Article

Limb Salvage Using Distraction Osteogenesis: A Classification Of The Technique

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Abstract

We report the results of distraction osteogenesis (callotasis) for the reconstruction of extensive defects after the excision of skeletal tumours in the limbs. Bone transport was performed in ten patients (five osteosarcomas and five giant-cell tumours), shortening-distraction in three (two osteosarcomas and one Ewing's sarcoma), and distraction osteogenesis combined with an intramedullary nail to reduce the time of external fixation in six (three osteosarcomas, two chondrosarcomas, and one malignant fibrous histiocytoma). The mean length of the defects after excision of the lesion was 8.4 cm. The mean external fixation index was 39.5 days/cm for the group treated by bone transport, 34.1 days/cm for the shortening-distraction group, and 24.0 days/cm for the group treated by distraction and an intramedullary nail. Functional evaluation gave excellent results in 12 patients, good in five and fair in two. There were ten complications in 19 patients, all of which were successfully treated. We also classified reconstruction using distraction osteogenesis into five types based on the location of the defects after resection of the tumour: type 1, diaphyseal; type 2, metaphyseal; type 3, epiphyseal; type 4, subarticular reconstruction; and type 5, arthrodesis. Our results suggest that reconstruction using distraction osteogenesis provides bone which will develop sufficient biomechanical strength and durability. It is beneficial in patients with an expectation of long-term survival and in growing children.

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... However, these methods have disadvantages and a high incidence of complications. Long-term results can be unsatisfactory especially after resection of extensive or juxta-articular tumours [2,567. Ilizarov introduced the concept of induction of local bone formation with a minimally invasive procedure, the process he called distraction osteogenesis (DO) [8]. ...
... DO has been used widely to treat traumatic bone loss, nonunion, osteomyelitis, malunion, limb-length discrepancy and to correct deformity9101112 . The method embraces biomechanical stability, minimally invasive surgery, regeneration of new bone with gradual lengthening of the soft tissues [5]. There are few studies of its use in the treatment of benign bone tumours [13, 14]. ...
... We applied EBI monolateral fixator for lengthening and deformity correction. There is a concern regarding the risk for malignant degeneration in patients when an osteotomy is performed in bone with a coexisting benign tumour [5]. Similarly, there are concerns over the quality of new bone formation during distraction osteogenesis in what is 'diseased' bone [5]. ...
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The mechanical features of and biologic response to using distraction osteogenesis with the circular external fixator are the unique aspects of Ilizarov’s contribution that allows deformity correction and reconstruction of bone defects. We present a retrospective study of 20 patients who suffered from a variety of benign tumours for which external fixators (EF) were used to treat deformity, bone loss, and limb-length discrepancy. A total of 26 bony segments in twenty patients (10 males, 10 females; mean age 17 years; range 7–58 years) were treated with EF for residual problems from the tumour itself (primary treatment) in 8 patients and for complications related to the primary surgery (secondary treatment) in 12 patients. Histological diagnoses were Ollier’s disease (n = 4), Fibrous Dysplasia (n = 5), Congenital multiple exostosis (n = 5), giant cell tumour (n = 2) and one case for chondromyxoid fibroma, desmoid fibroma, chondroma and unicameral bone cyst. Various types of external fixators used to treat these problems. These were Ilizarov, unilateral fixator, multiaxial correction frame (Biomet, Parsippany, NJ), Taylor spatial frame (Memphis, TN) and smart correction multiaxial frame. The mean follow-up time was 69.5 months (range 35–108 months). The mean external fixation time was 159.5 days (range 27–300 days). The mean external fixation index was 67.4 days/cm (12–610) in 26 limbs who underwent distraction osteogenesis. The mean length of distraction was 4.9 cm (range 0.2–14 cm). At final follow-up, all patients had returned to normal activities. Complications were in the form of knee arthrodesis in one patient, pin tract infection in six and residual shortening in eight patients. The use of EF and the principles of distraction osteogenesis, in the management of problems associated with benign bone tumours and related surgery yields successful results especially in young patients. With this approach, the risk for recurrence of shortening and deformity may be minimized with overcorrection or over-lengthening as dictated by preoperative planning.
... Segmental resection of diaphyseal metastatic tumors is more suitable for pain control and pathological fracture (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23), and there were many advantages, including preservation of the juxta-articular bone and joint, reduced long-term mechanical problems, and epiphysis preservation in children (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28). However, the optimal reconstruction method after resection of malignant tumors involving the diaphysis of long bones remains undefined (6,8,9,11). ...
... Extra-corporeally irradiated autogenous bone can be used as an alternative to allografts (8); however, it is brittle and takes a long time to revascularize and incorporate into the surrounding bone (11,22). Distraction osteogenesis and bone transport may provide adequate biomechanical strength (27,28), but is time-consuming (1 mm/day) and not suitable for large defects (<15 cm) (28). This potentially results in the formation of new bone that lacks sufficient mechanical strength to withstand physiological loading (18). ...
... Extra-corporeally irradiated autogenous bone can be used as an alternative to allografts (8); however, it is brittle and takes a long time to revascularize and incorporate into the surrounding bone (11,22). Distraction osteogenesis and bone transport may provide adequate biomechanical strength (27,28), but is time-consuming (1 mm/day) and not suitable for large defects (<15 cm) (28). This potentially results in the formation of new bone that lacks sufficient mechanical strength to withstand physiological loading (18). ...
Article
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Reconstruction of bone defects following femoral diaphyseal tumor resection is challenging. Segmental allograft (SA) and intercalary prosthesis (IP) are the most common reconstruction methods for femoral diaphyseal metastatic tumors with pathological fracture. However, whether the complications and functional outcomes differ between SA and IP remains unclear. To compare the clinical outcomes and complications for patients treated with SA reconstruction or IP replacement for femoral shaft tumors, 34 patients who had undergone intercalary resection for metastatic tumor with pathological fracture in the femoral diaphysis were evaluated. Of these, 18 had received SA and 16 IP. There were 11 males, and 24 females, with a mean age of 64.5±11.3 years. The most common sites of primary metastases were lung (26.5%), breast (17.6%) and liver (14.7%). The visual analog scale (VAS), implant-related complications and the Musculoskeletal Tumor Society (MSTS) scores for each patient were collected. The follow-up period for patients ranged from 2 to 27 months. At the most recent follow-up, 28 patients had succumbed to mortality, with a mean survival time of 6.9±3.7 months for the IP group and 7.4±3.0 months for the SA group. Patients with IP had a significantly shorter time to full weight bearing and hospitalization time than those who received SA (P=0.003 and P=0.002, respectively). The rates of overall complications and implant-related complications were significantly lower for IP as compared with SA (18.8 vs. 66.7%, P=0.007; 12.5 vs. 55.6%, P=0.013). The reoperation rate of the SA group was higher than that of the IP group (38.9 vs. 12.5%), however the difference between the two groups was statistically insignificant (P=0.125). MSTS scores were significantly higher for the IP group as compared with the SA group at one month after surgery (IP, 26.7±1.6 vs. SA, 20.3±1.5; P<0.05), without a significant difference at the final follow-up. There were no statistically significant differences in age, sex, length of resection, follow-up time, operative time or blood loss between the two groups. In summary, IP reconstruction may provide improved early functional outcomes and fewer early complications, particularly for patients with a shorter life expectancy due to femoral metastatic tumors with pathological fracture.
... The intercalary tumour resection results in a segmental bone defect and can represent a challenging reconstructive problem. The surgical options for reconstructing these defects include biologic reconstructions such as an allograft [1][2][3], nonvascularised or vascularised fibular grafts [4,5], autogenous extracorporeally-treated bone [6][7][8][9][10], bone transport [11,12] or the combination of an allograft with vascularised fibular grafts. Nonbiologic reconstructions, on the other hand, use intercalary endoprostheses [13][14][15]. ...
... Vascularised fibular grafting does not have the benefit of a sufficiently thick original bone, thus delaying full weightbearing until several years after the surgery, and the patients need crutches for extended periods. Furthermore, stress fractures, nonunions, malunions and infections represent other possible complications [11]. ...
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PurposeIn 1999, we developed a technique using frozen autografts—tumour-containing bone treated with liquid nitrogen—for the reconstruction of malignant bone tumours. The purpose of this study was to evaluate the functional and oncological outcomes of frozen autografts for intercalary reconstruction of malignant bones and soft tissue tumours. Methods This retrospective study was designed to assess 34 patients of mean age 35 (range, 6–79) years. The mean follow-up period was 62 (24–214) months. The median length of the frozen autografts was 138.4 ± 60.39 (50–290) mm. ResultsPostsurgically, 20 patients remained disease-free, seven patients survived with no evidence of disease, five patients were alive with disease, and two patients died of disease. The five- and ten-year survival rates of the frozen autografts were 91.2% and the mean International Society of Limb Salvage score was 90%. Complete bony union was achieved in 97% of the patients. There were five cases of nonunion, six cases of fracture, two cases of deep infection and four cases of local recurrence. Conclusion Utilizing intercalary frozen autografts for patients with a nonosteolytic primary or secondary bone tumour without involvement of the subchondral bone is a good alternative treatment, because it is a straightforward biological technique and can provide excellent limb function.
... Despite being a highly effective tool for correction and lengthening, the use of an external fixator (EF) is cumbersome for patients. [1][2][3] Recently, where lengthening without deformity correction is required, an upsurge in the use of intramedullary lengthening nails (PRECICE Nail®) has been seen 4,5 in other countries; however, such devices are not approved for use in Japan by the insurance systems. This results in a dependence on EF for lengthening and deformity correction. ...
... The average EFP was 213.2 ± 116.9 (range, 21-376) days with the average lengthening 2.6 ± 2.3 (range, 0-9) cm. The average number of operations was 2.6 ± 2.0 (range, [1][2][3][4][5][6][7][8][9][10][11][12][13], and the average postoperative ISOLS score was 25.3 ± 11.7 (range, 7-30) points. ...
Article
Background: This survey aims to assess the satisfaction of patients who have had treatment using external fixation (EF). Materials and methods: An original questionnaire and a Short Form 36 (SF-36) were distributed to 121 patients who underwent treatment using EF for deformity correction and lengthening between 2006 and 2016. A multivariate analysis was performed on the factors associated with satisfaction. Results: Sixty patients returned a response. The average satisfaction score was 83.6 points. In the 5-point satisfaction survey, 43 of 60 patients (71.7%) responded "very satisfied" or "satisfied" and 27 patients (45.0%) responded "yes" to the question as to whether they would request EF treatment again if presenting with the original preoperative condition. In addition, the subjectively expressed tolerance for having an external fixator device on the limb was 92.1 days on average. A correlation was established with the ISOLS score. Conclusion: The top three factors that determined subjective inconvenience with EF are pain, walking, and heaviness. Although EF treatment was stressful, the satisfaction scores were high. Furthermore, the satisfaction with EF treatment was improved by (1) pain control, (2) shortening the EF period, and (3) psychological support. How to cite this article: Ugaji S, Matsubara H, Kato S, et al. Patient-reported Outcome and Quality of Life after Treatment with External Fixation: A Questionnaire-based Survey. Strategies Trauma Limb Reconstr 2021;16(1):27-31.
... To fill the defect, bone transport and shortening-distraction may be used. [3] Distraction osteogenesis can be achieved by different kinds of external fixations, including unilateral or circular fixators. [4] Nevertheless, the utilization of external fixators has been associated with many complications. ...
... Between 1994 and 2009, 13 patients were treated for infected juxta-articular nonunion around the ankle joint, with a mean bone loss of 4.8 cm (range: 1-7 cm). Mean age of the patients was 50 years (range: 27-79 years), and mean number of previous operations was 1.77 (range: [1][2][3][4]. Demographic data were collected after reviewing the medical records and registry of patients maintained in our department. All patients were assessed for local skin conditions, shortening, deformity, distal neurovascular status, and joint function. ...
Article
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Objective: The purpose of this study was to summarize our clinical results with distraction osteogenesis for the treatment of infected tibial nonunion around the ankle joint. Methods: Between 1994 and 2009, 13 patients with a mean age of 50 years (range: 27-79 years) underwent tibial reconstruction for the treatment of infected nonunion of the distal tibia, with a mean bone loss of 4.8 cm (range: 1-7 cm). Lengthening over an intramedullary nail as a second procedure was used in 2 patients, bifocal compression and distraction technique in 5 cases, compression with Ilizarov external fixator in 5 cases, and Taylor Spatial Frame (TSF, Smith Nephew, Memphis, TN, USA) in 1 case. At final follow-up, functional and radiographic results were evaluated according to Paley's bone and functional healing criteria. Results: Mean duration of follow-up was 36 months. Mean external fixation time was 198 days, and mean external fixation index was 29 days/cm. According to Paley's bone healing criteria, there were 10 excellent, 2 good, and 1 poor result(s); additionally, according to Paley's functional healing criteria, there were 5 excellent, 6 good, and 2 fair results. There were 11 problems, 5 obstacles, and 1 sequel according to Paley's classification of complications. There was 1 persisting nonunion, which underwent revision with a retrograde intramedullary nail. Conclusion: External fixator and/or combined treatment are effective and reliable methods to treat infected nonunion of the distal tibia. Every patient should be evaluated according to their infection level and bony defects for reconstruction.
... These limb salvage methods include tumor prosthetic replacement, free vascularized autologous fibular graft, allogenic bone graft, allograft prosthetic composite, distraction osteogenesis, low heat treated autobone, and irradiated autologous bone graft. [2][3][4][5][6][7][8][9][10] Of these, the free vascularized fibular graft was described by Taylor et al. in 1975 and has been used to reconstruct bone defects since then. 3 Fibular bone grafts provide a good bone stock since a large amount of graft bone can be harvested and it contains a strong double cortical bone that can support the internal fixation device. ...
Article
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We report the case of a pediatric patient with Ewing’s sarcoma of the tibia treated with vascularized fibular autograft where the resulting limb deformity and leg length discrepancy (LLD) were corrected using Ilizarov external fixator. A 14-year-old girl presented to our outpatient clinic with a deformity of the right proximal and distal tibia and an 11.7 cm of LLD after tumor reconstruction surgery. Deformity correction and limb lengthening were simultaneously performed using double corticotomy on the right proximal and distal tibia. One year postoperatively, the union of the right proximal tibia had progressed, but nonunion was observed at the right distal corticotomy site. To address this, osteosynthesis with tricortical iliac bone allograft was performed after the removal of the Ilizarov external fixator. After 6 months, the union of the distal tibia was confirmed, and the varus deformity of proximal and distal tibia improved. The LLD was also decreased, but the left lower limb was still longer by 3 cm. This report shows that vascularized fibular autografts can potentially be used for the gradual correction of LLD and deformities. However, for the treatment of multiple deformities in bones previously reconstructed with vascularized fibular graft, the possibility of impaired bone forming potential of the fibular graft should be considered.
... Tsuchiya et al. classified five types of reconstructive strategies using external fixation based on tumor location. Among them, joint-preservation surgery included diaphyseal reconstruction (type I), metaphyseal reconstruction (type II), and subarticular reconstruction (type III) (Fig. 4) [37]. ...
Article
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Bone sarcoma often occurs in childhood, as well as in adolescents and young adults (AYAs). AYAs differ from pediatric patients in that their bone is skeletally mature and the physis has almost disappeared with the completion of growth. Although AYAs spend less time outside, they often participate in sports activities, as well as driving, working, and raising a family, which are natural activities in daily living. Multidisciplinary approaches involving imaging, multi-agent chemotherapy, surgical procedures, and careful postoperative care has facilitated an increase in limb-sparing surgery for bone sarcoma. In addition, recent advances in imaging modalities and surgical techniques enables joint-preservation surgery, preserving the adjacent epiphysis, for selected patients following the careful assessment of the tumor margins and precise tumor excision. An advantage of this type of surgery is that it retains the native function of the adjacent joint, which differs from joint-prosthesis replacement, and provides excellent limb function. Various reconstruction procedures are available for joint-preserving surgery, including allograft, vascularized fibula graft, distraction osteogenesis, and tumor-devitalized autografts. However, procedure-related complications may occur, including non-union, infection, fracture, and implant failure, and surgeons should fully understand the advantages and disadvantages of these procedures. The longevity of the normal limb function for natural activities and the curative treatment without debilitation from late toxicities should be considered as a treatment goal for AYA patients. This review discusses the concept of joint-preservation surgery, types of reconstruction procedures associated with joint-preservation surgery, and current treatment outcomes.
... However, most specialists agree that biological reconstructions should especially be used in patients with stage I and, if useful, stage II tumours, whereas in patients with advanced primary bone tumours (stage III) or secondary lesions (metastases)—in which early full weight bearing and functionality are major concerns compared to durability—tumour endoprostheses are preferred[4,5]. Depending on the localization, defect size and shape (segmental/hemicortical), underlying entities and adjuvant treatment modalities, biological reconstruction strategies include massive or hemicortical allografts (with or without vascularised autografts)[6][7][8], distraction osteogenesis[9], replantation of the sterilized tumour-bearing bone segment (e.g. after extracorporeal irradiation)[10], the induced membrane technique[11]or the use of vascularised or non-vascularised bone grafts[1,12,13]. The use of non-vascularised fibula grafts originated at the beginning of the twentieth century and was the gold standard for biological reconstructions for more than 60 years. ...
Article
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Background The reconstruction of meta−/diaphyseal bone defects following bone tumour resection is challenging, and biological treatment options should be applied whenever possible, especially in benign lesions and early stage sarcomas. We aimed to evaluate the results of segmental (SR) and hemicortical reconstructions (HR) at the extremities using non-vascularised fibula grafts. Methods We retrospectively enrolled 36 patients who were treated with non-vascularised fibula reconstructions (15 SR, 21 HR) after bone tumour resection (15 malignant, 21 benign). All cases were evaluated regarding consolidation, hypertrophy at the graft-host junctions, and complications; moreover, the functional and oncological results were assessed. The mean follow-up was 8.3 years (2.1–26.6 years). Results Primary union was achieved in 94% (SR 87%, HR 100%) of patients, and 85% (SR 81%, HR 88%) showed hypertrophy at the graft-host junction. The overall complication rate was 36% with 4 patients (11%) developing local recurrence. There was a significant correlation between the development of mechanical complications (fracture, delayed-/non-union) and a defect size of ≥12 cm (p = 0.013), segmental defects (p = 0.013) and additional required treatment (p = 0.008). The functional outcome was highly satisfactory (mean MSTS score 86%). Conclusions Due to encouraging results and advantages (such as their remodelling capacity at the donor site), non-vascularised fibula reconstructions should be considered a valuable alternative treatment option for patients with hemicortical defects or segmental reconstructions of less than 12 cm in which no additional neo-/adjuvant treatment is necessary.
... Also, we did not use distraction osteogenesis in all cases (the frame was used statically for fixing pedicled fibula transfer in some cases). If we compare our results with those of Tsuchyia et al. [11], we find that we had lower ASAMI-function score (87% were excellent and good versus 89% in their study), This might be a result of including complicated cases with previous surgeries as cases 8 and 10 and their cases received intra-arterial chemotherapy, which is more effective than conventional chemotherapy. On the other hand, we had fewer complications (2 versus 10). ...
Article
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Objective: evaluate the Ilizarov fixator in the management of bone tumours regarding the duration and the ease of the procedure, the outcome and the complications. Methods: This study was done at the Department of Orthopedic surgery in Ain Shams University Hospitals. 15 patients with benign or malignant tumours were treated by resection followed by bone and soft tissue reconstruction and Ilizarov circular fixator in January 2012-April 2013 and followed up till July 2014. Results: Follow-up was done with a mean period of 21.7 (14-28) months. Adjustment of the frame was done as required. As regards malignant tumours, the disease free survival has a mean of 22.8 (12-30) months. 2 patients developed local recurrence. The overall survival was a mean of 25.8 (13-30) months. 1 patient died as a result of chemotherapy. The MSTS score was 50% to 100% with a mean value of 84.6%. ASAMI-bone score was excellent in 53% of the cases, good in 2 cases, fair in 1 case but poor in 4 cases. ASAMI-function score was excellent in 53% of cases, good in 33% of cases, fair in 1 case and poor in 1 case. The adverse effects were 7 problems, 5 obstacles and 6 complications according to Paley’s classification. Conclusion: Biological reconstruction using Ilizarov circular fixator should be considered safe and effective in the management of benign and low grade malignant tumours, and a salvage treatment in case of failure of other methods of limb salvage.
... In limb salvage operations in patients with osteosarcoma after resection of large bone segments, bone defects appear; some scholars propose that the bone transfer technology as a biological reconstruction of bone defect can obtain a therapeutic effect. In 1997, Tsuchiya et al. [44] applied bone transfer technology, shortening extension technology, distraction osteogenesis combined with intramedullary nail technology in the treatment of 5, 2 and 3 cases of osteosarcoma patients, respectively; the operations were successful, and according to the position of the bone defect after resection divided into Type 5: Type I Diaphysis, Type II Metaphyseal, Type III Epiphysis, Type IV subarticular reconstruction, and Type IV joint fusion. Shalaby and his team members [45] applied Ilizarov technology combined with autogenous fibular grafting in 6 patients with distal tibial osteosarcoma who refused to undergo amputation. ...
Article
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Osteosarcoma is the most common primary malignant bone tumor; its standard treatment includes neoadjuvant chemotherapy combined with surgery. Neoadjuvant chemotherapy has significantly improved the 5-year survival and limb salvage rates in osteosarcoma since the 1870s. The survival rate of patients with limb salvage was not inferior to that of amputees, and therefore, limb salvage has become the main surgical option for patients with osteosarcoma. The 5-year survival rate for osteosarcoma has plateaued. However, new advances in limb salvage therapy in osteosarcoma, including adjuvant chemotherapy, ablation techniques, bone transport techniques, and computer navigation techniques, are now available. This report summarizes the recent advances in limb salvage therapy for osteosarcoma over the past decade.
... The bone defects after these resection can be bridged by intercalary implants or size matched allografts if one has access to good tissue bank. Biological method of reconstruction has the advantage that once it incorporates with the host bone it is a life long procedure and is not associated with the complications of using a prosthesis [3,4]. Alternative technique of biological reconstruction if one does not have access to a tissue bank would be to use a vacularised or non vascularised autograft like fibula. ...
Article
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Allograft bone fractures are critical complications in massive allograft bone transplantations. There are limited studies available on the application of 3D printing for massive allograft bone transplantation complications, and no related reports on the treatment of an allograft bone fracture with a complete biological intramedullary nail. A complex case of allograft bone fracture after massive bone transplantation for a right tibial osteosarcoma was treated with fixation of an individualized 3D printed biological tibial intramedullary nail. Prior to the operation, the intramedullary nail was designed and printed based on the results of computed tomography examination of the affected limb, and the surface of the intramedullary nail was treated with a hydroxyapatite coating. Intraoperatively, the intramedullary nail was implanted according to the preoperative 3D design plan. The intraoperative and postoperative examinations showed that the 3D printed intramedullary nail achieved good matching between the implant and the medullary cavity, and the biological coating integrated well with surrounding bone. The follow‐up results 44 months postoperatively showed that the patient was satisfied with the surgical results, where his ankle function met his daily needs, and the Musculoskeletal Tumor Society score was 24. 3D printing tibial intramedullary nail fixation can be successful in the treatment of allograft bone fractures and should be considered as a treatment of choice. In this case, the intramedullary nail matched the surrounding bone well, had good osseointegration, and the patient regained basic function. 3D customized biological tibial intramedullary nail fixation for the treatment of massive allograft bone fracture
Chapter
Bone tumors are commonly located around the knee, in the distal femur and proximal tibia and less frequently in the proximal fibula and patella. Treatment of bone tumors depends on the histological grade, the size and location of the tumor and the characteristics of the patient. Generally, benign bone tumors are adequately treated by either an intralesional or a marginal resection. To reduce the risk of recurrence, the intralesional resection may be extended with mechanical, chemical, and thermal adjuncts. Primary bone sarcomas and some aggressive benign tumors require a wide resection. Limb salvage principles are largely employed if neurovascular structures can be preserved and a level of function maintained. After tumor resection with a wide margin, the defect left poses a reconstructive challenge. In this chapter, we will refer to bone tumors that most frequently arise around the knee and may affect adult population. First, we consider the basic characteristics of these tumors and then the surgical treatment, focusing in those techniques that preserve the joint.
Chapter
Prior to the 1970s, amputation or disarticulation was the standard treatment for malignant bone tumors in pediatric patients. Limb-sparing surgeries are now standard treatment due to multidisciplinary advancements in areas including radiological evaluation, chemotherapy, surgical techniques, implant technology, and tumor biology. Reconstruction methods of limb salvage include allograft, endoprostheses, and recycled autografts such as autoclaved bone and irradiated bone. However, limb function remains limited and deteriorates over time. When subsequent complications such as deep infection, fracture, and implant failure occur, it is likely that amputation or disarticulation will be eventually performed to solve problems. Therefore, biological reconstruction using distraction osteogenesis or frozen autograft was newly developed to obtain better limb function and reduce complications for bone tumor reconstruction. Our goal of limb-sparing surgery is the normalization of the affected limb in function and appearance. Based on this concept, we first performed and have been continuing biological reconstruction using a distraction osteogenesis technique and massive frozen tumor-bearing bone treated with liquid nitrogen. In this chapter, we introduce our original biological reconstruction procedure using distraction osteogenesis for osteosarcoma according to our classification (Type I–VI) based on tumor site, size, and response to chemotherapy. Cases indicated for joint preservation with the distraction osteogenesis method should have tumors of Types I–IV according to our classification system, not more than 15 cm in length (resulting in a treatment time of less than 1 year), and with a good response to chemotherapy. Types V and VI are indicated for arthrodesis with distraction osteogenesis. The frozen autograft method can be applied to all types (in Chap. 15).
Chapter
In Children, the vast majority of bone tumours are benign or benign aggressive entities. For the purposes of this discussion however, we are focusing on the management of primary and secondary bone malignancies.
Article
Improvements in imaging and treatment of musculoskeletal tumors have increased the variety of options for reconstruction following joint-sparing diaphyseal resection. The purpose of this case series was to show that reconstruction of malignant tumors of the radial shaft with an intercalary prosthesis may be an option for patients with segmental bone loss. Three consecutive patients underwent wide resection of the radial diaphysis followed by reconstruction with a custom intercalary prosthesis. A custom intercalary prosthesis with lap joint design was used in all 3 cases. Mean follow-up was 18 months (range, 9-25 months). All patients were weight bearing as tolerated 1 week postoperatively. At the most recent follow-up, patients' mean elbow flexion and extension arc was 137° (range, 130°-140°). At the forearm, mean supination was 60° (range, 30°-90°) and mean pronation was 70° (range, 60°-90°). At the wrist, mean palmar flexion was 80° (range, 70°-90°) and mean dorsiflexion was 80° (range, 70°-90°). All patients reported minimal to no pain and no significant functional limitations. Mean Musculoskeletal Tumor Society score was 26/30 (87%). Reconstruction with an intercalary prosthesis is a viable option for patients with metastatic disease of the radial shaft. All patients had satisfactory results and early return to function; none required return to the operating room. Possible advantages of reconstruction with an intercalary prosthesis compared with reconstruction with a bone graft or polymethylmethacrylate osteosynthesis include early return to function and minimal weight-bearing restrictions postoperatively. [Orthopedics. 201x; xx(x):exx-exx.].
Article
Distraction osteogenesis (DO) technique could be used to manage large-size bone defect successfully, but DO process usually requires long duration of bone consolidation. Innovative approaches for augmenting bone consolidation are of great need. Staphylococcal enterotoxin C2 (SEC2) has been found to suppress osteoclastogenesis of mesenchymal stem cells in vitro. In this study, we investigated the effect of SEC2 on proliferation and osteogenic differentiation of rat bone marrow derived mesenchymal stem cells (rBMSCs). Further, we locally administrated SEC2 (10 ng/ml) or PBS into the distraction gap in Sprague-Dawley male rat DO model every three days till termination at 3 and 6 weeks. The regenerates were subjected to X-rays, micro-computed tomography, mechanical testing, histology and immunohischemistry examinations to assess new bone quality. SEC2 had no effect on cell viability. The calcium deposition was remarkably increased and osteogenic marker genes were significantly up-regulated in rBMSCs treated with SEC2. In rat DO model, SEC2 group had higher bone volume/total tissue volume in the regenerates. At 6 weeks, mechanical properties were significantly higher in SEC2-treated tibiae comparing to the control group. Histological analysis confirmed that the new bone had improved quality in SEC2 treated group, where the osteocalcin and osterix expression in the regenerates was up-regulated, indicating faster bone formation. The current study demonstrated that SEC2 local injection promotes osteogenesis and enhanced bone consolidation in DO. The findings support application of SEC2 as a potential novel strategy to expedite bone consolidation in patients undergoing DO treatment. This article is protected by copyright. All rights reserved.
Chapter
Here we present a case of osteosarcoma in the proximal diaphyseal tibia , which was reconstructed using Taylor spatial frame .
Chapter
»Weichgewebssarkom« bzw. die Synonyme »Weichteilsarkom«, »maligner Weichteiltumor« und »maligner Weichgewebstumor« definieren eine inhomogene Gruppe von Tumoren, die weniger als 1% aller bösartigen Neubildungen ausmachen. Sie zeichnen sich durch ein heterogenes biologisches Verhalten, histologische Erscheinungsvielfalt, Unterschiede in Aggressivitätsgrad, zytogenetischen Merkmalen, Ansprechraten auf Chemotherapeutika, Strahlensensibilität, Metastasierungsmuster und Lokalrezidivraten aus.
Chapter
Prior to the 1970s, amputation or disarticulation was the standard treatment for malignant bone tumors in pediatric patients. Limb-sparing surgeries are now standard treatment due to multidisciplinary advancements in areas including radiological evaluation, chemotherapy, surgical techniques, implant technology, and tumor biology. Reconstruction methods of limb salvage include allograft, endoprostheses, and recycled autografts such as autoclaved bone and irradiated bone. However, limb function remains limited and deteriorates over time. When subsequent complications such as deep infection, fracture, and implant failure occur, it is likely that amputation or disarticulation will be eventually performed to solve problems. Therefore, biological reconstruction using distraction osteogenesis or frozen autograft was newly developed to obtain better limb function and reduce complications for bone tumor reconstruction. Our goal of limb-sparing surgery is the normalization of the affected limb in function and appearance. Based on this concept, we first performed and have been continuing biological reconstruction using a distraction osteogenesis technique and massive frozen tumor-bearing bone treated with liquid nitrogen. In this chapter, we introduce our two original biological reconstruction procedures for malignant tumors according to our classification (Types I–VI) based on tumor site, size, and response to chemotherapy. Cases indicated for joint preservation with the distraction osteogenesis method should have tumors of Types I–IV according to our classification system, of not more than 15 cm in length (resulting in a treatment time of less than 1 year), and with a good response to chemotherapy. Types V and VI are indicated for arthrodesis with distraction osteogenesis. The frozen autograft method can be applied to all types.
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The focus of this chapter is the effect of tumors on physeal growth, and not on the details of patient demographics, imaging, histology or treatment of the tumor. Tumor and tumor-like conditions that injure the physis may be benign or malignant and occur primarily in the metaphysis. Some cross the physis into the epiphysis (transphyseal). Tumors, benign or malignant, located exclusively in the epiphysis which cause injury to the physis, are a rare occurrence [4]. For the purpose of this chapter a tumor or tumor-like condition is defined as a space occupying lesion of normal or abnormal tissue for that location, rather than some expression of neoplasia.
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Diaphyseal resection and reconstruction is a relatively uncommon procedure in the management of benign and malignant bone tumours. The actual methodology utilised is usually tailored to the patient’s individual needs, considering age, skeletal maturity, aggressivity of the tumour and the need for ancillary adjuvant treatment. Biological reconstruction appears to function best where patients are younger, the pathology is more in the benign spectrum and patients can tolerate a longer period of post-operative morbidity.
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This case reports a 49 year old female who was involved in a high-speed motor vehicle accident. She suffered a limb threatening type IIIC open distal tibia fracture with circumferential skin and muscle loss. She had exposed neurovascular structures. She was managed with limb salvage of aggressive surgical debridement, bony stabilization with a circular fixator, and early soft tissue coverage. Residual limb length discrepancy was addressed with staged proximal tibial osteoplasty.
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Adamantinomas are rare bone tumors of unknown origin. They have low potential for metastasis and treatment consists of marginal resection. As they are usually located in the diaphyseal region of the tibia, resection leads to a bone defect. In this case we present a patient with adamantinoma located in the mid-diaphyseal region of the tibia. Following resection, the defect was reconstructed with bifocal transport using Ilizarov ring fixator. At the end of the trasportation of the segment, bone grafting and plate osteosynthesis was performed due to non union of the bone ends.
Article
Background: The use of curettage, phenol, and cement is accepted by most experts as the best treatment for giant-cell tumor of bone. The present study was performed to evaluate whether equivalent results could be obtained with curettage with use of a high-speed burr and reconstruction of the resulting defect with autogenous bone graft with or without allograft bone. Methods: The prospectively collected records of patients who had a giant-cell tumor of a long bone were reviewed to determine the rate of local recurrence after treatment with curettage with use of a high-speed burr and reconstruction with autogenous bone graft with or without allograft bone. All of the patients were followed clinically and radiographically, and a biopsy was performed if there were any suspicious changes, Results: Fifty-nine patients met the criteria for inclusion in the study. According to the grading system of Campanacci et al,, two patients (3 percent) had a grade-I tumor, twenty-nine (49 percent) had a grade-II tumor, and twenty-eight (47 percent) had a grade-III tumor. Seventeen patients (29 percent) had a pathological fracture at the time of presentation. The mean duration of follow-up was eighty months (range, twenty-eight to 132 months). Seven patients (12 percent) had a local recurrence. Six of these seven were disease-free at the latest follow-up examination after at least one additional treatment,vith curettage or soft-tissue resection (one patient). One patient had resection and reconstruction with a prosthesis after a massive local recurrence and pulmonary metastases. Conclusions: Despite the high rates of recurrence reported in the literature after treatment of giant-cell tumor with curettage and bone-grafting, the results of the present study suggest that the risk of local recurrence after curettage with a high-speed burr and reconstruction with autogenous graft with or without allograft bone is similar to that observed after use of cement and other adjuvant treatment. It is likely that the adequacy of the removal of the tumor rather than the use of adjuvant modalities is what determines the risk of recurrence.
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There has been a dramatic improvement in the survival rate of patients with sarcomas and in the successful salvage of limbs as a result of progress in chemotherapy, radiological evaluation, surgical technique, and the technology of materials and implants. Complications, however, such as deep infection, fracture, bone resorption, and breakages of prostheses still occur. The challenge to provide long-lasting survival and function of the limb after reconstruction is now being met with biological solutions using living bone. The ideal reconstruction should have biological affinity, resistance to infection, sufficient biomechanical strength, and durability. Vascularized bone transfer has limitations in terms of length and strength. Since 1990, distraction osteogenesis, which can regenerate bone of sufficient strength for reconstruction, has been adopted for tumor surgery.
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An intercalary reconstruction is defined as replacement of the diaphyseal portion of a long bone after segmental skeletal resection (diaphysectomy). Intercalary reconstructions typically result in superior function compared to other limb-sparing procedures as the patient's native joints above and below the reconstruction are left undisturbed. The most popular reconstructive options after segmental resection of a bone sarcoma include allografts, vascularized fibula graft, combined allograft and vascularized fibula, segmental endoprostheses, extracorporeal devitalized autograft, and segmental transport using the principles of distraction osteogenesis. This article aims to review the indications, techniques, limitations, pros and cons, and complications of the aforementioned methods of intercalary bone tumor resections and reconstructions in the context of the ever-growing, brave new field of limb-salvage surgery.
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Here we present a case of osteosarcoma in the proximal diaphyseal tibia , which was reconstructed using Taylor spatial frame .
Article
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.
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Background To date, the usefulness of parathyroid hormone [PTH (1–34)] in distraction osteogenesis has been reported in several studies. We aimed to determine the optimal timing of PTH (1–34) administration in a rabbit distraction osteogenesis model. Methods The lower hind leg of a Japanese white rabbit was externally fixed, and tibial osteotomy was performed. One week after the osteotomy, bone lengthening was carried out at 0.375 mm/12 h for 2 weeks. After 5 weeks, the lower leg bone was collected. Bone mineral density (BMD), peripheral quantitative computed tomography (pQCT), micro-computed tomography (micro-CT), and mechanical tests were performed on the distracted callus. The rabbits were divided into three groups according to the timing of PTH (1–34) administration: 4 weeks during the distraction and consolidation phases (group D + C), 2 weeks of the distraction phase (group D), and the first 2 weeks of the consolidation phase (group C). A control group (group N) was administered saline for 4 weeks during the distraction and consolidation phases. Furthermore, to obtain histological findings, lower leg bones were collected from each rabbit at 2, 3, and 4 weeks after osteotomy, and tissue sections of the distracted callus were examined histologically. Results The BMD was highest in group C and was significantly higher than group D. In pQCT, the total cross-sectional area was significantly higher in groups D + C, D, and C than group N, and the cortical bone area was highest in group C and was significantly higher than group D. In micro-CT, group C had the highest bone mass and number of trabeculae. Regarding the mechanical test, group C had the highest callus failure strength, and this value was significantly higher compared to group N. There was no significant difference between groups D and N. The histological findings revealed that the distracted callus mainly consisted of endochondral ossification in the distraction phase. In the consolidation phase, the chondrocytes were almost absent, and intramembranous ossification was the main type of ossification. Conclusion We found that the optimal timing of PTH (1–34) administration is during the consolidation phase, which is mainly characterized by intramembranous ossification.
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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.
Article
Introduction The options for the reconstruction of diaphyseal defects following the resection of bone tumors include biological or prosthetic implants. The purpose of our study was to evaluate different types of intercalary reconstruction techniques, including massive bone allograft, extracorporeal devitalized autograft, vascularized free fibula, and modular prosthesis. Methods We performed a systematic review of articles using the terms diaphyseal bone tumor and intercalary reconstruction. All the studies reporting the non-oncological complications such as infection, nonunion and fracture of the intercalary reconstructions were included. We excluded articles published before 2000 or did not involve humans in the study. Case reports, reviews, technique notes and opinion articles were also excluded based on the abstracts. Thirty-three articles included in this review were then studied to evaluate failure rates, complications and functional outcome of different surgical intercalary reconstruction techniques. Results Nonunion rates of allograft ranged 6%–43%, while aseptic loosening rates of modular prosthesis ranged 0%–33%. Nonunion rates of allograft alone and allograft with a vascularized fibula graft ranged 6%–43% and 0%–33%, respectively. Fracture rates of allograft alone and allograft with a vascularized fibula graft ranged 7%–45% and 0%–44%, respectively. Infection rates of allograft alone and allograft with a vascularized fibula graft ranged 0%–28% and 0%–17%, respectively. All of the allograft (range: 67%–92%), extracorporeal devitalized autograft including irradiation (87%), autoclaving (70%), pasteurization (88%), low-heat (90%) or freezing with liquid nitrogen (90%), and modular prosthesis (range: 77%–93%) had similar Musculoskeletal Tumor Society functional scores. Addition of a vascularized fibula graft to allograft did not affect functional outcome [allograft with a vascularized fibula graft (range: 86%–94%) vs. allograft alone (range: 67%–92%)]. Conclusion Aseptic loosening rates of modular prosthesis seem to be less than nonunion rates of allograft. Adding a vascularized fibula graft to allograft seems to increase bone union rate and reduce the risk of fractures and infections, though a vascularized fibula graft needs longer surgical time and has the disadvantage of donor site morbidity. These various intercalary reconstruction techniques with or without a vascularized fibula autograft had similar functional outcome.
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Background: Joint-preserving intercalary tumor resection can result in better proprioception and a more normal joint function after reconstruction. However, most reported reconstruction techniques are usually associated with frequent complications. Therefore, the approach of reconstruction following joint-preserving tumor resection warrants further study. Methods: Between September 2016 and October 2018, 12 patients with metaphyseal malignant bone tumors around the knee joint were treated by joint-preserving intercalary resections with the aid of three-dimensional (3D)-printed osteotomy guide plates and reconstructions using 3D-printed intercalary prostheses. We assessed the accuracy of the resection by comparing the cross sections at the resection plane with 3D-printed matching surface of the prostheses. The functional outcomes, complications and oncological status were also evaluated. Results: All patients were observed for 7 to 32 months with an average follow-up of 22.5 months. The achieved resection was accurate, with accurate matching between the residual bone and prosthesis. The mean MSTS score was 28 (range, 26-30). Superficial infection occurred in two patients. Local recurrence was observed in one patient, while pulmonary metastasis was identified in one patient. Conclusions: The personalized osteotomy guide plate and prosthesis based on 3D printing technique facilitate joint-preserving tumor resection and functional reconstruction. However, longer follow-up and larger sample size are required to clarify its long-term outcomes. Level of evidence: Level IV, therapeutic study.
Article
Distraction osteogenesis (DO) is an ideal model to study bone regeneration. The major limitation is relatively long period required for new bone consolidation. Here, we investigated whether the application of polycaprolactone (PCL) and hydroxyapatite (HA) composite microspheres could enhance bone formation in DO. Pure PCL microspheres and composite PCL and 10% HA microspheres were synthesized. Bone mesenchymal stem cells isolated from green fluorescent protein rats (GFP‐rBMSCs) were cultured with microspheres in a rotary bioreactor system. Scanning electron microscopy was used to examine the microstructures. Osteogenic differentiation of rBMSCs was confirmed. Moreover, PCL/HA (20 mg) and PCL (20 mg) were locally administered into the distraction gap in rat DO model towards to the end of distraction period. Imaging detection, mechanical and histological examinations were performed to assess the quality of 4‐week regenerates. Results showed that the microspheres were of uniform size and monodisperse. After incubation with rBMSCs in culture, PCL/HA microspheres showed better ability of cell adhesion and osteogenic differentiation comparing to PCL microspheres. In vivo, bone volume/total tissue volume, bone mineral density, and mechanical properties of new callus were significantly higher in the PCL/HA group compared to PCL group. Histological analyses confirmed improved bone formation and vascularization in PCL/HA group. We presented an effective protocol for the generation of functionalized microspheres and demonstrated implantation of PCL/HA microspheres into the distraction regenerate could significantly enhance bone consolidation. Thus, application of PCL/HA composite microspheres may be a novel approach for promoting bone regeneration. This article is protected by copyright. All rights reserved This article is protected by copyright. All rights reserved.
Article
Background Endoprosthetic replacement is a valuable treatment option following intercalary resection of bone tumours in the diaphysis. Objectives To identify indication, operative technique, implants currently available, literature results and alternative procedures for the alloplastic reconstruction of segmental bone defects. Materials and methods This review article summarizes the authors’ own experiences and relevant clinical studies focussing on this topic. Results According to the literature, 10-year-survival rates of intercalary endoprostheses range between 64 and 80%. Yet, comparisons between different publications are difficult due to the limited number of cases, different implants, follow-up periods and the heterogeneous patient populations. Biological alternatives for reconstruction are autologous bone transplantation, distraction osteogenesis and bone transport, allogenic bone transplantation, and the induced membrane technique. Innovative tissue engineering approaches are still limited to preclinical testing. Conclusions Short- to mid-term results for segmental endoprostheses following intercalary resections are satisfactory and may be regarded as superior to those of biological reconstructions due to the immediate full weight-bearing capability. However, they are mainly applied for elderly patients and in palliative situations because of potential long-term complications.
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Due to accurate preoperative imaging techniques, early diagnosis and effective chemotherapy, many tumors arising in the metaphyseo-diaphyseal regions of long bones can be segmentally resected with joint preservation. The intercalary resection of malignant bone tumor results in a bone defect which can represent a challenging reconstructive problem. The most commonly used surgical reconstructive options for these defects include biologic reconstructions such as allografts, vascularized fibular grafts, autogenous extracorporeally devitalized tumor bearing bone graft, combination of allografts or devitalized autografts with vascularized fibular grafts, segmental bone transport, or induced membrane technique. Nonbiologic reconstructions, on the other hand, use intercalary endoprostheses. Every patient should be carefully evaluated and the reconstructive option should be individually selected. The aim of this article is to discuss the surgical options of reconstruction of bone defects after intercalary resection of malignant bone tumors with reviewing of their indications, advantages, disadvantages and complications.
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Background Use of an implant is one of the risk factors for surgical site infection (SSI) after malignant bone tumor resection. We developed a new technique of coating titanium implant surfaces with iodine to prevent infection. In this retrospective study, we investigated the risk factors for SSI after malignant bone tumor resection and to evaluate the efficacy of iodine-coated implants for preventing SSI. Methods Data from 302 patients with malignant bone tumors who underwent malignant bone tumor resection and reconstruction were reviewed. Univariate analyses were performed, followed by multivariate analysis to identify risk factors for SSI based on the treatment and clinical characteristics. Results The frequency of SSI was 10.9% (33/302 tumors). Pelvic bone tumor (OR: 4.8, 95% CI: 1.8–13.4) and an operative time ≥ 5 h (OR: 3.4, 95% CI: 1.2–9.6) were independent risk factors for SSI. An iodine-coated implant significantly decreased the risk of SSI (OR: 0.3, 95% CI: 0.1–0.9). Conclusion The present data indicate that pelvic bone tumor and long operative time are risk factors for SSI after malignant bone tumor resection and reconstruction, and that iodine coating may be a promising technique for preventing SSI.
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Distraction osteogenesis (DO) is a commonly used technique in multiple orthopaedic specialties, including trauma, oncology and pediatrics. This technique aims to produce new bone formation in the distraction gap in a controlled manner. The issue with this technique has been the high risk of complications, one of which is poor regenerate formation during the distraction process. Although several factors (including patient and operative factors) and techniques (including surgical, mechanical and pharmacological) have been described to ensure successful regenerate formation during the process of DO, these factors are sometimes difficult to control clinically. Our aim from this review is to highlight the different factors that affect DO, modalities to assess the regenerate and review treatment options for poor regenerate in the distraction gap. In addition, we propose a management protocol derived from the available literature that can be used to facilitate in the management of inadequate regenerate formation.
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Patient: Male, 54 Final Diagnosis: Metastatic lesion of tibia from renal cell carcinoma Symptoms: Mass in anterior tibia • pain Medication: — Clinical Procedure: Resection and allograft interposition Specialty: Orthopedics and Traumatology Objective Unusual clinical course Background Renal cell carcinoma (RCC) is the most common malignancy of the kidney, with clear cell (ccRCC) subtype identified in 85% of the cases; one-third of these patients experience synchronous metastatic disease, while 20–30% of the remaining patients develop metachronous metastatic RCC. The axial skeleton (pelvis and sacrum) is the second most common location (following the lungs), with a reported incidence of 35%. Diaphysis of the long bones is rarely involved, with the tibia being an even rarer site of metastasis. Case Report We present a rare case of solitary diaphyseal tibial metachronous metastasis from RCC in a 54-year-old male that appeared 8 years after nephrectomy without any previous evidence of disease. He underwent segmental skeletal resection, intercalary allograft over locked reamed intramedullary nailing, and soleus flap coverage. Thirty months later he presented with hardware failure and nonunion at the distal part of the allograft site. He was successfully treated with exchange nailing, fibular osteotomy, and bone grafting, showing excellent clinical and radiological outcome without any evidence of recurrence 5 years after the index operation. Conclusions Wide resection and biological reconstruction using intramedullary nailing and incorporated allograft is a good option for metachronous solitary RCC tumors.
Article
Diaphyseal defects in long bones of extremities following segmental resection are very common in the clinic, and reconstruction remains a great challenge. Although there are many treatments for diaphyseal defects at present, reconstruction with an intercalary endoprosthesis may be an optimal method. We demonstrate a surgical technique for reconstruction of a humeral shaft defect with an intercalary endoprosthesis following tumor resection, and achieve a good clinical outcome. We conclude that in comparison with other methods, reconstruction with an intercalary endoprosthesis is simple, effective, and allows for earlier weight bearing and more rapid restoration of function.
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Background: Although a simple bone cyst carries the risk of pathological fractures, it rarely causes severe deformity. Here we report a case of severe femoral deformity after multiple pathological fractures due to simple bone cysts, and consider the reason for the progression of malunion despite multiple previous treatments. Finally, we propose a treatment option for malunion correction. Case presentation: A 9-year, 7-month-old Japanese girl was referred to our facility with obvious deformity of her right femur, caused by multiple simple bone cyst-related pathological fractures. The deformity included bowing of approximately 90° and an internal rotation of 60° in the middle third of the femoral shaft. To correct this deformity, we excised the lesion, thus shortening the femur, then corrected the alignment and applied an Ilizarov fixator to extend the bone. At present, 3 years after surgery, the deformity has not recurred and our patient is living without any limitations in daily activities or regular exercise. Conclusions: When a long bone is in a prolonged state of deformation, the deformity not only progresses as the bone grows, but the soft tissues remain unbalanced and treatment becomes increasingly difficult. To prevent increasing bone deformity and fragility, the deformity should be corrected as quickly as possible using intramedullary nailing or other fixation techniques. We believe that our shortening-distraction method is effective for the treatment of severe deformity with unbalanced soft tissues.
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This study was performed to explore the clinical efficacy of bone transport using external fixation for treatment of large bone defects after tibial tumor resection in five patients. Bone transport started 14 days postoperatively at 1 mm/day and was adjusted according to the callus-to-diameter ratio. The bone transport time, bone graft fusion, relapse, and metastasis were recorded. Clinical efficacy was evaluated using the Musculoskeletal Tumor Society (MSTS) scoring system. The tumors included osteosarcoma (n=2), Ewing sarcoma (n=1), malignant schwannoma (n=1), and hemangioma (n=1). The average bone defect length after resection was 11.6 cm. The five patients were followed up for an average of 50.8 months, and the average bone transport time was 15.5 months. Three patients who underwent postoperative chemotherapy were followed for 22.7 months, and two who did not undergo chemotherapy were followed for 4.75 months. Four patients underwent iliac bone grafting, and one underwent vascular pedicle fibular transplantation. The average MSTS score was 21.2 (19.3 for patients who underwent chemotherapy and 24.0 for patients who did not). No relapse or metastasis was observed. Bone transport is effective for reconstruction of large bone defects after tibial tumor resection as well as tibial malignancies with high doses of chemotherapy.
Article
PurposeWe report the oncological and functional results of limb salvage for bone sarcomas involving the distal tibia using hybrid surgical technique of resection arthrodesis by bone transport then plating. Methods Five patients (mean age 18.6 years) with primary distal tibial sarcomas (two Ewing’s sarcomas and three osteosarcomas) were treated by this method. The average duration of follow-up is 53 months. All patients accepted distraction osteogenesis with a standard technique using external fixator after wide (four cases) or marginal (one case) resection in the first operation. They were re-admitted for the second surgical treatment (plate insertion and removal of the external fixator) one to two months after they achieved the necessary limb length and desired alignment. ResultsSolid union of the lengthening site and sound fusion of the ankle were achieved in all five patients with full and unassisted weight bearing. The mean lengthening was 11.8 cm (range 8–14 cm) and the external fixation index (EFI) was 29.3 days/cm (range 22.8–36.3 days/cm). The mean functional score according to the rating system of the Musculoskeletal Tumour Society was 88% (83–90%). One patient showed poor response to chemotherapy, had local recurrence of sarcoma one year after plating, and was treated with above-knee amputation. Conclusions In carefully selected patients with primary distal tibial sarcomas, this hybrid method can effectively eliminate tumor lesion, reconstruct function, and shorten the length of wearing an external fixator by a meticulous conversion to internal fixator.
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Für die biologische Rekonstruktion von Knochendefekten wird häufig eine Kombination von allogenen und autogenen Knochentransplantaten verwendet. Autologe Knochentransplantate können entweder in Form von strukturellen oder spongiösen Transplantaten verwendet werden. Die osteogene Potenz von autologer Spongiosa ist hinlänglich bekannt und gilt nach wie vor als Goldstandard in Bezug auf Osteoinduktion und Remodellierung. Strukturelle Transplantate wie Fibula oder trikortikale Beckenkammspäne können entweder frei, d. h. nicht vaskularisiert, oder aber vaskularisiert mit Anastomosierung der Gefäße transplantiert werden. Allogene Knochentransplantate können ebenso spongiös oder strukturell verwendet werden. In der Revisionsendoprothetik hat sich durch die Einführung trabekulärer Metalle als dauerhaft stabile Platzhalter die Verwendung von allogenen Knochentransplantaten im Wesentlichen auf das Impaktionsgraft reduziert. Durch 3‑D-Printing und der damit verbundenen individualisierten angepassten Rekonstruktion wurden allogene Transplantate zurückgedrängt. In Einzelfällen bieten kombinierte Rekonstruktionen aus Allograft und Endoprothese die Vorteile der sicheren Lastübertragung und dauerhaften Rekonstruktion durch die Endoprothese sowie der Möglichkeit der Weichteilinsertion des Allografts.
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Successful cure is achieved in almost 70% of patients with primary bone sarcomas with currently available therapies. Some soft tissue sarcomas require wide bone resection in order to achieve appropriate margins for cure of disease, and patients undergoing these procedures need durable reconstruction. Biological reconstruction has been shown to provide patients with superior long-term results over other alternatives. Distraction osteogenesis is well studied in the correction of deformities as well as in addressing some congenital musculoskeletal pathologies. The use of this technique in tumor settings has been avoided by many surgeons for a multitude of concerns, including infection risk, potential tumor activation, and uncertainty regarding the effect of systemic therapy on the callus regenerate. We review the use of this reconstruction technique using cases from our institutional experience to illustrate its incorporation into the successful management of orthopedic oncology patients. Distraction osteogenesis is an effective method for reconstructing even large bony defects and is safe in the setting of systemic therapy. This technique has the potential to address some of the common problems associated with orthopedic oncology resection, such as infection and leg length discrepancy.
Article
Reconstruction options in children after bone tumor resection are as varied as they are challenging. Advances in biologic and endoprosthetic design have led to many choices, all of which must be considered in the context of prognosis, treatment limitations, and patient/family expectations. The current experience and results of limb-sparing surgery following bone sarcoma resection in growing children are discussed, including allograft, autograft, and metallic prostheses alone and in combination, especially as they pertain to the knee. In some cases, the ablative options of amputation and rotationplasty must be seen as equal and, at times, superior choices to limb salvage.
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In this chapter, the authors introduce applications of external fixators to benign and malignant bone tumor surgery. In the section of benign bone tumor, the authors introduce the treatment of deformity correction and limb length discrepancy caused by Ollier’s disease, fibrous dysplasia, osteofibrous dysplasia, nonossifying fibroma, and multiple or solitary exostosis because these diseases are relatively common. However, distraction osteogenesis in patients with a high-grade tumor requires expertise and experience; once a physician obtains the necessary means, skill, or know-how, patients with a favorable chemotherapy response are also good candidates for this treatment because a good prognosis is expected. In the section of malignant bone tumor, the authors introduce reconstruction techniques, pitfalls, and common errors of malignant bone tumor surgery.
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We report two patients with malignant bone tumours treated by wide marginal resection in whom the residual bone defect was replaced by progressive distraction after allowing union to commence in the shortened position.
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In immature long bones, radical excision of malignant tumours of the metaphysis may necessitate sacrifice of the adjacent epiphysis. To preserve the adjacent joint while allowing a safe margin of excision, we used physeal distraction before removing the tumour. From July 1984 to August 1992, we operated on 20 patients by this method. After a mean follow-up of 54 months there was no local recurrence in the epiphyseal region. Three patients had developed pulmonary metastases.
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We have used the Ilizarov technique for the management of subarticular defects after the excision of giant-cell tumours in the proximal tibia in five patients. The defect was reconstructed with a segment of 5 to 6 cm obtained from the diaphysis of the affected tibia and by autogenous bone graft from the iliac crest. The newly developed defect in the diaphysis was reconstructed by distraction using the Ilizarov apparatus. Bone grafting at the docking site was performed soon after positioning the bone segments. The mean length of the bone defect was 5.7 cm and the mean duration of external fixation was 233 days. The relative blood flow in the leg measured by 99m Tc angiography increased by 1.7 to 2.3 times that of the control level during distraction and consolidation. When seen at a mean of 43 months all patients showed a normal range of motion in the knee and ankle with no collapse of the articular surfaces.
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Fifty-three fresh, frozen cadaveric allografts (50 osteoarticular, three intercalary grafts for arthrodesis) were employed to reconstruct tumors and other defects (e.g., failed prior allografts, trauma) of the proximal tibia. Forty-eight patients had 2 or more years of follow-up. Most patients had low-grade neoplasms (giant cell tumor in 28 cases), although seven patients had high-grade malignancies (osteosarcoma in six). The functional results were judged to be excellent in 44%, good in 26.7%, fair in 2.2%, and to have failed in 26.7%. Tumor complications included two instances of metastases and five local recurrences. Deep infection occurred in 13.2% and fracture in 20.7%. If consideration is given to those patients who failed initially but were salvaged by a second graft, satisfactory results were achieved in 86%. The authors consider this to be a reasonable reconstructive option for tumors and other bony defects involving the proximal tibial articulation.
Article
Osteosarcoma is the most malignant bone tumor of the extremities that occurs in younger age groups; however, the prognosis of this disease has been improving. Limb-saving procedures have been successfully performed in more than half of the new cases of this disease. Because osteosarcoma occurs in young patients and their life expectancy is generally long, the rescued limbs must provide as full a service as possible for several decades. We have attempted the rescue of limbs in osteosarcoma patients, using the vascularized fibular graft (VFG). We performed a retrospective clinical and radiographic review of 12 patients with at least 3 years of follow up. The results were satisfactory in 11 out of the 12 patients from both the oncologic and functional point of view. There were no severe complications or donor site morbidity. Functional status, evaluated according to the system of Enneking et al. (Enneking WF, Dunham W, Gebhart MC, et al. A system for functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop 1993;286:241–246), with some modifications exceeded 80%, except in one patient. The results of this study suggest that, because of the resulting durability of the reconstructed limb, VFG should be considered for limb rescue in young patients with osteosarcoma.
Article
There are few reports on skeletal reconstruction using the bone transport technique to repair bone defects caused by resections of tumors associated with osteosarcoma. We attempted to reconstruct a 23 cm bone defect after resection of an osteosarcoma of the left femur, and succeeded in gaining 17 cm by bone transport. Five years after surgery, this patient remains alive without metastasis or local recurrence.
Article
We evaluated the results of reconstruction of a skeletal defect with use of a vascularized bone graft from the iliac crest or fibula in 160 patients who had been managed consecutively between 1979 and 1989. The indications for the procedure were a skeletal defect including non-union, resulting from resection of a tumor; traumatic bone loss; osteomyelitis; or a congenital anomaly. The average duration of follow-up was forty-two months (range, twelve to 112 months). For the entire series, the rate of union after the primary procedure was 61 per cent and the over-all rate at the latest follow-up examination (including the patients who had a secondary procedure) was 81 per cent. In a subgroup of seventy-six patients who had union after the primary procedure and did not have additional treatment, the average interval until union was six months and the average interval until full activity was sixteen months. The results were more favorable for the patients who had had reconstruction for resection of a tumor (of sixty-nine patients, fifty-six had union), for a congenital anomaly (of six patients, five had union), or for a non-union without infection (of twenty-five patients, twenty-three had union). The results were less satisfactory for patients who had had the reconstruction for bone loss due to osteomyelitis (of sixty patients, forty-six had union). Our data suggest that vascularized bone transfer for the reconstruction of large skeletal defects is a valuable procedure in appropriately selected patients.
Article
We report the prognoses for 107 patients treated by limb-salvage surgery and 147 treated by amputation or disarticulation, during the period 1980-1985, at 22 university hospitals, cancer centers and national hospitals in Japan. In this multi-institute non-randomized study, the five-year cumulative survival rate was 70% for the former group and 49% for the latter. The prognosis was more favorable among patients who responded to preoperative chemotherapy than among those who did not. Limb-salvage surgery was feasible for most of the surgical stage IIB patients with small extraosseous tumor extensions who had responded to preoperative chemotherapy. Local tumor recurrences were seen in 15 (14%) of the 107 patients in the limb-salvage surgery group, nine of whom died of the metastasis. While limb-salvage surgery is being increasingly used in Japan, present indications show the procedure not to reduce survival rate for osteosarcoma patients. The survival rate of patients with wide-with-marginal margins was similar to that of patients with wide margins. Taking into account the long-term survival of osteosarcoma patients, limb-salvage surgery can be recommended when the osteosarcoma responds to preoperative chemotherapy.
Article
The Ilizarov method of segmental bone transport has been shown to be an alternative to more conventional treatments of posttraumatic bony defects. After extensive clinical experience with the unreamed tibial nail in open fractures up to Grade IIIb, a new monorail fixation system for callus distraction and segmental bone transport was devised. This Monorail system is composed of an unreamed intramedullary (IM) nail and a unilateral AO distraction device. The new fixation method and the preliminary clinical experience are reported here. Four patients who previously sustained Grades II-IIIb open tibial fractures had an average bony defect of 9 cm. Two patients had previous bony infections. All patients had had serial debridements and myocutaneous flaps were required in three patients. An unreamed IM nail was inserted, and the transport device was applied. After an osteotomy, segmental transport was carried out until docking was achieved. The external fixator was removed after interlocking of the transported segment. The mean duration of external fixation was 17.9 days/cm and the mean period until roentgenographic consolidation of the distraction and nonunion site was 41.2 days/cm. There were two pin-tract infections but no IM infections. One nail broke after osseous consolidation of the regenerate at the distal interlocking site and required exchange. The goal of transport was achieved in all cases without angular or rotational deformity or length discrepancy. There were no neurovascular injuries.
Article
Allograft prosthetic composite arthroplasty is a reconstruction alternative after limb salvage for aggressive bone tumors. It combines an off-the-shelf implant with a fresh-frozen allograft and has several potential advantages over conventional techniques. Good clinical results can be achieved with acceptable morbidity. The procedure can be performed successfully even in patients receiving chemotherapy. Nonunion was the most common complication encountered but was amenable to autogenous iliac bone graft. The procedure can be customized to meet the needs of the patient, making custom implant manufacturing delay and expense unnecessary.
Article
We studied the function of twenty-two patients who had had a malignant skeletal tumor adjacent to the knee. An above-the-knee amputation was done in seven; a resection arthrodesis, in nine; and a replacement arthroplasty, in six. The patients all walked at a similar speed (sixty-one to sixty-six meters per minute), which is slower than normal (eighty meters per minute). They all walked with comparable efficiency at three velocities: the mean consumption of oxygen was 0.210 milliliter per kilogram of body weight per meter at free velocity, 0.215 milliliter per kilogram of body weight per meter when they walked 25 per cent faster, and 0.211 to 0.240 milliliter per kilogram of body weight per meter when they walked 50 per cent faster. The three groups of patients and a normal control group consumed oxygen at similar rates. The patients who had had an amputation were very active, and they were the least worried about damaging the affected limb, but they had difficulty walking on steep, rough, or slippery surfaces. The patients who had had an arthrodesis had a more stable limb and performed the most demanding physical work and recreational activities, but they had difficulty sitting. The patients who had had an arthroplasty led sedentary lives and were the most protective of the limb, but they were the least self-conscious about the limb.
Article
For 40 years, the author has been developing a system of orthopedics, traumatology, and limb lengthening using a circular transfixion-wire external skeletal fixator, often in combination with biomechanic methods of stimulating the formation of new osseous tissue within a widening osteotomy distraction site. The factors important for neoosteogenesis after osteotomy include: maximum preservation of extraosseous and medullary blood supply; stable external fixation; a delay prior to distraction; a distraction rate of 1 mm per day in frequent small steps; a period of stable neutral fixation after lengthening; and physiologic use of the elongating limb. For a successful fixator application, the apparatus must be applied with consideration given to the number, size, and location of the rings, the placement and tension on the wires, the technique of wire insertion, the effect of soft-tissue transfixion on limb use, and the prevention of bone and joint deformities caused by countertension in soft tissues. Clinical application of the author's techniques permits stature increase in certain forms of dwarfism, correction of deformities and limb-length inequalities, and stump elongation. For many of these applications, motorized distraction can provide continuous limb lengthening while the apparatus is on the patient.
Article
Limb-sparing surgery for malignant bone tumors in the growing child usually has been avoided because of anticipated limb-length discrepancy, especially in the lower extremity. Therefore, amputation or modified amputation was often the treatment of choice. The purpose of this article is to introduce a new concept: an expandable and adjustable internal prosthesis that can be used in the growing child in the properly selected patient after removal of the malignant neoplasm. This procedure is an alternative to amputation.
Article
Wide resection is an acceptable alternative to amputation for the management of primary sarcomas of the long bones or pelvis. The resected bone can be debrided of gross tumor tissue, autoclaved, and then replaced over intramedullary fixation to reconstruct the limb anatomically. The procedure can be combined with prosthetic reconstruction of adjacent joints with sufficient strength to allow early unprotected weight-bearing. Resection and replacement for 28 low-grade (G1) and 14 selected high-grade (G2) sarcomas were performed in 42 patients. The hemipelvis was resected and replaced four times, the proximal or distal femur 28 times, the proximal or distal tibia eight times, and the proximal humerus two times. Replacement of an adjacent joint, most commonly using a long-stemmed hip or knee prosthesis, was accomplished in 33 patients. All patients had been followed for a minimum of two years, nine months after treatment. The mean follow-up period is four years, ten months. Six individuals, all with high-grade sarcomas, developed tumor-related complications. Two evidenced a local recurrence of tumor, and four developed distant metastases. None of the patients with low-grade sarcomas developed a recurrence or metastases. Fifteen patients suffered complications unrelated to tumor control; 13 required reoperation, including two who required amputations for persistent pseudoarthrosis and graft infection, respectively. There was one other infection, successfully eradicated by drainage followed by local and systemic antibiotics. Due to mechanical failure or loosening, six patients were treated by successful revision of their joint arthroplasties. Two years after initial surgery, five patients had failures of union at the graft-host junction. Four healed after cancellous grafting and one was revised to a custom prosthesis. There were no late fatigue fractures of the grafts. The technique does not compromise the margins for adequate tumor resection. It preserves a graft strong enough to support a joint arthroplasty and to allow early weight-bearing with a low risk of pseudarthrosis or late fatigue fracture.
Article
Callotasis is a new technique of limb lengthening involving slow distraction of the callus formed in response to a proximal submetaphyseal corticotomy. Using a dynamic axial fixator with telescoping capabilities, distraction begins after 2 weeks. When the required length is attained, the fixator is held in the rigid mode until radiographic evidence of callus is observed. The locking screw is then released, and dynamic axial loading is instituted to promote corticalization. One hundred bony segments have been lengthened; 50 patients had limb length inequality, and 23 had achondroplasia. The mean lengthening achieved was 22% (maximum, 58%). There were 14 complications (14%).
Article
The size and shape of the patella make it suitable for the partial replacement of a femoral or tibial condyle resected for tumour, or destroyed by trauma. It can provide a good articular surface and may give satisfactory knee function. Nineteen cases of patellar grafts are presented, with follow-up from two to nine years. Good consolidation of the graft and fair stability of the joint were obtained; the range of movement was 90 degrees or more in 79% of cases. In contrast with an allograft of a femoral or tibial condyle, the technique described does not need an allograft bank, has a lower risk of infection, and allows better and quicker consolidation and revascularisation of the grafts, as well as a better range of movement at the knee, probably because of the lack of fibrosis from immunological reaction. Merle d'Aubigné's technique, using a patellar graft with a vascular muscle pedicle, is useful only for some cases, requires a longer period of immobilisation and weakens the extensor apparatus. Our series shows that consolidation and revascularisation of a patellar graft can occur in the absence of a pedicle.
Article
To evaluate the effect of application of pulsed direct current electrical stimulation to callus tissue, a 1-cm bone-lengthening model using an external lengthener was applied to rabbit tibia. Twenty-microampere pulsed direct current was applied 12 hours daily from the day of osteotomy until 40 days after the completion of lengthening. The area, bone mineral content, and bone mineral density of the distracted callus and of the proximal and distal segments of the tibia were evaluated using dual-energy xray absorptiometry. The absolute and relative values of bone mineral density of the electrically stimulated callus were significantly increased as compared with those in the control group. Pulsed direct current electrical stimulation may be indicated in bone lengthening to stimulate the poorly mineralized callus, and may shorten the overall time course of leg lengthening.
Article
The tibiae of rabbits were lengthened by 10 mm in 2 weeks, then approximately one half of the limbs were shortened by 2 mm in 3 days, and left for 3 days. Histological and cytomorphometrical findings of the calluses in both groups were compared. In the shortened callus, marked histologic changes were observed in the central mesenchymal cell layer where the number of the osteoblasts increased 4 fold, and massive primitive fiber bone formation took place. Cartilaginous tissue did not seem to respond to the axial shortening stress.
Article
An osteoarticular allograft was used to reconstruct a skeletal deficiency in sixteen patients after resection of a tumor in the proximal end of the tibia. The status of each allograft and the condition of each involved limb were evaluated an average of nine years (range, six to fourteen years) postoperatively. The status of the allograft was evaluated according to the survival of the allograft and the occurrence of complications. Of the original sixteen allografts, seven were removed: six, between two and five years after the reconstruction and one, seven years after the reconstruction. A second reconstruction with use of an allograft was performed in five of the seven patients. Fifteen complications occurred in association with eleven of the original sixteen allografts. These included fracture of the allograft (five patients), subchondral collapse (five patients), infection (two patients), non-union (two patients), and instability of the joint (one patient). At the latest follow-up examination, nine patients had retained the original allograft, five had had a second allograft procedure, and two had had an above-the-knee amputation. The most recent result was rated excellent or good in eleven patients and fair or a failure in five, with use of the system of Mankin et al. It was rated good or excellent in nine patients and fair, poor, or a failure in six, and it was not rated in one patient who had died, according to the system of the Musculoskeletal Tumor Society.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
Seventeen patients (age, 12-63 years; median, 22 years) treated with proximal tibial allografts were identified. Nine cases were intercalary and eight were osteoarticular allografts. Complications, number of operations, and oncologic and functional results were reviewed. The functional results of the allografts were compared with a prior cohort of patients who had endoprosthesis at the same institution by the same surgeons. There were 14 malignant tumors, two benign aggressive tumors, and one sclerosing osteomyelitis mimicking osteosarcoma. Twelve of 17 patients had complications, the most common being fracture, deformity, and infection. Six patients required more than one procedure, and three had amputations after allograft reconstruction. The ultimate function was excellent in three patients, good in seven, fair in six, and poor in one. There were 14 patients with endoprosthetic reconstruction. Wound problems followed by prosthetic loosening were the most common complications. Of the eight patients requiring a second procedure, three had an amputation. Three had excellent, seven good, and four fair functional results at the final evaluation. No patient in either group had a local recurrence. Allograft provides an alternative to endoprosthetic reconstruction; however, the high incidence of complications makes the outcome unpredictable. Allograft or prosthetic reconstruction provides better functional results than amputation without sacrificing oncologic results.
Article
The reconstruction of a large diaphyseal bone defect is a surgical challenge. Autologous bone grafts are usually insufficient to bridge the gap and allografts are prone to infection and may pose problems with internal fixation. Another solution is presented for the reconstruction of a large ulnar defect due to tumour resection, using the Ilizarov technique of segmental transport.
Treatment of bone and soft tissue tumours using external fixators
  • H Tsuchiya
  • K Tomita
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Tsuchiya H, Tomita K, Tsubota S, Shinokawa Y, Katsuo S, Tokuumi Y. Treatment of bone and soft tissue tumours using external fixators. Proceedings of 7th International Symposium on Limb Salvage, Singapore, 1993:137-43.
Operative elongation of the leg with simultaneous correction of the deformities Limb lengthening by callus distraction (callotasis)
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The use of proximal tibial allografts in the reconstruction of tumors and other defects New developments for limb salvage in musculoskeletal tumors Function after amputation, arthrodesis, or arthroplasty for tumors about the knee
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  • Mankin
  • Harris Ie
  • Ar Leff
  • S Gitelis
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Gebhardt MC, Mankin HJ. The use of proximal tibial allografts in the reconstruction of tumors and other defects. In: Yamamuro T, ed. New developments for limb salvage in musculoskeletal tumors. Tokyo, Springer-Verlag, 1989:573-83. 21. Harris IE, Leff AR, Gitelis S, Simon MA. Function after amputation, arthrodesis, or arthroplasty for tumors about the knee. J Bone Joint Surg [Am] 1990;72-A:1477-85.
Joint reconstruction utilizing autoclaved bone grafting
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Tsuchiya H, Tomita K. Joint reconstruction utilizing autoclaved bone grafting. J Joint Surg 1996;15:53-60.
Vascularised fibular autogrft as medial support of massive allografts after femur resections for bone tumours
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Manfrini M, Capanna R, Ceruso M, et al. Vascularised fibular autogrft as medial support of massive allografts after femur resections for bone tumours (preliminary results). Proceedings of 7th International Symposium on Limb Salvage, Singapore, 1993:155-9.
Limb salvage method using autoclaved autograft supplemented with vascularised fibular graft
  • Y Taguchi
  • Who Pho
  • A K Kour
Taguchi Y, Pho WHO, Kour AK, et al. Limb salvage method using autoclaved autograft supplemented with vascularised fibular graft. Proceedings of 7th International Symposium on Limb Salvage, Singapore, 1993:161-5.
Reconstruction of bony defect after resection of a high grade osteosarcoma using bone transport technique: a case report
  • Y Nakatsuka
  • T Ozaki
  • A Kawai
  • H Akazawa
  • H Inoue
Nakatsuka Y, Ozaki T, Kawai A, Akazawa H, Inoue H. Reconstruction of bony defect after resection of a high grade osteosarcoma using bone transport technique: a case report. Proceedings of 7th International Symposium on Limb Salvage, Singapore, 1993;596.
Intra-arterial chemotherapy combined with caffeine and conservative surgery for osteosarcoma
  • H Tsuchiya
  • K Tomita
  • M Sugihara
Tsuchiya H, Tomita K, Sugihara M, et al. Intra-arterial chemotherapy combined with caffeine and conservative surgery for osteosarcoma. In: Rao RS, Deo MG, Sanghvi LD, eds. Proceedings of the XVI International Cancer Congress, Monduzzi Editore, Bologna, 1994:2453-6.
Clinical application of the tension-stress effect for limb lengthening Removal of metaphyseal bone tumours with preservation of the epiphysis: physeal distraction before excision
  • Ga Ilizarov
  • F Forriol
  • Ja Cara
Ilizarov GA. Clinical application of the tension-stress effect for limb lengthening. Clin Orthop 1990;250:8-26. 15. Cã nadell J, Forriol F, Cara JA. Removal of metaphyseal bone tumours with preservation of the epiphysis: physeal distraction before excision. J Bone Joint Surg [Br] 1994;76-B:127-32.
Operative elongation of the leg with simultaneous correction of the deformities
  • Ga Ilizarov
  • Aa Deviatov
Ilizarov GA, Deviatov AA. Operative elongation of the leg with simultaneous correction of the deformities. Ortop Travmatol Protez 1969;30:32-7.