Abstract
Purpose: Use of massive allografts for reconstruction of major bone stock defects remains a controversial issue. We reviewed our experience to compare results with other methods, particularly free vascularised bone transfer reconstructions.
Material and method: Between 1983 and 1995, 36 patients (15 men and 21 women) underwent cancerological resection of a long bone shaft for primary malignant tumour. Mean age was 19 years (8–84). The tumour was a high-grade sarcoma in 26 cases, low grade sarcoma in eight and adamantinoma in two. Mean length of resection was 19 cm (14–34). Cryopreserved allografts were used in 24 cases, gamma irradiated allografts in 12. Various osteosynthesis procedures were used, generally combining an axial assembly with a single or dual epiphyseal construct. Localisations were: femur 24, tibia ten and humerus four. All patients were reviewed at a minimum follow-up of five years (range 5–16 years, mean 8 years). Functional outcome was assessed with the Enneking criteria. Bone healing at junctions was considered to be achieved when there was no clinical expression and radiographic images remained unchanged for two years.
Results: All immediate complications were infections (one femur four tibias) and required partial or total ablation of the allograft in four cases and amputation in one (tibia). The predominant late complications were late consolidation (n=13) and stress fracture of the allograft (n=6). Six patients died before bone healing and were not retained for analysis. Among the 28 patients retained for analysis (eight excluded: six deaths, one amputation, one total ablation of the allograft), only ten achieved bone healing after one procedure. The other eighteen required on the average four reoperations to achieve consolidation (3–11 procedures for osteosynthesis and new allograft material). All patients had achieved bone healing at last follow-up. Functional outcome was excellent for femurs, good for tibias, and fair for humeri due to the impact on shoulder function. There was no significant difference in consolidation with cryopreserved and irradiated bone material but two irradiated grafts could not be used correctly because they were to friable.
Discussion: These more or less satisfactory results must be examined in light of the context. Cancerologicl resection (periosteum + soft tissue), generally combined with adjuvant treatment (chemotherapy for 24 patients and radiotherapy for three), places the patient in conditions highly unfavourable for bone healing. Use of allografts alone, combined with approximate fixation procedures early in our experience, demonstrated the limitations of the technique (only two primary consolidations among 18 patients). However, when the allograft was combined with axial fixation and immediate allograft or allograft after adjuvant treatment, primary consolidation was achieved in 80% of the cases (eight out of ten). All patients who achieved long-term remission conserved a functional limb with relatively preserved bone stock.
Conclusion: Despite controversial results, massive allograft reconstructions can provide a useful alternative to fill major bone stock defects of the femur or humerus. For the tibia the risk of infections may require further discussion before determining the best approach. These results should be compared with those in a homogeneous series of patients treated with a vascularised free bone transfer, but to our knowledge no such series is available in the literature.
The abstracts were prepared by Pr. Jean-Pierre Courpied (General Secretary). Correspondence should be addressed to him at SOFCOT, 56 rue Boissonade, 75014 Paris, France
