Luis A. Aponte-Tinao

Intercalary femur and tibia segmental allografts provide an acceptable alternative in reconstructing tumor resections.

Intercalary femur and tibia segmental allografts were implanted in 59 consecutive patients after segmental resection—52 for malignant and seven for benign aggressive bone tumors. The patients were followed up for an average of 5 years. Allograft survival was determined with the Kaplan–Meier method. Infection, fracture, and nonunion rates were determined. The overall 5-year survivorship for the 59 intercalary allografts was 79%, and we found no significant differences between allograft survival in patients receiving or not receiving adjuvant chemotherapy. Infection and fracture rates were 5% and 7% respectively. From 118 host-donor junctions, 11 did not initially heal (9%). The nonunion rate (10 of 69 osteotomies) for diaphyseal junctions was higher than the rate (one of 49 osteotomies) for metaphyseal junctions. Although some patients required reoperations because of allograft complications, it seems that the use of intercalary allograft clearly has a place in the reconstruction of a segmental defect created by the resection of a tumor in the diaphyseal and /or metaphyseal portion of the femur or tibia.

Use of Distal Femoral Osteoarticular Allografts in Limb Salvage Surgery

BACKGROUND As diagnostic and therapeutic techniques improve, patients with a musculoskeletal sarcoma should expect longer survival, fewer complications and side effects, and an improved quality of life. Functional longevity of the reconstruction after resection of the tumor becomes a major concern, especially in young and physically active patients. The purpose of this study was to analyze the mid-term and long-term survival of reconstructions with a distal femoral osteoarticular allograft in a series of patients. METHODS We retrospectively reviewed the results of eighty reconstructions with a distal femoral osteoarticular allograft following resection of a bone tumor in seventy-six patients. The mean duration of follow-up was eighty-two months. The rates of survival of the allograft and the joint surface were estimated with use of the Kaplan-Meier method. Cox regression analysis was performed to determine whether age, gender, the percentage of the femur that had been resected, and the use of chemotherapy were independent prognostic factors. Functional and radiographic results were documented according to the Musculoskeletal Tumor Society scoring system at the time of the latest follow-up. RESULTS Five patients were lost to follow-up, leaving seventy-five allografts in seventy-one patients available for study. Thirteen patients (thirteen allografts) died of tumor-related causes without allograft failure before a two-year radiographic follow-up could be performed. Of the remaining sixty-two allografts, fourteen failed: six failed as a result of infection; four, because of local recurrence; one, because of massive resorption; and three, as a result of fracture. At the time of final follow-up, at a mean of 125 months, forty-eight allografts were still in place. The overall rate of allograft survival was 78% at both five and ten years, and the rate of allograft survival without the need for resurfacing with a knee prosthesis was 71% at both five and ten years. With the numbers available, age, gender, the percentage of the femur that had been resected, and the use of chemotherapy were not found to have a significant effect on the overall allograft survival rates. The patients who retained the original allograft had good or excellent functional and radiographic results. CONCLUSIONS The life expectancy for most patients with a highly aggressive or malignant tumor in the distal part of the femur is now several decades. In this study, we found a high rate of survival of distal femoral allograft reconstructions at both five and ten years.

Partial Epiphyseal Preservation and Intercalary Allograft Reconstruction in High-Grade Metaphyseal Osteosarcoma of the Knee

BACKGROUND The purpose of this study was to analyze a series of patients with a high-grade metaphyseal osteosarcoma of the knee who had been treated with a transepiphyseal resection, with preservation of the distal femoral and the proximal tibial (articular) portions of the epiphysis, and an intercalary allograft reconstruction. METHODS The cases of thirteen patients with a high-grade metaphyseal osteosarcoma around the knee who had transepiphyseal resection and reconstruction with an intercalary allograft were retrospectively reviewed at a mean of sixty-three months. Complications, disease-free survival of the patient, final preservation of the limb and epiphysis, and functional results according to the Musculoskeletal Tumor Society scoring system were documented at the time of the latest follow-up. RESULTS At the final follow-up examination, eleven of the thirteen patients continued to be disease-free. One patient died of bone and pulmonary metastases with no evidence of local recurrence, and the remaining patient had no evidence of disease after resection of a local recurrence of the tumor in the soft tissues. No patient had a local recurrence in the remaining epiphysis. Seven patients had complications that included a fracture (three patients), diaphyseal nonunion (two), deep infection (one), and a local recurrence in the soft tissues (one). The allograft was removed in only four of these patients. At the latest follow-up examination, twelve patients were alive with preserved limbs. In one patient, the epiphysis, which originally had been preserved, was resected because of a metaphyseal fracture, and the limb was reconstructed with an osteoarticular allograft. The patients with a preserved epiphysis had an average functional score of 27 points (maximum, 30 points). CONCLUSIONS Preservation of the epiphysis in high-grade metaphyseal osteosarcoma at the knee is an alternative in carefully selected patients. Crucial factors needed to obtain local tumor control and achieve an acceptable functional result are a positive response to chemotherapy, accurate preoperative assessment of tumor extension to the epiphysis, and appropriate fixation techniques for intercalary allografts. LEVEL OF EVIDENCE Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Survivorship and radiographic analysis of knee osteoarticular allografts.

An evaluation of long-term survival and radiographic deterioration of 118 knee osteoarticular allografts in 114 patients was performed. Radiographic analysis was done according to the Musculoskeletal Tumor Society grading system. A failure was defined as when the allograft was removed during a revision procedure or amputation. Ten patients were lost to followup during the first 2 years after surgery. Eighteen patients without allograft failures died of complications related to the tumor. Twenty-six allografts failed because of infection (13 allografts), local recurrence (eight allografts), massive resorptions (three allografts) and fractures (two allografts). Sixty-four allografts still were in place at a mean of 98 months (range, 36-360 months) after implantation. The Kaplan-Meier 5-year survival rate for the knee osteoarticular allografts was 73% and the limb preservation rate was 93%. The mean radiographic score was 83%. Sixty-four percent of the allografts showed no radiologic changes or minor articular deterioration. Fourteen percent had narrowing of the joint space of more than 2 mm, and 22% had some form of subchondral bone collapse. Five patients required joint resurfacing to preserve the original allograft. Most of the allograft failures occurred during the first 4 years, and the allograft survival rate for the current series remained unchanged after 5 years.

Tumors About the Knee Misdiagnosed as Athletic Injuries

Background: Musculoskeletal tumors may originally mimic a traumatic condition, and, on the basis of an erroneous diagnosis of an athletic injury, an invasive diagnostic or therapeutic procedure may be performed. We determined the number of such cases treated at our institution, and we analyzed the initial and final diagnoses as well as the changes in the indicated oncologic surgical technique due to the initial erroneous diagnosis. Methods: Twenty-five patients who had a bone or soft-tissue tumor about the knee that originally had been diagnosed as an athletic injury were referred to our institution. The complete clinical, radiographic, and pathological records were reviewed. Studies that had been performed prior to the invasive procedure and at the time of admission to our institution were evaluated to determine differences in the tumor stage and the oncologic treatment that was indicated at each time. Results: Of 667 knee tumors diagnosed in our institution, twenty-five (3.7%) previously had been treated with an intra-articular procedure as a result of a misdiagnosis of an athletic injury. The final diagnoses made at our institution were a benign tumor in eleven patients and a malignant tumor in fourteen. Oncologic surgical treatment was affected in fifteen of the twenty-five patients. Conclusions: When a knee tumor is initially misdiagnosed as an athletic injury, treatment may be adversely affected by the delay in diagnosis or an inappropriate invasive procedure that results in extension of the tumor. Initial poor-quality radiographs and an unquestioned original diagnosis despite persistent symptoms were the most frequent causes of an erroneous diagnosis. Level of Evidence: Prognostic study, Level IV (case series). See Instructions to Authors for a complete description of levels of evidence.

Accuracy of 3-D planning and navigation in bone tumor resection.

Surgical precision in oncologic surgery is essential to achieve adequate margins in bone tumor resections. Three-dimensional preoperative planning and bone tumor resection by navigation have been introduced to orthopedic oncology in recent years. However, the accuracy of preoperative planning and navigation is unclear. The purpose of this study was to evaluate the accuracy of preoperative planning and the navigation system. A total of 28 patients were evaluated between May 2010 and February 2011. Tumor locations were the femur (n=17), pelvis (n=6), sacrum (n=2), tibia (n=2), and humerus (n=1). All resections were planned in a virtual scenario using computed tomography and magnetic resonance imaging fusion. A total of 61 planes or osteotomies were performed to resect the tumors. Postoperatively, computed tomography scans were obtained for all surgical specimens, and the specimens were 3-dimensionally reconstructed from the scans. Differences were determined by finding the distances between the osteotomies virtually programmed and those performed. The global mean of the quantitative comparisons between the osteotomies programmed and those obtained through the resected specimen was 2.52±2.32 mm for all patients. Differences between osteotomies virtually programmed and those achieved by navigation intraoperatively were minimal.

Use of Distal Femoral Osteoarticular Allografts in Limb Salvage Surgery: Surgical Technique

BACKGROUND As diagnostic and therapeutic techniques improve, patients with a musculoskeletal sarcoma should expect longer survival, fewer complications and side effects, and an improved quality of life. Functional longevity of the reconstruction after resection of the tumor becomes a major concern, especially in young and physically active patients. The purpose of this study was to analyze the mid-term and long-term survival of reconstructions with a distal femoral osteoarticular allograft in a series of patients. METHODS We retrospectively reviewed the results of eighty reconstructions with a distal femoral osteoarticular allograft following resection of a bone tumor in seventy-six patients. The mean duration of follow-up was eighty-two months. The rates of survival of the allograft and the joint surface were estimated with use of the Kaplan-Meier method. Cox regression analysis was performed to determine whether age, gender, the percentage of the femur that had been resected, and the use of chemotherapy were independent prognostic factors. Functional and radiographic results were documented according to the Musculoskeletal Tumor Society scoring system at the time of the latest follow-up. RESULTS Five patients were lost to follow-up, leaving seventy-five allografts in seventy-one patients available for study. Thirteen patients (thirteen allografts) died of tumor-related causes without allograft failure before a two-year radiographic follow-up could be performed. Of the remaining sixty-two allografts, fourteen failed: six failed as a result of infection; four, because of local recurrence; one, because of massive resorption; and three, as a result of fracture. At the time of final follow-up, at a mean of 125 months, forty-eight allografts were still in place. The overall rate of allograft survival was 78% at both five and ten years, and the rate of allograft survival without the need for resurfacing with a knee prosthesis was 71% at both five and ten years. With the numbers available, age, gender, the percentage of the femur that had been resected, and the use of chemotherapy were not found to have a significant effect on the overall allograft survival rates. The patients who retained the original allograft had good or excellent functional and radiographic results. CONCLUSIONS The life expectancy for most patients with a highly aggressive or malignant tumor in the distal part of the femur is now several decades. In this study, we found a high rate of survival of distal femoral allograft reconstructions at both five and ten years.

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

BackgroundThe 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/purposesWe asked whether over the past three decades limb-sparing procedures in high-grade osteosarcoma had increased, and whether this affected survival and ultimate amputation.MethodsWe 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.ResultsThe 5-year survival rate in the first period was 36%, whereas in the 1990s, it was 60% and 67% from 2000–2004. Limb salvage surgery rate in the 1980s was 53% (28 of 53), whereas in the 1990s, 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 1990s, it was 81% (79 of 97) and 93% from 2000–2004 (94 of 101).ConclusionsPatients with osteosarcoma treated in the last two periods had higher rates of limb salvage treatment and survival, with lower secondary amputation.Level of EvidenceLevel III, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Long-Term Results of Allograft Replacement After Total Calcanectomy. A Report of Two Cases*

Total calcanectomy for the treatment of a primary tumor of the calcaneus is rarely indicated, and options for reconstruction after this procedure are limited. However, replacement of the entire calcaneus with a massive allograft is one option. We report the cases of two patients who had a reconstruction with a total calcaneal allograft and were followed for thirty-two and nine years. The case of the first patient was reported previously in The Journal of Bone and Joint Surgery, in 1953, after a short duration of follow-up8. We are not aware of any previous reports on the long-term results of this procedure. CASE 1. A fourteen-year-old boy was admitted to our hospital in July 1948 with a swollen, painful left ankle. Routine laboratory data (including the erythrocyte sedimentation rate, the leukocyte count, and the serum levels of alkaline phosphatase, calcium, and phosphorus) were within normal limits, and radiographs of the lungs revealed normal findings. Radiographs of the left foot and ankle showed an osteolytic lesion involving most of the calcaneus (Fig. 1-A). FIG1-A: Figs. 1-A, 1-B, and 1-C: Case 1. Fig. 1-A: Preoperative lateral radiograph showing an osteolytic lesion involving most of the calcaneus. An aspiration biopsy and a subsequent open biopsy confirmed the diagnosis of chondrosarcoma. An aspiration biopsy and a subsequent open biopsy established the diagnosis of chondrosarcoma, which was confirmed by Dr. Fritz Schajowicz. The patient was operated on by Dr. Carlos Ottolenghi in August 1948. The entire calcaneus was removed, and an allogenic fresh-frozen calcaneus was inserted (Fig. 1-B). There was a problem with the size of the allograft because the only calcaneus that was available at the time of the operation was smaller than the calcaneus that had been removed from the patient. The allograft was drilled in several directions in an attempt to …

A High-grade Sarcoma Arising in a Patient With Recurrent Benign Giant Cell Tumor of the Proximal Tibia While Receiving Treatment With Denosumab

BackgroundA giant cell tumor of bone is a primary benign but locally aggressive neoplasm. Malignant transformation in a histologically typical giant cell tumor of bone, without radiotherapy exposure, is an uncommon event, occurring in less than 1% of giant cell tumors of bone. Although surgery is the standard initial treatment, denosumab, a monoclonal antibody drug that inhibits receptor activator of nuclear factor-κB ligand (RANKL), has shown considerable activity regarding disease and control of symptoms in patients with recurrence, unresectable, and metastatic giant cell tumors of bone.Case DescriptionWe report the case of a 20-year-old woman with a recurrent benign, giant cell tumor of bone, who had a bone sarcoma develop while receiving denosumab treatment.Literature ReviewTo our knowledge, there have been no reports of infection or malignancy with low-dose denosumab administration for osteoporosis. However, while there are relatively few reported side effects, the safety of denosumab and adverse events seen with higher doses, as used in treatment of giant cell tumors of bone are not well defined.Clinical RelevanceDenosumab has become a valuable adjunct for treatment of recurrent or unresectable giant cell tumor of bone. It is not clear if our patient’s malignant transformation of a giant cell tumor of bone while receiving denosumab treatment was caused by denosumab, but it is important to be aware of the possibility if more cases occur. Future studies should focus on the safety of high-dose denosumab administration in patients with a benign unresectable giant cell tumor of bone.