Infection in massive bone allografts

We studied a series of 945 patients who received cadaveric allografts implanted for nonpelvic bone or soft tissue tumor lesions since 1971. We specifically were interested in the role of infection in the graft process, and, more specifically its history, frequency, and affect on outcome. Primary infections (not related to reoperations for nonunions or fractures of the graft) occurred in 75 patients (7.9%), and an additional 46 patients had infections related to reoperations, increasing the total number of patients with infections to 121 (12.8%). The highest frequency of infection occurred in patients with soft tissue tumors, radiated sites, Musculoskeletal Tumor Society Stage IIB tumors, or surgeries consisting of an allograft arthrodesis. Most of the infected grafts failed; however, none of the patients died. One patient had hepatitis C develop, and one patient became HIV positive after receiving the virus from a blood transfusion. A comparison with other series of surgically treated patients, including those receiving metallic devices, suggests that the infection rate may be related to the surgery or the graft's immunologic resistance, rather than the graft. The problem of infection is a major issue for tumor surgeons. Suggestions regarding how to decrease the frequency of this complication are presented.     

肢体大块骨缺损的大段同种异体骨关节移植

作者为３５例四肢恶性肿瘤切除后的骨缺损患者进行了大段同种异体骨移植重建，其中男性２３例，女性１２例。股骨下端和胫骨上端占６８．５％。骨肉瘤占４０％。所有病例均经术前、术后化疗。植骨材料来源于该院综合骨库。作者强调充分的术前准备，仔细选择匹配移植骨段，手术中注意设计骨膜袖套和软组织袖套以利于骨愈合。本组病例随访５个月～１０年，平均３年，其中无病存活者２５例，死亡６例，带病存活４例。部分患者于术后２年、４年进行移植骨段活检及９９ｍＴｅＳＰＥＣＴ骨扫描，显示骨段大部完成爬行替代。本组１０例出现１８个合并症，占２８．６％。骨接触端的紧密结合，坚强可靠的内固定或带锁髓内钉固定是有效减少骨不愈合的方法。作者认为，复合同种大段骨移植将成为今后发展的方向。     

肢体大块骨缺损的大段同种异种骨关节移植

作者为３５例四肢恶性肿瘤切除后的骨缺损患者进行了大段同种异体骨移植重建，其中男性２３例，女性１２例。股骨下端和胫骨上端占６８．５％。骨肉瘤占４０％。所有病例均经术前、术后化疗。植骨材料来源于该院综合骨库。作者强调充分的术前准备，仔细选择匹配移植骨段，手术中注意设计骨膜油套和软组织袖套以利于骨愈合。本组病例随访５个月￣１０年，平均３年，其中无病存活者２５例，死亡６例，带病存活４例。部分患者于术后２年     

大段异体骨关节移植后长期转归的观察

目的观察大段人异体骨关节移植后的转归。方法取植入４～６５个月的大段异体骨关节标本,采用组织学及ＢＭＰ分子原位杂交及免疫组化方法,结合随访Ｘ线片及骨核素扫描进行研究。结果外骨痂由宿主骨皮质向异体骨皮质侧生长连接愈合,皮质骨爬行替代相当缓慢,５年时仍大量死骨与活骨共存。异体骨骨松质内可见新骨、骨髓及新生血管,但骨小梁有吸收。非主要负重区的关节软骨细胞部分存活。４个月时异体骨皮质浅层及骨痂ＢＭＰ免疫组化染色及分子原位杂交阳性。植入１２个月至６５个月骨皮质浅、深层及活骨ＢＭＰ表达均呈阴性。结论（１）骨痂由自体骨向异体骨侧生长连接以达到骨性愈合。异体骨关节血运可重建。（２）非负重区关节软骨可部分存活。关节塌陷与骨小梁吸收有关。（３）异体骨内ＢＭＰ在移植后早期的新骨替代及愈合中起作用,１２个月后则主要是靠骨传导而不是骨诱导。（４）坏死骨单位的排除不完全,是异体骨皮质新骨替代慢的原因。     

Tissue-typing in human massive allografts of frozen bone

The cases of twenty-six patients who received a massive allotransplant of frozen bone, with a known degree of histocompatibility between the donor and the recipient, were studied. Twenty-two patients were followed for more than two years (range, twenty-four to ninety-two months). Twenty-three biopsies were performed in sixteen patients from nine to seventy-eight months after transplantation. No clear relationship could be established between the degree of histocompatibility of the donor and the recipient and the incorporation of the graft, probably in part due to the number of variables involved and the polymorphism of the HLA system. However, no early massive resorption of the transplant was seen in this series, in which, by the design of the protocol, no recipients had pre-existing circulating antibodies to the antigens of the donor. Two allografts showed infiltration by round cells and vascular lesions in the absence of infection, which is suggestive of an immune response against antigens from the donor. Both matched poorly with the donor for HLA antigens. The individual who had the strongest reaction was the only recipient in the series who had a massive failure of the transplant.     

Infection in massive bone allografts sterilised by radiation

Summary Massive bone allografts sterilised by radiation have been used in our hospital since 1985. The 164 consecutive reconstructions which we carried out before December 1990 were in equal part for tumour resections and revision arthroplasties associated with major bone defects. The allografts were used as intercalary or composite graft-prosthesis reconstructions. Fourteen (8.5%) skin sloughs or infections occurred, all but one after operations for malignant tumours. The grafts never appeared to be responsible. Infection after malignant tumour resection most commonly occurred at the knee when preoperative radiation had been used. Twenty-five reconstructions were performed in the presence of infection, which only recurred in one case. Twelve infections were treated, but 2 other patients died for other reasons within a year. One patient had to have an amputation and one had persistent infection. In the other cases, the infection healed. Only two debridements alone were successful. Removal of the graft and replacement with antibiotic-loaded cement was the most effective treatment.

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Résumé Les auteurs ont utilisé depuis 1985 des allogreffes massives radio-stérilisées. Des 164 reconstructions successives faites jusqu'à Décembre 1990, la moitié concernait des tumeurs et l'autre des reprises de prothèses avec dégâts osseux majeurs (excluant les petites reconstructions faites avec des têtes fémorales de banque). Il s'agissait de reconstructions intercalaires ou composites (allogreffe-prothèse). Quatorze nécroses cutanées ou infections ont été observées (8,5%). Toutes concernaient des reconstructions pour tumeurs malignes, sauf une, survenue après révision d'une prothèse initialement septique. Les greffes n'ont jamais paru être la cause de l'infection. Le risque septique s'est avéré plus important après résection tumorale et pourtant le rôle de la chimiothérapie n'a pu être prouvé. Des lambeaux de couverture auraient dû éviter les nécroses cutanées qui sont toutes survenues au genou. Vingt-cinq reconstructions ont été faites alors qu'il existait des antécédents d'infection; une seule a récidivé. Douze infections ont été traitées (deux malades étant décédés au cours de la première année d'une cause non infectieuse). Un patient ayant reçu une radiothérapie pré-opératoire a dû être amputé et une infection persiste après un nettoyage simple. Dans les autres cas, l'infection est apparemment guérie, le plus souvent après ablation de la greffe, remplacée temporairement par du ciment imprégné d'antibiotiques, avant reconstruction osseuse secondaire.

     

Consolidation of massive bone allografts in limb-preserving operations for bone tumours

Summary This study analysed the influence of several factors affecting the consolidation time of 83 massive bone allografts in 79 patients with malignant bone tumours: osteosarcoma 57; Ewing's sarcoma 8; malignant fibrous histiocytoma 3; chondrosarcoma 4; fibrosarcoma 5; and giant cell tumours 2. The mean age of the patients was 19 years and the mean length of the allografts was 18 cm. The minimum follow up was for 12 months. The mean consolidation time for metaphyseal and diaphyseal osteotomies was 6.5 and 16 months respectively. Fifteen diaphyseal osteotomies required autologous cancellous grafting. There were 8 allograft fractures after consolidation. The following factors which might influence consolidation were analysed: age of the host and donor; allograft length and site; type of osteotomy and osteosynthesis; intra-arterial and systemic chemotherapy; intraoperative and external radiotherapy. In diaphyseal osteotomies there were statistically significant differences in consolidation time with the use of systemic chemotherapy, external radiotherapy and the recipient's age.

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Résumé Dans le present travail, est analysé le temps de consolidation et les facteurs qui ont pu l'influencer de 83 allogreffes corticospongieuses placées chez 79 patients affectés de tumeurs osseuses primitives malignes (57 ostéosarcomes, 8 sarcomes d'Ewing, 3 HFM, 4 chondrosarcomes, 5 fibrosarcomes et 2 TCG), traités par chirurgie conservatrice, avec un age compris entre 4 et 69 ans (m=19). La durée moyenne de consolidation fut 6.5 mois pour les ostéotomies métaphysaires, 16 pour les diaphysaires, avec 1 pseudarthrose métaphysaire et 7 diaphysaires. Quinze allogreffes ont eu besoin d'un apport de greffe autologue pour consolider et 8 eurent une fracture une fois consolidé. On a analysé les différents facteurs qui ont pu influencer la consolidation; âge du donneur et du receveur, longueur et localisation de l'allogreffe, type d'ostéotomie et d'ostéosynthèse, chimiothérapie (intra-art`erielle ou systémique) et radiothérapie (intraopératoire ou externe). Dans les ostéotomies diaphysaires, la chimiothérapie systémique (p<0.05), la radiothérapie externe (p<0.01) et l'age du receveur (p<0.01) retardent la consolidation.

     

Experimental study on vascularized bone allografts for reconstruction of massive bone defects

To study the healing mechanism of vascularized bone allografts under short-term as well as long-term immunosuppression with cyclosporin A, experimental vascularized intercalary bone allograft transplantation was carried out between inbred rats using the tibiofibula graft model. Bone scintigram and radiographs were used as an indicator for early detection of rejection after transplantation and bone union. In vascularized bone allografts under long-term immunosuppression with cyclosporin A, early bone union and continuous incorporation were similar to that observed in vascularized bone autograft transplantation. When administration of cyclosporin A was discontinued before completion of bone union, the graft was rejected and bone union was delayed. Apparent swelling on the operated limb associated with a decrease in bone scintigram uptake suggested the occurrence of rejection of the allograft. Vascularized bone allograft transplantation is useful for reconstruction of massive bone defects only if immunosuppressants are used and maintained at least until bone union is obtained. © 1994 Wiley-Liss, Inc.     

Survival of massive allografts in segmental oncological bone defect reconstructions

Reconstructions of large segmental bone defects after resection of bone tumours with massive structural allografts have a high number of reported complications including fracture, infection and non-union. Our goal is to report the survival and complications of massive allografts in our patients. A total of 32 patients were evaluated for fracture, infection, non-union rate and survival of their massive allograft reconstructions. The average follow-up for this group was five years and three months. The total fracture rate was 13% with a total infection rate of 16%. We found a low union rate of 25%. The total survival of the allografts was 80.8% (± 18.7%) after five years. We found a five-year allograft survival of 80.8% which is comparable with other studies.

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Résumé  La reconstruction des larges pertes de substances osseuses après la résection des tumeurs osseuses par des allogreffes structurales est pourvoyeuse d’un pourcentage élevé de complications, telles que fractures, infections et pseudarthroses. Le but de notre étude est de rapporter la courbe de survie et les complications de ces allogreffes massives. 32 patients ont été évalués en terme de fractures, d’infections et de pseudarthroses, après mise en place d’allogreffes massives, le suivi moyen du groupe a été de 5 ans et 3 mois. le taux de fractures est de 13%, le taux d’infections de 16%. Nous avons trouvé un taux relativement bas de consolidation 25%. La survie de ces allogreffes, globalement est de 80,8% (± 18,7%) après 5 ans. le taux de survie de ces allogreffes à plus de 5 ans est de 80,8%, il est comparable aux autres études.

     

异体骨关节移植修复肢体大段骨缺损的术后并发症

目的 分析肢体恶性肿瘤患者接受异体骨关节移植修复重建大段骨缺损的术后并发症并探讨其处理方法。方法 因肢体恶性骨肿瘤行瘤段切除,采用不同内固定方式进行异体骨－关节移植术并有完整随访资料的患者１０６例,随访时间１０～１１２个月,平均３２．３个月。术后最终结果按Ｍａｎｋｉｎ’ｓ标准评价。结果 与深低温冷冻异体骨相比,酒精浸泡异体骨移植更易发生感染、骨不连等并发症;异体骨段移植或复合人工关节移植优于半关节     

Initial stability of circumferential meshes with impacted bone allografts for massive femoral defects

When the proximal femur is absent due to a failed femoral stem in total hip arthroplasty, impacted bone grafts contained within circumferential meshes could be an alternative reconstructive method. The purpose of this study was to analyse the initial resistance to axial and rotational forces in a fresh frozen bovine model with complete loss of the proximal femur reconstructed with a circumferential metal mesh, impacted bone allografts and a long cemented stem. Four bovine femurs with a complete proximal bone defect were reconstructed with a circumferential mesh, impacted bone grafts and a cemented stem. The results were compared with four intact femurs using the same implant. Under axial load, subsidence was observed at an average of 617 kg in the experimental group, and a cortical fracture occured at 1335 kg in the control group. Under rotational load, experimental femurs failed at an average of 79 kg and the control femurs fractured at 260 kg. This model provided 50% of the resistance to axial load and 30% of the resistance to rotational load compared to an intact femur, which is enough to resist physiological load. This stability encourages the use of circumferential meshes, impacted bone allografts and cemented stems in revision hip surgery with massive bone loss.     

Femoral reconstruction by massive allografts in revision of hip prostheses with major bone defects

Summary Major bone defects are commonly encountered in revision of total hip arthroplasties. We reconstruct both the acetabular and femoral component with bone allografts to allow successful implantation of a new prosthesis. Frozen femoral heads are used for all kinds of acetabular defects and for small femoral defects, and irradiated massive cortical allografts have been used since 1985 for major deficiencies of the femur. The femoral reconstruction technique differed according to the type of surgery: —After removal of a failed massive femoral prosthesis, a long-stem Charnley prosthesis was cemented in the proximal allograft and the distal host femoral shaft. —When revision of standard arthroplasties was performed, different surgical procedures were used according to the type of bone deficiency encountered, the goal being to preserve as much host bone as possible. We used either segmental allografts covered with the remaining host femoral cortex preserved with its soft tissue attachments, or segmental allografts impacted into an enlarged residual shaft. In other cases, a semi-circular allograft strut was used for replacing or reinforcing a deficient cortex. A cemented longstem Charnley prosthesis was generally used, but whenever possible a standard stem was implanted.From 1985 to the end of 1992, 102 upper femoral reconstructions for major revision arhtroplasties were performed in our department. Onlay struts had excellent results, always united, and complications were rare. Segmental allografts had a higher complication rate. The frequency of trochanteric complications (20%) implies firm initial fixation, apparently better ensured by plates, though screwing through the graft risks damaging it, as occurred once. Graft or prostheses failures were rare, and occurred mainly with large segmental allografts used in custommade massive prosthesis replacement, the conditions then being comparable with malignant tumor reconstruction surgery. When complications occurred, the benefit of initial bone stock repair was preserved in most cases, allowing easy further revision.Massive irradiated allografts appear to be an effective method in major femoral reconstructions. These results rely on safe bone banking procedures, which require predefined and strictly controlled methods. Good results also depend on suitable surgical techniques, particularly efficient graft stability, secure muscle reattachment, and reliable prostheses. The aim of the different surgical technics we used in revision arthroplasties was to obtain good anatomic situation, alignment and length, while preserving as much as possible of the residual host bone.     

The versatility of massive allografts in the treatment of bone tumours of the proximal humerus

Endoprosthetic replacement (EPR) of the proximal humerus following tumour resection has resulted in proximal subluxation, pain, instability and poor function. Alternative reconstructive options to EPR include leaving the shoulder flail, insertion of a passive spacer and arthrodesis. Five patients were treated using massive cadaveric allografts as the method of reconstruction following tumour resection. The pathology was three osteosarcoma, one chondrosarcoma and one metastasis from a renal primary. The patients were evaluated clinically using the Musculoskeletal Tumour Society (MSTS) and Constant shoulder assessments. All four patients with primary tumours were alive and disease free at review after a median follow-up of 23 months (range 14–112). No patients suffered immediate complications. Three of the four patients were pain free. Function was limited, causing at least partial occupational restriction in three of four patients. Allograft remains a viable alternative to EPR in reconstruction following tumour resection. Costs are favourable, and patients gain good analgesia. Function is sacrificed (as it is in EPR), especially if tumour resection necessitates nerve sacrifice. In our patients, the allograft was used either as a passive spacer, arthrodesis or arthroplasty, demonstrating its versatility.     

Determination of in vivo glenohumeral translation using fluoroscopy and shape-matching techniques

The purpose of this study was to investigate glenohumeral translation in-vivo during active shoulder abduction in the scapular plane. Three-dimensional (3D) models of 9 shoulders were created from CT scans. Fluoroscopic views aligned to the plane of the scapula were recorded during active arm abduction with neutral rotation. 3D motions were determined using model-based 3D-to-two-dimensional (2D) registration. Humeral translation was referenced to the glenoid center in the superior/inferior direction. The humerus moved an average of 1.7 mm superior with arm abduction, from an inferior location to the glenoid center. The humeral head was centered within 1 mm from the glenoid center above 80 degrees abduction. Variability in glenohumeral translation between shoulders decreased significantly from initial to final arm abduction. Our findings agree with some authors' observations of inferior-to-central translation of the humerus and behavior as a congruent ball and socket. We believe this information will help improve the understanding of shoulder function.     

Factors affecting outcome of massive intercalary bone allografts in the treatment of tumours of the femur

We retrospectively reviewed 101 consecutive patients with 114 femoral tumours treated by massive bone allograft at our institution between 1986 and 2005. There were 49 females and 52 males with a mean age of 20 years (4 to 74). At a median follow-up of 9.3 years (2 to 19.8), 36 reconstructions (31.5%) had failed. The allograft itself failed in 27 reconstructions (24%). Mechanical complications such as delayed union, fracture and failure of fixation were studied. The most adverse factor on the outcome was the use of intramedullary nails, followed by post-operative chemotherapy, resection length > 17 cm and age > 18 years at the time of intervention. The simultaneous use of a vascularised fibular graft to protect the allograft from mechanical complications improved the outcome, but the use of intramedullary cementing was not as successful. In order to improve the strength of the reconstruction and to advance the biology of host-graft integration, we suggest avoiding the use of intramedullary nails and titanium plates, but instead using stainless steel plates, as these gave better results. The use of a supplementary vascularised fibular graft should be strongly considered in adult patients with resection > 17 cm and in those who require post-operative chemotherapy.     

Long-term results of anti-protrusion cage and massive allografts for the management of periprosthetic acetabular bone loss

From 1992 to 1995, 71 total hip arthroplasties with extensive acetabular bone loss underwent revision using bulk allografts and Burch-Schneider anti-protrusio cages. Twelve patients died of unrelated causes and 3 were lost to follow-up. Fifty-six hips were available for clinical and radiographic follow-up examination at an average of 11.7 years after surgery. The average final Harris hip score was 75. X-ray signs of incorporation of massive bone graft were observed in 49 hips. Two cases developed deep infection that required resection arthroplasty. Aseptic loosening of the acetabular cage occurred in 5 patients, and 2 of them underwent re-revision. With a total survival rate of 87.5%, anti-protrusio cages and structural allografts compare favorably with other techniques in the long-term reconstructive treatment of extensive loss of acetabular bone stock.