Allograft-prosthetic Composites Research Articles

Resurfaced allograft-prosthetic composite for proximal tibial reconstruction in children: intermediate-term results of an original technique.

Reconstruction of the proximal part of the tibia in children with megaprostheses or standard composite devices removes the distal femoral physis, and osteoarticular allografts have a high incidence of mechanical failure. We evaluated the results of an alternative original technique for proximal tibial reconstruction after tumor resection. Nineteen children, ranging in age from six to sixteen years, who underwent surgical resection and reconstruction with a resurfaced allograft-prosthetic composite were retrospectively reviewed at a mean follow-up time of seventy-eight months. Eighteen children had high-grade sarcoma (fourteen had osteosarcoma and four had Ewing sarcoma), and one child had an aggressive giant cell tumor of the proximal part of the tibia. Surgical resection and its complications, disease-free survival of the patients, implant survival, and functional results according to the Musculoskeletal Tumor Society scoring system were analyzed at the time of the latest follow-up. In all patients, wide surgical margins were obtained and no local recurrence was observed. At the time of the latest follow-up, nine of the eighteen patients with a high-grade malignant tumor were continually disease-free, another six had had metastases but had no evidence of disease, and three had died of the disease. The patient with a giant cell tumor was continually disease-free after 168 months. The mean implant survival was sixty-eight months (range, six to 188 months). The major complications were one deep infection; two nonunions, which healed after surgical revision; and six allograft fractures. Limb-length discrepancy was the most frequent complication but, following contralateral epiphysiodesis, resulted in a mean discrepancy of 1.9 cm at the time of the latest follow-up. At the time of the latest follow-up, eight patients had a Musculoskeletal Tumor Society score deemed as excellent or good. In children and young teenagers with bone tumors of the proximal part of the tibia requiring an intra-articular resection, knee reconstruction with a resurfaced allograft-prosthetic composite may represent a valid alternative to conventional megaprostheses or to osteoarticular allograft.

Are custom triflange acetabular components effective for reconstruction of catastrophic bone loss?

Although the introduction of ultraporous metals in the forms of acetabular components and augments has increased the orthopaedic surgeon's ability to reconstruct severely compromised acetabuli, there remain some that cannot be managed readily using cups, augments, or cages. In such situations, allograft-prosthetic composites or custom acetabular components may be called for. However, few studies have reported on the results of these components. The purposes of this study were to determine the (1) frequency of repeat revision, (2) complications and radiographic findings, and (3) Harris hip scores in patients who underwent complex acetabular revision surgery with custom acetabular components. Between August 2003 and February 2012, 26 patients (28 hips) have undergone acetabular reconstruction with custom triflange components. During this time, the general indications for using these implants included (1) failed prior salvage reconstruction with cage or porous metal construct augments, (2) large contained defects with possible discontinuity, (3) known pelvic discontinuity, and (4) complex multiply surgically treated hips with insufficient bone stock to reconstruct using other means. This approach was used in a cohort of patients with Paprosky Type 3B acetabular defects, which represented 3% (30 of 955) of the acetabular revisions we performed during the study period. Minimum followup was 2 years (mean, 57 months; range, 28-108 months). Seven patients (eight hips) died during the study period, and three (11%) of these patients (four hips; 14%) were lost to followup before 2 years, leaving 23 patients (24 hips) with minimum 2-year followup. Sixteen patients were women. The mean age of the patients was 67 years (range, 47-85 years) and mean BMI was 28 kg/m2 (range, 23-39 kg/m2). Revisions and complications were identified by chart review; hip scores were registered in our institution's longitudinal database. Pre- and postoperative radiographs were analyzed by the patient's surgeon to determine whether migration, fracture of fixation screws, or continued bone loss had occurred. There have been four subsequent surgical interventions: two failures secondary to sepsis, and one stem revision and one open reduction internal fixation for periprosthetic femoral fracture. There were two minor complications managed nonoperatively, but all of the components were noted to be well-fixed with no obvious migration or loosening observed on the most recent radiographs. Harris hip scores improved from a mean of 42 (SD, ±16) before surgery to 65 (SD, ±18) at latest followup (p<0.001). Custom acetabular triflange components represent yet another tool in the reconstructive surgeon's armamentarium. These devices can be helpful in situations of catastrophic bone loss. Level IV, therapeutic study.

Successful Limb Salvage of a "Too-Short Segment" of the Proximal Part of the Femur with Use of a Compression Osseointegration Implant: A Case Report.

After resection of a bone tumor, reconstruction can be performed with use of a variety of techniques, including large-segment allografts, allograft-prosthetic composites, endoprostheses, and other types of tissue-transfer procedures1-5. All of these options rely on healthy native bone and soft tissues. The difficulty of achieving a successful outcome increases as the segment of remaining normal bone decreases6,7. For example, endoprosthetic implants with stems require a sufficient length of bone to achieve either press-fit or cemented fixation. Similarly, allografts and vascularized bone transfers require healthy bone to achieve adequate fixation8. When short segments of bone remain after tumor resection, traditional implants will not fit, and the surgeon has to rely on alternatives such as allograft-prosthetic composites, custom implants, or replacement of the entire bone (as with total replacement of the femur). Determining what constitutes sufficient bone to perform a reconstruction is not known and depends on the surgeon’s experience, the implants that are available, the patient’s acceptance of surgical risks, and the resources available for postoperative rehabilitation. To the best of our knowledge, there are no studies in the literature that specifically provide information or guidance on how to perform an endoprosthetic reconstruction of the femur when only the proximal metaphysis is intact. We present a case of a seventy-five-year-old man who underwent successful endoprosthetic replacement of the entire femur, distal to the lesser trochanter and including the knee joint, after complications associated with a chondrosarcoma resection. This case demonstrates a novel technique with use of a compression osseointegration implant for preservation of the native hip joint while replacing almost the entire femur. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A seventy-five-year-old man presented with a four-to-six-month history of pain …

Uncemented allograft-prosthetic composite reconstruction of the proximal femur.

Background:Allograft–prosthetic composite can be divided into three groups names cemented, uncemented, and partially cemented. Previous studies have mainly reported outcomes in cemented and partially cemented allograft–prosthetic composites, but have rarely focused on the uncemented allograft–prosthetic composites. The objectives of our study were to describe a surgical technique for using proximal femoral uncemented allograft–prosthetic composite and to present the radiographic and clinical results.Materials and Methods:Twelve patients who underwent uncemented allograft–prosthetic composite reconstruction of the proximal femur after bone tumor resection were retrospectively evaluated at an average followup of 24.0 months. Clinical records and radiographs were evaluated.Results:In our series, union occurred in all the patients (100%; range 5-9 months). Until the most recent followup, there were no cases with infection, nonunion of the greater trochanter, junctional bone resorption, dislocation, allergic reaction, wear of acetabulum socket, recurrence, and metastasis. But there were three periprosthetic fractures which were fixed using cerclage wire during surgery. Five cases had bone resorption in and around the greater trochanter. The average Musculoskeletal Tumor Society (MSTS) score and Harris hip score (HHS) were 26.2 points (range 24-29 points) and 80.6 points (range 66.2-92.7 points), respectively.Conclusions:These results showed that uncemented allograft–prosthetic composite could promote bone union through compression at the host–allograft junction and is a good choice for proximal femoral resection. Although this technology has its own merits, long term outcomes are yet not validated.

Allograft-Prosthetic Composite Reconstruction for Massive Bone Loss Including Catastrophic Failure in Total Elbow Arthroplasty

Revision total elbow arthroplasty with an allograft-prosthetic composite is a difficult salvage procedure due to massive bone loss and a compromised soft-tissue envelope. High failure rates in prior studies of patients treated with allograft-prosthetic composites and an increased burden of revision total elbow arthroplasties necessitate optimized reconstructive techniques to improve incorporation of allograft-prosthetic composites. The goal of this report is to describe novel techniques for, and outcomes of, reconstructions done with an allograft-prosthetic composite. From 2003 through 2008, twenty-five patients underwent revision total elbow arthroplasty with an allograft-prosthetic composite in the humerus (six), ulna (eighteen), or both (one). Indications included aseptic implant loosening with a fracture or cortical breach (eleven), aseptic implant loosening without fracture (three), infection (seven), failed implants (one), bone loss after hemiarthroplasty (one), nonunion (one), and resection arthroplasty (one). Three reconstructive strategies were used: intussusception of the allograft-prosthesis-composite (Type I), strut-like coaptation (Type II), and side-to-side contact between the cortices of the allograft-prosthetic composite and the host bone (Type III). The outcomes that were examined included the Mayo Elbow Performance Score (MEPS), radiographic union, and overall revision and complication rates. The mean MEPS improved from 30 points preoperatively to 84 points at the time of follow-up. Ninety-two percent of the allograft-prosthetic composites incorporated. There were eight major and four minor complications in nine patients, leading to nine reoperations in six patients. Complications included infection (three), fracture (three), nonunion (one), malunion (one), skin necrosis (one), triceps insufficiency/weakness (two), and ulnar nerve paresthesia (one). Four of the twenty-five patients had definitive resection arthroplasty, one had osteosynthesis, and one had a successful revision, so twenty-one (84%) of the twenty-five had a functional elbow. Five of seven infected joints were salvaged with staged allograft-prosthesis-composite procedures. Larger graft-host contact areas in the three types of allograft-prosthetic composites provided good functional outcomes and a high rate of union compared with prior experience and resection arthroplasty. Allograft-prosthetic composites can be a safe, reliable option with an acceptable complication rate for revision total elbow arthroplasty.

The Posterior Iliac Crest Outperforms the Anterior Iliac Crest When Obtaining Mesenchymal Stem Cells from Bone Marrow

The clinical application of freshly isolated connective-tissue progenitors, as well as the potential preparation of culture-expanded mesenchymal stem cell populations for therapeutic applications, will benefit from clinical methods that maximize the yield of the starting population. We compared the number of cells, concentration, and prevalence of colony-founding connective-tissue progenitors from the anterior and posterior iliac crest. In addition, we compared the expansion kinetics and multilineage differentiation potential of their culture-expanded progeny when processed to form mesenchymal stem cells. Marrow aspirate was collected from both the anterior and posterior iliac crest of twenty-two patients. The concentration and prevalence of colony-founding connective-tissue progenitors were estimated with use of a colony formation assay. The expansion kinetics and multilineage differentiation potential of the culture-expanded mesenchymal stem cell populations derived from these starting samples were compared. The yield of colony-founding connective-tissue progenitors was 1.6 times greater in the posterior compared with the anterior iliac crest. No differences were found with respect to the viability, phenotype, expansion kinetics, or multilineage differentiation potential of mesenchymal stem cell populations derived from these two sites. The concentration and yield of colony-founding connective-tissue progenitors were greater when aspirate was obtained from the posterior compared with the anterior iliac crest, whereas the biological potential of the cells derived from these sites appeared comparable. The harvesting of bone marrow from the posterior iliac crest appears to be preferred, as it provided a modestly higher concentration of colony-founding connective-tissue progenitors than comparable aspirate from the anterior iliac crest.

Biological Reconstruction for Sarcoma

Particularly in children and young adults, bone allografts and autografts seem to be a perfect and long-lasting alternative to the use of prostheses after bone resection due to bone or soft tissue sarcomas. However, several topics like osteoarticular massive allografts are still discussed controversially. Might allograft-prosthetic composites reconstructions serve as stable and durable alternatives? Questions like this as well as the long-term results have not been answered sufficiently yet. In a review, L. A. Holzer and A. Leithner focus on the historical highlights, the present role, and possible future options for biological extremity reconstruction. While hand transplantation is already an option, above-elbow transplantation or limb regeneration might become a topic in the future. K. Rabitsch et al. report their experience with intercalary reconstructions of the lower limb using a vascularized fibula and an allograft in 12 patients. Although the event-free survival was only 51% at a two-year follow-up full weight bearing was achieved in all cases with all autografts still in place. The authors conclude that this method is a stable and durable reconstruction technique. M. Niethard et al. illustrate their technique using bilateral vascularized fibular grafts for reconstruction of metadiaphyseal defects of the femur and tibia in 11 patients. Despite a similar complication rate as reported by K. Rabitsch et al., all of the complications were manageable without the loss of the biological reconstruction. The authors also report on the increased risk of fixation failure after radiotherapy. L. E. Ritacco et al. describe the workflow for structural allograft selection of their renowned three-dimensional virtual bone bank system. Preoperative planning includes a 3D CT-derived bone model to define the exact size and shape in comparison to the planned resection. F. Traub et al. provide a retrospective analysis of their experience in biological reconstruction following the resection of pelvic tumors. Twenty-seven patients were evaluated for oncological as well as clinical and functional outcome. Hip transposition was used in 16 patients, and autologous nonvascularized fibular grafts were used in five patients. Despite the difficult situation after pelvic resection, MSTS score (mean 16.5) was good or excellent in most of the patients. The second paper by K. Rabitsch et al. reports on the technique of distal radius osteoarticular allografts, which were used in five patients. With all allografts still in place at a mean follow-up of 32 months the functional results were good or excellent (DASH 8, Mayo wrist 84). L. A. Aponte-Tinao et al. describe their high level of experience in biological upper extremity reconstruction in 70 patients, including 38 osteoarticular allografts, 24 allograft-prosthetic composites, and eight intercalary allografts. After a mean follow-up of 5 years the authors conclude that intercalary humeral allografts had the best outcome, while the other techniques led to articular deterioration, fracture, and allograft resorption with the need for revision surgeries in 16 patients. G. L. Farfalli et al. compare 50 nonconstrained knee allograft-prosthetic composites with 36 matched constrained ones. In both groups the authors observed more allograft fractures when the prosthetic stem did not bypass the host-donor osteotomy. However, both groups had good or excellent MSTS functional scores. These papers represent an exciting and insightful snapshot of the current techniques of biological reconstruction after sarcoma resection. Some sophisticated methods, existing challenges, and possible future topics are highlighted in this special issue, which may inspire the reader and provide a stimulus for the present discussion on limb salvage techniques.

Allograft Reconstruction for the Treatment of Musculoskeletal Tumors of the Upper Extremity

In comparison with the lower extremity, there is relatively paucity literature reporting survival and clinical results of allograft reconstructions after excision of a bone tumor of the upper extremity. We analyze the survival of allograft reconstructions in the upper extremity and analyze the final functional score according to anatomical site and type of reconstruction. A consecutive series of 70 allograft reconstruction in the upper limb with a mean followup of 5 years was analyzed, 38 osteoarticular allografts, 24 allograft-prosthetic composites, and 8 intercalary allografts. Kaplan-Meier survival analysis of the allografts was performed, with implant revision for any cause and amputation used as the end points. The function evaluation was performed using MSTS functional score. Sixteen patients (23%) had revision surgery for 5 factures, 2 infections, 5 allograft resorptions, and 2 local recurrences. Allograft survival at five years was 79% and 69% at ten years. In the group of patients treated with an osteoarticular allograft the articular surface survival was 90% at five years and 54% at ten years. The limb salvage rate was 98% at five and 10 years. We conclude that articular deterioration and fracture were the most frequent mode of failure in proximal humeral osteoarticular reconstructions and allograft resorption in elbow reconstructions. The best functional score was observed in the intercalary humeral allograft.

Massive bone loss

Revision total hip arthroplasty (THA) is projected to increase by 137% from the years 2005 to 2030. Reconstruction of the femur with massive bone loss can be a formidable undertaking. The goals of revision surgery are to create a stable construct, preserve bone and soft tissues, augment deficient host bone, improve function, provide a foundation for future surgery, and create a biomechanically restored hip. Options for treatment of the compromised femur include: resection arthroplasty, allograft prosthetic composite (APC), proximal femoral replacement, cementless fixation with a modular tapered fluted stem, and impaction grafting. The purpose of this article is to review the treatment options along with their associated outcomes in the more severe femoral defects (Paprosky types IIIb and IV) in revision THA.

Interprosthetic humeral fracture revision using a tibial allograft total elbow prosthetic composite in a patient with hemophilia A : a case report

IntroductionInterprosthetic fractures of the humerus are rare. Revisions of total elbow arthroplasty components in these cases are difficult. We report the first case of a patient with hemophilia who underwent a revision with a tibial allograft prosthetic composite without the need for hardware augmentation.Case presentationA 43-year-old Caucasian man with a history of hemophilia and transfusion-related human immunodeficiency virus and hepatitis B and C presented with an interprosthetic fracture of his humerus after months of pain between his total elbow and total shoulder arthroplasties. Because of the poor remaining bone stock available in his distal humerus, a revision using a barrel-staved tibial allograft prosthetic composite was performed. Our patients’ factor VIII level was optimized before the operation and he suffered no major long-term complications at 28 months. His only complication was an incomplete radial nerve palsy that ultimately recovered and left him with some numbness on the dorsum of his hand.ConclusionCareful use of an allograft prosthetic composite is a very reasonable option when a patient experiences an interprosthetic fracture. We have successfully performed revision total elbow arthroplasty for a patient with hemophilia with an interprosthetic fracture using a tibial allograft and no additional fixation, which resulted in his return to full activities of daily living, minimal pain and full incorporation of the allograft to host bone.

Modified technique using allograft-prosthetic composite in the distal femur after bone tumor resection

BackgroundThe purpose of this retrospective study was to analyze the results of treatment of bone tumor resection of the distal femur with the modified technique of allograft-prosthetic composite. MethodsTwelve patients with distal femoral bone tumors were treated with deep-frozen cortical allograft struts and allograft-prosthesis composites. There were five males and seven females with a median age of 29.5y. The minimum follow-up time was 12mo (median, 45.7mo; range, 12–81mo). Diagnoses included osteosarcoma in five patients, chondrosarcoma in three patients, giant cell tumors in three patients, and malignant fibrous histiocytoma in one patient. Five osteosarcoma patients were treated with adjuvant chemotherapy. ResultsAt the latest follow-up examination, 11 patients were alive with no evidence of disease, and the limb was preserved in nine patients. One patient died of pulmonary metastases with no evidence of local recurrence. Seven healed without complications. A surgical procedure was performed in four patients because of complications, which included a fracture (one patient), deep infection (one patient), instability (one patient), and local recurrence (one patient). ConclusionThe modified technique of allograft-prosthetic composite is an effective treatment for bone tumor resection of the distal femur. This technique has many advantages, including augmentation of the bone stock, minimizing the risk of allograft fracture and nonunion, and decreasing the need for revision operations.

Segmental proximal femoral bone loss and revision total hip replacement in patients with developmental dysplasia of the hip

The treatment of substantial proximal femoral bone loss in young patients with developmental dysplasia of the hip (DDH) is challenging. We retrospectively analysed the outcome of 28 patients (30 hips) with DDH who underwent revision total hip replacement (THR) in the presence of a deficient proximal femur, which was reconstructed with an allograft prosthetic composite. The mean follow-up was 15 years (8.5 to 25.5). The mean number of previous THRs was three (1 to 8). The mean age at primary THR and at the index reconstruction was 41 years (18 to 61) and 58.1 years (32 to 72), respectively. The indication for revision included mechanical loosening in 24 hips, infection in three and peri-prosthetic fracture in three. Six patients required removal and replacement of the allograft prosthetic composite, five for mechanical loosening and one for infection. The survivorship at ten, 15 and 20 years was 93% (95% confidence interval (CI) 91 to 100), 75.5% (95% CI 60 to 95) and 75.5% (95% CI 60 to 95), respectively, with 25, eight, and four patients at risk, respectively. Additionally, two junctional nonunions between the allograft and host femur required bone grafting and plating. An allograft prosthetic composite affords a good long-term outcome in the management of proximal femoral bone loss in revision THR in patients with DDH, while preserving distal host bone.

The Surgical Treatment of Periprosthetic Elbow Fractures Around the Ulnar Stem Following Semiconstrained Total Elbow Arthroplasty

Limited information exists related to the treatment of periprosthetic fractures of the ulna after semiconstrained elbow arthroplasty. Our goals were to characterize the clinical and radiographic features of periprosthetic fractures around the stem of a loose ulnar component and to determine the outcomes after surgical treatment. Between 1980 and 2008, thirty consecutive periprosthetic fractures around the ulnar stem were treated surgically at our institution. Eighteen fractures occurred after primary arthroplasty, and twelve occurred after revision arthroplasty. The mean time between the index arthroplasty and the fracture was eight years. All ulnar components were loose. Ulnar bone loss was moderate in fourteen elbows and severe in sixteen. Surgical reconstruction included revision of the ulnar component in all cases. Fracture fixation was achieved with a longer stemmed implant only in two elbows. Strut allografts were used in twenty elbows, with additional impaction graft augmentation in eight of them. Three additional elbows were revised with impaction grafting alone, and five were reconstructed with an allograft ulnar prosthetic composite. Seven patients were lost to follow-up, one died, and one was managed with conversion to a resection arthroplasty following a deep infection. The remaining twenty-one patients were followed for a mean of 4.9 ± 2.6 years. At the time of the most recent follow-up, eighteen patients reported no pain or mild pain and three patients reported moderate pain. The mean arc of elbow flexion and extension was 112°. The Mayo Elbow Performance Score was 82 points (with fifteen good or excellent results and six fair or poor results). Fracture-healing was achieved in the twenty-one followed patients. Complications included three deep infections, one superficial infection, one case of ulnar component loosening, and one case of transient dysfunction of both the median and radial nerves. Periprosthetic ulnar fractures around the stem of a loose ulnar component after total elbow arthroplasty usually combine implant loosening and severe bone loss. Revision of the ulnar component may require additional strut allografts, allograft-prosthetic composites, or impaction grafting. Satisfactory outcomes were seen after the majority of revisions; however, deep infections and component loosening continue to be serious complications.

Alloprosthetic Composite is a Suitable Reconstruction After Periacetabular Tumor Resection

Resection of a tumor of the pelvis is most disabling when the acetabulum is excised and a durable reconstruction of the defect is hard to achieve. All available methods are associated with frequent complications. Few large series have been published, and fewer have focused entirely on complete resections of the acetabulum. The use of an allograft-prosthetic composite allows customization on the operating table. However, while such composites restore anatomy and function of the pelvis the use of pelvic allografts is controversial and the durability is unknown. We therefore examined (1) the frequency of allograft and prosthetic failure, (2) positive and negative factors influencing the survival of the allograft prosthetic composite, and (3) function of patients with this reconstruction. We retrospectively evaluated 35 patients who had resection of the entire acetabulum and reconstruction with an allograft-prosthetic composite. Function was scored by the Musculoskeletal Tumor Society system. Followup in 24 survivors averaged 120 months (range, 61-188 months). Greater than 75% of the allografts were still in place at last followup, and the original prosthetic reconstruction was still in place in 56%. Infection was an important negative factor for allograft survival. The average functional score was 72%, with better mean scores for patients who had reconstruction with a stemmed cup and an artificial ligament (average 89%). An allograft-prosthetic composite provides a versatile substitution of the pelvis and hip, with functional scores approximately 75% of normal.

Internal Hemipelvectomy for Musculoskeletal Tumors—Indications and Options for Reconstruction

Resection of all or part of the bony pelvis is commonly referred to as internal hemipelvectomy. This procedure is a common treatment for various localized primary tumors of the hemipelvis, and rarely for metastatic lesions. Options for reconstruction following tumor resection include allograft, allograft-prosthetic composite (APC), and endoprosthetic reconstruction. An alternative method of limb salvage following resection of the hemipelvis is resection arthroplasty. Controversy exists among musculoskeletal oncologists regarding the most durable and functional method of reconstruction. As primary musculoskeletal tumors involving the pelvis are rare, there are few well-designed studies from which to draw definitive conclusions. The purpose of this paper is to review the indications for internal hemipelvectomy and to examine the risks and benefits of the available reconstruction methods.

Long-term Results in Children With Massive Bone Osteoarticular Allografts of the Knee for High-grade Osteosarcoma

Reconstruction of distal femur or proximal tibia in growing patients is a challenge for the high rate of complications and limb length discrepancy at the end of growth. The purpose of this study was to evaluate the long-term outcome of children affected by high-grade osteosarcoma of the knee region, reconstructed by osteoarticular bone allograft of distal femur, and proximal tibia. We retrospectively reviewed 25 patients treated for high-grade osteosarcoma, 13 in the distal femur and 12 in the proximal tibia. The mean follow-up was 124 months. Clinical and radiologic evaluation was carried out in the 20 long-term survivors with a minimum follow-up of 7 years from surgery. The rates of survival of the implants were estimated with use of the Kaplan-Meier method. Functional and radiographic evaluation was done according to the Musculoskeletal Tumor Society scoring system at the time of the latest follow-up in all the patients that still had the allograft. Five patients died during the first 2 years of follow-up for disease-related causes. Of the remaining 20 osteoarticular allografts (10 of the distal femur and 10 of the proximal tibia), 12 failed: 4 in the distal femur and 8 in the proximal tibia. All the failures were related to a graft fracture, but in 4 patients with subchondral collapse the graft was maintained and converted into an allograft prosthetic composite. No deep infection of the primary reconstruction was observed. The overall rate of allograft survival was 70% at 5 years and 58% at 10 years in the distal femur, and 45% at 5 years and 20% at 10 years in the proximal tibia. At final follow-up, 8 patients still walked on the primary implant, 6 in the distal femur, and 2 in the proximal tibia. The functional outcome of these patients was evaluated as good in 5 patients (3 with distal femoral and 2 with proximal tibial allograft), and poor in 3. Although mechanical complications significantly affect the outcome, osteoarticular allografts may represent a viable option for reconstruction in children older than 8 with high-grade sarcomas about the knee. Level IV.

Experts' agreement on therapy for bone metastases

Experts' agreement on therapy for bone metastases

Local Recurrence, Survival and Function After Total Femur Resection and Megaprosthetic Reconstruction for Bone Sarcomas

The choices of treatment for patients with extensive tumors of the femur include total femur megaprosthesis or large allograft-prosthetic composites. Previous reports suggest variable survival ranging from 60-70% at 1 to 2 years. However, these studies described earlier prostheses and techniques. To confirm previous reports we determined (1) risk of local recurrence; (2) overall survivorship; and (3) function in patients with total femur reconstructions for tumors. We retrospectively reviewed 23 patients with total femur megaprostheses implanted between 1987 and 2006 after resection of bone tumors. Two patients lost at followup were excluded; the remaining 21 included 15 males and six females with a mean age of 21 years. The mean followup was 48 months (range, 1 month 17 years). Function was assessed according to the MSTS System II. No patient developed a local recurrence during followup. At last followup, six patients were continuously disease-free at a mean of 148 months, one patient had no evidence of disease after treatment of a recurrence, one patient was alive with disease, and 13 patients died of their disease at a mean time of 17 months. In 15 patients evaluated with the MSTS score, the mean score was 66%; four patients had over 75%, eight from 51% to 75%, three from 26% to 50%. Four patients (19%) had complications requiring further surgery in absence of trauma. A fifth patient had a posttraumatic periprosthetic fracture. A total femur prosthesis allows a limb-preserving procedure in tumors with extensive femoral involvement or in the presence of a skip lesion along the femur. The prognosis of these tumors is poor, but this reconstruction provides function with a relatively low rate of major complications.

Distal Femoral Osteoarticular Allografts: Long-term Survival, But Frequent Complications

Complications are frequent with osteoarticular allografts, and their long-term survivorship in the distal femur is unclear. Thus, the benefits of osteoarticular allografting remain controversial. We therefore determined the frequency of complications in osteoarticular allografts of the distal femur relative to their potential long-term survival. We retrospectively reviewed 26 patients who had osteoarticular allograft reconstruction of the distal femur after resection of a malignant or aggressive benign tumor of bone. The minimum followup was 15 months (average, 156 months; range, 15-283 months) for all patients and 98 months (average, 191 months; range, 98-283 months) for the surviving patients. At last followup, 16 of the 26 original allografts were still in place. The overall 5-year and 10-year allograft survival rates were 69% and 63%, respectively. The 5-year and 10-year survival rates of the joint surface were 79% and 65%, respectively. Eleven patients retained their original osteoarticular allograft without a resurfacing procedure, and nine had been converted to allograft-prosthetic composites. Five patients were converted to megaprostheses and one had an amputation for local recurrence. At last followup, 25 of 26 patients retained a functional limb. Osteoarticular allograft reconstructions of the distal femur can provide long term survival and restore function but the risk of complications and their physical and monetary costs for patients are not trivial. Lacking the benefit of improved soft tissue attachments inherent in other anatomic sites, we believe this option is most appropriate for restoring bone stock in young patients with expectations of long-term survival.

Functional outcomes and complications of reconstruction of the proximal humerus after intra-articular tumor resection

To evaluate functional outcomes and complications of reconstruction of the proximal humerus after intra-articular tumor resection. Twenty-five patients who underwent Malawer I type resection and reconstruction of the proximal humerus for treatment of malignant or invasive benign tumors from August 1999 to August 2005 were evaluated. A variety of reconstructive procedures, including modular tumor prosthesis, osteoarticular allograft, and allograft-prosthetic composite (APC), were performed after resection of tumor. Oncological and radiographic parameters were evaluated. The modified Musculoskeletal Tumor Society (MSTS) evaluation system was used to assess limb functional outcome. The study group consisted of 10 male and 15 female patients, among which there were 20 malignant and 5 benign tumors. Restoration of shoulder function was achieved with a prosthesis in 6 patients, osteoarticular allograft in 12, and allograft-prosthesis composite in 7. At a mean of 48 months follow-up, 2 patients had died of disease. Two patients had local recurrence and 2 had metastatic disease. On the basis of the modified MSTS functional evaluation, the mean scores were 22.50 in the modular prosthesis group, 24.58 in the osteoarticular allograft group, and 27.00 in APC group, respectively. Joint instability and subluxation were serious complications affecting shoulder function in 10 patients. Reconstruction of the proximal humerus is an option that provides good relief of pain and preserves manual dexterity. Functional outcomes are better for APC and allograft than for modular prosthesis, due to retention of the rotation cuff. Complications in the APC group were less than in the allograft one.