Factors affecting outcome of massive intercalary bone allografts in the treatment of tumours of the femur

Abstract

We retrospectively reviewed 101 consecutive patients with 114 femoral tumours treated by massive bone allograft at our institution between 1986 and 2005. There were 49 females and 52 males with a mean age of 20 years (4 to 74). At a median follow-up of 9.3 years (2 to 19.8), 36 reconstructions (31.5%) had failed. The allograft itself failed in 27 reconstructions (24%). Mechanical complications such as delayed union, fracture and failure of fixation were studied. The most adverse factor on the outcome was the use of intramedullary nails, followed by post-operative chemotherapy, resection length > 17 cm and age > 18 years at the time of intervention. The simultaneous use of a vascularised fibular graft to protect the allograft from mechanical complications improved the outcome, but the use of intramedullary cementing was not as successful. In order to improve the strength of the reconstruction and to advance the biology of host-graft integration, we suggest avoiding the use of intramedullary nails and titanium plates, but instead using stainless steel plates, as these gave better results. The use of a supplementary vascularised fibular graft should be strongly considered in adult patients with resection > 17 cm and in those who require post-operative chemotherapy.

Does Intraoperative Navigation Assistance Improve Bone Tumor Resection and Allograft Reconstruction Results?

“…However, we found a lower nonunion rate (6%) if we compare our series with previous reports that show nonunion rates of more than 10% [1,6,12]. Nonunions are frequently related to the accuracy of the osteotomies performed at the hostallograft junctions.…”

“…The complications reported in this series did not differ from the expected in this kind of surgery [1,6,12]. However, we found a lower nonunion rate (6%) if we compare our series with previous reports that show nonunion rates of more than 10% [1,6,12].…”

“…Navigation of both the tumor resection and the intraoperative manipulations of the allograft [15] as well as the preoperative allograft selection with a virtual bone bank may increase accuracy of the whole procedure [13]. This is aimed to reduce local tumor recurrences as a result of inaccuracies between the planned osteotomies and the osteotomies finally performed [14] and allograft complications resulting from technical errors during implantation; however, again, these purported advantages have been the subject of relatively little research to date [2,6].…”

Is There Benefit to Free Over Pedicled Vascularized Grafts in Augmenting Tibial Intercalary Allograft Constructs?

“…Massive bone allograft and vascularized fibula graft, either alone or combined, are common biologic sources for reconstruction of intercalary defects after tumor resection, either as a primary or a salvage procedure [7]. When used alone, massive bone allografts are associated with complications such as nonunion at the host-allograft junction, allograft fracture, and infection [3,5,17,32]; by contrast, vascularized fibula grafts used alone or supplemental are associated with longer surgical times, risk of donor site morbidity, lengthy times to hypertrophy, and a high frequency of stress fracture [19]. Some studies have suggested that the shortcomings of each technique can be mitigated by using intercalary allografts in conjunction with a vascularized fibula autograft in primary and salvage situations, where immediate mechanical support is provided by the massive bone allograft allowing biologic activity of the vascularized fibula graft to result in hypertrophy and incorporation [7,8].…”

Evaluating effects of deferoxamine in a rat tibia critical bone defect model

“…1 Allograft has its own shortcomings including infection and lower rates of union. 2 BMP is expensive and has limited Food and Drug Administration (FDA) approval. 3 An ideal surgery or bone substitute, that would cause 100% union rate in critical bone defects, is yet to be found.…”