Aims: Massive allografts have been widely employed to replace skeletal defects after bone tumour resection. They have major advantages but the major concern is the long term behaviour of the implant. The aim of the present study was to evaluate the incidence of complications in allograft reconstruction and to describe the new techniques to decrease their rate. Methods: The present series includes 68 patients with 70 massive allografts operated from 1996 to 2002. 35 were males and 35 females with an average age of 31 years (4–79). The massive allograft was used as osteoarticular reconstruction in 28 cases, composite in 28, intercalary in 10, knee arthrodesis reconstruction in 3 and scapular replacement in one case. In 7 cases a vascularized fibula was associated. The femur was involved in 23 cases, the humerus in 16 and the tibia in 17, the pelvis in 7, the radius in 3, the scapula in 2 and patella and a finger in 1 case. Results: Infection rate on 68 cases was 6% (4 cases). All infections healed after surgical revision. Two patients were lost at fu and 10 patients have less than 12 months of fu. The 58 patients left have an average fu of 34 months (12–71). Among these patients 45% had one or more complications treated surgically and 2/3 of the cases healed. Non union rate was 12% and fracture rate 5%. Conclusion: Allograft reconstruction showed a high rate of complications. Almost half of the patients (45%) presented one or more complications which required surgery in 40% of cases. Aggressive antibiotic perioperative regimen and adequate soft tissue coverage of the graft may reduce the risk of infections. Biologic augmentation with vascularized grafts, bone marrow and/or growth factors may reduce non union rate. Cement filling of the graft and composite implant (with prosthesis association) have been introduced in order to decrease the risk of diaphyseal and articular fractures

Purpose: Massive allografts have been used in orthopaedic surgery for many years. Early results have generally been encouraging, but the risk of long-term resorption remains to be evaluated. We analysed resorption of 39 allografts implanted more than 10 years earlier. Material and methods: Thirty-nine massive allografts implanted to sheath hip, knee or shoulder prostheses were studied a mean 13 years (range 10 – 17) after implantation. These allografts had been prepared in the same manner: preservaton at −30°C, sterilisation by 25000 Gy before implantation. A radiological scale was used to class graft resorption as minor (less than 5 mm in depth and less than 1 cm in length), moderate, or major (concerning the entire thickness of the allograft over three quarters of the circumference, irrespective of the length involved. These allografts measured more than 15 cm and were used for revision of loosened total hip arthroplasties, or reconstruction after tumour resection (tibia, femur, humerus). Among the 39 patients, 21 had received postoperative chemotherapy alone or in combination with radiotherapy. Results: The allograft healed within the first or second postoperative year. Peripheral resorption was only observed at last follow-up. Among the 39 massive allografts assessed more than 10 years after implantation, 28 exhibited radiologically visible resorption. Among these 28, resorption was minimal for 15, moderate for nine and major for four. The first factor favouring resorption was complementary treatment, particularly local radiotherapy after carcinological resection. To a lesser degree, chemotherapy, given alone, also favoured resorption. None of the allografts implanted during a revision procedure for loosened total hip arthroplasty exhibited signs of absorption 10 years later. Two patients who had undergone resection of a chondrosarcoma with no complementary treatment exhibited only minor allograft resorption. Minor and moderate resorption was observed preferentially in the upper portions of the tibia and humerus, compromising the implant (three loosenings at more than 10 years. Peripheral resorption of the allograft appeared generally between the third and seventh postoperative year. Beyond that time, resorption did not appear to occur or increase. Evident polyethyl-ene wear observed in several patients operated on more than 10 years earlier was not associated with endosteal osteolysis of the subjacent allograft. Discussion: Resorption of massive allografts is preferentially observed in the upper portions of the humerus and tibia, and generally occurs in patients who have undergone carcinological resection of a tumour followed by complementary treatment. Resorption is exceptional for allografts inserted during total prosthesis revision

Purpose of the study: Extensive loss of femoral bone subsequent to implant loosening raises an unsolved problem. The purpose of this work was to examine mid-term results of 18 iterative total hip arthroplasties with femoral reconstruction using massive allografts performed between 1986 and 1997. Materials and methods: Using the Vives classification, the femoral bone lesions were grade 3 (n = 2) and grade 4 (n = 16). The reconstruction was achieved with radiated massive allografts measuring 11 to 35 cm implanted in a split host femur. Charnley-Kerboull implants with a long stem were cemented in the reconstructed femurs. Results: Mean follow-up was 4 years 10 months (range 2 to 9 years). Nine complications in 7 hips were observed: 6 trochanter nonunions, two recurrent prosthesis dislocations and 1 femoral fracture. At last follow-up, the functional result was excellent or very good in 12 hips (Merle d’Aubigné classification). A stable fixation persisted for 15 implants and 3 had loosened. Graft-host femur consolidation was achieved in all cases except 1. There were 3 cases with extensive resorption of the graft including 2 associated with loosening of the femoral component. Discussion: Reconstruction of the femur after extensive bone loss using a massive allograft appears to be a useful method for restoring bone tissue and providing immediate mechanical support for the femur

Introduction: Chronic hip arthroplasty infection is a difficult situation to solve. The use of uncemented stem is questionable, as no antibiotic loaded cement is used to fix the implant. Bone deficiencies are often enlarged by the chronic infection process and the multiple previous surgeries. We report our experience in two stage revisions with massive allograft and uncemented distal locked stem. Material and method: We have retrospectively reviewed 15 patients operated on from chronic hip arthroplasty infection and secondary large femoral defects. Two stages revision with a temporarily antibiotic loaded cement spacer and 6-weeks second look reconstruction were performed with massive proximal femoral allograft and a long distally locked stem. The uncemented stem was cemented into the allograft and remained uncemented in the recipient distal femur. Outcome was assessed regarding infection control, allograft complication and function according to the Merle d’Aubigné score. Results: Patients mean age was 62 years (SD 11). Patients were already operated from the same hip 5.9 +/− 2.3 times before the actual procedure. Isolated microorganisms were MRSE (7), staph Aureus (4), MRSA (1), VRE (1), enterococcus (2). Muscle flaps were performed in 2 cases and discuss for 2 more. Allograft length was 22 +/− 9 cm. Antibiotic treatment was maintained for 4.6 +/− 2.5 months (median 3 months). Mean follow-up was 29 months (SD 26; median 23). Clinical outcome based on Merle d’Aubigné score is 5.3 +/− 3 before treatment and 13.8 +/− 2.5 at the last visit. Complications were registered in 4 cases. Infection recurrence was observed in 3 cases (2,7,20 months) but the function was preserved in all cases. One of them needed a two stage procedure with a new allograft after 19 months due to acute staph Aureus infection. One allograft was broken after 80 months and need one stage revision. Discussion: While the treatment of these cases was particularly demanding as bone deficiencies and microorganisms antibiotic resistance were high, functional result obtained was good. When infection recurrence was observed, function remains preserved. The use of uncemented distal locked stem with a cemented massive allograft did not lead to mechanical or hardware problem and allow us to restore the bone stock and the gluteus tendons insertion. The use of a modular stem was very helpful in solving these complex situations. Massive allografts can be used in case of infection as antibiotic delivery system

Purpose: Revision total knee arthroplasty (RTKA) is particularly difficult and results more variable than primary total knee arthroplasty due to the added problem of bone loss. Massive bone allografts have been proposed to restore bone stock and mechanical conditions as close to the physiological situation as possible. The purpose of this retrospective analysis was to assess clinical and radiological results after knee reconstruction with massive allografts in patients undergoing revision total knee arthroplasty. Materials and method: This series included 14 patients who underwent a revision procedure between February 1990 and August 1998 for RTKA with segmentary bone loss and bone defects. This group included seven patients with mechanical failure and seven others with septic loosening. Reconstruction was achieved with a massive allograft sealed around a long stem cemented implant. The composite assembly was impacted into the patient’s bony segment. The allografts were used to reconstruct the distal femur in nine cases, the proximal tibia in one, and both in the others. The IKS score and radiographic homogenisation of the host-graft junction were assessment criteria. Results: Mean follow-up was 50 months (24–110). Mean IKS score was significantly improved from 43 (11–70) pre-operatively to 75 (40–100) at last follow-up (Wilcoxon test, p = 0.002). At last follow-up, the flexion-extension amplitude was 91±10°. Radiographic integration of the allografts was achieved in 14 out of 18 grafts. Three allografts were resorbed leading to fracture with subsequent implant failure and a new revision in two. There were no infections. Discussion and conclusion: Bone grafts may be a solution to the difficult problem of bone loss during RTKA. Massive grafts combined with long stem implants have given encouraging early and mid-term results. The duration of these results is under evaluation

From 1984 to 1988 we implanted 127 massive allografts irradiated with a dose of 25,000 grays. These were reviewed at a minimum follow-up of three years to determine the effect of irradiation on infection, the complications and the functional result. No bacteriological infection was seen in the 44 patients who had allografts for revision of joint arthroplasty or for a tumour with no adjuvant therapy. For the 83 patients who also had chemotherapy or radiotherapy or both for a bone tumour, the rate of infection was 13%. The major mechanical complications were nonunion in seven grafts (5.5%) and fracture in eight (6%). These rates do not differ greatly from those reported for non-irradiated grafts. Our results suggest that irradiation, which remains the most convenient and acceptable method of sterilisation, does not jeopardize the clinical results

After resection of a malignant tumour, the options for reconstruction include the use of massive allografts. The potential benefits of allografts include the ability to shape the graft to match the defect at the time of surgery and high rates of union in metaphyseal bone. The options for fixation of allografts include intramedullary nails and plating. The AO-LISS DF (less invasive stabilisation system for the distal femur) is a new plate designed for fractures of the femur. The screws lock into the plate and the system is thought to provide excellent purchase in metaphyseal bone. A jig allows percutaneous screw insertion. We describe a case in which a 28 year old woman with a high grade sarcoma of the distal femur underwent reconstruction using an intercalated allograft and two LISS-DF plates. This technique allowed the knee joint to be preserved. Although the surgical approach to the femur was medial, the LISS-DF jig allowed a plate to be placed on the lateral side of the femur in a “less invasive” fashion. Although the plate is designed for application to the lateral side of the femur, in this case adequate fit on the medial side was obtained with a plate from the contralateral limb. This reconstruction provided excellent early stability at the junctions between host and allograft bone

The purpose of this study is to enhance massive bone allografts osseointegration used to reconstruct large bone defects. These allografts show >50% complication rate requiring surgical revision in 20% cases. A new protocol for total bone decellularisation exploiting the vasculature can offer a reduction of postoperative complication by annihilating immune response and improving cellular colonization/ osseointegration. The nutrient artery of 18 porcine bones - humerus/femur/radius/ulna - was cannulated. The decellularization process involved immersion and sequential perfusion with specific solvents over a course of one week. Perfusion was realized by a peristaltic pump (mean flow rate: 6ml/min). The benefit of arterial perfusion was compared to a control group kept in immersion baths without perfusion. Bone samples were processed for histology (HE, Masson's trichrome and DAPI for cell detection), immunohistochemistry (IHC : Collagen IV/elastin for intraosseous vascular system evaluation, Swine Leukocyte Antigen – SLA for immunogenicity in addition to cellular clearance) and DNA quantification. Sterility and solvent residues in the graft were also evaluated with thioglycolate test and pH test respectively. Compared to native bones, no cells could be detected and residual DNA was <50ng/mg dry weight. Intramedullary spaces were completely cleaned. IHC showed the preservation of intracortical vasculature with channels bounded by Collagen IV and elastin within Haversian systems. IHC also showed a significant decrease in SLA signaling. All grafts were sterile at the last decellularization step and showed no solvent residue. The control group kept in immersion baths, paired with 6 perfused radii/ulnae, showed that the perfusion is mandatory to ensure complete decellularisation. Our results prove the effectiveness of a new concept of total bone decellularisation by perfusion. These promising results could lead to a new technique of Vascularized Composite Allograft transposable to pre-clinical and clinical models

Six massive femoral allografts followed up for 22 to 36 years are described. Three were intercalary, two were osteoarticular and one was a total femoral replacement. Their functional rating according to the Musculoskeletal Tumor Society System (Enneking 1987) averaged 82% (56 to 100). The radiographic score averaged 75% (48 to 100). Four allografts had suffered fractures, but three of these had later united to give good final scores. Our study shows that massive femoral allografts can function well for as long as 36 years

Paediatric musculoskeletal (MSK) disorders often produce severe limb deformities, that may require surgical correction. This may be challenging, especially in case of multiplanar, multifocal and/or multilevel deformities. The increasing implementation of novel technologies, such as virtual surgical planning (VSP), computer aided surgical simulation (CASS) and 3D-printing is rapidly gaining traction for a range of surgical applications in paediatric orthopaedics, allowing for extreme personalization and accuracy of the correction, by also reducing operative times and complications. However, prompt availability and accessible costs of this technology remain a concern. Here, we report our experience using an in-hospital low-cost desk workstation for VSP and rapid prototyping in the field of paediatric orthopaedic surgery. From April 2018 to September 2022 20 children presenting with congenital or post-traumatic deformities of the limbs requiring corrective osteotomies were included in the study. A conversion procedure was applied to transform the CT scan into a 3D model. The surgery was planned using the 3D generated model. The simulation consisted of a virtual process of correction of the alignment, rotation, lengthening of the bones and choosing the level, shape and direction of the osteotomies. We also simulated and calculated the size and position of hardware and customized massive allografts that were shaped in clean room at the hospital bone bank. Sterilizable 3D models and PSI were printed in high-temperature poly-lactic acid (HTPLA), using a low-cost 3D-printer. Twenty-three operations in twenty patients were performed by using VSP and CASS. The sites of correction were: leg (9 cases) hip (5 cases) elbow/forearm (5 cases) foot (5 cases) The 3D printed sterilizable models were used in 21 cases while HTPLA-PSI were used in five cases. customized massive bone allografts were implanted in 4 cases. No complications related to the use of 3D printed models or cutting guides within the surgical field were observed. Post-operative good or excellent radiographic correction was achieved in 21 cases. In conclusion, the application of VSP, CASS and 3D-printing technology can improve the surgical correction of complex limb deformities in children, helping the surgeon to identify the correct landmarks for the osteotomy, to achieve the desired degree of correction, accurately modelling and positioning hardware and bone grafts when required. The implementation of in-hospital low-cost desk workstations for VSP, CASS and 3D-Printing is an effective and cost-advantageous solution for facilitating the use of these technologies in daily clinical and surgical practice

Introduction. The management of periprosthetic pelvic bone loss is a challenging problem in hip revision surgery. This study evaluates the minimum 10-year clinical and radiographic outcome of major column structural allografts combined with the Burch-Schneider antiprotrusio cage for acetabular reconstruction. Methods. From January 1992 to August 2005, 106 hips with periprosthetic osteolysis underwent acetabular revision using massive allografts and the Burch-Schneider antiprotrusio cage. Forty-five patients (49 hips) died for unrelated causes without further surgery. Fifty-nine hips in 59 patients underwent clinical and radiographic evaluation at an average follow-up of 15.1 years. There were 17 male and 42 female patients, with age ranging from 29 to 83 years (mean 59). Results. Ten hips required rerevision because of infection (3), aseptic loosening (6), and flange breakage (1). Moreover, 4 cages showed x-ray signs of instability with severe bone resorption. The survivorship of the Burch-Schneider cage at 21.9 years with removal for any reason or radiographic migration and aseptic or radiographic failure as the end points were 76.3 and 81.4, respectively. The average Harris hip score improved from 33.2 points preoperatively to 75.7 points at the latest follow-up (p < 0.001). Discussion. In hip revision surgery, severe deficiency of pelvic bone stock is a critical concern because of the difficulty in providing a stable and durable fixation of the prosthesis. Although antiprotrusio cages have a limited role in acetabular revision, the use in association with massive allografts in extended bone loss demonstrated highly successful long-term results, enabling bone stock restoration and cup stability

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. Patients and Methods. A total of 23 patients with a mean age of 16 years (five to 40) who had undergone resection of an intercalary bone tumour of the femur and reconstruction with a VFG and allograft were reviewed clinically and radiologically. The mean follow-up was 141 months (24 to 313). The mean length of the fibular graft was 18 cm (12 to 29). Full weight-bearing without a brace was allowed after a mean of 13 months (seven to 26). Results. At final follow-up, the mean Musculoskeletal Tumor Society Score of 22 evaluable patients was 94% (73 to 100). Eight major complications, five fractures (21.7%), and three nonunions (13%) were seen in seven patients (30.4%). Revision-free survival was 72.3% at five, ten, and 15 years, with fracture and nonunion needing surgery as failure endpoints. Overall survival, with removal of allograft or amputation as failure endpoints, was 94.4% at five, ten, and 15 years. Discussion. There were no complications needing surgical revision after five years had elapsed from surgery, suggesting that the mechanical strength of the implant improves with time, thereby decreasing the risk of complications. In young patients with an intercalary bone tumour of the femur, combining a VFG and massive allograft may result in a reconstruction that lasts a lifetime. Cite this article: Bone Joint J 2018;100-B:378–86

Aims. We retrospectively report our experience of managing 30 patients with a primary malignant tumour of the distal tibia; 25 were treated by limb salvage surgery and five by amputation. We compared the clinical outcomes of following the use of different methods of reconstruction. Patients and Methods. There were 19 male and 11 female patients. The mean age of the patients was 19 years (6 to 59) and the mean follow-up was 5.1 years (1.25 to 12.58). Massive allograft was used in 11 patients, and autograft was used in 14 patients. The time to union, the survival time of the reconstruction, complication rate, and functional outcomes following the different surgical techniques were compared. The overall patient survival was also recorded. Results. Out of 14 patients treated with an autograft, 12 (86%) achieved union at both the proximal and distal junctions. The time to union at both junctions of the autograft was significantly shorter than in those treated with an allograft (11.1 vs 17.2 months, p = 0.02; 9.5 vs 16.2 months, p = 0.04). The complication rate of allograft reconstruction was 55%. The five patients treated with an amputation did not have a complication. Out of the 25 patients who were treated with limb salvage, three (12%) developed local recurrence and underwent amputation. The mean functional Musculoskeletal Tumor Society (MSTS) score after autograft reconstruction was higher than after allograft reconstruction (81% vs 67%; p = 0.06), and similar to that after amputation (81% vs 82%; p = 0.82). The two- and five-year overall rates of survival were 83% and 70%, respectively. Conclusions. This consecutive case series supports the safety of limb salvage and the effectiveness of biological reconstruction after the resection of a primary tumour of the distal tibia. Autograft might be a preferable option. In some circumstances, below-knee amputation remains a valid option

The June 2014 Oncology Roundup. 360 . looks at: Infection still a problem in endoprosthetic reconstruction; massive allografts not as successful as we perhaps think; curopsy for aneurysmal bone cysts?; lengthening prosthesis: days are numbered; new WHO classification in brief; proximal tumours and fluid levels: bad news; infection is predictable in orthopaedic oncology; psychosocial support key in oncological outcomes

The reconstruction of a skeletal defect after resection of a bone tumour represents a challenge for the orthopaedic surgeon. Age, site of the lesion and extension of the disease often limit the choice of surgical technique for a conservative procedure, but several options are available, mainly modular, composite or custom prostheses, massive bone allografts with or without autologous vascularised fibular grafts (AVF), and arthrodeses. An interesting reconstructive technique uses the AVF graft, with microsurgical technique, alone or associated with a massive allograft. The association of a fibular transplant with an allograft increases the mechanical strength of the reconstruction, also promoting more rapid integration. The fibula is a cortical bone and it may provide mechanical strength in the reconstruction of a large segmental bony defect if employed as a viable biological rod. In the present paper the authors discuss their experience with 17 patients treated at the Oncological Orthopaedic Unit of the G.Pini Orthopaedic Institute, for bone tumour resection and reconstruction using AVF graft, almost always combined with a bone allograft. No treatments were performed as augmentation in osteoarticular massive allografts. Subjects’ ages ranged from 7 to 66 years (mean 25.2 years). Most of the patients were referred for a diagnosis of malignancy (15 of 17 cases) and in only two patients were the tumours not aggressive. In 11 patients the AVF was transplanted immediately after tumour resection, while in the others it was used after problems of previous reconstruction. The authors report two cases of deep infection and four mechanical fractures (all healed after a period of cast immobilisation with or without bone bridging). All the AVF survived and healed with a good functional result for the patients except for two recurrences that required an amputation

We report the contamination rate in the Cambridge bone bank of 35 consecutive allograft specimens, all harvested in a clean-air environment, using a strict aseptic technique and antibiotic cover. Five of 27 femoral heads taken from living donors and three of eight massive allografts taken from cadavers were found to be contaminated. The contaminated femoral heads were discarded. All massive allografts were rendered sterile by gamma-irradiation. It is important to exclude bacteriological contamination of harvested and banked bone

We present our mid-term results with the use of structural allografts in cases of revision of failed THA due to infection. Eighteen patients with a deep infection at the site of a THA were treated with a two-stage revision, which included reconstruction with massive allografts. All the allografts were frozen and sterilised by gamma-irradiation. The mean age at the time of the revision was 65.9 years. A cement spacer containing 1 g of Gentamicin was used during the interval period. Parenteral antibiotics were administrated for a period of three to four weeks. Oral antibiotics were given for an average of 18 weeks. The patients were followed for a mean of 8.9 years (5.4–14.2). Definite deep wound infection developed in one patient (5.6%), who underwent resection arthroplasty. An additional patient underwent re-revision of an acetabular component for mechanical loosening. The mean HHS improved from 34.2 points preoperatively to 70.7 points at the last review. Sixteen of the patients (88.9%) had a successful outcome. Kaplan-Meier survivorship analysis predicted 80.95% rate of survival at 14 years. Radiographicly, all allografts were found to be united to host bone. There were no signs of definite loosening of any of the implants. The complications include one fracture and two postoperative recurrent dislocations. The use of massive allografts in a two-stage reconstruction for infected THA gives satisfactory results and should be considered in cases complicated with severe bone stock loss, where standard revision techniques are not an option

We reviewed 25 patients who had undergone resection of a primary bone sarcoma which extended to within 5 cm of the knee with reconstruction by a combination of a free vascularised fibular graft and a massive allograft bone shell. The distal femur was affected in four patients and the proximal tibia in 21. Their mean age at the time of operation was 19.7 years (5 to 52) and the mean follow-up period 140 months (28 to 213). Three vascularised transfers failed. The mean time to union of the fibula was 5.6 months (3 to 10) and of the allograft 19.6 months (10 to 34). Full weight-bearing was allowed at a mean of 21.4 months (14 to 36). The mean functional score at final follow-up was 27.4 (18 to 30) using a modfied 30-point Musculoskeletal Tumour Society rating system. The overall limb-salvage rate was 88%. The results of our study suggest that the combined use of a vascularised fibular graft and allograft is of value as a limb-salvage procedure for intercalary reconstruction after resection of bone tumours around the knee, especially in skeletally immature patients

Autografts produced by recycling of tumor-bearing bone have been used for bridging intercalary bone defects but they are known to act as massive allografts after recycling procedures due to devitalisation. Recycled bone is superior to massive allografts since it allows anatomical reconstruction. Vascularised fibular grafts are inserted into recycled bone segments to provide biological support and to promote healing. Twelve patients with a mean age of 13.3 years (6–31), who had undergone curative resection of malignant bone tumor followed by biological reconstruction comprised of recycled bone combined with vascularised fibula, were followed up for a mean period of 16.8 (6–46). The tumor was located in distal femur in 7 patients, proximal femur in 2, proximal tibia in 2 and mid-diaphyseal tibia in 1. Cryopreservation with liquid nitrogen was employed for all patients. Contralateral single strut vascularised fibular grafts were used in all except one patient for whom bilateral fibula grafts were harvested to span a longer defect. Plates were used for fixation in 11 patients, and intramedullary nailing in one case. Mean length of bony defect was 16.1 cm (9.0–25.0). Mean fibular graft length was 17.5 cm (10.0–23.0 cm). Complete union and full weight bearing was achieved in 6 patients, and mean time to detect the commencement of union was 6 months (4–8). Incomplete union was detected in 4 patients and no union in 2. Five patients were complicated by implant failure, 1 with deep infection and 1 with drop foot. In order to fill large defects after resection of bone tumors, recyled bone combined with vascularised fibular graft is an effective reconstructive tool. Union rate of this technique is quite satisfactory with good functional results