Intercalary frozen autograft for reconstruction of malignant bone and soft tissue tumours (original) (raw)
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Pedicle frozen autograft reconstruction in malignant bone tumors
Journal of Orthopaedic Science, 2010
Background Standardizing limb salvage surgery for malignant bone tumors should result in improved limb function after tumor excision and reconstruction. Recently, we developed and clinically applied a method of biological reconstruction using tumor-bearing autografts treated with liquid nitrogen. We report this newly modified technique using pedicle frozen autografts to save the continuity of anatomical structures. Methods We treated 33 malignant bone tumor patients. Diagnoses of the tumors were 17 osteosarcomas, 11 metastatic tumors, 2 Ewing’s sarcomas, 2 chondrosarcomas, and 1 undifferentiated pleomorphic sarcoma. The sites of the tumors were 23 femurs, 5 tibias, 4 humeri, and 1 calcaneus. Operative procedures consisted of exposing the tumor, performing one-site osteotomy or joint dislocation, rotating and freezing the tumor lesion in liquid nitrogen for 20 min, and reconstruction using intramedullary nailing, plates, or composite arthroplasty. Results Postoperative function was excellent in 25 patients (75.7%), good in 5 patients (15.1%), and fair in 3 patients (9.0%). At the final follow-up, 8 patients had died at a mean of 17 months postoperatively, and 18 patients remained disease-free for a mean follow-up period of 30 months (range 7–69 months). Seven patients were alive but with disease. Complications were encountered in 12 patients, including 4 deep infections, 3 fractures, 3 local recurrences from surrounding soft tissue, 2 nonunions, and 1 collapse. All were managed successfully. Conclusions The pedicle frozen autograft, which was newly developed to solve drawbacks of previously reported free frozen autografts, achieved success for reconstruction of malignant bone tumors. This is a new, simple, effective surgical technique for biological reconstruction that is still investigated but has potential for development.
Indian Journal of Orthopaedics
Background Many reconstruction methods have evolved to offer limb salvage surgery (LSS) to patients with musculoskeletal sarcomas. It can be achieved using endoprosthesis or biological reconstruction methods like allograft or autograft or a combination of both. In carefully selected patients, resected bone can be recycled and reimplanted after sterilisation using methods like irradiation, autoclaving, pasteurisation or liquid nitrogen. Methods From 2010 to 2016, 10 patients with primary musculoskeletal sarcoma underwent limb salvage surgery (LSS) by wide resection of the tumour and reconstruction using recycled autograft treated with liquid nitrogen. Intercalary resection was carried out in six patients and intra-articular in four. The resected bone was dipped in liquid nitrogen for 25 min, thawed at room temperature for 15 min followed by dipping in vancomycin-mixed saline for 10 min. The recycled bone was re-implanted into its original site and stabilised with internal fixation. Results At a mean follow-up period of 39.6 months (range 6-97 months), all patients had a good function (mean functional score of 80%) with no evidence of local recurrence in the re-implanted bone or otherwise. Union was achieved at 15 of the 16 osteotomy sites with a mean union time of 5.2 months (range 4-7 months) without any additional surgical interventions. In none of the patient, augmentation with vascularised/non-vascularised fibula was done. No complication like fracture of the autograft, implant failure or deep/superficial infection was reported in any patient. Conclusion Recycled tumour-bearing autograft after treatment with liquid nitrogen is an anatomical, cost-effective, relatively simpler and reliable technique for reconstruction of bone defect after resection in selective primary musculoskeletal sarcoma patients.
Scientific Reports, 2022
There have been no studies comparing the outcomes of nonvascularized autograft (NA) and allograft after resection of primary bone tumors. This study compares the clinical, functional outcomes of NA and allograft reconstruction and analyzes the risk factors for failure after these procedures. A retrospective study of patients with primary bone tumors of the extremities who underwent NA (n = 50) and allograft reconstruction (n = 47). The minimum follow up time was 24 months. The mean time to union for the NA and allograft group was 9.8 ± 2.9 months and 11.5 ± 2.8 months, respectively (p = 0.002). Reconstruction failure in the NA and allograft group was 19 (38%) and 26 (55.3%), respectively. Nonunion (30%) was the most common complication found in the NA group, while structural failure (29.8%) was the most common in the allograft group. There was no significant difference in functional outcome in terms of the mean Musculoskeletal Tumor Society score between the NA and allograft groups (23.5 ± 2.8 and 23.9 ± 2.1, respectively, p = 0.42). Age, sex, tumor location, graft length, method of reconstruction did not significantly influence failure of reconstruction. Chemotherapy was the only significant risk factor affecting outcomes (HR = 3.49, 95% CI = 1.59-7.63, p = 0.002). In the subgroup analysis, the use of chemotherapy affected graft-host nonunion (p < 0.001) and structural failure in both the NA and allograft groups (p = 0.02). Both NA and allograft reconstruction methods provide acceptable clinical and functional outcomes. Chemotherapy is a risk factor for failure of both reconstructions, particularly graft-host nonunion and structural failure. Massive bone defect after resection of primary bone tumors remains a challenging problem. The treatment includes biological, endoprosthesis, and a combination of biological and endoprosthesis reconstructions. Each method has its advantages and disadvantages. The benefits of endoprosthesis reconstruction include its availability and early ambulation post-procedure. The disadvantages include complications that compound over time, such as aseptic loosening and bone loss 1. Biological reconstruction has advantages in long-term use when host-bone graft incorporation is achieved, providing bone stock for future reconstruction and soft tissue attachment, thus improving joint kinematics and function 2,3. The disadvantages include technical difficulty, prolonged operative time, and a high complication rate, including infection 4 , nonunion 5 , fracture, and joint degeneration 6. Biological reconstruction methods include vascularized and nonvascularized autograft (NA), allograft, recycled bone by freezing with liquid nitrogen, irradiation, autoclaving, and pasteurization 7. NA and allograft reconstruction methods have long been used in biological reconstructions of the extremities. NA reconstruction is widely used for massive bone defects such as distal radius replacement, intercalary bone graft for diaphyseal bone defect of long bones, and resection arthrodesis procedure. The advantages of NA reconstruction are no risk of disease transmission or immune reaction and no special equipment required. The disadvantages of NA reconstruction include donor site pain, fracture, and the limited quantity of bone graft 8. The use of allograft in bone tumor surgery is mostly from frozen allograft, which has an advantage over autograft in that there is no
Scientific Reports, 2021
Biological reconstruction is widely used to reconstruct bone defects after resection of bone tumors in the extremities. This study aimed to identify risk factors for failure and to compare outcomes of the allograft, nonvascularized autograft, and recycled frozen autograft reconstruction after resection of primary malignant bone tumors in the extremities. A retrospective study was performed at a single center between January 1994 and December 2017. Ninety patients with primary malignant bone tumors of the extremities were treated with tumor resection and reconstruction using one of three bone graft methods: nonvascularized autograft (n = 27), allograft (n = 34), and recycled frozen autograft (n = 29). The median time for follow-up was 59.2 months (range 24-240.6 months). Overall failure of biological reconstruction occurred in 53 of 90 patients (58.9%). The allograft group had the highest complication rates (n = 21, 61.8%), followed by the recycled frozen autograft (n = 17, 58.6%) and nonvascularized autograft (n = 15, 55. 6%) groups. There was no statistically significant difference among these three groups (p = 0.89). The mean MSTS score was 22.6 ± 3.4 in the nonvascularized autograft group, 23.4 ± 2.6 in the allograft group, and 24.1 ± 3.3 in the recycled frozen autograft group. There was no significant difference among the groups (p = 0.24). After bivariate and multivariable analyses, patient age, sex, tumor location, graft length, methods, and type of reconstruction had no effects on the failure of biological reconstruction. Biological reconstruction using allograft, nonvascularized autograft, and recycled frozen autograft provide favorable functional outcomes despite high complication rates. This comparative study found no significant difference in functional outcomes or complication rates among the different types of reconstruction. Choices of bone reconstruction after resection of bone tumors include biological, endoprosthesis, and a combination of biological and endoprosthesis. Endoprosthesis reconstruction provides immediate stability with no disease transmission, but its longevity and cost are the main concerns 1. Nowadays, biological reconstruction for the treatment of a large bone defect is increasingly used. The advantages of biological reconstruction include its durability when host-bone graft incorporation is achieved and its cost-effectiveness. The disadvantages include the lengthy time needed to achieve bony union and various complications that require secondary procedures. Choices for biological reconstruction include allograft, vascularized and nonvascularized autograft, bone transportation, and recycled autograft 2. Allograft has been used for more than one hundred years. Its limitations are donor availability, size-matching, and disease transmission. Nonvascularized and vascularized autograft can be used in specific locations, such as in small bone defects of the distal radius or large bone defects such as in the resection arthrodesis procedure of the knee or intercalary reconstruction of long bones. Recycled autograft has been increasingly used as an alternative procedure when allograft is not available. The advantages of this method are anatomic conformation, non-transmission of disease, and low cost. Various methods of recycled autograft include autoclaving, irradiation, pasteurization, and freezing with liquid nitrogen 2,3 .
Autoclaved Tumor Bone for Reconstruction
Clinical Orthopaedics & Related Research, 2006
The options for reconstruction after excision of skeletal tumors include reimplanting the autoclaved tumor-bearing bone. We asked whether such bone will survive and unite with normal bone and whether the local tumor recurrence rate increases after its use. We ascertained the functional outcome (Musculoskeletal Tumor Society score) and complications in 19 patients. After wide excision, the bony segment was autoclaved at 120°for 10 minutes and reimplanted at the original defect with intramedullary nails and compression plates. Twelve of our 19 patients were available for followup. The autoclaved segment united with the normal bone in 11 of the 12 patients. No patients had fracture or resorption of the autoclaved segment. Two patients had local tumor recurrence in nearby soft tissues, apparently unrelated to the autoclaved bone. The mean functional score was 70%. Complications included fatigue failure of the nail in one patient, superficial infection in three patients, and deep infection in two patients. Reconstruction with autoclaved tumor-bearing bone is a simple and effective tool in limb salvage. This technique is a cost-effective alternative for developing countries circumventing complications of prosthetic and allograft reconstruction. Level of Evidence: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.
American Journal of Otolaryngology, 2009
The aim of the study was to assess the possibility of mandibular reconstruction with autologous freeze-treated bone after mandibular resection for malignant tumors. Patients: The medical records of 72 consecutive patients surgically treated with segmental mandibular resection and reconstruction with autologous freeze-treated mandible were reviewed. Results: All tumors were in stage T4a for deep infiltration of the mandible. Soft tissues were reconstructed with a direct mucosal closure (4 cases), with a pedicled pectoralis flap (17 cases), and with a forearm fasciocutaneous free flap without or with radial periosteum (18 and 33 cases). Four patients presented with a recurrence after previous surgery and radiotherapy, and 26 patients underwent postoperative radiotherapy. We resected the mental arch in 35 cases and the lateral mandible in 37 cases. Forty-one patients (56.9%) retained their autologous mandibular graft. In 31 cases, the bone graft was removed for mucosal dehiscence and bone infection. Lateral resections achieved a better success rate than anterior resections (75.7% vs 37.1%). The pedicled pectoralis flap achieved the worse success rate (35.3%) in comparison with forearm fasciocutaneous flap (66.7%). Postoperative radiotherapy decreased the success rate (40.0% vs 69.1%). Conclusions: Mandibular reconstruction with autologous frozen bone is an interesting alternative to more sophisticated methods for patients with oral cancer involving the bone. It is time and cost sparing in comparison to fibula or iliac crest flaps. However, in spite of any intraoral reconstruction, the success rate is not stirring. In our opinion, this type of mandibular reconstruction must be reserved to patients with lateral tumors, with poor prognosis, or severe comorbidities not allowing more complex bone reconstruction.
Cryosurgery in the treatment of bone tumors
Operative Techniques in Orthopaedics, 1999
The concept and technique of cryosurgery in the treatment of benign and malignant bone tumors are presented. Cryosurgery extends the margin of curettage and makes it equivalent to wide resection. Compared with other techniques, cryosurgery with composite fixation not only preserves joint function, but also significantly decreases the rate of local tumor recurrence. Although a relatively simple procedure, cryosurgery can cause a significant morbidity if performed inappropriately. Effective and safe procedures must follow these consecutive steps: (!) adequate exposure of the tumor cavity; (2) meticulous curettage and burr-drilling; (3) soft tissue mobilization and protection before introduction of liquid nitrogen to the tumor cavity; (4) internal fixation of the tumor cavity; and (5) protection of the operated bone throughout the healing period.
Asia-Pacific Journal of Clinical Oncology, 2014
Aim: To evaluate the clinical results of primary malignant musculoskeletal tumors treated with wide resection and recycling autograft reconstruction using liquid nitrogen. Methods: We reviewed 12 patients who had a primary malignant bone and soft tissue tumor treated by wide resection and recycling autograft reconstruction using liquid nitrogen between March 2006 and March 2013. The results were judged by recurrence, functional status and complications. Functional status was assessed according to the Musculoskeletal Tumor Society Score (MSTSS). Clinical failure was defined as need for reoperation in order to change the type of reconstruction or to amputate, and the presence of local recurrence. Results: The most common tumor was osteosarcoma (eight cases) followed by Ewing's sarcoma (two cases). The tibia was the most frequently involved skeletal site (six cases) followed by the femur (three cases). The median follow-up period was 32 months. In 12 patients, 7 were still alive without recurrence. There were 3 clinical failures: 1 local recurrence and 2 graft complications at 28, 51 and 20 months after reconstruction, respectively. The main complication was infection (three cases). All osteotomy sites were radiographic unions, and the union time was 8.2 ± 2.7 months. The mean ± SD MSTSS score was 79% ± 11%; excellent functional results were achieved in seven patients. Conclusions: Recycling autograft reconstruction using liquid nitrogen had favorable clinical outcomes in terms of functional status and local recurrence. This reconstruction method, therefore, represents a reasonable alternative for limb salvage surgery.