Comparative Efficacy of Intraoperative Extracorporeal Irradiated and Alcohol Inactivated Autograft Reimplantation in Management of Osteosarcomas– A Multicentre Retrospective Study.

Background: The biologic bone reconstruction in the treatment of malignant bone tumours for the limb salvage surgery has always been a controversial strategie. Vary inactivation methods, convenient, stable, curative effect and economy need to be considered. This study aims to compare the clinical efficacy between intraoperative extracorporeal irradiated and alcohol inactivated autograft reimplantation methods for limb salvage surgery with osteosarcomas. Methods: We retrospectively analysed 28 patients with osteosarcomas, 14 patients treated with intraoperative cobalt 60 irradiation and reimplantation treatment (Group A), 14 patients treated by alcohol-inactivated autograft reimplantation (Group B). The postoperative complications and clinical efficacy was compared by statistical analysis. Results: The local recurrence rate was 14.3% in each group. Complete bony union was achieved in 64.3% in group A and 71.4% in group B. The overall 5-year survival rate was 71.4% in group A and 78.6% in group B. The mean MSTS score was 25.33 ± 4.72 (range 15–30 ) in group A and 24.00 ± 5.85 (range 15–30 ) in group B. The mean ISOLS score was 25.79 ± 5.13 (range 20–36 ) in group A and 26.14 ± 5.33 (range 20–30 ) in group B. P < 0.05 was considered to indicate a significant difference, there was no difference in the long-term clinical efficacy between the extracorporeal irradiation and alcohol-inactivated methods.Conclusions: For limb salvage surgery with osteosarcomas, either intraoperative extracorporeal irradiation or alcohol-inactivated autograft repimlantation had equivalent outcomes for biological reconstruction. The alcohol-inactivated technology could be a much more convenient and cheap treatment to reconstruct bone defects. Additional studies and more case studies are needed to fully evaluate the clinical efficacy and safety of the alcohol-inactivated surgical approach.

Extracorporalis irradiatio: nagy csontdefektussal járó tumorresectiót követő biológiai rekonstrukció

Összefoglaló. A malignus csonttumorok sebészi ellátása során kialakuló szegmentális csontdefektusok pótlása fontos szempont a végtagmegtartó sebészetben. Felnőttkorban a megoldás rendszerint tumorprotézis beültetése, 10 évesnél fiatalabb gyermekeknél azonban ez nehezen alkalmazható módszer a kis csontméret és az igen magas várható szövődményarány miatt. A bemutatott, hazánkban még ritkán alkalmazott beavatkozás, a tumoros csontszegmentum műtét alatti sugárkezelése, visszaültetése megfelelő rekonstrukciós lehetőség a végtag funkciójának megtartása mellett, csökkentve a későbbi reoperációk, protézisrevíziók számát. Célkitűzés: A hazánkban eddig az ismertetett módon végzett műtétek bemutatása, az eredmények összevetése nemzetközi irodalmi adatokkal. Módszer: Magyaroszágon eddig 12 alkalommal végeztünk végtagmegtartó műtétet malignus csonttumor miatt 12 évesnél fiatalabb gyermekeknél, és e műtétek során biológiai rekonstrukciós módszerként extracorporalis irradiatiót, autograft-reimplantatiót (ECRT, ECI) végeztünk. A műtétek mindegyike primer malignus csonttumor (Ewing-sarcoma 7 esetben, osteosarcoma 4 esetben, chondrosarcoma 1 esetben) miatt történt. Betegeink átlagéletkora 9 (3–12) év volt, az átlagos utánkövetési idő 32,5 (2–73) hónap. A felmérés során fizikális vizsgálat, valamint minden alkalommal röntgenfelvételek készítése történt, szükség esetén szövettani mintavétellel, vérelemzéssel vagy egyéb képalkotással kiegészítve. Eredményeinket nemzetközi irodalmi adatokkal hasonlítottuk össze. Eredmények: Lokális tumorkiújulást egyetlen esetben sem észleltünk, másik csontot érintő skip (’ugró’) metastasis miatt egy alkalommal amputatiót végeztünk. A szövődmények tekintetében eredményeink megfelelnek a nemzetközi irodalomban leírtaknak. Két esetben jelentkezett szeptikus szövődmény (16,7%). A resectiós sík radiológiai átépülése 3–9 hónap alatt történt meg az esetek 60%-ában. Álízület, grafttörés, graft részleges elhalása miatt 3 esetben végeztünk reoperációt, kétszer újabb allograft felhasználásával, egy esetben pedig tumorprotézis beültetésével. Betegeink szubjektív véleménye a módszerről pozitív, a legtöbb esetben megőrizték jó fizikai aktivitásukat, az esetleges reoperációk ellenére végtagjukat terhelik, akár sporttevékenységet is végeznek. Következtetések: Vizsgálatunk alapján az extracorporalis irradiatio hasznos biológiai rekonstrukciós módszer 12 évesnél fiatalabb gyermekek esetében szegmentális csontdefektusok pótlására tumoros indikációval. A felmerülő szövődmények aránya alatta marad a hasonló korban beültetett tumorprotézisek szövődményarányainak, ideális esetben pedig több, további kiterjesztett műtét elkerülhető vele. Szövődmény esetén a későbbiekben tumorprotézis-beültetés mint végtagmegtartó vészmegoldás még mindig elvégezhető. Orv Hetil. 2020; 161(45): 1914–1919. Summary. Introduction: Reconstruction of massive segmental bone defects is a crucial point of limb salvage surgeries after malignant bone tumor resections. Megaendoprostheses implantation is a commonly used method for adult patients, but hardly usable for children below 12 years old, because of the small size of the host bone and multiple mechanic complications. Objective: Extracorporeal irradiation and allograft reimplantation (ECRT, ECI) are promising methods for these young children for limb salvage, reducing the number of prostheses revisions, reoperations. Method: In Hungary, we performed limb salvage surgery for malignant bone tumor in 12 cases in children under 12 years old, using extracorporeally irradiated autografts as biological reconstruction. All cases were primary bone tumors (Ewing’s sarcoma: 7, osteosarcoma: 4, chondrosarcoma: 1). The average age of our patients was 9 (3–12) years, the average follow-up was 32.5 (2–73) months. At follow-up, we performed physical examination, X-ray, and other imaging methods if they were necessary. Our results were compared to international publications. Results: We observed no local recurrence, but in one case we had to perform above-knee amputation, due to a skip metastasis in the proximal tibia. The complication rates were similar to those reported in other papers. Septic complications were treated in two cases (16.7%). Total union of the resection lines was observed at 3–9 months in 60% of all cases. Reoperations were performed due to nonunion, or allograft fracture/partly desorganization in 3 cases, twice with new allograft, and with prostheses in one case. The subjective opinion of our patients is positive, they walk with full weightbearing, some of them do even light sporting activities. Conclusions: We found extracorporeal irradiation a useful and safe method for children under 12 years old for biological reconstruction after malignant bone tumor resection. Complication rate stays under the rate of growing prostheses complications, in optimal cases further radical, and extensive surgeries may be avoided. In the case of major complications, megaendoprostheses implantation later on is still an option as salvage procedure with limb salvage. Orv Hetil. 2020; 161(45): 1914–1919.

Parosteal Osteosarcoma: A Benign-Looking Tumour, Amenable to a Variety of Surgical Reconstruction

Osteosarcoma arising from cortical surface is classified into parosteal, periosteal and high-grade surface osteosarcoma. Along the spectrum, parosteal osteosarcoma occupies the well-differentiated end. It is a relatively rare disease entity, comprised only 4% of all osteosarcomas and barely reported in the literature. The objective of this study is to describe cases of parosteal osteosarcoma as well as a variety of treatment options amenable to such entity. Six cases of parosteal osteosarcoma were identified based on histopathological reports in a tertiary referral hospital in Jakarta, Indonesia between January 2001 and December 2019. The mean age was 29.8 years old; four of them (66.7%) were male. Distal end of femur was the most commonly involved bone (five cases, 83.3%). The patients were treated with wide excision followed by several different reconstruction methods: replacement with endoprosthesis, extracorporeal irradiation, knee arthrodesis, or prophylactic fixation. One of our patients presented with dedifferentiated component, and therefore was treated by limb ablation. While two cases died of pulmonary metastasis, other patients reported fair to excellent functional outcome.

Analysis of vascularized fibula graft integration to the extracorporeal irradiated bone after replantation: 2-year follow-up

Background: Major bone segmental defects in oncologic patients continue as a therapeutic challenge to orthopedic surgeons. The few alternatives for its management and the relationship between functional outcome and surgical complications remain among the main restrictions for the indication of different techniques. One of these alternatives is the vascularized fibular graft in association with the creation of a bone channel made from resection of the tumor bone segment after being submitted to the extracorporeal irradiation technique. There is little subject information about long-term follow-up either prospective than retrospective studies. Aim of the study: Retrospective evaluation of vascularized fibular graft union capacity from diaphysis and metaphysis and its integration to the irradiated bone after transplantation. Methods: Eleven patients submitted to extracorporeal irradiation technique and replantation with vascularized fibular graft had their radiographic images on 6, 12 and 24 months of postoperative period evaluated. Results: We observed 45,4% in diaphysis integration in the first year and 72,7% in the second year of follow-up, progressive in the diaphysis focus, and maintenance of the metaphysis focus (33,3%). Conclusion: The fibula has a good capacity for bone integration, showing less influence on the union of the metaphysis portion.Descriptors: Bone Transplantation; Osteosarcoma; Microsurgery; Surgical Oncology.ReferencesMyers GJ, Abudu AT, Carter SR, Tillman RM, Grimer RJ. The long-term results of endoprosthetic replacement of the proximal tibia for bone tumours. J Bone Joint Surg Br. 2007;89(12):1632-37.Muscolo DL, Ayerza MA, Aponte-Tinao L, Farfalli G. Allograft reconstruction after sarcoma resection in children younger than 10 years old. Clin Orthop Relat Res. 2008;466(8):1856-62.Puri A, Gulia A, Jambhekar N, Laskar S. The outcome of the treatment of diaphyseal primary bone sarcoma by resection, irradiation and re-implantation of the host bone: extracorporeal irradiation as an option for reconstruction in diaphyseal bone sarcomas. J Bone Joint Surg Br. 2012;94(7):982-88.Hong AM, Millington S, Ahern V, McCowage G, Boyle R, Tatersall M et al. Limb preservation surgery with extracorporeal irradiation in the management of malignant bone tumor: the oncological outcomes of 101 patients. Ann Oncol. 2013;24(10):2676-80.Manfrini M, Vanel D, De Paolis M, Malaguti C, Innocenti M, Ceruso M et al. Imaging of vascularized fibula autograft placed inside a massive allograft in reconstruction of lower limb bone tumors. AJR Am J Roentgenol. 2004;182(4):963-70.Spira E, Lubin E. Extracorporeal irradiation of bone tumor. A preliminary report. Isr J Med Sci. 1968;4(5):1015-19.Krieg AH, Davidson, AW, Stalley PD. Intercalary femoral reconstruction with extracorporeal irradiated autogenous bone graft in limb-salvage surgery. J Bone Joint Surg Br. 2007;89(3):366-71.Ceruso M, Falcone C, Innocenti M, Delcroix L, Capanna R, Manfrini M. Skeletal reconstruction with a free vascularized fibula graft associated to bone allograft after resection of malignant bone tumor of limbs. Handchir Mikrochir Plast Chir. 2001;33(4):277-82.Ortiz-Cruz E, Gebhardt MC, Jennings LC, Springfield DS, Mankin HJ. The results of transplantation of intercalary allografts after resection of tumors. A long-term follow-up study. J Bone Joint Surg Am. 1997;79(1):97-106.Farfalli GL, Aponte-Tinao L, Lopez-Millán L, Averza MA, Muscolo DL. Clinical and functional outcomes of tibial intercalary allografts after tumor resection. Orthopedics. 2012;35(3):e391-96.Aponte-Tinao L, Farfalli GL, Ritacco LE, Averza MA, Muscolo DL. Intercalary femur allografts are an acceptable alternative after tumor resection. Cln Orthop Relat Res. 2012;470(3):728-34.

Reconstructive Challenges of Proximal Ulnar Bone Tumors: Our Experience with Biological Osteoarticular Reconstruction Using Extracorporeal Irradiation and Reimplantation

Introduction. Limb salvage surgery following proximal ulna resection poses a challenge in reconstruction of the complex elbow anatomy. Various reconstruction methods described offer inadequate restoration of function and stability. Following resection of proximal ulna tumors, we aimed to restore the joint using the resected osteochondral segment of proximal ulna treated with extracorporeal irradiation and reimplantation. Questions/Purposes. (1) Does irradiated osteoarticular autograft reconstruction for proximal ulna allow anatomical joint restoration and what are the oncological and functional outcomes? (2) Is there evidence of graft-related complications or osteoarthritis at a minimum of 2 years follow-up with irradiated osteoarticular autografts for the proximal ulna? (3) How does our method of reconstruction fare as compared to reported reconstruction options in the literature? Materials and Methods. 3 patients with primary bone tumors involving the proximal ulna underwent limb salvage surgery with en bloc resection and reconstruction using the resected bone after treating it with extracorporeal irradiation of 50 Gy. Minimum follow-up of 2 years was considered for assessment of final outcomes. Radiographs were assessed for bony recurrence, union across osteotomy junction, and signs of joint arthritis. Functional outcome measures included range of movement, muscle power testing, and functional and disability scores. Results. 2 complete and 1 partial olecranon involving proximal ulnar resections were performed for three cases of Ewing’s sarcoma in 2 males and 1 female. Follow-up ranged from 28 to 42 months, and all patients continue to remain disease free. All 3 patients have achieved full range of flexion-extension and pronosupination movement in comparison to the contralateral side. Muscle power for flexion and extension was 5/5. MSTS score: 100% (30/30); MEPS score: 100; and DASH score: zero were achieved for all patients. Union across osteotomy junctions at median follow-up of 8 months without need for intervention/bone grafting was achieved. No complications related to joint laxity/subluxation, infection, graft fracture, or implant failure was noted. None of the patients have clinical or radiological signs of joint arthritis across the irradiated articulation. Conclusion. Biological restoration of elbow anatomy using osteoarticular irradiated graft for proximal ulna reconstruction offers great joint stability and functional outcomes. Although the potential risks of infection and graft failure need to be considered, reconstruction with the size-matched radiated autograft eliminates donor site morbidity, offers a low-cost alternative to endoprosthesis, and provides outcomes superior to any other methods of reconstruction as analyzed from the literature.