A New Reconstructive Technique for Intercalary Defects of Long Bones: The Association of Massive Allograft with Vascularized Fibular Autograft. Long-Term Results and Comparison with Alternative Techniques

106

108

Background With the improved survival for patients with malignant bone tumors, there is a trend to reconstruct defects using biologic techniques. While the use of an intercalary allograft is an option, the procedures are technically demanding and it is unclear whether the complication rates and survival are similar to other approaches. Questions/purposes We evaluated survivorship, complications, and functional scores of patients after receiving intercalary femur segmental allografts. Patients and Methods We retrospectively reviewed 83 patients who underwent an intercalary femur segmental allograft reconstruction. We determined allograft survival using the Kaplan-Meier method. We evaluated patient function with the Musculoskeletal Tumor Society scoring system. Minimum followup was 24 months (median, 61 months; range, 24-182 months).Results Survivorship was 85% (95% confidence interval: 93%-77%) at 5 years and 76% (95% confidence interval: 89%-63%) at 10 years. Allografts were removed in 15 of the 83 patients: one with infection, one with local recurrence, and 13 with fractures. Of the 166 host-donor junctions, 22 (13%) did not initially heal. Nonunion rate was 19% for diaphyseal junctions and 3% for metaphyseal junctions. We observed an increase in the diaphysis nonunion rate in patients fixed with nails (28%) compared to those fixed with plates (15%). Fracture rate was 17% and related to areas of the allograft not adequately protected with internal fixation. All patients without complications had mainly good or excellent Musculoskeletal Tumor Society functional results. Conclusions Diaphyseal junctions have higher nonunion rates than metaphyseal junctions. The internal fixation should span the entire allograft to avoid the risk of fracture. Our observations suggest segmental allograft of the femur provides an acceptable alternative in reconstructing tumor resections.

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Intercalary Femur Allografts Are an Acceptable Alternative After Tumor Resection

Aponte-Tinao

Farfalli

Ritacco

et al. 2012

106

108

“…Although they have their own complications of loosening, wear, mechanical failure, and instability [35], complications occur later [22,28] and seem to be easier to fix. Another option that has become more common is the combination of an intercalary allograft and a free vascularized fibula graft, which has been shown to have fewer problems with fracture, nonunion, and infection compared with either individual treatment [2,19,25]. The use of free vascularized fibula grafts also may have a role in osteoarticular allografts, either in the initial reconstruction or in treating the common complications of allografts [11].…”

Section: Discussionmentioning

confidence: 99%

Long-term Results for Limb Salvage with Osteoarticular Allograft Reconstruction

Ogilvie

Crawford

Hosalkar

et al. 2009

Osteoarticular allograft reconstruction after extremity tumor resection has been shown to have a high rate of complications. Although good functional results have been seen, long-term outcomes have not been well studied. We performed a retrospective review of 20 patients who underwent primary osteoarticular allograft reconstruction after extremity sarcoma resection. All postoperative complications related to the allograft reconstruction were recorded.

“…To provide the patient with an adequate oncological margin during the tumor resection, large osseous defects can be created that hamper functional limb salvage. Traditionally, structural allografts have been used to fill these defects, providing structural support using cortical bone; however, they are associated with a high complication rate as a result of the avascular nature of the allograft [5,11,13,24,25,27,31].…”

Section: Introductionmentioning

confidence: 99%

What Is the Outcome of Allograft and Intramedullary Free Fibula (Capanna Technique) in Pediatric and Adolescent Patients With Bone Tumors?

Houdek

Wagner

Stans

et al. 2016

Background After bone tumor resection, reconstruction for limb salvage surgery can be challenging because of the resultant large segmental bony defects. Structural allografts have been used to fill these voids; however, this technique is associated with high complication rates. To circumvent the complications associated with this procedure, massive bony allografts have been supplemented with an intramedullary vascularized free fibula. However, few studies have examined the outcomes using this technique in the pediatric and adolescent populations. Questions/purposes The purpose of this study was to examine the revision-free survival using he Capanna technique for limb salvage for pediatric lower limb salvage. We attempted to answer the following questions: (1) What was the overall limb salvage rate along with incidence of reoperation and complications? (2) How did pediatric and adolescent patients functionally perform after this technique? (3) What was the incidence of late complications including infection and fracture? (4) What was the incidence of limb length discrepancy? Methods Eighteen pediatric patients who underwent lower extremity limb salvage with the use of cadaveric allograft and intramedullary free fibular transfer (Capanna technique) were identified. There were nine boys males and nine girls with a mean age of 11 years (range, 5-18 years) and mean followup of 8 years (range, 2-15 years), respectively. All patients had at least 2 years followup. Three patients have not been seen in followup during the past 5-years; however, all had made it to their 5-year clinical followup. The patients' medical records were reviewed for clinical and functional outcomes as well as postoperative complications. Time to union was recorded through an evaluation of radiographs. Mankin functional outcome and Musculoskeletal Tumor Society (MSTS) rating scale were recorded for each patient. Results The overall limb salvage rate was 94%. Fourteen patients underwent an additional surgical procedure. Six patients underwent additional procedure(s) to treat a symptomatic nonunion. Seventeen of the patients had a good or excellent Mankin score with a mean MSTS rating of 93% at last followup. Six of the patients underwent a limb length modification procedure. Conclusions Use of large allografts in conjunction with intramedullary vascularized free fibulas appears to be a reliable method for the reconstruction of large bony tumors of the lower extremity in this population, although we did not directly compare this with allografts alone in our study. The use of locked plates may improve union times. The proportion of patients achieving limb preservation was high and complication rates are acceptable. Level of Evidence Level IV, therapeutic study.