We have treated 50 patients with bony malignancy by en bloc resection, extracorporeal irradiation (ECI) with 50Gy and re-implantation of the bone segment as a method of limb salvage. Mean survivor follow-up is 38 months (12–92). 42 patients remain alive without disease. 4 recurrences occurred. Functional results were generally good: Mankin grades 17 excellent, 13 good, 9 fair, 3 failures; MSTS mean 77 (20–100); TESS mean 81 (40–100). Solid bony union was the norm, however bone resorption was seen in some cases. The dose of radiation is theoretically lethal to all cells and produces a dead autogenous bone graft of perfect fit. ECI is a useful technique of limb salvage where there is a reasonable residual bone stock. It allows effective re-attachment of muscle tendons, and produces a lasting biological reconstruction. The risk from the re-implanted bone of both local recurrence and of late radiotherapy induced malignancy should be nil.

Extracorporeal Irradiation and Reimplantation (EIR) of tumor bearing bone segments is an alternative reconstruction method for major osseous resections. In contrast with endoprosthetic reconstruction, EIR is a biologic solution and after a prolonged healing and remodeling period it is expected to create a structural and metabolic almost normal bone. After oncologic resection the bone segment is cleaned from adhered soft tissues and send to irradiation which kills malignant and normal cells. Reimplantation consists of fixation, mostly by plates, vascularised fibular graft insertion in the medullary canal, iliac bone graft in critical sites and ligamentous sutures. Since 2001 fifteen patients were submitted to EIR in our institution. Resections affected seven distal femurs, four proximal tibias, one acetabulum, one iliac bone and the proximal forehand bones once which bear 11 osteosarcomas, 2 Ewing’s sarcomas, 1 chondrosarcoma and 1 rhabdomyosarcoma. There were six males and nine females with age ranging from five to 55 years. Ten patients were submitted to osteoarticular reconstructions, three to intercalary and two to partial pelvis reconstructions. Local recurrence leading to amputation occurred in one patient and resection of an infected innominate bone occurred once. Three patients died two to nine months after surgery because of their disease. Five patients had metaphyseal fractures after one to 14 months after surgery. Four patients had no fracture; three of them had intercalary resections. The patient with osteoarticular resection and no fracture had his metaphyseal region injected with cement which prevented fracture and after 23 months have not developed osteoarthritis. All the cases in which a vascularised fibular graft was implanted progressive fusion of the living and dead bones were observed. As a conclusion EIR is a good alternative for intercalary resections. For osteoarticular resections improvement of the method are necessary to prevent fracture and ligamentous laxity

Extracorporeal irradiation and re-implantation of a bone segment is a technique employed in bone sarcoma surgery for limb salvage in the setting of reasonable bone stock. There is neither consensus nor rationale given for the dosage of irradiation used in previous studies, with values of up to 300Gy applied. We investigated the influence of extracorporeal irradiation on the elastic and viscoelastic properties of bone. Bone specimens were extracted from mature cattle and subdivided into thirteen groups; twelve groups exposed to increasing levels of irradiation and a control group. The specimens, once irradiated, underwent mechanical testing in saline at 37°C.

Mechanical properties were calculated by experimental means which included Young's Modulus, Poisson's Ratio, Dissipation Factor, Storage Modulus, Loss Modulus and Dynamic Modulus. These were all obtained for comparison of the irradiated specimens to the control group.

We found there to be a statistically significant increase in Poisson's ratio after increasing irradiation doses up to 300Gy were applied. However, there was negligible change in all other mechanical properties of bone that were assessed. Therefore, we conclude that the overall mechanical effect of high levels of extracorporeal irradiation (300Gy) is minute, and can be administered to reduce the risk of malignancy recurrence.

Extracorporeal irradiation and re-implantation of a bone segment is a technique employed in bone sarcoma surgery for limb salvage in the setting of reasonable bone stock. There is neither consensus nor rationale given for the dosage of irradiation used in previous studies, with values of up to 300Gy applied. We investigated the influence of extracorporeal irradiation on the elastic and viscoelastic properties of bone. Bone specimens were extracted from mature cattle and subdivided into thirteen groups; twelve groups exposed to increasing levels of irradiation and a control group. The specimens, once irradiated, underwent mechanical testing in saline at 37°C.

Mechanical properties were calculated by experimental means which included Young's Modulus, Storage Modulus and Loss Modulus. These were all obtained for comparison of the irradiated specimens to the control group.

There were non-significant negligible changes in all of the mechanical properties of bone that were assessed with increasing dosage of irradiation. Therefore, we conclude that the overall mechanical effect of high levels of extracorporeal irradiation (300Gy) is minute, and can be administered to reduce the risk of malignancy recurrence.

Introduction and Aims: To assess and compare treatment of pelvic Ewing’s sarcoma, particularly extracorporeal irradiation (ECI) and re-implantation of bone segments.

Method: We reviewed all patients presenting to the New South Wales Bone Tumor Service with Ewing’s sarcoma of the pelvis from 1995 until 2003. All received chemotherapy. There were 17 patients. Resection was performed in 14 cases: 12 were reconstructed by ECI and re-implantation of the bone segment; one with autograft and THR; one with allograft and THR. Three patients with sacral lesions had chemotherapy and radiotherapy only. All margins were clear. All patients were clinically and radiologically reviewed. Three scoring systems were used: The Musculoskeletal Tumor Society score (MSTS), the Toronto Extremity Salvage Score (TESS), and the Harris Hip Score (HHS).

Results: The average age at presentation was 18 years (range six to 35). There were seven males and 10 females. One patient presented with metastatic disease. Survivor follow-up ranged from 25 to 105 months (mean 55). In those who developed metastases these were detected at a mean of 27 months (range one to 79). Deaths occurred at a mean 31 months (range eight to 65). Fourteen underwent surgery. Seven had THR as part of their reconstruction. There have been no local recurrences after surgery. Six patients have died, 11 patients are alive (65%), one with metastatic disease. Overall disease-free survival is 59%. The disease-free survival in those who underwent ECI and re-implantation is 75% (minimum two-year follow-up). Functional outcome is good. The TESS mean was 83 (range 60–100). The MSTS score mean 85 (range 60–97). The HHS mean 92 (range 67–100). Radiologically solid bony union at the osteotomy sites was the norm. Lysis existed at two periacetabular osteotomies, around the posterior iliac crest of one osteotomy, and a fibrous union occurred at one sacro-iliac joint with breakage of the sacro-iliac screws. There have been no graft fractures.

Conclusion: The best surgical management for these difficult cases is extracorporeal irradiation and re-implantation of bone segments.

Extracorporeal irradiation of resected bone segments has been used for pelvic reconstruction for 12 years in our unit. The technique allows for a perfect fit, preservation of muscle attachments, and thus, facilitating reconstruction, more rapid osteotomy of autograft bone, low cost, and a low infection rate.

Of particular interest is its use in children; revascularisation appears more complete with irradiated autograft, as compared to allograft. There is sparing of adjacent growth plates if the irradiation is given outside the body, whereas external beam radiation would destroy the proximal femoral growth plate—leading to significant leg length discrepancy.

Avoiding external beam irradiation also removes any risk of late radiation induced sarcoma and removes the late effects of soft tissue fibrosis due to external beam irradiation.

Twenty-seven pelvic reconstructions have been done over a 12-year period, with three failures due to infection and seven due to further disease. Four of these have been for de-differentiated chondrosarcoma of the pelvis, where local recurrence led to failure. In the presence of de-differentiated pelvic chondrosarcoma, we do not recommend this form of reconstruction.

Long term functional outcome scores for the first 50 cases completed between August 1996 and June 2003 gave a TESS score of 82% and MSTS score of 78%. This is more than comparable to published series using other forms of reconstruction.

We have used extracorporeal irradiation as part of the treatment of primary bone tumours since 1996. It is a technique that preserves bone stock, with no allograft cost, is tailor made for the individual and can protect the epiphyseal plates in the immature skeleton.

All cases are biopsied, staged and if appropriate undergo pre-operative chemotherapy. The resected specimen is wrapped in sterile drapes, sealed and then irradiated in either the linear accelerator or a blood product irradiator. The mid-plane dose delivered to the specimens was 50 Gy. The specimen is then reimplanted using varied methods. Post-operative chemotherapy is given if indicated, and the patients have 6 weeks of antibiotics. Regular review is undertaken in the outpatients. We individually reviewed all the patients, examined them and scored their functional results according to the Mankin and Enneking Systems. The pelvic/proximal femur patients also had a Harris Hip Score recorded.

There were 31 cases all over 6 months from surgery with an average follow up of 24 months. Mean age at diagnosis was 24.9 years (range 3 to 66), in 15 males and 16 females. Pathology included 10 osteosarcomas, 13 Ewing’s and 8 chondrosarcomas. Affected bones were 4 proximal humeri, 14 hemipelvises, 12 femurs and 1 tibia. Reconstruction varied from autograft alone, to autograft with a prosthesis, intramedullary nail or blade plate. 10 patients had supplementary vascularized fibula grafts and 2 pedicle flaps. There have been 4 deaths of disease, 2 alive with disease and 25 currently disease free. The Enneking scores averaged 70%, the Harris Hip Scores averaged 74 in the pelvic reconstructions and 92 in the proximal femurs.

This study reviews the implantation of extracorporally irradiated autografts as a treatment modality and alternative for pelvic Ewing’s Sarcoma.

We identified 13 cases between 1994 and 2004 (7 male, 6 female), with mean age 14 years (6.5–34.5). The disease free survival was 69% overall, (75% excluding one case initially treated elsewhere) with a mean follow-up of 6.1 years (3.1 – 8.2). Four patients died with distant metastases at a mean time of 17 months (13–23).

Functional results showed a median MST-Score of 86% (IQR 68.5 to 91.5), a median TES-Score 85% (IQR78.5 to 93.5) and a median Harris Hip-Score 89% (IQR 82.5 to 96.5).

Solid bony union was observed at all osteotomy sites. Consolidation was achieved after median 6 months (IQR 5 to 7).

There were three complications (23%) which required operative intervention, one (8%) due to infection, which required removal of the autograft.

Advantages with this technique include ideal fit in the defect and thus promotes healing through greater contact at osteotomy junctions. It avoids early and late loosening and/or breakage of a prosthesis. It acts as a biological bridge for creeping substitution and bony incorporation in the defect. It allows re-attachment of tendons and ligaments, and thus preserves anatomic relationships. There is no risk of disease transmission or immunological reactions. It is cost effective and convenient in any institution with radiotherapeutic equipment.

We conclude this is an appropriate treatment option for localised and resectable pelvic Ewing Sarcoma.

Aim

To identify factors leading to the success or failure of extracorporeal irradiation and re-implantation of bone (ECIR).

Aim: To identify factors leading to the success or failure of extracorporeal irradiation and reimplantation of bone (ECIR).

Method: Review of experience of this technique since 1996 documenting successes and failures.

Results: 35 patients with a variety of malignant bone tumours underwent ECIR from 1996 up to 2007. The most common diagnosis was Ewings’ sarcoma (15) followed by osteosarcoma (9) and chondrosarcoma (5) with the most common sites being the pelvis (15) followed by the tibia (10) and humerus (3). The age range was from 7 to 66 and 8 were skeletally immature at the time of surgery. The bones were sterilised with a dose of 90Gy before reimplantation.

The overall patient survival was 69% at 5 years and 62% at 10 years. Local recurrence arose in 4 cases, 3 of whom already had metastatic disease. None of the LR arose in the irradiated bone. The rate of non union was 9% at the 58 osteotomies, the greatest risk being in the tibia. There were four graft fractures of which 3 needed fixation and all united. There is one case of convincing graft resorbtion after 12 years. Two patients developed infections but there have been none since the done was routinely immersed in antibiotics whilst being irradiated.

Conclusion: ECIR is a useful technique with very limited indications. In the majority of cases it works well. It appears particularly useful in pelvic resections and diaphyseal resections. Distal tibial reconstructions do worst. The irradiated bone needs reinforcing with either cement or a bone graft for best results.

Aim: To clinically and radiologically review our first 50 cases of treatment of malignant bone tumours by extra-corporeal irradiation (ECI) and re-implantation and review the world literature’s other 100 such cases.

Methods: We have treated 50 patients with bony malignancy by en bloc resection, ECI with 50Gy and reimplantation of the bone segment as a method of limb salvage. Mean survivor follow-up is 38 months (12–92).

Results: 42 patients remain alive without disease. 4 recurrences occurred. Functional results were generally good: Mankin grades 17 excellent, 13 good, 9 fair, 3 failures; MSTS mean 77 (20–100); TESS mean 81 (40–100). Solid bony union was the norm, however bone resorption was seen in some cases.

Discussion: The dose of radiation is theoretically lethal to all cells and produces a dead autogenous bone graft of perfect fit. ECI is a useful technique of limb salvage where there is a reasonable residual bone stock. It allows effective re-attachment of muscle tendons, and produces a lasting biological reconstruction. The risk from the re-implanted bone of both local recurrence and of late radiotherapy induced malignancy should be nil.

Aim

To review the first 50 cases, looking at survivorship of the irradiated autograft, complications and functional outcomes in a wide range of bony malignancies and anatomical locations.