What Are the Complications of Allograft Reconstructions for Sarcoma Resection in Children Younger Than 10 Years at Long-term Followup?

BACKGROUND: Preservation of limb function after resection of malignant bone tumors in skeletally immature children is challenging. Resection of bone sarcomas and reconstruction with an allograft in patients younger than 10 years old is one reconstructive alternative. However, long-term studies analyzing late complications and limb length discrepancy at skeletal maturity are scarce; this information would be important, because growth potential is altered in these patients owing to the loss of one physis during tumor resection. QUESTIONS/PURPOSES: At a minimum followup of 10 years after reconstructions in children younger than 10 years of age at the time of reconstruction, we asked what is (1) the limb length discrepancy at skeletal maturity and how was it managed; (2) the risk of amputation; (3) the risk of allograft removal; and (4) the risk of second surgery resulting from complications? METHODS: Between 1994 and 2006, we performed 22 bone allografts after bone sarcoma resections in children younger than 10 years of age. Of those, none were lost to followup before the minimum followup of 10 years was reached, and an additional six had died of disease (of whom three died since our last report on this group of patients), leaving 16 patients whom we studied here. Followup on these patients was at a mean of 13.5 years (range, 10-22 years). During the period in question, no other treatments (such as extendible prostheses, amputations, etc) were used. The mean age at the time of the original surgery was 7 years (range, 2-10 years), and the mean age of the 16 alive patients at last followup was 20 years (range, 15-28 years). This series included 10 boys and six girls with 14 osteosarcomas and two Ewing sarcomas. Ten reconstructions were performed with an intercalary allograft and six with an osteoarticular allograft. The growth plate was uninvolved in three patients, whereas in the remaining 13, the growth plate was included in the resection (seven intercalary and six osteoarticular allografts). Limb length discrepancy at skeletal maturity was measured with full-length standing radiographs, and data were collected by retrospective study of a longitudinally maintained institutional database. The risk of amputation, allograft removal, and secondary surgery resulting from a complication was calculated by a competing-risk analysis method. RESULTS: We observed no limb length discrepancy at skeletal maturity in the three patients with intercalary resections in whom we preserved the physes on both sides of the joint (two femurs and one tibia); however, one patient developed malalignment that was treated with corrective osteotomy of the tibia. The remaining 13 patients developed limb length discrepancy as a result of loss of one physis. Seven patients (four femurs, two tibias, and one humerus) developed shortening of ≤ 3 cm (mean, 2.4 cm; range, 1-3 cm) and no lengthening was performed. Six patients developed > 3 cm of limb discrepancy at skeletal maturity (all distal femoral reconstructions). In four patients this was treated with femoral lengthening, whereas two declined this procedure (each with 6 cm of shortening). In the four patients who had a lengthening procedure, one patient had a final discrepancy of 4 cm, whereas the other three had equal limb lengths at followup. The risk of amputation was 4% (95% confidence interval [CI], 0-15) and none occurred since our previous report. The risk of allograft removal was 15% (95% CI, 1-29) and none occurred since our previous report on this group of patients. The risk of other operations resulting from a complication was 38% (95% CI, 19-57). Eleven patients underwent a second operation resulting from a complication (three local recurrences, five fractures, one infection, one nonunion, and one tibial deformity), of which three were performed since our last report on this group of patients. CONCLUSIONS: Limb length inequalities and subsequent procedures to correct them were common in this small series of very young patients as were complications resulting in operative procedures, but overall most allografts remained in place at long-term followup. In skeletally immature children, bone allograft is one alternative among several that are available (such as rotationplasty and endoprosthesis), and future studies with long followup may be able to compare the available options with one another. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Is Navigation-guided En Bloc Resection Advantageous Compared With Intralesional Curettage for Locally Aggressive Bone Tumors?

BACKGROUND: The treatment of locally aggressive bone tumors is a balance between achieving local tumor control and surgical morbidity. Wide resection decreases the likelihood of local recurrence, although wide resection may result in more complications than would happen after curettage. Navigation-assisted surgery may allow more precise resection, perhaps making it possible to expand the procedure's indications and decrease the likelihood of recurrence; however, to our knowledge, comparative studies have not been performed. QUESTIONS/PURPOSES: The purpose of this study was to compare curettage plus phenol as a local adjuvant with navigation-guided en bloc resection in terms of (1) local recurrence; (2) nononcologic complications; and (3) function as measured by revised Musculoskeletal Tumor Society (MSTS) scores. METHODS: Patients with a metaphyseal and/or epiphyseal locally aggressive primary bone tumor treated by curettage and adjuvant therapy or en bloc resection assisted by navigation between 2010 and 2014 were considered for this retrospective study. Patients with a histologic diagnosis of a primary aggressive benign bone tumor or low-grade chondrosarcoma were included. During this time period, we treated 45 patients with curettage of whom 43 (95%) were available for followup at a minimum of 24 months (mean, 37 months; range, 24-61 months), and we treated 26 patients with navigation-guided en bloc resection, of whom all (100%) were available for study. During this period, we generally performed curettage with phenol when the lesion was in contact with subchondral bone. We treated tumors that were at least 5 mm from the subchondral bone, such that en bloc resection was considered possible with computer-assisted block resection. There were no differences in terms of age, gender, tumor type, or tumor location between the groups. Outcomes, including allograft healing, nonunion, tumor recurrence, fracture, hardware failure, infection, and revised MSTS score, were recorded. Bone consolidation was defined as complete periosteal and endosteal bridging visible between the allograft-host junctions in at least two different radiographic views and the absence of pain and instability in the union site. All study data were obtained from our longitudinally maintained oncology database. RESULTS: In the curettage group, two patients developed a local recurrence, and no local recurrences were recorded in patients treated with en bloc resection. All patients who underwent navigation-guided resection achieved tumor-free margins. Intraoperative navigation was performed successfully in all patients and there were no failures in registration. Postoperative complications did not differ between the groups: in patients undergoing curettage, 7% (three of 43) and in patients undergoing navigation, 4% (one of 26) had a complication. There was no difference in functional scores: mean MSTS score for patients undergoing curettage was 28 points (range, 27-30 points) and for patients undergoing navigation, 29 (range, 27-30 points; p = 0.10). CONCLUSIONS: In this small comparative series, navigation-assisted resection techniques allowed conservative en bloc resection of locally aggressive primary bone tumors with no local recurrence. Nevertheless, with the numbers available, we saw no difference between the groups in terms of local recurrence risk, complications, or function. Until or unless studies demonstrate an advantage to navigation-guided en bloc resection, we cannot recommend wide use of this novel technique because it adds surgical time and expense. LEVEL OF EVIDENCE: Level III, therapeutic study.

What Happens to the Articular Surface After Curettage for Epiphyseal Chondroblastoma? A Report on Functional Results, Arthritis, and Arthroplasty.

BACKGROUND: Chondroblastoma is an uncommon, benign, but locally aggressive bone tumor that occurs in the apophyses or epiphyses of long bones, primarily in young patients. Although some are treated with large resections, aggressive curettage and bone grafting are more commonly performed to preserve the involved joint. Such intralesional resection may result in damage to the growth plate and articular cartilage, which can result in painful arthritis. Prior studies have focused primarily on oncologic outcomes rather than long-term joint status and functional outcomes. QUESTIONS/PURPOSES: (1) What local complications can be expected after aggressive intralesional curettage of epiphyseal chondroblastoma? (2) What is the joint survival of a joint treated in this way for chondroblastoma? (3) What additional procedures are used in treating symptomatic joint osteoarthritis after treatment of the chondroblastoma? (4) What are the functional outcomes in this group of patients? METHODS: A retrospective study of our prospectively collected database between 1975 and 2013 was done. We found 64 patients with a diagnosis of chondroblastoma of bone. After applying our selection criteria, 53 patients were involved in this study. We excluded seven patients with tumors initially treated with en bloc resection (five located in the extremities and two in the axial skeleton) and two patients with apophyseal tumors. One patient who underwent nonsurgical treatment and one patient lost to followup were also excluded. The mean age was 18 years (range, 11-39 years); the minimum followup was 2 years with a mean followup 77 months (range, 24-213 months). We analyzed all patients with a diagnosis of epiphyseal chondroblastoma of the limb treated with aggressive curettage and joint preservation surgery. During the period in question, our general indications for curettage were patients with active, painful tumors and those with more aggressive ones that remained intracompartmental, whereas initial wide en bloc resection was indicated in patients who had tumors with an extracompartmental extension breaching the adjacent joint cartilage and massive articular destruction. The tumor location was the distal femur in 14 patients, proximal tibia in 11, proximal humerus in 10, proximal femur in eight, the talus in seven, and elsewhere in the lower extremity in three. Local complications including joint degeneration and tumor recurrence were evaluated. Based on radiographic analysis, secondary osteoarthritis was classified by using the Kellgren-Lawrence grading system from Grade 0 to Grade IV. Patients who underwent joint replacement resulting from advanced symptomatic osteoarthritis were considered to have had joint failure for purposes of survivorship analysis, which was estimated using the Kaplan-Meier method. Functional results were evaluated with the Musculoskeletal Tumor Society functional score by the treating surgeon, who transcribed the results on the digital records every 6 months of followup. RESULTS: Twenty-two patients (42%) developed 26 local complications. The most common local complication was osteoarthritis in 20 patients (77% [20 of 26 complications]); tumor recurrence was observed in four patients; an intraarticular fracture and superficial infection treated with surgical débridement and antibiotics developed in one patient each. Joint survival was 90% at 5 years (95% confidence interval [CI], 76%-100%) and 74% at 10 years (95% CI, 48%-100%). Proximal femoral tumor location was associated with lower survivorship of the joint than other locations showing a 5-year survival rate of 44% (95% CI, 0%-88%; p = 0.000). Of the 20 patients with osteoarthritis, four were symptomatic enough to undergo joint replacement, all of which were for tumors in the proximal femur. The mean Musculoskeletal Tumor Society functional score was 28 of 30 points (93%). CONCLUSIONS: Osteoarthritis was a frequent complication of aggressive curettage of epiphyseal chondroblastoma, and tumors located in the proximal femur appeared to be at particular risk of secondary osteoarthritis and prosthetic replacement. Because chondroblastoma is a tumor that disproportionately affects younger patients, the patient and surgeon should be aware that arthroplasty at a young age is a potential outcome for treatment of proximal femoral chondroblastomas. LEVEL OF EVIDENCE: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Is Needle Biopsy Clinically Useful in Preoperative Grading of Central Chondrosarcoma of the Pelvis and Long Bones?

BACKGROUND: Central chondrosarcoma of bone is graded on a scale of 1 to 3 according to histological criteria. Clinically, these tumors can be divided into low-grade (Grade 1) and high-grade (Grade 2, Grade 3, and dedifferentiated) chondrosarcomas. Although en bloc resection has been the most widely used treatment, it has become generally accepted that in selected patients with low-grade chondrosarcomas of long bones, curettage is safe and effective. This approach requires an accurate preoperative estimation of grade to avoid under- or overtreatment, but prior reports have indicated that both imaging and biopsy do not always give an accurate prediction of grade. QUESTIONS/PURPOSES: (1) What is the concordance of image-guided needle preoperative biopsy and postoperative grading in central (intramedullary) chondrosarcomas of long bones, and how does this compare with the concordance of image-guided needle preoperative biopsy and postoperative grading in central pelvic chondrosarcomas? (2) What is the concordance of preoperative image-guided needle biopsy and postoperative findings in differentiating low-grade from high-grade central chondrosarcomas of long bones, and how does this compare with the concordance in central pelvic chondrosarcomas? METHODS: Between 1997 and 2014, in our institution, we treated 126 patients for central chondrosarcomas located in long bones and the pelvis. Of these 126 cases, 41 were located in the pelvis and the remaining 85 cases were located in long bones. This study considers 39 (95%) and 40 (47%) of them, respectively. We included all cases in which histological information was complete regarding preoperative and postoperative tumor grading. We excluded all cases with incomplete data sets or nondiagnostic preoperative biopsies. To evaluate the needle biopsy accuracy, we compared the histological tumor grade, obtained from the preoperative biopsy, with the final histological grade obtained from the postoperative surgical specimen. The weighted and nonweighted kappa statistics were used to evaluate the agreement. RESULTS: Concordance between the preoperative biopsy and the final pathological analysis in terms of histological grade was much higher in long-bone chondrosarcoma than in pelvic chondrosarcoma (83% [33 of 40] versus 36% [14 of 39]; odds ratio, 8, 48). Likewise, the weighted kappa coefficients were higher in long-bone chondrosarcoma than in pelvic chondrosarcoma for the determination of histological grade (0.63; 95% confidence interval [CI], 0.34-0.91 versus 0.12; -0.32 to 0.57; p < 0.001). When categorizing the lesions as low grade or high grade, concordance between the preoperative biopsy and the final pathological analysis was much higher in long-bone chondrosarcoma than in pelvic chondrosarcoma (90% [36 of 40] versus 67% [26 of 39]; odds ratio, 4, 5). Likewise, the weighted kappa coefficients were higher in long-bone chondrosarcoma than in pelvic chondrosarcoma (0.73; 95% CI, 0.51-0.94 versus 0.26; 0.04-0.48; p < 0.001). CONCLUSIONS: Image-guided needle biopsy, when performed by a specialist radiologist and evaluated by an experienced bone pathologist, is a useful tool in determining the histological grade of long-bone chondrosarcomas allowing identification of true low-grade tumors. The histological grade should be correlated with imaging and the clinical presentation, but under these circumstances, experienced tumor surgeons may use this information in planning surgical treatment. The same appears not to be true for pelvic lesions, in which histological grade established by needle biopsy should be interpreted with caution. LEVEL OF EVIDENCE: Level III, diagnostic study.

Proximal Tibia Reconstruction After Bone Tumor Resection: Are Survivorship and Outcomes of Endoprosthetic Replacement and Osteoarticular Allograft Similar?

BACKGROUND: The proximal tibia is one of the most challenging anatomic sites for extremity reconstructions after bone tumor resection. Because bone tumors are rare and large case series of reconstructions of the proximal tibia are lacking, we undertook this study to compare two major reconstructive approaches at two large sarcoma centers. QUESTIONS/PURPOSES: The purpose of this study was to compare groups of patients treated with endoprosthetic replacement or osteoarticular allograft reconstruction for proximal tibia bone tumors in terms of (1) limb salvage reconstruction failures and risk of amputation of the limb; (2) causes of failure; and (3) functional results. METHODS: Between 1990 and 2012, two oncologic centers treated 385 patients with proximal tibial resections and reconstruction. During that time, the general indications for those types of reconstruction were proximal tibia malignant tumors or bone destruction with articular surface damage or collapse. Patients who matched the inclusion criteria (age between 15 and 60 years old, diagnosis of a primary bone tumor of the proximal tibia treated with limb salvage surgery and reconstructed with endoprosthetic replacement or osteoarticular allograft) were included for analysis (n = 149). In those groups (endoprosthetic or allograft), of the patients not known to have reached an endpoint (death, reconstructive failure, or limb loss) before 2 years, 85% (88 of 104) and 100% (45 of 45) were available for followup at a minimum of 2 years. A total of 88 patients were included in the endoprosthetic group and 45 patients in the osteoarticular allograft group. Followup was at a mean of 9.5 (SD 6.72) years (range, 2-24 years) for patients with endoprosthetic reconstructions, and 7.4 (SD 5.94) years for patients treated with allografts (range, 2-21 years). The following variables were compared: limb salvage reconstruction failure rates, risk of limb amputation, type of failures according to the Henderson et al. classification, and functional results assessed by the Musculoskeletal Tumor Society system. RESULTS: With the numbers available, after competitive risk analysis, the probability of failure for endoprosthetic replacement of the proximal tibia was 18% (95% confidence interval [CI], 10.75-27.46) at 5 years and 44% (95% CI, 31.67-55.62) at 10 years and for osteoarticular allograft reconstruction was 27% (95% CI, 14.73-40.16) at 5 years and 32% (95% CI, 18.65-46.18) at 10 years. There were no differences in terms of risk of failures at 5 years (p = 0.26) or 10 years (p = 0.20) between the two groups. Fifty-one of 88 patients (58%) with proximal tibia endoprostheses developed a reconstruction failure with mechanical causes being the most prevalent (32 of 51 patients [63%]). A total of 19 of 45 osteoarticular allograft reconstructions failed (42%) and nine of 19 (47%) of them were caused by early infection. Ten-year risk of amputation after failure for endoprosthetic reconstruction was 10% (95% CI, 5.13-18.12) and 11% (95% CI, 4.01-22.28) for osteoarticular allograft with no difference between the groups (p = 0.91). With the numbers available, there were no differences between the groups in terms of the mean Musculoskeletal Tumor Society score (26.58, SD 2.99, range, 19-30 versus 27.52, SD 1.91, range, 22-30; p = 0.13; 95% CI, -2,3 to 0.32). Mean extension lag was more severe in the endoprosthetic group than the osteoarticular allograft group: 13.56° (SD 18.73; range, 0°-80°) versus 2.41° (SD 5.76; range, 0°-30°; p < 0.001; 95% CI, 5.8-16.4). CONCLUSIONS: Reconstruction of the proximal tibia with either endoprosthetic replacement or osteoarticular allograft appears to offer similar reconstruction failures rates. The primary cause of failure for allograft was infection and for endoprosthesis was mechanical complications. We believe that the treating surgeon should have both options available for treatment of patients with malignant or aggressive tumors of the proximal tibia. (S)he might consider an allograft in a younger patient to achieve better extensor mechanism function, whereas in an older patient or one with a poorer prognosis where return to function and ambulation quickly is desired, an endoprosthesis may be advantageous. LEVEL OF EVIDENCE: Level III, therapeutic study.

What Are the Risk Factors and Management Options for Infection After Reconstruction With Massive Bone Allografts?

BACKGROUND: Massive bone allografts have been used for limb salvage of bone tumor resections as an alternative to endoprosthesis, although they have different outcomes and risks. The use of massive bone allografts has been thought to be associated with a high risk for infection, and there is no general consensus on the management of this complication and final outcome. Because infection is such a devastating complication of limb salvage, at times leading to loss of a limb, recognizing the risk factors for infection and the results of treatment is important. QUESTIONS/PURPOSES: The purposes of this study were (1) to analyze the frequency of infection in a group of patients treated with massive bone allografts; (2) to analyze risk factors such as age, sex, affected bone, type of reconstruction, operative room used, primary or revision procedure, length of postoperative antibiotic administration, and use of chemotherapy; and (3) to determine the likelihood that treatment of an infected allograft will result in a successful reconstruction. METHODS: We retrospectively analyzed the records of patients treated with massive bone allografts for a benign or malignant bone tumor or as a revision for a previous limb salvage procedure between 1985 and 2011. During this period, 673 patients were reconstructed with massive bone allografts in long bones, which included 272 osteoarticular, 246 intercalary, and 155 allograft-prosthetic composite reconstructions. Using a chart review, we ascertained the frequency of infection and reoperations after the treatment of infected allografts. Minimum followup was 2 years unless death occurred earlier (mean, 106 months; range, 6-360 months), and no patient was lost to followup. The selected variables were analyzed using multivariate logistic regression to identify risk factors for infection. We analyzed survivorship free of infection as the endpoint. RESULTS: During followup, 60 patients (9%) had a bacterial infection of the allograft with a survivorship free from infection of 92% at 5 years (95% confidence interval [CI], 90%-94%) and 91% at 10 years (95% CI, 89%-93%). We found that tibia allografts (p < 0.001; odds ratio [OR], 3.17; 95% CI, 1.80-5.60), male patients (p < 0.029; OR, 1.92; 95% CI, 1.08-3.49), procedures performed in a conventional operating room (p < 0.002; OR, 3.15; 95% CI, 1.58-6.62), and the use of longer periods of postoperative antibiotics (p < 0.041; OR, 2.25; 95% CI, 1.02-4.88) were patient factors associated with a greater risk of infection. In 11 patients (18%, 11 of 60 infections) the infection was controlled with antibiotics and surgical débridement; however, in 49 patients (82%, 49 of 60 infections), this approach failed, so the allograft was removed and a temporary cement spacer with antibiotic was implanted to control the infection. Forty-one patients subsequently had the spacer removed and were reconstructed after infection control with another bone allograft in 24 and an endoprostheses in 17. Four patients underwent an amputation for infection and four died of disease with the spacer in place. When we analyzed the 41 patients with a second reconstruction, 14 failed with a new infection (34%, 14 of 41 secondary reconstructed) of whom 12 had been reconstructed with bone allograft (29%) and two had endoprostheses (5%). CONCLUSIONS: Management of infections of massive bone allografts with antibiotics and surgical débridement usually resulted in failure. Infections could be treated with resection of the allograft, antibiotics, a temporary cement spacer with antibiotics, and a repeat reconstruction; however, this approach is unlikely to be successful if a second bone allograft is used. Infections are difficult to treat, and more studies are needed, but we propose that it might be preferable to use endoprosthesis reconstruction for salvage of an infected allograft. LEVEL OF EVIDENCE: Level III, therapeutic study.

Should fractures in massive intercalary bone allografts of the lower limb be treated with ORIF or with a new allograft?

BACKGROUND: Massive bone allografts have been used for limb salvage of bone tumor resections as an alternative to endoprostheses, although they have different outcomes and risks. There is no general consensus about when to use these alternatives, but when it is possible to save the native joints after the resection of a long bone tumor, intercalary allografts offer some advantages despite complications, such as fracture. The management and outcomes of this complication deserve more study. QUESTIONS/PURPOSES: The purposes of this study were to (1) analyze the fracture frequency in a group of patients treated with massive intercalary bone allografts of the femur and tibia; (2) compare the results of allografts treated with open reduction and internal fixation (ORIF) with those treated with resection and repeat allograft reconstruction; and (3) determine the likelihood that treatment of a fracture resulted in a healed intercalary reconstruction. METHODS: We reviewed patients treated with intercalary bone allografts between 1991 and 2011. During this period, patients were generally treated with intercalary allografts when after tumor resection at least 1 cm of residual epiphysis remained to allow fixation of the osteotomy junction. To obtain a homogeneous group of patients, we excluded allograft-prosthesis composites and osteoarticular and hemicylindrical intercalary allografts from this study. We analyzed the fracture rate of 135 patients reconstructed with segmental intercalary bone allografts of the lower extremities (98 femurs and 37 tibias). In patients whose grafts fractured were treated either by internal fixation or a second allograft, ORIF generally was attempted but after early failures in femur fractures, these fractures were treated with a second allograft. Using a chart review, we ascertained the frequency of osseous union, complications, and reoperations after the treatment of fractured intercalary allografts. Followup was at a mean of 101 months (range, 24-260 months); of the original 135 patients, no patient was lost to followup. RESULTS: At latest followup, 19 patients (14%) had an allograft fracture (16 femurs [16%] and three tibias [8%]). Six patients were treated with internal fixation and addition of autologous graft (three femurs and three tibias) and 13 patients were treated with a second intercalary allograft (13 femurs). The three patients with femoral allograft fractures treated with internal fixation and autologous grafts failed and were treated with a second allograft, whereas those patients with tibia allograft fractures treated by the same procedure healed without secondary complications. When we analyzed the 16 patients with a second intercalary allograft (13 as primary treatment of the fracture and three as secondary treatment of the fracture), five failed (31%) and were treated with resection of the allograft and reconstructed with an endoprosthesis (four patients) or an osteoarticular allograft (one patient). CONCLUSIONS: Fractures of intercalary allografts of the tibia could successfully be treated with internal fixation and autologous iliac crest bone graft; however, this treatment failed when used for femur allograft fractures. Femoral fractures could be treated with resection and repeat allograft reconstruction, however, with a higher refracture frequency. The addition of a vascularized fibular graft in the second attempt should be considered. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Survival, recurrence, and function after epiphyseal preservation and allograft reconstruction in osteosarcoma of the knee.

BACKGROUND: Bone tumor resections for limb salvage have become the standard treatment. Recently, intercalary tumor resection with epiphyseal sparing has been used as an alternative in patients with osteosarcoma. The procedure maintains normal joint function and obviates some complications associated with osteoarticular allografts or endoprostheses; however, long-term studies analyzing oncologic outcomes are scarce, and to our knowledge, the concern that a higher local recurrence rate may be an issue has not been addressed. QUESTIONS/PURPOSES: We wanted to assess (1) the overall survival in patients treated with this surgical technique; (2) the percentage of local recurrence and limb survival, specifically the incidence of recurrence in the remaining epiphysis; (3) the frequency of orthopaedic complications, and, (4) the functional outcomes in patients who have undergone intercalary tumor resection. METHODS: We analyzed all 35 patients with osteosarcomas about the knee (distal femur and proximal tibia) treated at our center between 1991 and 2008 who had resection preserving the epiphysis and reconstruction with intercalary allografts. Minimum followup was 5 years, unless death occurred earlier (mean, 9 years; range, 1-16 years), and no patients were lost to followup. During the study period, our indications for this approach included patients without metastases, with clinical and imaging response to neoadjuvant chemotherapy, that a residual epiphysis of at least 1 cm thickness could be available after a surgical margin width in bone of 10 mm was planned, and 16% of patients (35 of 223) meeting these indications were treated using this approach. Using a chart review, we ascertained overall survival of patients, oncologic complications such as local recurrence and tumor progression, limb survival, and orthopaedic complications including infection, fracture, and nonunion. Survival rates were estimated using the Kaplan-Meier method. Patient function was evaluated using the Musculoskeletal Tumor Society (MSTS)-93 scoring system. RESULTS: Overall survival rate of the patients was 86% (95% CI, 73%-99%) at 5 and 10 years. Five patients died of disease. No patient had a local recurrence in the remaining bony epiphysis, but three patients (9%; 95% CI, 0%-19%) had local recurrence in the soft tissue. The limb survival rate was 97% (95% CI, 89%-100%) at 5 and 10 years. Complications treated with additional surgical procedures were recorded for 19 patients (54%), including three local recurrences, two infections, 11 fractures, and three nonunions. In 10 of these 19 patients, the allograft was removed. Only five of the total 35 study patients (14%) lost the originally preserved epiphysis owing to complications. The mean functional score was 26 points (range, 10-30 points, with a higher score representing a better result) at final followup. CONCLUSIONS: Although the recurrence rate was high in this series, the small sample size means that even one or two fewer recurrences might have resulted in a much more favorable percentage. Because of this, future, larger studies will need to determine whether this is a safe approach, and perhaps should compare epiphyseal preservation with other possible approaches, including endoprosthetic reconstruction and/or osteoarticular allografts. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Does intraoperative navigation assistance improve bone tumor resection and allograft reconstruction results?

BACKGROUND: Bone tumor resections for limb salvage have become standard treatment. Recently, computer-assisted navigation has been introduced to improve the accuracy of joint arthroplasty and possible tumor resection surgery; however, like with any new technology, its benefits and limitations need to be characterized for surgeons to make informed decisions about whether to use it. QUESTIONS/PURPOSES: We wanted to (1) assess the technical problems associated with computer-assisted navigation; (2) assess the accuracy of the registration technique; (3) define the time required to perform a navigated resection in orthopedic oncology; and (4) the frequency of complications such as local recurrence, infection, nonunion, fracture, and articular collapse after tumor resection and bone reconstruction with allografts using intraoperative navigation assistance. METHODS: We analyzed 69 consecutive patients with bone tumors of the extremities that were reconstructed with massive bone allografts using intraoperative navigation assistance with a minimum followup of 12 months (mean, 29 months; range, 12-43 months). All patients had their tumors reconstructed in three-dimensional format in a virtual platform and planning was performed to determine the osteotomy position according to oncology margins in a CT-MRI image fusion. Tumor resections and allograft reconstructions were performed using a computer navigation system according to the previously planned cuts. We analyzed intraoperative data such as technical problems related to the navigation procedure, registration technique error, length of time for the navigation procedure, and postoperative complications such as local recurrence, infection, nonunion, fracture, and articular collapse. RESULTS: In three patients (4%), the navigation was not carried out as a result of technical problems. Of the 66 cases in which navigation was performed, the mean registration error was 0.65 mm (range, 0.3-1.2 mm). The mean required time for navigation procedures, including bone resection and allograft reconstruction during surgery, was 35 minutes (range, 18-65 minutes). Complications that required a second surgical procedure were recorded for nine patients including one local recurrence, one infection, two fractures, one articular collapse, and four nonunions. In two of these nine patients, the allograft needed to be removed. At latest followup, three patients died of their original disease. CONCLUSIONS: The navigation procedure could not be performed for technical reasons in 4% of the series. The mean registration error was 0.65 mm in this series and the navigation procedure itself adds a mean of 35 minutes during surgery. The complications rate for this series was 14%. We found a nonunion rate of 6% in allograft reconstructions when we used a navigation system for the cuts. LEVEL OF EVIDENCE: Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.

Can wedge osteotomy correct depression of the lateral tibial plateau mimicking posterolateral rotatory knee instability?

BACKGROUND: The literature suggests rotatory knee instability (pseudolaxity) can be associated with depressions of the lateral tibial plateau in patients despite an intact arcuate ligament complex. Correcting this bone deformity by an open-wedge osteotomy of the lateral tibia plateau, elevating the depressed bone may restore knee stability. QUESTIONS/PURPOSES: We therefore asked whether: (1) knee stability is restored after this procedure; (2) Lysholm functional scores improve after this treatment; and (3) the limb alignment changes. PATIENTS AND METHODS: We retrospectively evaluated 12 patients who underwent a subchondral open-wedge osteotomy of the lateral tibial plateau combined with a knee arthroscopic procedure for the treatment of a knee rotational instability secondary to a lateral compartment bone deficit between 2000 and 2007. Eleven patients with a mean age of 35 years were available for followup at a minimum of 2 years (average, 5.4 years; range, 2-9 years). Preoperatively and at last followup, patients were clinically and radiographically evaluated by the Lysholm score and with comparative knee radiographs. Complications were recorded. RESULTS: At last followup all patients rated their knees as stable. All osteotomies healed uneventfully. The Lysholm score improved from 62 to 87. Followup radiographs showed no changes in the femorotibial axis as result of the osteotomy. CONCLUSIONS: Patients with chronic depression of the posterolateral tibial plateau may exhibit symptoms of posterolateral knee instability, a sort of pseudolaxity. In these patients, an open-wedge osteotomy of the lateral tibia plateau, elevating the depressed bone, and tensioning posterolateral structures improves this secondary posterolateral knee instability. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Intercalary femur allografts are an acceptable alternative after tumor resection.

BACKGROUND: With the improved survival for patients with malignant bone tumors, there is a trend to reconstruct defects using biologic techniques. While the use of an intercalary allograft is an option, the procedures are technically demanding and it is unclear whether the complication rates and survival are similar to other approaches. QUESTIONS/PURPOSES: We evaluated survivorship, complications, and functional scores of patients after receiving intercalary femur segmental allografts. PATIENTS AND METHODS: We retrospectively reviewed 83 patients who underwent an intercalary femur segmental allograft reconstruction. We determined allograft survival using the Kaplan-Meier method. We evaluated patient function with the Musculoskeletal Tumor Society scoring system. Minimum followup was 24 months (median, 61 months; range, 24-182 months). RESULTS: Survivorship was 85% (95% confidence interval: 93%-77%) at 5 years and 76% (95% confidence interval: 89%-63%) at 10 years. Allografts were removed in 15 of the 83 patients: one with infection, one with local recurrence, and 13 with fractures. Of the 166 host-donor junctions, 22 (13%) did not initially heal. Nonunion rate was 19% for diaphyseal junctions and 3% for metaphyseal junctions. We observed an increase in the diaphysis nonunion rate in patients fixed with nails (28%) compared to those fixed with plates (15%). Fracture rate was 17% and related to areas of the allograft not adequately protected with internal fixation. All patients without complications had mainly good or excellent Musculoskeletal Tumor Society functional results. CONCLUSIONS: Diaphyseal junctions have higher nonunion rates than metaphyseal junctions. The internal fixation should span the entire allograft to avoid the risk of fracture. Our observations suggest segmental allograft of the femur provides an acceptable alternative in reconstructing tumor resections. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Case report: Common femoral artery ligation after sarcoma resection in an infant.

BACKGROUND: Vascular reconstruction in infants constitutes a surgical challenge and is indicated frequently for acute occlusions. With the presence of a subacute vascular occlusion, including that produced by tumor resection, collateral circulation develops quickly. Thus a surgeon can consider tumor and vessel resection, without the need for vascular reconstruction. CASE DESCRIPTION: We report the 2-year postoperative outcome of a 2-month-old boy who had a groin synovial cell sarcoma with vascular involvement, treated using limb salvage surgery with resection of the femoral vessels and without performing vascular reconstruction. LITERATURE REVIEW: In adults with military wounds, ligation of the superficial femoral artery and common femoral artery reportedly result in amputation rates of 54% and 86%, respectively. Infants with a common femoral artery ligation may have a lower amputation rate because of some congenital collateral vessels, such as the sciatic artery. Further, when tumors involve major peripheral vessels, subacute or chronic vascular compression likely would facilitate development of collateral circulation. Similar chronic situations have been described in adults treated with debridement and common femoral artery ligation, after infected femoral artery pseudoaneurysms. PURPOSES AND CLINICAL RELEVANCE: Considering our patient's history and clinical and radiographic findings, infants with musculoskeletal sarcomas involving vascular structures can be treated selectively with tumor and vessel resection without the need for vascular reconstruction if distal limb perfusion is detected intraoperatively.

Mucormycosis osteomyelitis after anterior cruciate ligament reconstruction: treatment and outcomes of 21 reported cases.

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: IVCite this article: Bone Joint Open 2020;2(1):3-8.

Does increased rate of limb-sparing surgery affect survival in osteosarcoma?

BACKGROUND: The emergence of limb salvage surgery as an option for patients with osteosarcoma is attributable to preoperative chemotherapy and advancements in musculoskeletal imaging and surgical technique. While the indications for limb salvage have greatly expanded it is unclear whether limb salvage affects overall survival. QUESTIONS/PURPOSES: We asked whether over the past three decades limb-sparing procedures in high-grade osteosarcoma had increased, and whether this affected survival and ultimate amputation. METHODS: We retrospectively reviewed 251 patients with high-grade osteosarcoma treated from 1980 to 2004 with a multidisciplinary approach, including neoadjuvant chemotherapy. We compared survival rates, limb-salvage treatment, and amputation after limb-sparing procedure during three different periods of time. Fifty-three patients were treated from 1980 to 1989, 97 from 1990 to 1999, and 101 from 2000 to 2004. Thirty-seven patients were treated with primary amputations and 214 with primary limb salvage. RESULTS: The 5-year survival rate in the first period was 36%, whereas in the 1990 s, it was 60% and 67% from 2000-2004. Limb salvage surgery rate in the 1980s was 53% (28 of 53), whereas in the 1990 s, it was 91% (88 of 97) and 97% from 2000-2004 (98 of 101). In the limb salvage group, 22 of the 214 patients (10%) required secondary amputation; the final limb salvage rate in the first period was 36% (19 of 53), whereas in the 1990 s, it was 81% (79 of 97) and 93% from 2000-2004 (94 of 101). CONCLUSIONS: Patients with osteosarcoma treated in the last two periods had higher rates of limb salvage treatment and survival, with lower secondary amputation.

Proximal tibia osteoarticular allografts in tumor limb salvage surgery.

BACKGROUND: Resection of large tumors of the proximal tibia may be reconstructed with endoprostheses or allografts with fixation. Endoprosthetic replacement is associated with high failure rates and complications. Proximal tibia osteoarticular allografts after tumor resection allows restoration of bone stock and reconstruction of the extensor mechanism, but the long-term failure rates and complications are not known. QUESTIONS/PURPOSES: We therefore determined (1) the middle- and long-term survival of proximal tibia osteoarticular allografts, (2) their complications, and (3) functional (Musculoskeletal Tumor Society score) and radiographic (International Society of Limb Salvage) outcomes in patients treated with this reconstruction. PATIENTS AND METHODS: We retrospectively reviewed 52 patients (58 reconstructions including six repeat reconstructions) who underwent osteoarticular proximal tibia allograft reconstructions after resection of a bone tumor. The minimum followup of the 46 surviving patients was 72 months (mean, 123 months; range, 10-250 months). Survival of the allograft was estimated using the Kaplan-Meier method. We documented outcomes using the Musculoskeletal Tumor Society functional scoring system and the International Society of Limb Salvage radiographic scoring system. RESULTS: Six patients died from tumor-related causes without allograft failure before the 5-year radiographic followup. At last followup, 32 of the 52 remaining allografts were still in place; 20 failed owing to infections, local recurrences, or fractures. Overall allograft survival was 65% at 5 and 10 years, with an average Musculoskeletal Tumor Society functional score of 26 points and an average radiographic result of 87%. CONCLUSIONS: Based on these data we believe proximal tibia osteoarticular allograft is a valuable reconstructive procedure for large defects after resection of bone tumors. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Proximal femur allograft-prosthesis with compression plates and a short stem.

UNLABELLED: Proximal femur allograft-prosthesis composites (APCs) performed with compression plates and a short stem theoretically could minimize the resorption or nonunion that reportedly occurs with long stems bypassing the diaphyseal osteotomy. To confirm this theoretical consideration, we retrospectively reviewed 34 patients with 38 proximal femoral APCs using a short-cemented femoral stem and compression plates for diaphyseal osteotomy fixation. In 26 patients, the plate fixation extended over at least half the femoral stem and in 12, it did not. We reinserted the abductor mechanism with two techniques: in 10 cases the host trochanter was reattached to the APC, and in 28 the host tendons were sutured to the tendinous insertion of the allograft. The overall survival of the entire series was 72% at 5 years and 69% at 10 years. Eleven of the 38 (29%) APCs were removed: three for infection, one for local recurrence of tumor, and seven for fractures. Trendelenburg gait occurred in four of 21 patients with direct tendon-to-tendon suture of the abductor mechanism and in three of six patients with trochanteric osteotomy. The overall APC survival rate was greater in patients in whom the allograft was adequately protected with internal fixation than in patients in whom it was not. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Simultaneous rupture of the anterior cruciate ligament and a knee tumor.

We report two patients with simultaneous lesions about the knee; a traumatic injury (acute anterior cruciate ligament rupture) and a musculoskeletal tumour; that may be particularly misleading for the treating surgeon.

Massive bone loss from fungal infection after anterior cruciate ligament arthroscopic reconstruction.

Although there are numerous reports of septic pyogenic arthritis after arthroscopic anterior cruciate ligament (ACL) reconstruction, there is limited information regarding the outcomes of fungal infection. We determined the outcomes of six patients with mycotic infection after regular ACL reconstruction. There were four males and two females with a mean age of 33 years. We determined the number of procedures performed, bone loss originating to control infection, and final reconstruction in these patients. An average of five arthroscopic lavage procedures had been performed at the referring centers. Fungal infection was diagnosed based on pathologic samples; five infections were the result of mucormycosis and one was Candida. After final débridement, the mean segmental bone loss was 12.8 cm. All patients were treated with intravenous antifungal coverage and cement spacers before final reconstruction. At final followup, all patients were free of clinical infection. Three had reconstruction with an allograft-prosthesis composite, two with hemicylindrical allografts, and one with an intercalary allograft arthrodesis. Despite the extremely unusual presentation of this complication, surgeons should be aware of potential and catastrophic consequences of this severe complication after ACL reconstruction.

Joint preservation after extensive curettage of knee giant cell tumors.

UNLABELLED: Curettage is the most attractive procedure for surgically treating a giant cell tumor because it preserves joint function. However, since many giant cell tumors compromise subchondral bone this technique can jeopardize the articular surface with subsequent fractures or collapse. We asked whether intralesional curettage of a giant cell tumor close to the knee that combined morselized bone and cortical structural allograft would preserve joint function. We retrospectively reviewed 22 patients treated with that approach. The minimum followup was 2 years (average, 48 months; range, 24-80 months). The distal femur was involved in 12 patients and proximal tibia in 10. Complications and failures were recorded and functional results evaluated with Musculoskeletal Tumor Society score. We determined survivorship using the Kaplan-Meier technique using removal of the implant as the endpoint. The survival was 85% and the average functional score 28 points. Three of the 22 patients had a local tumor recurrence and one had a partial subchondral collapse not requiring further treatment. Among the remaining patients, none had fracture, infection, or knee instability. The combination of fragmented and cortical allograft allows reconstructing the bone defect and ligaments created after extensive curettage of a knee giant cell tumor obtaining normal joint function and a high survival rate with minimal complications in a high percentage of the patients. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.