MPA Bus1, JAM Bramer1, GR Schaap1, RPH Veth3, HWB Schreuder3, PC Jutte4, MAJ van de Sande2, ICM van

der Geest3, PDS Dijkstra2, AHM Taminiau2

Intercalary AllograftsWhen are they successful?

1Academic Medical Center, Amsterdam 2Leiden University Medical Center, Leiden3Radboud University Medical Center, Nijmegen 4University Medical Center, Groningen

• Resection: save adjacent joints • Intercalary reconstruction

Diaphyseal tumors

Option: intercalary allograft

+ Stable+ Saves bone stock

- Dead bone

Ortiz-Cruz (JBJS 1997) – 104 patients• Non-union 30%• Fracture 17%• Infection 12%• Failure 14%

Frisoni (JBJS 2012) – 101 patients (femur)• Non-union 46.5%• Failure 31.5%

Literature

Treatment of bone tumors: centralized in 4 appointed centers

Dutch situation

JAM Bramer

GR Schaap

PDS Dijkstra

MAJ vd Sande

(AHM Taminiau)

ICM vd Geest

HWB Schreuder

(RPH Veth)

PC Jutte

How successful are they?When can we use them?

How should we fixate them?

Intercalary Allografts – Dutch results

Retrospective study in 4 centers

– 1989-2009

– Resection primary bone tumor in extremity

– Reconstruction with intercalary allograft

– Whole circumference

– Minimum follow-up six months

Methods

• Characteristics of patient, tumor, treatment, allograft & reconstruction

• Complications• Non-union• Infection• Fractures• Other

• Time to full weight-bearing

Methods

• 94 total (51 male, 43 female)

Patients

Diagnoses

• Osteosarcoma 43 (46%)

• Ewing’s sarcoma 18 (19%)

• Adamantinoma 15 (16%)

• Chondrosarcoma 12 (13%)

• Other 6 ( 6%)

Localization

• Femur 50 (55%)

• Tibia 34 (36%)

• Humerus 7 ( 7%)

• Radius 2 ( 2%)

• Fibula 1 ( 1%)

• Mean 15 cm, median 14.5 cm (range 4 – 31 cm)

• >1/3 of bone length 67 (71%)

• > Median-1SD (9.33 cm) 83 (88%)• > 17 cm 31 (33%)• > Median+1SD (19.33 cm) 18 (19%)

Allograft length

Osteosynthesis

Bridging 67 (71%)

Non-bridging27 (29%)

Osteosynthesis

• Plate 43 (46%)

• Plate + fibular strut 22 (23%)

• Plate + im nail 12 (13%)

• Im nail 12 (13%)

• Screws 5 ( 5%)

Adjuvant therapy

• Chemotherapy 57 (61%)

• Radiotherapy 8 ( 9%)

• Both 7 ( 7%)

• All: 6.3 years (0.5 – 22)• 77 survivors: 7.5 years (0.5 – 22)• 17 deceased: 2.3 years (0.5 – 12)

• >2 years follow-up: 80% (for survivors: 91%)

• >5 years follow-up: 60% (for survivors: 68%)

Follow-up

• In 66 patients (70%)• ≥2 in 35 patients (37%)

Complications

• Non-union 33 (35%)

• Fracture 23 (25%)

• Infection 12 (13%)

• Re-operation(s) in 59 patients (63%)

Complications

• Median 59 weeks (1 – 288)

Time to first complication

• Median 109 weeks (1 – 884)

Time to last complication

• For femur & tibia (84 patients)

• Data for 53 patients (63%)– Median 41 weeks– Range 7 weeks – 6.5 years

Time to full weight-bearing

• 16 failures (17%)

Failures

6 non-unions (38%)6 infections (38%)4 fractures (25%)

• Reconstruction length – groups compared at different cut-off points

• Risk of…– Infections?– Fractures?– Non-unions?– Complications?– ↑ time to full weight-bearing?

When to use – risk factors?

• Reconstructions >9.33 cm (median-1SD) compared with those <9.33 cm

• Risk of…– Infections? No– Fractures? No– Non-unions? Significant higher– Complications? No– ↑ time to full weight-bearing? No

When to use – risk factors?

Significant higher risk of non-union in reconstructions > 9.33 cm

< 9.33 cm > 9.33 cm pNon-union 1 / 11 (9%) 32 / 83 (38%) 0.05

Allograft length

• Chemotherapy compared with no chemotherapy

• Risk of…– Infections? No– Fractures? No– Non-unions? No– Complications? No– ↑ time to full weight-bearing? No

When to use – risk factors?

• Radiotherapy compared with no radiotherapy

• Risk of…– Infections? No– Fractures? Trend to higher risk– Non-unions? No– Complications? No– ↑ time to full weight-bearing? Significant longer

When to use – risk factors?

Trend to higher fracture risk

Significant longer time to full weight-bearing

RT No RT p

Patients with a fracture

4 / 8 (50%) 19 / 86 (22%) 0.07

RT No RT p

Mean 103 50 0.04Median 71 37Range 41 - 201 7 - 348

Radiotherapy

• Non-bridging compared with bridging

• Risk of...– Infections? No– Fractures? Significant higher– Non-unions? No– Complications? No– ↑ time to full weight-bearing? No

How to fixate – risk factors?

Significant higher fracture risk in case of non-bridging osteosynthesis

Bridging Non-bridging pAll 12 / 67 (18%) 11 / 27 (41%) 0.02

Femur & tibia 11 / 62 (18%) 10 / 22 (45%) 0.01

Osteosynthesis

• Plate compared with other types of osteosynthesis

• Risk of...– Infections? No– Fractures? No– Non-unions? No– Complications? No– ↑ time to full weight-bearing? No

How to fixate – risk factors?

• Im nail compared with other types of osteosynthesis

• Risk of...– Infections? No– Fractures? No– Non-unions? Higher risk – Complications? No– ↑ time to full weight-bearing? Significant longer

How to fixate – risk factors?

Higher non-union risk

Longer time to full weight-bearing

Im nail only Other p

All 7 / 12 (58%) 26 / 82 (32%) 0.07

Femur & tibia 6 / 10 (60%) 21 / 74 (28%) 0.04

Intramedullary nail

Im nail only Other p

Mean 120 46 < 0.01

Median 71 39

Range 13 - 349 7 - 145

• High percentage complications (70%)• Most in first 3 years but some (very) late (infection,

fracture)

• Considerable risk of– Non-union (35%)– Fracture (25%)– Infection (13%)

• High percentage re-operation(s) (63%)• Long partial- and non weight-bearing time

Summary

• Influence of chemotherapy unsure

• Radiotherapy– more fractures– longer non weight-bearing time

Summary

• Non-bridging osteosynthesis – more fractures

• Intramedullary nail only– more non-unions– longer non weight-bearing

• Reconstruction length > 9.33 cm (median-1SD)– more non-unions

Summary

• Therefore:– Not for short term results – Not in case of poor prognosis

– Careful in case of radiotherapy and large defects

– Osteosynthesis• Bridging• Use plates, not (only) im nail

Recommendations

THANK YOU FOR YOUR ATTENTION

Localization within bone piece

Epi-diaphyseal 10 (11%)Meta-diaphyseal 35 (37%)Diaphyseal 49 (52%)

Proximal 20 (21%)Mid 49 (52%)Distal 25 (27%)

Vascularized fibula

• Vascularized fibula 6 ( 6%)• No vascularized fibula 88 (94%)

Complications