Intramedullary, antibiotic-loaded cemented, massive allografts for skeletal reconstruction 26 cases compared with 19 uncemented allografts

Abstract

We compared the outcomes of 26 intramedullary cemented massive allografts with 19 allografts without cementation; all allografts were used for reconstruction after excision of bone sarcomas. In the cementation group, 12 allografts were used as osteochondral grafts (proximal humerus 4, proximal tibia 4, and distal femur 4), 7 as intercalary diaphyseal allografts of the femur, and 7 for a knee arthrodesis. In the uncemented allografts, 3 allografts were used as osteochondral grafts (proximal humerus 2, proximal tibia 1), 2 as intercalary diaphyseal allograft of the femur, and 14 for a knee arthrodesis. The average length of follow-up was 40 (25-60) months. 14 of 26 cemented allografts had an excellent (osteotomy line: not visible) or good (fusion > or = 75% of the cortical thickness) healing of the junction site. Infection developed in 1 allograft. Fracture occurred in 4 of 12 cemented osteochondral allografts due to a subchondral collapse (all in the proximal tibia). Fractures at the junction site in the lower extremity developed in 4 of 22 cemented allografts. In 19 allografts without cementation, 11 had excellent or good healing of the junction. Late infection developed in 4 allografts, fracture of the allograft in 3 cases, and junction fracture in 3 of 17 patients with reconstruction of the lower extremity. Intramedullary graft cementation seems to reduce the fracture and infection rates.

Case Report: Reconstruction of a 16-cm Diaphyseal Defect after Ewing's Resection in a Child

“…Allograft reconstructions are attractive; they allow mechanical and biologic reconstruction during the same procedure. Nonetheless, they are associated with high rates of complications, including fracture, nonunion, and infection, and their long-term survival is a concern for children [4,16]. Use of a vascularized bone autograft is an attractive option because it allows reconstruction of a bony defect and the autograft may enlarge with time and growth.…”

“…Diaphyseal endoprostheses [1,3], allografts [4,16], bone transport [6], and vascularized autograft [7,14] are some of the preferred methods. Nonbiologic materials provide immediate reconstruction but the potential for high implant failure and additional operations is likely [1,3].…”

“…Biologic reconstructions usually are favored for young patients with the potential for long-term survival. However, allograft reconstructions and vascularized bone autograft are associated with complications such as fracture, nonunion, infection, and donor site morbidity [4,7,14,16]. In a previous series of 35 adult patients, Masquelet et al [15] reported the use of an innovative two-stage technique that involves insertion of a cement spacer, induction of a membrane, and reconstruction of the defect with cancellous bone autograft.…”

“…Different techniques have been proposed to reconstruct such bone defects, including diaphyseal endoprostheses [1,3], allografts [4,16], bone transport [6], and vascularized autograft [7,14]. Restoring original bone anatomy and strength to withstand the rigors of use and growth is challenging.…”

Is the Induced-membrane Technique Successful for Limb Reconstruction After Resecting Large Bone Tumors in Children?

“…The Ilizarov technique often is associated with complications, including pin tract infections, segmental alignment problems, and nonunion. Allograft reconstructions are associated with complications such as fracture, nonunion, and infection [15,24]. The transfer of vascularized bone from the fibula, with or without growth plate [19], is widely used to bridge large defects; however, donor-site morbidity has been reported to occur in as much as 19% of patients [27].…”