTS) was 94.3%. Good osseointegration was observed on the interface between the bone and prosthesis. Conclusion: A 3D printed porous prosthesis with cone-like structures successfully achieved joint-sparing reconstruction of proximal humeral tumorous defects with satisfying functional outcomes. The preservation of the rotator cuff and humeral head plays an essential role in the function of the shoulder joint.

Factors Influencing Nonunion and Fracture Following Biological Intercalary Reconstruction for Lower-Extremity Bone Tumors: A Systematic Review and Pooled Analysis

OBJECTIVES

To determine nonunion rate, fracture rate, and their risk factors following biological intercalary reconstruction for lower extremity bone tumors.

METHODS

A systematic review and pooled analysis were conducted. PubMed, Embase, and Wiley Cochrane Library were searched from inception up to June 01, 2020. Studies concerning biological intercalary reconstruction after resection of lower extremity bone tumors were included. Overall nonunion and fracture rates were calculated. For studies reporting patient outcomes individually with precise graft characteristics and fixation methods, the individual data were extracted. Patients with demographical and clinical characteristics, including age, sex, tumor location, graft characteristics, and fixation method, were pooled for a multivariate analysis. For each factor of interest, odds ratio (OR), 95% confidence interval (95% CI), and p-value from logistic regression were reported.

RESULTS

A total of 2776 articles were identified from the initial literature search and 76 studies (2052 patients) were included. Sixty-nine studies were case series and seven were comparative studies. The overall nonunion rate was 19% (382/2052; range: 0%-53%), and the overall fracture rate was 17% (344/2052; range: 0%-75%). Thirty of the 76 studies (362 patients) reported patients' characteristics individually and were thus included in the pooled multivariate analysis. Intramedullary nail fixation was associated with a significantly higher nonunion rate compared to plate fixation (OR = 2.2, 95% CI: 1.23-4.10, p = 0.009). Reconstruction with a vascularized fibula graft had a statistically non-significant lower nonunion rate than reconstruction without the graft (OR = 0.6, 95% CI: 0.34-1.07, p = 0.086). Devitalized autografts had a lower fracture risk than allografts (OR = 0.3, 95% CI: 0.14-0.64, p = 0.002), and males tended to have higher fracture risk than females (OR = 2.1, 95% CI: 1.00-4.44, p = 0.049).

CONCLUSIONS

Reconstruction with intramedullary nail fixation is related to an elevated risk of nonunion. Allografts and males have a higher fracture risk than devitalized autografts and females, respectively. Further high-quality comparative analyses with large sample sizes and adequate follow-up duration are needed to validate these findings.

Application of allograft and absorbable screws in the reconstruction of a massive bone defect following resection of giant osteochondroma: A retrospective study

Background

This study aims to introduce a reconstruction method of applying allografts and absorbable screws to repair large bone defects caused by the resection of giant osteochondroma.

Methods

A retrospective study of a series of patients who underwent the resection of giant osteochondroma reconstructed by allografts and absorbable screws was conducted from February 2020 to September 2021. Their demographic data, location site, area of bone defect, and pertinent operative details were recorded. The reconstruction modality of allografts was elaborated on. In the follow-up, radiographic images were utilized to determine bone union, and the Musculoskeletal Tumor Society score was used to evaluate postoperative limb function.

Results

A total of seven patients were included, including three males and four females with an average age of 16.6 ± 6.5 years. Among them, three cases of tumors occurred in the humerus and four cases occurred in the femur. The average follow-up time was 11.3 ± 3.0 months. The average area of bone defect was 25.9 ± 8.3 cm². No complications such as infection, nonunion, and allograft bone fracture were found during the follow-up period. Six months after the operation, the average Musculoskeletal Tumor Society score was 26.4 ± 1.6, with acceptable postoperative function.

Conclusions

The cooperative application of absorbable screw fixation and allografts including mixed cortical bone and cancellous bone, which yielded satisfactory functional outcomes and acceptable postoperative complications, is an effective reconstruction method for a massive bone defect after the resection of giant osteochondroma.

Plate configuration for biological reconstructions of femoral intercalary defect - a finite element evaluation

BACKGROUND AND OBJECTIVE

Biological reconstruction was commonly used for femoral intercalary defect. The initial stability by plate fixation was believed to have an effect on bone union and implant failure. Our study was proposed to explore relationship of plate configuration and initial stability for femoral intercalary reconstruction using allo-/autograft.

METHODS

Femoral intercalary defect models were established with four different plate configurations: (1) Single lateral bridging plate, SLP (2) Lateral bridging plate + Orthogonal adjuvant plate, LP+OAP (3) Lateral bridging plate + Medial adjuvant plate, LP+MAP (4) Lateral bridging plate + Medial bridging plate, LP+MP. A diaphysis defect of 12 cm was simulated, and the removed native femoral bone was used as a structural allograft with the osteotomy gap of 2 mm. Models were analyzed by finite element simulations under an axial compression of 2000N and an axial moment of 10 Nm, respectively.

RESULTS

Axial load: (1) The peak von Mises stress of SLP, LP+OAP, LP+MAP, LP+MP were 993.50 MPa, 335.63 MPa, 240.03 MPa, 281.73 MPa, respectively and LP+MAP was the lowest (p < 0.01); (2) The mean displacement of SLP, LP+OAP, LP+MAP, LP+MP was 0.765, 0.130, 0.121, 0.235 mm, respectively. LP+MAP showed the best stability while SLP had a crash in the medial proximal gap; (3) The LP+MAP configuration had the most uniform stress distribution and the lowest maximum von Mises stress of 79.7 MPa within plates. Axial torsional load: (1) The peak von Mises stress of SLP, LP+OAP, LP+MAP, LP+MP were 431.66Mpa, 120.73 MPa, 72.31 MPa, 109.86 MPa, respectively; (2) The rotation angle of SLP, LP+OAP, LP+MAP, LP+MP was 4.30°, 1.35°, 1.20°, 1.57°, respectively. All of LP+OAP, LP+MAP and LP+MP showed an optimal torsional stability.

CONCLUSIONS

For femoral intercalary reconstruction using allo-/autograft fixed by plates, LP+MAP and LP+MP configurations showed superior stability in terms of axial compression and torsion load by FE simulation. A better stability was believed to be associated with higher union rate and lower hardware failure rate.

Skeletal regeneration for segmental bone loss: Vascularised grafts, analogues and surrogates

Massive segmental bone defects (SBD) are mostly treated by removing the fibula and transplanting it complete with blood supply. While revolutionary 50 years ago, this remains the standard treatment. This review considers different strategies to repair SBD and emerging potential replacements for this highly invasive procedure. Prior to the technical breakthrough of microsurgery, researchers in the 1960s and 1970s had begun to make considerable progress in developing non autologous routes to repairing SBD. While the breaktthrough of vascularised bone transplantation solved the immediate problem of a lack of reliable repair strategies, much of their prior work is still relevant today. We challenge the assumption that mimicry is necessary or likely to be successful and instead point to the utility of quite crude (from a materials technology perspective), approaches. Together there are quite compelling indications that the body can regenerate entire bone segments with few or no exogenous factors. This is important, as there is a limit to how expensive a bone repair can be and still be widely available to all patients since cost restraints within healthcare systems are not likely to diminish in the near future. STATEMENT OF SIGNIFICANCE: This review is significant because it is a multidisciplinary view of several surgeons and scientists as to what is driving improvement in segmental bone defect repair, why many approaches to date have not succeeded and why some quite basic approaches can be as effective as they are. While there are many reviews of the literature of grafting and bone repair the relative lack of substantial improvement and slow rate of progress in clinical translation is often overlooked and we seek to challenge the reader to consider the issue more broadly.

How the Choice of Osteosynthesis Affects the Complication Rate of Intercalary Allograft Reconstruction? A Systematic Review and Meta-analysis

BACKGROUND

There is no clear consensus on the optimal type of fixation in intercalary allograft reconstruction. In this study, we aimed to compare the rate of most common complications following the plate and nail fixation of the intercalary allograft.

MATERIALS AND METHODS

We searched PubMed, EMBASE, Web of Science, Scopus, and Cochrane Library. Studies in which the complication rate of the single bridging plate and intramedullary nail fixation was extractable were included. Studies that used extra procedures such as cementation and fibular vascular graft augmentation were excluded. The primary outcome was the fixation-specific rate of nonunion. Secondary outcomes were the fixation-specific rate of fracture, infection, and local recurrence.

RESULTS

In total, 13 studies with 431 reconstructions (352 reconstructions in the plate group and 79 reconstructions in the intramedullary nailing group) were included in this study. In the plate fixation, the rate of nonunion, fracture, infection and local recurrence was 12%, 11%, 11%, and 3%, respectively. In the intramedullary nail fixation, the rate of nonunion, fracture, infection, and local recurrence was 37%, 5%, 4%, and 0%, respectively. The rate of nonunion was significantly higher in the intramedullary nail group (OR = 6.34; 95% CI 2.98-13.49, P < 0.001). The rate of fracture, infection, and local recurrence was not significantly different between the two fixation methods.

CONCLUSIONS

Intramedullary nail is associated with a significantly higher rate of nonunion. Since the rate of other complications was not significantly different between the two osteosynthesis types, plate fixation could be considered as a better type of fixation.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00563-7.

Reconstruction for bone tumours of the shoulder and humerus in children and adolescents

Reconstructions for paediatric bone tumours of the shoulder girdle and humerus are intended to optimize placement of the hand in space. Given the longevity of paediatric survivors of sarcoma, durability is an important planning consideration. Here, I review a subset of approaches based on anatomical site with an emphasis on function and longevity. Often, biological reconstructions that combine living bone with tendon repairs and transfers best address those goals.

Is three-dimensional-printed custom-made ultra-short stem with a porous structure an acceptable reconstructive alternative in peri-knee metaphysis for the tumorous bone defect?

Background

Long-lasting reconstruction after extensive resection involving peri-knee metaphysis is a challenging problem in orthopedic oncology. Various reconstruction methods have been proposed, but they are characterized by a high complication rate. The purposes of this study were to (1) assess osseointegration at the bone implant interface and correlated incidence of aseptic loosening; (2) identify complications including infection, endoprosthesis fracture, periprosthetic fracture, leg length discrepancy, and wound healing problem in this case series; and (3) evaluate the short-term function of the patient who received this personalized reconstruction system.

Methods

Between September 2016 and June 2018, our center treated 15 patients with malignancies arising in the femur or tibia shaft using endoprosthesis with a 3D-printed custom-made stem. Osseointegration and aseptic loosening were assessed with digital tomosynthesis. Complications were recorded by reviewing the patients’ records. The function was evaluated with the 1993 version of the Musculoskeletal Tumor Society (MSTS-93) score at a median of 42 (range, 34 to 54) months after reconstruction.

Results

One patient who experienced early aseptic loosening was managed with immobilization and bisphosphonates infusion. All implants were well osseointegrated at the final follow-up examination. There are two periprosthetic fractures intraoperatively. The wire was applied to assist fixation, and the fracture healed at the latest follow-up. Two patients experienced significant leg length discrepancies. The median MSTS-93 score was 26 (range, 23 to 30).

Conclusions

A 3D-printed custom-made ultra-short stem with a porous structure provides acceptable early outcomes in patients who received peri-knee metaphyseal reconstruction. With detailed preoperative design and precise intraoperative techniques, the reasonable initial stability benefits osseointegration to osteoconductive porous titanium, and therefore ensures short- and possibly long-term durability. Personalized adaptive endoprosthesis, careful intraoperative operation, and strict follow-up management enable effective prevention and treatment of complications. The functional results in our series were acceptable thanks to reliable fixation in the bone-endoprosthesis interface and an individualized rehabilitation program. These positive results indicate this device series can be a feasible alternative for critical bone defect reconstruction. Nevertheless, longer follow-up is required to determine whether this technique is superior to other forms of fixation.

Variability in the reported surgical techniques and methods for intercalary reconstruction following tumor resection

INTRODUCTION

There is currently no consensus regarding the best techniques or surgical strategies with which to maximize intercalary allograft reconstruction outcomes. The purpose of the current study was to assess which techniques and methods are being utilized by North American orthopaedic oncologists.

METHODS

Members of the Musculoskeletal Tumor Society (MSTS) were invited to complete an anonymous online questionnaire. The survey presented participants with two clinical scenarios and interrogated them on their preferred type of allograft, method of compression and fixation, and additional techniques used.

RESULTS

One hundred and twenty-six physicians completed the questionnaire. The majority studied in the United States (82%) and worked at an academic medical center (71%). Over half (54%) reported seeing over 10 primary bone tumors every year. Respondents were split between preferring a structural allograft alone or using a combined allograft-vascularized fibular graft. A majority indicated a preference for plate(s) and screw fixation but were divided between the use of two compression plates with a spanning plate, a single compression plate with a spanning plate, and two compression plates with an intramedullary nail. Screw fixation preferences were split between the use of unicortical locking only, bicortical locking only, and a combination of unicortical and bicortical locking. Almost equal percentages of respondents reported they would have used two, three, or four screws in both scenarios. Respondents were split between placing screws equidistantly and placing them peripherally within the allograft, adjacent to the allograft-host junction.

DISCUSSION

There is no clear surgical preference for intercalary reconstruction following tumor extirpation within this sample of orthopaedic oncologists. The current survey demonstrates variability across nearly every aspect of allograft reconstruction, which may, in part, explain the wide spectrum of outcomes reported within the literature. Prospective studies are warranted to better evaluate technique-specific outcomes in an effort to maximize reconstructive longevity and minimize allograft related complications.

Concave-convex Reaming of Intercalary Allograft: 1-year Clinical Outcomes

Complication rates associated with intercalary allograft reconstruction may be reduced by maximizing tenants of allograft reconstruction. Intercalary allograft reconstruction using a hemispherical reaming technique for graft-host interface may increase surface contact areas, provide intimate contact between surfaces, and equally distribute pressure subsequently decreasing risk of nonunion. The purpose of these case reports was to present short-term results for limb salvage using this novel technique for two young, active duty military members who returned to full-impact activity.

Bone Cement Implantation Syndrome in Bone Tumor Surgeries: Incidence, Risk Factors, and Clinical Experience

Objective

To investigate the incidence and risk factors of bone cement implantation syndrome (BCIS) in bone tumor surgeries.

Methods

This was a retrospective observational study. We investigated patients who underwent bone tumor surgeries requiring cementation as part of the surgery between March 2016 and January 2018. We reviewed medical records, including formal anesthesia records and operation notes. Patients with complete data files were included. To investigate the general incidence of BCIS in tumor surgeries, patients of all ages, genders and tumor types were included. Vital signs, including oxygen saturation, blood pressure, heart rate, and respiratory rate, were checked and recorded once every 1–2 min after cementation. Accurate time points of cementation were recorded on formal anesthesia record sheets by the anesthesiologists. The definition and severity of BCIS were based on the classification system proposed in previous studies: grade I, moderate hypoxia (SpO₂ <94%) or hypotension (fall in systolic blood pressure >20%); grade II, severe hypoxia (SpO₂ <88%) or hypotension (fall in systolic blood pressure >40%) or unexpected loss of consciousness; and grade III, cardiovascular collapse requiring cardiopulmonary resuscitation. We also compared the incidence of BCIS between those patients with and without possible risk factors, including intraoperative blood loss, arthroplasty, use of an intramedullary device, patient age, gender, tumor location, and preexisting lung cancer or lung metastasis.

Results

A total of 88 patients were included. BCIS occurred in 23 patients, with an incidence of 26.1%. Among them, 19 had grade I and 4 had grade II BCIS. There was no patients with grade III BCIS. The lowest blood pressure occurred within 10 min in 21 (87.5%) patients and within 20 min for all patients. A total of 9 grade I BCIS were self‐limiting. The other 10 grade I hypotension cases and all grade II hypotension cases recovered after administration of a vasoconstrictor medication. Preexisting lung cancer or lung metastasis was the risk factor for BCIS; 40.0% of patients (16 in 40 patients) with preexisting lung cancer or metastasis had BCIS, whereas only 14.6% of patients (7 in 48 patients) without lung lesions had BCIS. There was no risk difference in terms of arthroplasty, old age, and increased blood loss. Apart from grades I and II bone cement implantation syndrome, there were no other major complications, including death, cardiovascular events, or cerebrovascular events.

Conclusion

Bone cement implantation syndrome is not unusual in bone tumor surgeries, and preexisting lung cancer or lung metastasis is a risk factor.

Optimal configuration of a dual locking plate for femoral allograft or recycled autograft bone fixation: A finite element and biomechanical analysis

BACKGROUND

Allografts and recycled bone autograft are commonly used for biological reconstruction. The dual locking plates fixation method has been advocated for increasing allograft stability and preventing fixation failure; however, the biomechanical properties of the various configurations of dual locking plates have not been extensively studied.

METHODS

In a finite element (FE) analysis, we developed 6 patterns of different dual locking plate configurations for fixation of the mid shaft of the femur. The maximum strains were recorded for each of the 6 models then axial, bending and torsion stiffness were calculated. The FE analysis was validated the results with mechanical testing (axial compression, bending, and torsional stiffness) on a cadaveric femur.

FINDINGS

The highest axial compression (715.41 N/mm) and lateral bending (2981.24 N/mm) was found in Model 4 (with two 10-hole locking plates placed at the medial and lateral side), while the highest torsional stiffness (193.59 N·mm /mm) was found in Model 3 (with 8- and 10-hole locking plates placed at the posterior and lateral side). Excellent agreement was found between the finite element analysis and biomechanical testing (r² = 0.98).

INTERPRETATION

The dual locking plate configuration with medial and lateral, 10-hole locking plates provided the most rigid and strongest fixation of the femur; both in terms of axial compression and lateral bending stiffness.

Bone defect reconstruction with autologous bone inactivated with liquid nitrogen after resection of primary limb malignant tumors: An observational study

Surgical treatment of malignant bone tumors comprises tumor resection and reconstruction. The most commonly used reconstruction method is prosthesis replacement, which achieves good early function, but has a high long-term incidence of complications. Another reconstruction option is autologous bone replantation, which has the advantages of anatomical matching and no need for large bone bank support. Few studies have evaluated reconstruction with liquid nitrogen-inactivated autogenous bone.The present study aimed to evaluate the oncological results, bone healing results, complications, and indications of reconstruction with liquid nitrogen-inactivated autogenous bone grafts.The study population comprised 21 consecutive patients. The tumor site was the tibia in 9 cases, femur in 8, and humerus in 4. There were 37 osteotomy ends in total. After freezing and rewarming, the medullary cavity of the autogenous bone was filled with antibiotic bone cement. Seventeen patients received bilateral plate fixation, 2 received intramedullary nail and distal plate fixation, and 2 received single plate fixation.The average follow-up was 31 ± 6 months. Eighteen patients survived without tumors, and the 3-year survival rate was 80.4%. All cases had adequate surgical margins, but recurrence developed in 1 patient. Metastasis occurred in 3 patients, who all died of metastasis. Intraoperative inactivated bone fracture occurred in 1 patient, and screw breakage was found in 1 patient. Nonunion occurred at 1 humeral diaphysis osteotomy site, and 1 patient was lost to follow-up; the average healing time of the other 35 ends was 13 ± 6 months, and the bone healing rate was 97.2%. The average bone healing times in the metaphysis and diaphysis were 9 ± 3 months and 15 ± 6 months (P = .003). The average bone healing times in the upper and lower limbs were 16.6 ± 7.4 months and 12.3 ± 5.8 months (P = .020). The average Muscle and Skeletal Tumor Society score was 28 ± 3 (21-30) in the 18 survivors.Liquid nitrogen-inactivated autologous bone replantation for primary malignant limb tumor was safe and effective, as shown by the relatively low complication rate, high bone healing rate, and satisfactory postoperative function. This is a reliable biological reconstruction method for malignant bone tumors with specific site and bone destruction characteristics.

Intercalary Allograft to Reconstruct Large-Segment Diaphysis Defects After Resection of Lower Extremity Malignant Bone Tumor

Aim

To evaluate the clinical effect of intercalary allograft transplantation and reconstruction in the treatment of diaphyseal defect after resection of lower extremity malignant bone tumor.

Methods

Clinical data of 17 patients diagnosed with malignant lower-limb bone tumors and having undergone segmental allograft reconstruction with a mean follow-up of 49.8 (26–78) months were included. Segmental allografts of average 17-cm length preserved by deep-freezing were used and fixed using intramedullary nail, double plate, and intramedullary nail and plate combination in 2, 5, and 10 patients, respectively. Host–donor junctions were perfectly and roughly matched in 5 and 12 patients, respectively. Allograft union, local recurrence, and complications were assessed using clinical and radiological tests. Allograft union was evaluated using the International Society of Limb Salvage (ISOLS) scoring system. The functional prognosis was evaluated using the Musculoskeletal Tumour Society (MSTS) scoring system.

Results

Intercalary allograft reconstruction of femoral shaft, tibial shaft, and distal tibia with ankle arthrodesis was performed in eight, four, and five patients, respectively. Two patients had local recurrence and underwent amputation; one died of metastasis. Host–donor junctions in two patients showed nonunion; 12 patients achieved bone union. The average union time was 12.1 months. No allograft fracture or infection occurred. Union rates were 100% and 88.2% at metaphyseal and diaphyseal junctions, respectively. Healing time differed significantly between the precisely and roughly matched groups (p<0.01). The incidence of nonunion was higher after intramedullary nailing than after the other two methods (p<0.05). The mean MSTS score was 24.2 (14–29) at the end of follow-up.

Conclusion

Intercalary allograft transplantation is an effective strategy for diaphyseal defect following post-tumor resection in the lower extremity. Good bone healing after allograft reconstruction is achieved with stable internal fixation and perfectly matched host–donor interfaces.

Rehabilitation to Improve the Function and Quality of Life of Soft Tissue and Bony Sarcoma Patients

Sarcomas are bone and soft tissue tumors that can have significant effects on patient function and quality of life. Like most malignancies, treatment includes a combination of chemotherapy, radiation, and surgical resection, all of which also carry risks and long-term effects. A multidisciplinary rehabilitation plan can help minimize symptoms and sequelae which negatively affect the patient function and quality of life, including pain, chemotherapy-induced peripheral neuropathy, radiation fibrosis, activity restrictions following surgical excision, amputation, bowel and bladder dysfunction, and lymphedema. Patients should be evaluated by a rehabilitation specialist at any point during their diagnosis, treatment, and survivorship phase to determine appropriate interventions to minimize the impact of sarcomas and their treatment on patient function and quality of life.

Pre-clinical evaluation of bone allograft toughened with a novel sterilization method: An in vivo rabbit study

Bone allografts often undergo γ-irradiation sterilization to decrease infection risk. However this consequently degrades bone collagen and makes the allograft brittle. Our laboratory has previously found that pre-treatment with ribose ex vivo protects the bone. However, it remains unclear whether or not ribose-treated γ-irradiated allografts are able to unite and remodel in vivo. Using New Zealand White rabbits (NZWr), we aimed to evaluate if ribose-treated allografts can unite with host bone (compared to untreated (fresh-frozen) and conventionally-irradiated allografts). A critically-sized defect was created in the radii of NZWr and reconstructed with allografts fixed with an intramedullary Kirschner wire. Healing and union were assessed at 2, 6, and 12 weeks post operation, with radiographs, µCT, static and dynamic histomorphometry, backscatter electron microscopy, and torsion testing. Intramedullary fixation achieved stable reconstructions and bony union in all groups and no differences were found in the radiographic and biomechanical parameters tested. Interestingly, γ-irradiated allografts had significantly less bone volume due to evident resorption of the grafts. In contrast, ribose pre-treatment protected γ-irradiated allografts from this bone loss, with results similar to the fresh frozen controls. In conclusion, ribose-pretreated γ-irradiated allografts were able to unite in vivo. In addition to achieving bony union with host bone, ribose pre-treatment may protect against allograft resorption. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Failure rates and functional results for intercalary femur reconstructions after tumour resection

PURPOSE

To compare the results for patients treated with intercalary endoprosthetic replacement (EPR) or intercalary allograft reconstruction for diaphyseal tumours of the femur in terms of: (1) reconstruction failure rates; (2) cause of failure; (3) risk of amputation of the limb; and (4) functional result.

METHODS

Patients with bone sarcomas of the femoral diaphysis, treated with en bloc resection and reconstructed with an intercalary EPR or allograft, were reviewed. A total of 107 patients were included in the study (36 EPR and 71 intercalary allograft reconstruction). No differences were found between the two groups in terms of follow-up, age, gender and the use of adjuvant chemotherapy.

RESULTS

The probability of failure for intercalary EPR was 36% at 5 years and 22% for allograft at 5 years (p = 0.26). Mechanical failures were the most prevalent in both types of reconstruction. Aseptic loosening and implant fracture are the main cause in the EPR group. For intercalary allograft reconstructions, fracture followed by nonunion was the most common complication. Ten-year risk of amputation after failure for both reconstructions was 3%. There were no differences between the groups in terms of the mean Musculoskeletal Tumor Society score (27.4, range 16-30 vs. 27.6, range 17-30).

CONCLUSIONS

We have demonstrated similar failure rates for both reconstructions. In both techniques, mechanical failure was the most common complication with a low rate of limb amputation and good functional results.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The indications and donor-site morbidity of tibial cortical strut autografts in the management of defects in long bones

Aims

The primary aim of this study was to determine the morbidity of a tibial strut autograft and characterize the rate of bony union following its use.

Patients and Methods

We retrospectively assessed a series of 104 patients from a single centre who were treated with a tibial strut autograft of > 5 cm in length. A total of 30 had a segmental reconstruction with continuity of bone, 27 had a segmental reconstruction without continuity of bone, 29 had an arthrodesis and 18 had a nonunion. Donor-site morbidity was defined as any event that required a modification of the postoperative management. Union was assessed clinically and radiologically at a median of 36 months (IQR, 14 to 74).

Results

Donor-site morbidity occurred in four patients (4%; 95% confidence interval (CI) 1 to 10). One patient had a stress fracture of the tibia, which healed with a varus deformity, requiring an osteotomy. Two patients required evacuation of a haematoma and one developed anterior compartment syndrome which required fasciotomies. The cumulative probability of union was 90% (95% CI 80 to 96) at five years. The type of reconstruction (p = 0.018), continuity of bone (p = 0.006) and length of tibial graft (p = 0.037) were associated with the time to union.

Conclusion

The tibial strut autograft has a low risk of morbidity and provides adequate bone stock for treating various defects of long bones. Cite this article: Bone Joint J 2018;100-B:667-74.

Intercalary reconstruction of femur after tumour resection: is a vascularized fibular autograft plus allograft a long-lasting solution?

Aims

After intercalary resection of a bone tumour from the femur, reconstruction with a vascularized fibular graft (VFG) and massive allograft is considered a reliable method of treatment. However, little is known about the long-term outcome of this procedure. The aims of this study were to determine whether the morbidity of this procedure was comparable to that of other reconstructive techniques, if it was possible to achieve a satisfactory functional result, and whether biological reconstruction with a VFG and massive allograft could achieve a durable, long-lasting reconstruction.

Patients and Methods

A total of 23 patients with a mean age of 16 years (five to 40) who had undergone resection of an intercalary bone tumour of the femur and reconstruction with a VFG and allograft were reviewed clinically and radiologically. The mean follow-up was 141 months (24 to 313). The mean length of the fibular graft was 18 cm (12 to 29). Full weight-bearing without a brace was allowed after a mean of 13 months (seven to 26).

Results

At final follow-up, the mean Musculoskeletal Tumor Society Score of 22 evaluable patients was 94% (73 to 100). Eight major complications, five fractures (21.7%), and three nonunions (13%) were seen in seven patients (30.4%). Revision-free survival was 72.3% at five, ten, and 15 years, with fracture and nonunion needing surgery as failure endpoints. Overall survival, with removal of allograft or amputation as failure endpoints, was 94.4% at five, ten, and 15 years.

Discussion

There were no complications needing surgical revision after five years had elapsed from surgery, suggesting that the mechanical strength of the implant improves with time, thereby decreasing the risk of complications. In young patients with an intercalary bone tumour of the femur, combining a VFG and massive allograft may result in a reconstruction that lasts a lifetime. Cite this article: Bone Joint J 2018;100-B:378-86.