In order to investigate the efficacy of free vascularised fibular graft (VFG) after bone intercalary tumour resection in tibia, we present our results with a minimum follow-up of 2 years. From 1988 to 2001, 47 patients affected by high-grade tibial sarcoma in 31 cases (66%), and low-grade diesease in 16 cases (34%) were treated in our department. Average age was 19 years (range 5–60 years), with a male/female ratio of 1.35. The average length of tibial resection was 15 cm, while the average length of the fibular graft was 19 cm. In 11 cases (21%) VFG was assembled alone, while in 36 cases (79%) a massive bone allograft was associated to the fibula. Three patients developed a deep infection, treated by amputation in two cases and by graft removal and an Ilizarov device in one case. Minor complications occurred in 28 cases (55%) (stress fractures, wound slough, osteosynthesis breakage), all healed by minor surgery or conservative treatment. At an average follow-up of 108 months (range 24 to 185 months), four patients had died of disease and three were lost to follow-up. Regarding the overall results, the combined group of fibula plus massive allograft showed to be more effective than the group of fibula alone in terms of early weight bearing (6 versus 12 months), while VFG showed intrinsic efficacy in achieving early bony fusion at the osteotomy lines and hypertrophy of the graft in both groups. Furthermore, using the combined assembly the articular surface could be spared in all the trans-epiphyseal resections, while VFG alone appeared to be electively indicated for infected or irradiated fields. In conclusion, despite the demanding surgical technique, VFG appears to be a long-lasting and definitive biological reconstruction procedure after intercalary tibial resection.
In the period from 1999 to 2003 bacterial contamination of explanted cadaver bones and tendons from the Regional Tuscan Tissue and Cell Bank was studied. During this period 1124 explants from 402 donors were taken, of which 311 donors whose heart was beating and from 91 whose heart was not beating. The bone explantation procedure followed a standardized protocol. Al the samples were explanted in the operation room by a team of two surgeons and a nurse during the first 24 hours after death. The protocol concerning the sterility of the explanting procedure was standardized and followed accurately. The bacteriological examination was performed immediately after the explantation and before the samples were treated with antibiotic solution. Three different tests were used: superficial microbiological swabs of the bone surface, one from the medullar canal and a small bone or soft tissue sample. The samples were inoculated immediately in culture medium and incubated for at least 10 days. From 1124 explanted samples 430 were contaminated: 99 with pathological bacteria such as Staphylococcus aureus, Enterococcus, Escherichia coli etc., 331 with nosocomial bacteria such as coagulase neg. Staphylococcus, Corynebacteria, etc. The samples that were contaminated with pathological bacteria were excluded from the study. The other contaminated group was re-processed and re-tested for contamination. The factors influencing the results of contamination were anatomical location of the explants and the experience of the surgical team. In contrast, the donor type (heart beating vs. heart not beating) did not play any role. From 1999 to 2003 the University Hospital of Careggi in Florence, Italy, used 721 explants from which 624 were retrieved from the Regional Tuscan Tissue and Cell Bank, 72 from foreign banks and 14 from another national bank. The explants from foreign banks were all re-tested according to our standards. Among those, 699 samples were sterile and 22 samples (3%) were contaminated. Seventeen (2.3%) of the 22 samples were contaminated with pathological bacteria with low morbidity and 5 (0.7%) with medium morbidity. Compared to the control group contamination of the explants retrieved from the Regional Tuscan Tissue and Cell Bank was 2.8%. However, the contamination of samples of an explant is not necessarily correlated with a true infection of the specimen. This study shows that factors such as retrieval techniques, contamination factors in the operating room and laboratory mistakes can cause false-positive contamination results. In fact, only three of 604 patients who were operated in major orthopaedic procedures using bone and soft tissue allografts developed clinical evidence of infection (0.5%). In conclusion, the infection rate of our allografts in this study is not higher than the standard infection risk of any other major orthopaedic procedure (0.5%).
The reconstruction of large bone segments is a major goal in orthopaedic surgery. Autologous cancellous bone is recognized as the most biologically active graft material, but autologous bone harvest is associated with significant morbidity and founds its limit in the available quantity. Biomaterials or allografts do not encounter these limitations, but have no osteogenic and limited osteinductive potential. In order to enhance tissue regeneration and healing we have tried to obtain a graft with osteconductive, inductive and osteogenic properties. The day before operation 350 cc of autologous blood is donated from the patient and centrifuged to obtain a platelet-rich plasma. Bone marrow is aspirated from the posterior iliac crests with the patient under spinal anaesthesia and is processed to increase its stem cell content. The structural scaffold used is morcellized cancellous bone provided from our Bone Bank. At operation bone is mixed with bone marrow buffy coat and Platelet Rich Plasma in a sterile glass becker with addition of CaCl2 till clot formation to produce a gel-like component that is handled easily. We have utilized this technique from November 2000 till January 2004 for 68 patients: 41 of these patients required healing of large bone defects: 22 males and 19 females. Fresh bone marrow alone was used for a percutaneous injection in 11 cases; open surgery with autologous growth factors, bone marrow buffy coat and allograft was used in 30 patients. The radiological and clinical results showed early healing of the defects treated with this technique and no complications related to the procedure at an average follow up of 23 months (3–40).
We report the use of the uncemented Kotz modular femur and tibia reconstruction system after 95 distal femoral resections performed from 1983 to 1989. The average follow-up was 51 months; 62 patients had at least 36 months' follow-up and 36 at least 60 months. Complications required reoperation in 55%. The postoperative infection rate was 5% for primary cases, 6% for revision cases, and 43% for revision of previously infected cases. The polyethylene bushes failed in 42% of cases at an average of 64 months postoperatively. Stem breakage occurred in 6% and was associated with the use of narrow stems and extensive quadriceps excision. The radiological results were excellent or good in most cases and were related to the initial screw fixation, but not to age, chemotherapy, length of resection or size of stem. The clinical results were excellent or good in 75%, failure usually being associated with a complication, especially infection.