Distraction osteogenesis reconstruction of large segmental bone defects after primary tumor resection: pitfalls and benefits

Abstract

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.

Distraction Osteogenesis: Biological Principles and Its Application in Companion Animals

“…However, two studies compared patients who underwent DO with and without chemotherapy and it did not demonstrate any difference in the bone healing process between patient groups [73,74]. The hypothesis proposed is that DO's effect on osteoblast may counteract the inhibitory effects of chemotherapy [75].…”

“…Also, in a rabbit mandible model, it was found that osteogenesis is delayed after a 60-Gy dose of radiation, even though viable osteoblast and osteocytes may still be present [81]. It is therefore likely that distraction osteogenesis is negatively affected by radiation [75].…”

Current review of surgical management options for extremity bone sarcomas

“…The suggested advantages of this technique are: precise restoration of limb length discrepancies; stimulation effect on soft-tissue healing; easier management of potential infection; and durable biologic reconstruction with good long-term functional results. 3…”

Biological reconstruction in the treatment of extremity sarcoma in femur, tibia, and humerus

“…The biological reconstruction implies that the diseased bone is replaced by an expendable, which completely replaces the role of the removed portion and can be classified as either viable or nonviable. The former involves vascularized bone graft and lengthening of the bone, [ 14 ] while the latter involves devitalized tumor bone [ 15 ] and allograft. Vascularized bone grafting has been reported as a safe and reliable procedure for reconstruction of segmental skeletal defects resulting from intercalary resection of malignant bone tumors.…”

“…[ 16 , 17 ] Distraction osteogenesis with bone transport techniques for such significant bony defects involves a lengthy period in a cumbersome frame and a high incidence of complications, thus making it far from an ideal solution for these challenging cases. [ 14 ] Massive allografts are widely used because of biological fixation and attachments for soft tissue anchorage, with the problems of procurement, storage, immunological responses, and possible infection. Over recent years, there has been a great interest in recycling the tumor bone itself by various methods of sterilization and re-implantation.…”