Allograft-prosthetic Composites Research Articles

Proximal Humerus Reconstructions for Tumors

The optimal method for reconstructing the proximal humerus in patients with tumors is controversial. To determine functional outcomes and complication rates after different types of reconstructions, we reviewed a consecutive series of 49 patients who underwent proximal humerus resection and osteoarticular allograft (17 patients), allograft-prosthetic composite (16), or endoprosthetic (16) reconstruction. Operative indications included primary malignancies (24 patients), metastatic disease (19), and benign aggressive disease (six). Implant revision was more common after osteoarticular reconstruction (five of 17) than after allograft-prosthetic composite (one of 16) or endoprosthetic (zero of 16) reconstructions. At a minimum followup of 24 months (median, 98 months; range, 24-214 months) in surviving patients, Musculoskeletal Tumor Society functional scores averaged 79% for the allograft-prosthetic composite, 71% for the osteoarticular allograft, and 69% for the endoprosthetic reconstruction cohorts. Shoulder instability was associated with abductor mechanism compromise and was more common after endoprosthetic reconstruction. Allograft fractures occurred in 53% of patients receiving osteoarticular allografts. We recommend allograft-prosthetic composite reconstruction for younger patients with primary tumors of bone and endoprosthetic reconstruction for older patients with metastatic disease. Because of the unacceptable complication rate, we do not recommend osteoarticular allograft reconstruction for routine use in the proximal humerus. Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Analysis of complications of osteosarcoma around knee treated by resection and replacement of tumor-type prosthesis

To summarize the effects and complications of osteosarcoma around knee treated by wide resection and replacement by the tumor-type prosthesis. Between July 1997 and July 2004, 117 patients with osteosarcoma around the knee had been treated with wide resection and reconstruction with prosthesis. Alcohol-devitalized tumor bone prosthetic composite were used for reconstruction in 13 patients, and allograft prosthetic composite (APC) were used in 25 patients. All patients accepted 2 cycles of chemotherapy before the surgery. The mean follow-up period was 3.5 years (1 - 8 years). Nine patients had failure of union at the graft-host junction. Fracture of the stem of the prosthesis occurred in 5 patients, late infection was found in 19 patients, and aseptic loosening occurred in 3 patients. Bone fracture occurred in 1 patient and prosthesis sinking occurred in 2 patients. The tumor-type prosthetic reconstruction offers the best knee function after resection of the tumor around the knee, and recurrence rate can be accepted. However, the tumor-type prosthesis needs further improvement because of the high complication rate.

Functional outcome following shoulder tumor resection and reconstruction

To analyze the long-term limb sparing outcomes of various reconstructive procedures and complications associated with extensive excision in bone tumours of the shoulder girdle. Shoulder reconstruction following resection of bone tumors of the shoulder girdle was reviewed retrospectively for 32 patients at the Wesley Hospital or Princess Alexandra Hospital. The reconstructions were including arthrodesis (8 cases), allograft-prosthetic composite (7 cases), spacer (6 cases), no bone reconstruction (5 cases), prosthesis (3 cases), vascular fibular graft (2 cases) and allograft (1 case). The average duration of follow-up was 81 months for the 23 patients who were still alive at the time of the latest follow-up examination. Functional results were related to the type of resection and the method of shoulder reconstruction. After intra-articular resection of the proximal humerus with loss of the abductor mechanism, arthrodesis resulted in 87% functional score and more strength was found after reconstruction with prosthesis or allograft-prosthetic composite. Allograft-prosthetic composite had better function (Score 79%) than prosthesis alone after intra-articular resection of the humerus because reconstruction of the deltoid and the rotator cuff could be performed without increased prevalence of complication related to the allograft. After extra-articular resection of the glenoid cavity and the proximal humerus with abductor mechanism, reconstruction with a functional spacer frequently resulted in superior subluxation of the implant and only fair function (Score 66%) of the shoulder. With two teen-aged patients, a free fibular graft inserted after intra-articular resection of the proximal humerus led to fair function (Score 73%), to be followed by secondary arthrodesis when growth was complete. Indications for the method of reconstruction depend on type of resection, age, gender, occupation, the expected functional level and restriction of activity. After resection of the abductor mechanism, arthrodesis results in more strength and is the preferred option for the young active demanding patients. If the abductor mechanism is preserved, allograft-prosthetic composite gives good results.

Endoprosthetic and Allograft-prosthetic Composite Reconstruction of the Proximal Femur for Bone Neoplasms

Reconstruction of the proximal femur after tumor resection can be achieved with either an endoprosthesis or an allograft-prosthetic composite. We compared the two modalities for complications, functional outcome, and construct survival. We retrospectively analyzed 52 patients with endoprostheses and 20 with allograft-prosthetic composite reconstructions between 1974 and 2002. Median followup was 146 months and 76 months, respectively. Both methods were associated with low rates of early complications. Infections occurred in two patients with endoprostheses and one patient with an allograft-prosthetic composite reconstruction. Aseptic loosening was the most common (10%) late complication for patients with endoprostheses. Nonunion was the most common (10%) complication for patients with allograft prosthetic composite reconstructions. All host-allograft junctions eventually healed after bone-grafting. The Musculo skeletal Tumor Society scores were similar for patients with endoprostheses (70%) and allograft-prosthetic composites (82%). The median hip abductor strength was greater for patients with allograft-prosthetic composite reconstructions (4.6 of 5) than for patients with endoprostheses (2.8 of 5). Kaplan-Meier survivorship of the implant was 86% for both groups at 10 years. The consistent restoration of abductor muscle strength combined with the low morbidity and high durability support the use of allograft-prosthetic composite reconstruction in patients with long life expectancy. Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Femoral Fixation in the Face of Considerable Bone Loss

One option for dealing with considerable femoral bone deficiency at revision surgery is the use of extensively porous coated cobalt-chrome cylindrical stems. This technique has been shown to be a reliable, technically straightforward method that can be applied to all but the most severe femoral structural defects. Very high rates of osseointegration and durability of fixation are obtained when simple principles are followed. The key to success is obtaining initial endosteal diaphyseal fixation over 5 cm-7 cm. To achieve this, adequate exposure and accurate bone preparation are essential. The limitations of this technique relate directly to the severity of bone loss, which can be easily predicted on plain preoperative radiographs. For Paprosky 3B and 4 defects, other options such as allograft prosthetic composites, impaction grafting, or alternate modes of distal fixation should be considered.

The Use of Cement in Osteoarticular Allografts for Proximal Humeral Bone Tumors

In a proximal humerus resection for a bone tumor, the use of an osteoarticular allograft is considered the best restoration of shoulder function. We retrospectively reviewed the outcomes of 31 patients who had an intraarticular resection of the proximal humerus for a bone tumor. Twenty-three of the allografts were filled with cement. The average followup was 5.3 years. Of the 31 patients with more than 24 months followup, seven had revision surgery or removal of the allograft. Kaplan-Meier analysis showed that the probability of survival of the reconstruction was 78% at 5 years. Fracture was the main complication in 11 patients (37%) of whom seven were in the noncemented group. Four of these patients had successful surgery for conversion to an allograft-prosthetic composite, whereas one patient had a new allograft. Allografts that were filled with cement had four fractures (18%); three were subchondral fractures discovered by routine CT scans. None of these patients had pain or needed revision surgery. Osteochondral allograft in proximal humerus replacement is a reliable reconstructive technique if the allograft is augmented by filling the intramedullary space with cement. Moreover, cement augmented allografts are less expensive and technically easier than allograft-prosthetic composites.

Total elbow arthroplasty with massive composite allografts

Total elbow arthroplasty is challenging when there is extensive bone loss. We studied retrospectively the long-term (mean, 6.5 years) clinical and radiographic results of 10 patients in whom 14 massive allograft-prosthetic composites were used in such clinical situations. The mean arc of active flexion/extension was 92°. The Bryan-Morrey and Hospital for Special Surgery elbow scoring systems were used and revealed a modest improvement in pain and stability but a disappointing return of function, with independent self-care possible in only 3 patients, household and employment activities in 2, and recreational pursuits in 2. Three patients claimed that they were unable to use the elbow. Multiple procedures (mean, 2.2) were sometimes required to optimize the result. The 79% rate of allograft-host union is similar to that of hip and knee arthroplasty. The use of massive allografts is a reasonable alternative in salvage situations involving total elbow arthroplasty with massive bone loss.

Complex reconstruction in the management of extremity sarcomas.

The concept of limb-sparing surgery for bony sarcomas has evolved over the past 25 years. Today, more than 90% of patients treated by surgeons with expertise in musculoskeletal oncology undergo successful limb-sparing procedures. Many large centers have abandoned osteochondral allografts and resection arthrodesis for the reconstruction of segmental bone and joint defects in favor of metallic endoprostheses. Endoprosthesis survival rates now exceed 85% at 5 years for reconstructions about the knee, which is the most common site for primary bone sarcomas. In the shoulder girdle, the type of resection and soft-tissue reconstruction is probably more important than the type of implant. Extra-articular resection is recommended for most large stage IIB tumors. New expandable prostheses able to be lengthened nonoperatively hold promise for very young children with lower extremity sarcomas. Allograft-prosthetic composites and proximal femoral prostheses provide reliable and stable hip reconstructions. Acetabular components are not required, but attention to capsular reconstruction is necessary to prevent hip dislocation. Techniques of scapula replacement have advanced and provide better upper extremity function after scapula resection than resection alone.

Malignant Bone Tumors: Limb Sparing Versus Amputation

Amputation, once the mainstay of treatment of malignant bone tumors, now is used selectively and infrequently. Most patients are candidates for limb-sparing procedures because of effective chemotherapeutic agents and regimens, improved imaging modalities, and advances in reconstructive surgery. Patient age as well as tumor location and extent of disease help define the most appropriate surgical alternatives. Options for skeletal reconstruction include modular endoprostheses, osteoarticular or bulk allografts, allograft-prosthetic composites, vascularized bone grafts, arthrodesis, expandable prostheses, rotationplasty, and limb-lengthening techniques. Two key factors must be considered: survival rates should be no worse than those associated with amputation, and the reconstructed limb must provide satisfactory function. Functional outcome studies comparing limb-sparing procedures and amputation have inherent limitations, including the inability to randomize treatment and the subjective nature of important outcome measures.

The allograft prosthetic composite: when and how.

The allograft prosthetic composite: when and how.

Impaction allografting for femoral component revision in total hip arthroplasty: Surgical indications, techniques, and review of results

Several options have been described for revision of a failed femoral component in total hip arthroplasty. When severe bone-stock deficiency is present, techniques using cemented implants, cementless implants, allograft-prosthetic composites, and proximal femoral replacement prostheses have all been used. The present report focuses on a new technique: cancellous impaction allografting with cement. This reconstructive option involves inserting and shaping tightly packed cancellous bone into the femoral canal to create a so-called “neo-endosteum,” into which a prosthesis is inserted with cement. This article includes a brief history of the technique, an algorithm of surgical indications for the various femoral revision techniques, a summary of the surgical method as well as technical tips, the known complications of impaction allografting, and a review of published clinical results regarding this relatively new technique.

Allograft prosthetic composite replacement for bone tumors.

Limb salvage for bone tumors has become the standard method of treatment. This technique involves removal of large segments of bone, most commonly around the hip and knee. Various types of reconstructive options are currently available, including osteoarticular allograft arthroplasty, modular oncology prosthetic arthroplasty, allograft prosthetic composite (APC) arthroplasty, and arthrodesis. Compared to other techniques, APC arthroplasty has many advantages, including restoration of bone stock, customization with conventional implant components, soft tissue attachment of tendons and ligaments, and preservation of the medullary canal of the host bone. The disadvantages of this technique include slow healing in the presence of chemotherapy, the possibility of disease transmission, and availability. The technique is suited either for aggressive benign tumors or for low-grade sarcomas where chemotherapy is not necessary. Further, it represents a good alternative for a failed modular oncology prosthesis, and also for the failed osteoarticular allograft because it restores bone stock. Good functional results have been reported with APC replacements, but long-term follow-up is needed to determine their durability.

Reconstruction of Major Segmental Loss of the Proximal Femur in Revision Total Hip Arthroplasty

Reconstruction of major proximal femoral segmental defects is one of the most difficult challenges in revision total hip arthroplasty (THA). One technique that has been successful is the use of a modular, long-stemmed prosthesis, cemented to an allograft proximal femur and press-fit to the host bone. Since July 1989, the authors have used this technique in 30 hips (29 patients). The trochanteric slide approach was used in all cases. Sixty pounds of weight bearing was encouraged for six weeks, then full weight bearing as tolerated. The mean follow-up period was 22 months (range, two to 46 months). All but two grafts united to the host bone clinically and radiographically. Complications included five dislocations, one graft-host nonunion, one graft resorption, and one deep infection requiring resection arthroplasty. The latter patient was subsequently reconstructed successfully using the same technique. Although the follow-up period is short, the authors have been encouraged by the early success of these allograft-prosthetic composites. Advantages of this approach include rapid return to weight bearing, physiologic loading of the distal femur, and reconstitution of vital proximal bone stock.

The Use of Large Allografts for Tumor Reconstruction and Salvage of the Failed Total Hip Arthroplasty

Large bone defects have become a more common orthopedic problem in recent year. This is due to the increased enthusiasm for limb salvage surgery as a technique to manage patients with primary bone tumors and for patients who have had multiple joint arthroplasties with subsequent bone loss. One technique that has proven successful for this difficult problem is the use of fresh frozen allografts to reconstruct these skeletal defects. From January 1981 until January 1987, 60 large fragment fresh frozen allografts were used for skeletal reconstruction. These grafts were divided into three basic groups: intercalary, 15; osteoarticular, 16; and allograft-prosthetic composite, 29. The diagnoses included 43 bone tumors, 16 failed total hip arthroplasties, and one traumatic bone loss. The average patient age was 39.7 years and had an average follow-up period of 24 months. The average length of allograft was 12.4 cm. Using the Enneking Functional Evaluation System, the final functional analysis revealed excellent or good results in 86% of the patients and fair or poor results in 14% of the patients. Roentgenological union at the allograft-host bone junction was achieved in 90% of the patients in a mean time of 5.8 months after surgery. An additional three patients obtained union after autogeneic bone grafting. At the time of follow-up evaluation, 92.3% of the patients were free of tumor; they had no local recurrences. The use of fresh frozen allografts represents an acceptable alternative for the reconstruction of large skeletal defects. One can expect good or excellent function for the majority of patients. The best functional results were obtained with the intercalary allografts and the allograft-prosthetic composites.