Wide resection of primary tumors of bone and replacement with massive bone grafts: an improved technique for transplanting allogeneic bone grafts.

The treatment by wide resection of 104 local aggressive and low grade malignant bone tumors is presented with results after follow-up for 5.0 years on the average. The series comprises 29 giant cell tumors, most of them malignant or premalignant, 25 cartilaginous tumors (12 verified chondrosarcomas and 13 chondromas suspect of malignancy), 14 cases of sarcoma, 6 of fibrosarcoma, 4 parosseal sarcomas, 3 osteosarcomas and one chordoma. The remaining 36 cases include: aneurysmal bone cysts, fibrous dysplasia, chondroblastomas, osteoblastomas, giant chondromyxoid fibroma, and hemangiomas. After resection of the affected area, the resulting defect was replaced with massive autologous or allogeneic bone or osteoarticular graft in altogether 68 cases (autologous bone transplant in 61 cases and allograft in 7). A metallic endoprosthesis was used in replacement in 8 cases. No replacement of the defect was needed in 28 cases. The technique of the allogeneic bone transplantations consisted of massive bone or bone cartilage grafts which had been stored at a low temperature, and firm osteosynthesis. In every case, allogeneic (stored) bone was supplemented with autologous cancellous bone around the juncture of graft and host bone. This supplement proved to be important for success of the operation. The overall results were good in 81% and fair in 11%. Five cases had to be amputated and 3 patients were lost to follow-up, a possible total of 8% poor results. Extensive resection with massive bone grafting is a worthwhile approach in the treatment of selected cases of aggressive and low grade malignant bone tumors.

Application of free autogenous fibular graft in the treatment of aggressive bone tumours of the distal end of the radius.

Long-term results of the application of free autogenous fibular graft in the treatment of aggressive bone tumours of the distal end of the radius are presented. Six patients underwent radical resection of the tumour including the articular surface of the distal radius during the period 1969 to 1978, the average follow-up time being 5 years. In one case the tumour was low grade chondrosarcoma, in three cases a giant cell tumour grade two to three and in the remaining two a hemangioma. Five to twelve cm of the distal radius was resected and the defect was replaced using the ipsilateral proximal part of the fibula as free graft. Osteosynthesis was performed end to end with a plate fixation, or side to side with screw fixation. At follow-up, the range of motion in the radiocarpal joint was normal or close to normal in each case and all patients had returned to work within 6 months of the operation. None of the patients presented a recidive of the tumour.

Allogeneic transplantation in low-grade malignant bone tumours. A new operative technique to avoid amputation.

A massive allografting of deep-frozen cadaver bone or hemi-joint was performed in 11 patients with tumours which were diagnosed as aggressive, low-grade malignancies. One patient died from a pre-existing hepatic insufficiency. The other 10 patients have been followed up from 1 to 8 years. These patients received two bone grafts and eight hemi-joint grafts around the knee joint. The operative procedure consisted of fixation of the graft by stable osteosynthesis, surrounding the graft-host junction with an autogeneic iliac chips cuff and, in cases of hemi-joint grafts, reconstruction of the ligaments. X-ray, scintigraphy and biopsy were used to judge the incorporation of the graft. The patients had to be prepared to face a considerable morbidity with long non-weight-bearing periods and possibly further operations. A full restitution of function was achieved in the bone graft cases. The patients with hemi-joint grafts were also able to retain their limb with a good or satisfactory function. No metastases or recurrences were experienced. The allograft procedure appears to be useful for younger adults, whose long life expectancy makes this operation justifiable, although the fate of cartilage still is unpredictable.

Histological changes in clinical half-joint allograft replacements.

Fourteen biopsies of cartilage and subchondral bone were taken from nine half-joint knee allografts 10 weeks to 8 years after the transplantation. Deep-frozen cadaver grafts were used to replace the defective half-joint after resection for bone tumour. The biopsies revealed a slow substitution of the dead grafted bone and cartilage. Subchondrally, signs of incorporation could be seen from 12 months on. The dead cartilage matrix degraded gradually and slow simultaneous regeneration was observed. Thus, fibrocartilage was seen on the articular surface of the graft at 12 months, chondrocytes were present at 18 months, but islands of hyaline cartilage were not seen earlier than 7 years after the transplantation. In accordance with the earlier clinical findings, the histological signs of rejection were minimal. The long-term result of half-joint allograft transplantation is obviously dependent on the cartilage component.

Aneurysmal bone cyst: evaluation of resection and of curettage in 20 cases.

The clinical, angiographic and histological aspects of 20 cases of aneurysmal bone cyst suggest that angiography is a valuable aid in the diagnosis of a cyst, differentiating it from other cystic bone lesions. Angiographic information also has a certain bearing on the origin of the lesion. It was demonstrated that other, benign, lesions may exist adjacent to the cyst or prior to it; in most cases, however, the cyst appears in a bone which is otherwise normal. The failure to differentiate between aneurysmal bone cyst and giant cell tumor in relation to sex, age, localizaiton, morphology, and clinical course (e.g. tendency of recurrence and malignant transformation) may be responsible for confusion in the literature on these lesions. Good results of treatment are achievable by resection en bloc and by resection, or curettage with bone grafting. Curettage alone is inadequate. Only two recurrences (10%) were recorded in the present series during the average follow-up period of 4.5 years.