Walid Mnaymneh

Limb salvage with osteoarticular allografts after resection of proximal tibia bone tumors.

A retrospective study was performed between 1980 and 1995 on 38 recipients of proximal tibial allografts after wide resection of benign and malignant tumors. Twenty-one (55%) patients experienced one or more complications. Of the 26 patients who received chemotherapy, 15 (58%) experienced one or more complications, whereas of the 12 patients who did not receive chemotherapy, six (50%) experienced one or more complications. In the chemotherapy group, there were 12 (46%) fractures, four (15%) infections, three (12%) nonunions, and four (15%) instabilities. In the nonchemotherapy group there were three (25%) infections, two (17%) fractures, one (8%) instability, and one (8%) nonunion. These complications were managed adequately with multiple subsequent surgical procedures. Three patients underwent amputations for deep wound infections. Twelve (32%) patients underwent removal of the allograft, and the limb was salvaged by reallografting or by total knee arthroplasty. The results of both groups were 66% (25 of 38 patients) satisfactory (good or excellent). The chemotherapy group had a significantly higher incidence of fractures. All other complication rates and functional outcomes were not significantly different between these groups.

Computed tomography evaluation of stability in posterior fracture dislocation of the hip.

Measurements of the percentage of remaining posterior acetabulum on computed tomography (CT) scan (the Acetabular Fracture Index) in posterior fracture dislocations of the hip were evaluated to determine the stability of the joint. All hips with less than 34% of the remaining posterior acetabulum were unstable. Hips with greater than 55% were stable. Between these values, hips were either stable or unstable. A statistical analysis demonstrated highly significant differences in the average remaining posterior acetabulum between the stable and unstable group. These findings were based on a review of 26 patients with posterior fracture dislocations of the hip (Epstein Type I-IV injuries) combined with CT scan analysis. The clinical status of hip stability was correlated with the Acetabular Fracture Index, and this provided the basis for the study. A simple linear measurement of the remaining posterior acetabulum on CT (the Approximate Acetabular Fracture Index) can be done easily by a physician, and this closely approximates the true remaining acetabular arc. Seven of ten unstable hips in 31 Epstein Type I-V patients showed femoral head subluxation of 0.5 mm or more on CT scan, whereas none of the 21 stable hips had demonstrable subluxation. Risk analysis provided a means of predicting hip stability for individual patients.

Massive allografts in salvage revisions of failed total knee arthroplasties

Ten patients with failed total knee arthroplasties and severe bone loss were treated with massive whole distal femur and proximal tibial allografts in combination with prosthetic implants. Fourteen allografts were inserted either as invaginated or segmental grafts and were rigidly fixed to the host bone. Clinically and roentgenographically, 12 of 14 grafts (86%) seemed to have united to the host bone. The average range of motion was 92 degrees. Five patients developed complications; two of these involved the allograft (nonunion and fracture) and two were caused by inadequate healing at the ligament-allograft junction. One patient had a late infection. With careful planning and improved surgical techniques, these complications can be avoided. The massive allograft-prosthesis composite techniques is a viable reconstructive alternative worthy of further clinical trials.

Massive osteoarticular allografts in the reconstruction of extremities following resection of tumors not requiring chemotherapy and radiation.

Since 1976, 70 osteoarticular allografts have been used to reconstruct extremities from which tumors not requiring chemotherapy or radiotherapy have been resected. Allografts excised from cadavers were stored in the vapor phase of liquid nitrogen in liquid nitrogen freezers (-150 degrees) after exposure to 15% glycerol. Prior to their use, the allografts were thawed rapidly in either tissue culture or balanced salt solutions. Following resection of the tumor, the excised bone was replaced with allografts that were rigidly internally fixed with plates and screws or, occasionally, with intramedullary rods. Patients were observed carefully for complications and were subjected to functional evaluations. Complications did not include alterations suggestive of a pronounced immunologic response to the graft. Five patients developed either local recurrences or distal metastasis. Of the remaining 65 patients, followed for one year or longer, osteochondral allografts performed satisfactorily in 55 (84.6%). This group included eight patients with initial complications that were successfully treated. The group of ten patients with unsatisfactory results included four patients with fractures of the grafts, one with fragmentation of the humeral head, three with infections, and two with joint instabilities. Since all patients had either hemi-joint or quarter joint replacements, the overall results achieved so far have been rewarding. However, continued long-term observations of patients with allografts are indicated, as are studies that would allow for the improvement of cartilage preservation, decrease the incidence of fractures, and improve rigidity of internal fixation. The incidence of infection can be reduced by the improvement in surgical technique, particularly with reference to the wound closure.

Cryopreservation of articular cartilage. Ultrastructural observations and long-term results of experimental distal femoral transplantation.

Ultrastructural changes associated with the freeze-preservation of human articular cartilage have been investigated and related to changes in transplanted distal femoral allografts in nonhuman primates. Human osteoarticular specimens were frozen at 2 degrees/minute in the presence of 15% glycerol and kept in liquid nitrogen freezers (vapor phase) from one day to two years. Ultrastructural changes were confined primarily to chondrocytes and were related to the freezing phenomenon, not to the time of storage. The cartilage matrix was affected little, explaining why articular cartilage initially survives clinical transplantation, but later undergoes degenerative changes. Osteoarticular allografts of baboons were frozen in an identical fashion to the human articular cartilage and transplanted into adult baboons. Long-term observations (five years) on these animals showed healing and replacement of the osseous portion of cryopreserved allografts. Fractures that appeared to coincide with maximum revascularization of the graft were the principal complication. Articular surfaces of the cryopreserved allografts underwent degenerative changes over five years. These degenerative changes were also manifested radiologically and appeared similar to those observed in humans. By contrast, fresh osteoarticular allografts healed poorly through fibrous union. However, in one of two fresh allografts, the articular cartilage remained intact five years after transplantation.

Comparison of CT and MR imaging in musculoskeletal neoplasms.

Magnetic resonance (MR) and CT of 50 musculoskeletal neoplasms were compared to investigate the relative values of these modalities in the assessment and staging of musculoskeletal neoplasms and to determine how often they are complementary and when they are redundant. The material included 25 benign and 25 malignant neoplasms, of which 33 were skeletal and 17 were of soft tissue origin. Magnetic resonance was superior to CT with respect to all morphologic criteria except for cortical bone destruction, calcification, ossification, and the assessment of lytic and sclerotic changes in flat bones. Magnetic resonance was found to be complementary to CT in 48% of the cases (30% malignant, 18% benign). Use of both MR and CT was considered redundant in 52% of the cases (20% malignant, 32% benign). Magnetic resonance was found to be the modality of choice for all benign and malignant soft-tissue neoplasms. Both modalities are complementary and necessary for complete evaluation of malignant skeletal tumors. Benign skeletal tumors should be considered for evaluation by CT, MR, or both on an individual case basis.

Allograft reconstruction for bone sarcoma of the tibia in the growing child

The outcome of tibial allograft reconstruction after resection of a tumour is inconsistent and has a high rate of failure. There are few reports on the use of tibial allografts in children with open growth plates. We performed 21 allograft reconstructions (16 osteoarticular, five intercalary) in 19 consecutive patients between seven and 17 years of age. Two had Ewings sarcoma, one an adamantinoma and 16 osteosarcoma, one with multifocal disease. Five patients have died; the other 14 were free from disease at the time of follow-up. Six surviving patients (eight allograft reconstructions) continue to have good or excellent function at a mean of 59 months (14 to 132). One patient has poor function at 31 months. The other seven patients have a good or excellent function after additional procedures including exchange of the allograft and resurfacing or revision to an endoprosthesis at a mean of 101 months (43 to 198). The additional operations were performed at a mean of 47 months (20 to 84) after the first reconstruction. With the use of allograft reconstruction in growing children, joints and growth plates may be preserved, at least partially. Although our results remain inconsistent, tibial allograft reconstruction in selected patients may restore complete and durable function of the limb.

Massive distal femoral osteoarticular allografts after resection of bone tumors.

Records were reviewed for 96 patients who received distal femoral osteoarticular allografts to reconstruct femurs after wide resections of benign and malignant bone tumors. Thirteen of these were excluded from the study because of death or local recurrence. The mortality rate for all patients was 11%; for those with osteosarcomas it was 27%. The local recurrence rate was 3%. Eighty-three patients were subjected to further analysis. Their complications included fractures (14%), nonunions (12%), arthritis (10%), instability (7%), infections (6%), and resorption (6%). There was a significant difference in nonunion and infection rates between patients who received chemotherapy and those who did not. In the chemotherapy group, the infection rate was 13% versus 2% in the non-chemotherapy group. Nonunion rates were 23% versus 6% respectively. The differences in all other complication rates were not statistically significant. In patients not receiving chemotherapy (n = 53), final results were good or excellent in 70%, fair in 26%, and poor in 4%. In patients receiving chemotherapy (n = 30), final results were good or excellent in 53%, fair in 37%, and poor in 10%.

Allograft reconstruction after resection of malignant tumors of the scapula

The oncologic and functional outcomes of six patients who had scapular allograft reconstruction after scapulectomy for malignant tumors were reviewed. Five patients had Stage IIB and one patient had Stage IB tumors. Total scapulectomy was done in five patients, and partial scapulectomy (glenoid and neck) was done in one patient. Frozen glycerolized scapular allografts were implanted and fixed with plates and screws. The scapular muscles were reattached to the allograft. Tendon reconstruction to replace the excised muscles was done in two patients. The patients were followed up for an average of 3.8 years (range, 2–6 years). Cosmesis, elbow, and hand function were good in all patients. There were no infections, nonunions, or shoulder dislocations. One patient fractured the body of the allograft after a fall. One patient had local recurrence and had scapulectomy 5 years postoperatively. Two patients died 3 and 5 years postoperatively with lung metastases but with functioning grafts. The mean functional result using the Musculoskeletal Tumor Society functional score was 82 (range, 77–87). In this series, scapular allograft reconstruction restored cosmesis, shoulder stability, and function. Preservation or reconstruction of rotator cuff muscles is recommended.

Unplanned Surgical Excision of Tumors of the Foot and Ankle

BACKGROUND Soft-tissue tumors of the foot and ankle are relatively common and mostly benign. Thus, many malignant tumors in this region are improperly treated initially. Unplanned excisions can lead to complications that may adversely affect patient outcomes and prognosis. METHODS A retrospective review of patients treated at our institute over a 20-year period for malignant soft-tissue tumors of the foot and ankle was performed. The effect of unplanned surgical excisions on outcomes was examined. RESULTS When limb salvage was attempted, patients who underwent unplanned surgical excisions had more complications and more extensive surgical procedures involving free flaps, and they were more likely to require adjuvant radiotherapy. No difference in recurrence and disease-free survival was evident between the two patient populations. CONCLUSIONS Despite the lack of statistical power to demonstrate differences in recurrence and survival, unplanned surgical excisions of soft-tissue sarcomas of the foot and ankle probably adversely affect quality of patient care. Suspicious lesions should be referred to surgeons trained in oncologic principles for evaluation and treatment.