Aims. Intercalary allografts following resection of a primary diaphyseal tumour have high rates of complications and failures. At our institution intercalary allografts are augmented with intramedullary cement and fixed using compression plating. Our aim was to evaluate their long-term outcomes. Patients and Methods. A total of 46 patients underwent reconstruction with an intercalary allograft between 1989 and 2014. The patients had a mean age of 32.8 years (14 to 77). The most common diagnoses were osteosarcoma (n = 16) and chondrosarcoma (n = 9). The location of the tumours was in the femur in 21, the tibia in 16 and the humerus in nine. Function was assessed using the Musculoskeletal Tumor Society (MSTS) scoring system and the Toronto Extremity Salvage Score (TESS). The survival of the graft and the overall survival were assessed using the Kaplan-Meier method. Results. The median follow-up was 92 months (4 to 288). The mean MSTS 87 score was 29.1 (19 to 35), the mean MSTS 93 score was 82.2 (50 to 100) and the mean TESS score was 81.2 (43 to 100). Overall survival of the allograft was 84.8%. A total of 15 patients (33%) had a complication. Five allografts were revised for complications and one for local recurrence. Conclusion. Intercalary allografts augmented with intramedullary cement and compression plate fixation provide a reliable and durable method of reconstruction after the excision of a primary diaphyseal bone tumour, with high levels of function and satisfaction. . Cite this article: Bone Joint J 2017;99-B:973–8

Biological reconstruction techniques after diaphyseal tumour resection have increased in popularity in recent years. High complication and failure rates have been reported with intercalary allografts, with recent studies questioning their role in limb-salvage surgery. We developed a technique in which large segment allografts are augmented with intramedullary cement and fixed using compression plating. The goal of this study was to evaluate the survivorship, complications and functional outcomes of these intercalary reconstructions. Forty-two patients who had reconstruction with an intercalary allograft following tumour resection between 1989 and 2010 were identified from our prospectively collected database. Allograft survival, local recurrence-free, disease-free and overall survival were assessed using the Kaplan-Meier method. Patient function was assessed using the Musculoskeletal Tumour Society (MSTS) scoring system and the Toronto Extremity Salvage Score (TESS). The 23 women and 19 men had a mean age of 33 years (14–77). The most common diagnoses were osteosarcoma (n=16) and chondrosarcoma (n=9). There were 9 humerus, 18 femur and 15 tibia reconstructions. At a mean follow-up of 95 months (5–288), 31 patients were alive without disease, 10 were dead of disease and 1 was deceased of other causes. There were 4 local recurrences and 11 patients developed metastatic disease. 5-year local recurrence free survival was 92%, 5-year disease-free survival was 70% and overall survival was 75%. Fourteen of 42 patients (33%) experienced complications: 5 wound healing complications, 4 infections, 2 non-unions, 2 fractures and 1 nerve palsy. Four allografts (9.5%) were revised for complications and 2 (5%) for local recurrence. Mean allograft survival was 85 months (4–288). Mean time to union was 8.2 (3–36) months for the proximal osteotomy site and 8.1 (3–23) months for the distal osteotomy site. The mean score for MSTS 87 was 29.4 (+/− 4.4), MSTS 93 was 83.7 (+/−14.8) and TESS was 81.6 (+/−16.9). An intercalary allograft augmented with intramedullary cement and compression plate fixation provides a reliable and durable method of reconstruction after tumour resection. Complication rates are comparable to the literature and are associated with high levels of patient function and satisfaction

Aims. Our purpose was to describe an unusual series of 21 patients with fungal osteomyelitis after an anterior cruciate ligament reconstruction (ACL-R). Methods. We present a case-series of consecutive patients treated at our institution due to a severe fungal osteomyelitis after an arthroscopic ACL-R from November 2005 to March 2015. Patients were referred to our institution from different areas of our country. We evaluated the amount of bone resection required, type of final reconstructive procedure performed, and Musculoskeletal Tumor Society (MSTS) functional score. Results. A total of 21 consecutive patients were included in the study; 19 were male with median age of 28 years (IQR 25 to 32). All ACL-R were performed with hamstrings autografts with different fixation techniques. An oncological-type debridement was needed to control persistent infection symptoms. There were no recurrences of fungal infection after median of four surgical debridements (IQR 3 to 6). Five patients underwent an extensive curettage due to the presence of large cavitary lesions and were reconstructed with hemicylindrical intercalary allografts (HIAs), preserving the epiphysis. An open surgical debridement was performed resecting the affected epiphysis in 15 patients, with a median bone loss of 11 cm (IQR 11.5 to 15.6). From these 15 cases, eight patients were reconstructed with allograft prosthesis composites (APC); six with tumour-type prosthesis (TTP) and one required a femoral TTP in combination with a tibial APC. One underwent an above-the-knee amputation. The median MSTS functional score was 20 points at a median of seven years (IQR 5 to 9) of follow-up. Conclusion. This study suggests that mucormycosis infection after an ACL-R is a serious complication. Diagnosis is usually delayed until major bone destructive lesions are present. This may originate additional massive reconstructive surgeries with severe functional limitations for the patients. Level of evidence: IV. Cite this article: Bone Joint Open 2020;2(1):3–8

The August 2012 Oncology Roundup. 360. looks at: prolonged symptom duration; peri-operative mortality and above-knee amputation; giant cell tumour of the spine; surgical resection for Ewing’s sarcoma; intercalary allograft reconstruction of the femur for tumour defects; and an induced membrane technique for large bone defects

Introduction: Joint sparing is a prerequisite for biologic reconstructions allowing for permanent healing in bone tumors. The physis not crossed by vessels in children can provide a safe margin for tumor resection. In selected patients we have performed joint sparing procedures either by transepiphysial resection or by epiphysial distraction as introduced by Canadell and San Julian. Patients and methods: 8 children (1 ewing tumor, 8 osteosarcomas [1 multiple localizations]) with open physes 3 distal femurs, 6 proximal tibiae) were treated for metaphysial tumor localizations touching but not crossing to the physis. In 4 localizations epiphysial distraction was used, in the others transepiphysial resection. Reconstructions were performed with vascularized fibula alone in 4 cases, with vascularized fibula transfer and allograft in 1 patient, in the others only intercalary allografts were used. Results: F/u is 3 to 12 years. No local recurrence occurred. One intercalary allograft failed for infection after irradiation; this was salvaged by a modified rotation plasty. One patient with fibula reconstruction of the femur needed reosteosynthesis due to lack of fusion with a finally excellent result at 3 years f/u, in one the fractured allograft needed be replaced by autologous bone following temporary cement spacer, but the epiphysis could be retained. All patients have excellent joint function. Shortness due to loss of the physis is corrected by contralateral epiphysiodesis and/or lengthening. Conclusion: Epiphysial sparing tumor resection can be successful oncologically if patients are properly selected and surgery is respecting the tumor margins

The June 2015 Oncology Roundup. 360 . looks at: Infection in megaprosthesis; Impressive results for mid femoral reconstruction; Revered teaching or old myth? Femoral neck protection in metastatic disease; Megaprosthesis about the knee; Malignant transformation in multiple hereditary exostoses; Fracture of intercalary bone allograft; Comorbidity and outcomes in sarcoma; A worrying turn? Use of denosumab for giant cell tumour of bone

Haemangioendothelioma of bone is a rare intermediate grade malignancy. Because of its rareness there is a lack of information in the literature about the well established treatment strategies depending on series with large numbers. The outcome of wide resection with postoperative external irradiation would be presented. 4 patients (2 females, 2 males) with a mean age of 40.5 (26–52) with solitary haemangioendothelioma of bone admitted with local pain on the affected bone and limited restriction of function. Anatomical sites were scapula, calcaneum, midshaft of radius and metaphysodiaphyseal region of femur. Plain X-ray, CT, MRI, Tc 99 tecnetium wholebody bone scan investigations were applied. All lesions were hot on bone scan and lytic irregular permeative lesions T1 hypo, T2 hyper with gadolinium enhancement were present. Open biopsy resulted with the diagnosis of intermediate haemangioendothelioma of bone. Wide resection of tubular bones and intercalary lyophilised allograft recostruction with IM rod and cerclage wire and total calcaneum resection and allograft replacement with talar arthrodesis, total scapulectomy subsequent autoclaved bone reimplantation were the surgical procedures applied. Mean follow-up was 96 months (40–132). Three patients except scapula case received 50 Gy external irradiation. No patient developed local recurrence in the follow up. Regarding complications calcaneum patient developed skin necrosis after the irradiation which led to removal of the allograft but eventually healed. Scapula patient had late infection treated by antibiotics. All patients had satisfactory function. Intercalary allografts united in 6 months time. Calcaneum patient developed multiple small lung metastasis 1 year after the operation and treated by adriamycin based chemotherapy and interpherone. The lung lesions showed slight regression but the patient is alive since 112 months with no further relapse. Wide excision with subsequent irradiation and wide excision of total scapula resulted with no local recurrence in our small group of patients with this rare malignancy. Irradiation provided relatively less soft tissue sacrification and a sufficient local tumour control without risking the patient to an impending amputation in the occurence of local recurrence

Introduction: Infection following major orthopaedic oncological surgery is a serious complication and every precaution should be taken to avoid it. One potential source of infection is the biopsy procedure, particularly when is carried out of a referring centre. In fact up to 30 per cent of patients with soft tissues problems following a biopsy is reported. As an infected biopsy may make subsequent limb preservation surgery impractical, the greatest care should be taken in carrying out the biopsy. The implantation of foreign materials (prostheses, grafts, acrilic cement, metallic devices, etc) as the duration of the surgical procedure, intraoperative bleeding, possible deep haematomas, presence of drains, increase the risk of infection. Also the importance of haematogenous spread from other sites of infection to joint pros-thesis is well estabilished. Materials and methods: In this paper the Authors present their experience regarding septic complications after orthopaedic oncologie surgery. From 1988 to 2002, 143 patients underwent a major surgery for the treatment of skeletal neoplasms (wide resection and reconstruction employing modular or composite prostheses, osteoarticular or intercalary allografts, acrylic cement and osteosynthesis devices, major spinal surgery, internal hemipelvectomy, etc). Results: The patients were followed-up to detect the presence of a septic complication. Also patient’s files were revised to evaluate paramethers related to infection as bleeding, duration of surgery, postoperative fever, neutropenia, ESR and CRP, antibiotic prophylaxis, etc. The overall infection rate was approximately to 15 per cent. Conclusions: Immunosuppression from previous chemotherapy may predispose the patient to infection which may be occult, but which must be diligently sought. It has to be also emphasized that if at any stage the patient has had local radiotherapy, the tissues may be fibrosed and avascular and unable to combat local infection effectively. The Authors retain that the infection after major orthopaedic oncologie surgery could represent a serious threat to the implant and to the limb. The importance of meticolous asepsis practised at every stage has to be emphasized, together with prolonged use of prophylactic antibiotic, specially in immunosuppressed patients or chemotherapy

The proximal humerus is the third most common site for primary sarcoma of bone. Since the 1970’s the treatment of primary bone sarcoma has changed from amputation to limb salvage. This has been due to advances in chemotherapy, imaging and surgical techniques. The literature has shown that the survival after limb salvage is similar to that of amputation. The optimum method of reconstruction of the shoulder remains controversial. The aim of our study was to review the cases of primary bone sarcoma of the proximal humerus treated at Middlemore Hospital. The New Zealand Bone Tumour Registry was searched for all lesions of the proximal humerus, with the diagnosis of chondrosarcoma, Ewing’s sarcoma or osteosarcoma. These records were reviewed for presentation status, biopsy, and type of reconstruct ion, chemotherapy, complications and recurrence. Outcomes measured in months of disease free survival and overall survival. The Bone Tumour Registry identified 29 patients who were treated at Middlemore Hospital with the primary diagnosis of Ewing’s sarcoma, chondrosarcoma or osteosarcoma of the proximal humerus. Results were available for 26 of the 29 patients (90% follow-up). Of these 29 patients six had chondrosarcoma, four Ewing’s sarcoma and 19 osteosarcoma. The patients with chondrosarcoma had an average age of 50 years. three patients were treated with endoprosthesis (mean survival 48 months) and one with vascularised fibula reconstruction (status 27 months ANED). Of the four patients with Ewing’s sarcoma, two had surgical reconstruction, one with intercalary allograft reconstruction (status 96 months ANED) and one with endoprosthesis (status 84 months ANED). The 19 patients with osteosarcoma had an average age 27 years, 15 patients were treated surgically. Three had endoprosthetic reconstruction (mean survival 29 months), two allograft prosthetic composite reconstruction (mean survival 23 months), three vascularised fibula reconstruction (mean survival 217 months), one total shoulder replacement and proximal humeral autograft (status 68 months ANED), one hemiarthroplasty (status 21 months DOD) and one proximal humeral allograft (status 31 months ANED). 4 patients were treated with primary amputation (mean survival 55.25 months). The mean overall survival for limb salvage surgery in our institution is 74 months compared to 55.25 months for amputation; this is consistent with the published literature. Function of a salvaged upper limb is superior to amputation. A salvaged limb is socially and emotionally more acceptable for patients than amputation. Limb salvage remains the priority in the treatment of primary bone tumours of the proximal humerus

Aims

The aim of this study was to investigate the safety and efficacy of 3D-printed modular prostheses in patients who underwent joint-sparing limb salvage surgery (JSLSS) for malignant femoral diaphyseal bone tumours.

The August 2024 Oncology Roundup³⁶⁰ looks at: What factors are associated with osteoarthritis after cementation for benign aggressive bone tumour of the knee joint: a systematic review and meta-analysis; Recycled bone grafts treated with extracorporeal irradiation or liquid nitrogen freezing after malignant tumour resection; Intercalary resection of the tibia for primary bone tumours: are vascularized fibula autografts with or without allografts a durable reconstruction?; 3D-printed modular prostheses for the reconstruction of intercalary bone defects after joint-sparing limb salvage surgery for femoral diaphyseal tumours; Factors influencing the outcome of patients with primary Ewing’s sarcoma of the sacrum; The significance of surveillance imaging in children with Ewing’s sarcoma and osteosarcoma; Resection margin and soft-tissue sarcomas of the extremities treated with limb-sparing surgery and postoperative radiotherapy.

Aims

For paediatric and adolescent patients with growth potential, preservation of the physiological joint by transepiphyseal resection (TER) of the femur confers definite advantages over arthroplasty procedures. We hypothesized that the extent of the tumour and changes in its extent after neoadjuvant chemotherapy are essential factors in the selection of this procedure, and can be assessed with MRI. The oncological and functional outcomes of the procedure were reviewed to confirm its safety and efficacy.

Aims

The aims of this study were to analyse the long-term outcome of vascularised fibular graft (VFG) reconstruction after tumour resection and to evaluate the usefulness of the method.

Aims

To assess complications and failure mechanisms of osteoarticular allograft reconstructions for primary bone tumours.

The outcome of tibial allograft reconstruction after resection of a tumour is inconsistent and has a high rate of failure. There are few reports on the use of tibial allografts in children with open growth plates. We performed 21 allograft reconstructions (16 osteoarticular, five intercalary) in 19 consecutive patients between seven and 17 years of age. Two had Ewing’s sarcoma, one an adamantinoma and 16 osteosarcoma, one with multifocal disease.

Five patients have died; the other 14 were free from disease at the time of follow-up. Six surviving patients (eight allograft reconstructions) continue to have good or excellent function at a mean of 59 months (14 to 132). One patient has poor function at 31 months. The other seven patients have a good or excellent function after additional procedures including exchange of the allograft and resurfacing or revision to an endoprosthesis at a mean of 101 months (43 to 198). The additional operations were performed at a mean of 47 months (20 to 84) after the first reconstruction.

With the use of allograft reconstruction in growing children, joints and growth plates may be preserved, at least partially. Although our results remain inconsistent, tibial allograft reconstruction in selected patients may restore complete and durable function of the limb.

This paper describes the preliminary results of a proximal tibial endoprosthesis which spares the knee joint and enables retention of the natural articulation by replacing part of the tibial metaphysis and diaphysis. In eight patients who had a primary malignant bone tumour of the proximal tibia, the distal stem, which had a hydroxyapatite-coated collar to improve fixation, was cemented into the medullary canal. The proximal end had hydroxyapatite-coated extracortical plates which were secured to the remaining proximal tibial metaphysis using cortical screws. The mean age of the patients at operation was 28.9 years (8 to 43) and the mean follow-up was for 35 months (4 to 48). The mean Musculoskeletal Tumour Society score was 79% (57% to 90%), the mean Oxford Knee score was 40 points of 48 (36 to 46) and the mean knee flexion was 112° (100° to 120°). In one patient, revision to a below-knee amputation through the prosthesis was required because of recurrence of the tumour. Another patient sustained a periprosthetic fracture which healed with a painful malunion. This was revised to a further endoprosthesis which replaced the knee.

In the remaining six patients the prosthesis allowed preservation of the knee joint with good function and no early evidence of loosening. Further follow-up is required to assess the longevity of these prostheses.

Aims

After intercalary resection of a bone tumour from the femur, reconstruction with a vascularized fibular graft (VFG) and massive allograft is considered a reliable method of treatment. However, little is known about the long-term outcome of this procedure. The aims of this study were to determine whether the morbidity of this procedure was comparable to that of other reconstructive techniques, if it was possible to achieve a satisfactory functional result, and whether biological reconstruction with a VFG and massive allograft could achieve a durable, long-lasting reconstruction.