Intercalary reconstruction following resection of diaphyseal bone tumors: A systematic review

IntroductionThe options for the reconstruction of diaphyseal defects following the resection of bone tumors include biological or prosthetic implants. The purpose of our study was to evaluate different types of intercalary reconstruction techniques, including massive bone allograft, extracorporeal devitalized autograft, vascularized free fibula, and modular prosthesis.MethodsWe performed a systematic review of articles using the terms diaphyseal bone tumor and intercalary reconstruction. All the studies reporting the non-oncological complications such as infection, nonunion and fracture of the intercalary reconstructions were included. We excluded articles published before 2000 or did not involve humans in the study. Case reports, reviews, technique notes and opinion articles were also excluded based on the abstracts. Thirty-three articles included in this review were then studied to evaluate failure rates, complications and functional outcome of different surgical intercalary reconstruction techniques.ResultsNonunion rates of allograft ranged 6%–43%, while aseptic loosening rates of modular prosthesis ranged 0%–33%. Nonunion rates of allograft alone and allograft with a vascularized fibula graft ranged 6%–43% and 0%–33%, respectively. Fracture rates of allograft alone and allograft with a vascularized fibula graft ranged 7%–45% and 0%–44%, respectively. Infection rates of allograft alone and allograft with a vascularized fibula graft ranged 0%–28% and 0%–17%, respectively. All of the allograft (range: 67%–92%), extracorporeal devitalized autograft including irradiation (87%), autoclaving (70%), pasteurization (88%), low-heat (90%) or freezing with liquid nitrogen (90%), and modular prosthesis (range: 77%–93%) had similar Musculoskeletal Tumor Society functional scores. Addition of a vascularized fibula graft to allograft did not affect functional outcome [allograft with a vascularized fibula graft (range: 86%–94%) vs. allograft alone (range: 67%–92%)].ConclusionAseptic loosening rates of modular prosthesis seem to be less than nonunion rates of allograft. Adding a vascularized fibula graft to allograft seems to increase bone union rate and reduce the risk of fractures and infections, though a vascularized fibula graft needs longer surgical time and has the disadvantage of donor site morbidity. These various intercalary reconstruction techniques with or without a vascularized fibula autograft had similar functional outcome.     

Factors Influencing Nonunion and Fracture Following Biological Intercalary Reconstruction for Lower‐Extremity Bone Tumors: A Systematic Review and Pooled Analysis

ObjectivesTo determine nonunion rate, fracture rate, and their risk factors following biological intercalary reconstruction for lower extremity bone tumors.MethodsA systematic review and pooled analysis were conducted. PubMed, Embase, and Wiley Cochrane Library were searched from inception up to June 01, 2020. Studies concerning biological intercalary reconstruction after resection of lower extremity bone tumors were included. Overall nonunion and fracture rates were calculated. For studies reporting patient outcomes individually with precise graft characteristics and fixation methods, the individual data were extracted. Patients with demographical and clinical characteristics, including age, sex, tumor location, graft characteristics, and fixation method, were pooled for a multivariate analysis. For each factor of interest, odds ratio (OR), 95% confidence interval (95% CI), and p‐value from logistic regression were reported.ResultsA total of 2776 articles were identified from the initial literature search and 76 studies (2052 patients) were included. Sixty‐nine studies were case series and seven were comparative studies. The overall nonunion rate was 19% (382/2052; range: 0%–53%), and the overall fracture rate was 17% (344/2052; range: 0%–75%). Thirty of the 76 studies (362 patients) reported patients'' characteristics individually and were thus included in the pooled multivariate analysis. Intramedullary nail fixation was associated with a significantly higher nonunion rate compared to plate fixation (OR = 2.2, 95% CI: 1.23–4.10, p = 0.009). Reconstruction with a vascularized fibula graft had a statistically non‐significant lower nonunion rate than reconstruction without the graft (OR = 0.6, 95% CI: 0.34–1.07, p = 0.086). Devitalized autografts had a lower fracture risk than allografts (OR = 0.3, 95% CI: 0.14–0.64, p = 0.002), and males tended to have higher fracture risk than females (OR = 2.1, 95% CI: 1.00–4.44, p = 0.049).ConclusionsReconstruction with intramedullary nail fixation is related to an elevated risk of nonunion. Allografts and males have a higher fracture risk than devitalized autografts and females, respectively. Further high‐quality comparative analyses with large sample sizes and adequate follow‐up duration are needed to validate these findings.     

异体松质骨移植治疗骨肿瘤切除后骨缺损

目的：探讨应用异体松质骨移植治疗肿瘤切除后骨缺损的生物材料填充方法。方法：总结应用深低温冷冻保存异体松质骨移植治疗骨肿瘤切除后骨缺损57例。年龄6－56岁,平均年龄17．4岁。结果：除1例因感染异体骨取出外,其余56例均取得满意的骨愈合,愈合时间平均为4．5个月。依骨腔大小或植骨量的不同愈合时间 亦有所不同。单纯异体松质骨移植与异体松质骨加自体松质骨混合移植相比,愈合时间没有明显不同。植骨量越大,骨愈合时间越长。此组患者中未见明显排异反应及并发感染者。肿瘤复发率为7％。结论：同其他骨缺损填充方法和大块异体骨的使用相比,此种方法可行性较好,安全性较高。在骨愈合率,骨愈合时间上及复发以外并发症的发生上同自体松质骨植骨无明显差异。     

The use of vascularized cranial bone in reconstruction of the maxilla and mandible

Defects of the maxilla and mandible can cause significant functional and aesthetic problems for patients. Vascularized calvarium was used to reconstruct six mandible and four maxillary defects between 1991 and 1998. The ages of patients ranged from 15 to 68 years.Full thickness calvarial bone was preferred for the repair of segmental mandibular defects but split thickness calvarial bone onlay was used to reconstruct contour deformities. When full thickness calvarial bone was used, the donor site defect was covered with split thickness cranial bone. In small defects, a bipedicled galea pericranial flap was used for reconstruction. The bone was supplied by the superficial temporal vessels in all cases. A tunnel in the subcutaneous plane was used for the flap transfer to avoid facial nerve branches. Immediate expansion was performed during the preparation of the tunnel to prevent pedicle compression. Bone vascularization was checked with bone scan and serial X-rays and clinical examinations were also performed in the postoperative period. Flap necrosis was observed in one case, satisfactory functional and aesthetic results were achieved in all other patients. Vascularized cranial bone has not only the same structural features as facial bones but also a reliable vascular supply. The superficial temporal fascia and hairy skin may be included in the cranial bone flap to treat complex defects. The donor site scar is well hidden in the scalp. There is minimal donor site discomfort. In conclusion, vascularized cranial bone is a good method of treatment in selected cases. Received: 19 October 1998 / Accepted: 1 March 1999     

Reconstruction of a large mandible defect utilizing a full-thickness vascularized calvarial bone graft

Historically, mandibular reconstruction has always been a challenging problem. Various methods have been used including alloplasts such as stainless steel and titanium plates, trays filled with bone fragments, vascularized and non-vascularized bone grafts [1, 2]. Most methods have had variable success until the advent of microsurgical techniques. With the high success rate now obtainable utilizing free tissue transfer, mandible reconstruction has become a procedure with a more predictable outcome and most other reconstructive methods have now been abandoned. In spite of this, clinical situations do arise, such as with the case presented, where for one reason or another, microvascular techniques are either not available, not applicable or have failed. A case of mandibular reconstruction using a vascularized full-thickness calvarial bone graft is presented in which the end result was very satisfactory, both aesthetically and functionally. Received: 2 September 1997 / Accepted: 27 October 1997     

吻合血管的游离腓骨移植修复长段骨缺损

目的探讨吻合血管的游离腓骨移植(VFG)在骨科疾病中的应用。方法本组1例胫骨多发骨样骨瘤并病理骨折,行病灶边缘切除+对侧VFG+外固定架固定;1例桡骨远端骨巨细胞瘤并病理骨折,行瘤段广泛切除+同侧VFC+腕关节重建术;3例创伤性胫骨缺损,采用对侧VFG+外固定架固定。2例股骨近端骨肿瘤合并病理性骨折,采用病灶囊内刮除+对侧带血管折叠腓骨移植+95°角钢板桥接固定。术后随诊1～3年,依据Enneking肢体评分系统进行疗效评价。结果7例病人均获骨性愈合,全部病例供区功能正常,X线显示无踝关节外翻及关节炎改变。结论利用VFG治疗各种原因所致大段骨缺损,疗效良好,是临床治疗大段骨缺损的理想手术方法。     

同种异体骨移植重建四肢恶性骨肿瘤切除后骨缺损

[目的]探讨同种异体骨移植修复重建四肢恶性骨肿瘤切除后骨缺损的临床疗效。[方法] 2013年6月～2017年12月对本院收治的21例四肢恶性骨肿瘤切除后骨缺损病例进行大段同种异体骨移植重建,其中复合肿瘤型人工关节置换12例,单纯异体骨段移植9例。本组病例男13例,女8例;年龄11～51岁,平均(21.53±6.54)岁,均经过术前穿刺活检及术后病理确诊,Enneking分期ⅠB期4例,ⅡB期17例,其中骨肉瘤和尤文肉瘤患者术前均行2个疗程新辅助化疗及术后规范化疗。术后采用MSTS评分进行功能评价。[结果]所有患者获随访8～48个月,平均(29.64±11.22)个月,均未发生移植异体骨或假体周围骨折,无关节脱位及假体松动。其中19例肢体功能优良,MSTS功能评分16～28分,平均(22.82±4.47)分。[结论]异体骨移植联合肿瘤型人工关节复合置换,以及异体骨段移植重建长骨干缺损仍然是治疗四肢恶性骨肿瘤切除后骨缺损的一种有效重建方法。     

一期原位骨延长技术治疗四肢火器伤骨缺损的研究

目的　探讨四肢火器伤骨缺损的治疗方法和一期原位骨延长技术的生物学基础。　方法　对犬肢体火器伤骨缺损模型分别采用一期原位骨延长和传统的后期骨移植两种方法治疗,比较其骨愈合的病理过程及局部微循环血流量的变化。　结果　两组动物骨折局部血流量无显著差别。一期原位骨延长组８ 周内骨延长长度为２８２ ±０９４ ｃｍ , 相对长度为１９３ ％ （１５８ ％ ～２１４ ％ ） 。其骨愈合时间明显比后期植骨组短,伤肢功能也较好。软骨内化骨是骨延长过程中主要的成骨形式。　结论　一期原位骨延长技术治疗火器伤骨缺损,在缩短疗程,简化操作等方面具有明显优越性,且对火器伤骨折的愈合过程和局部血液循环无明显不良影响。     

Muscle reconstruction in reconstructive surgery: soft tissue repair and long bone reconstruction

Background We report a series of reconstructions of long bone defects in 35 patients. Bone defects ranged from 5.0 to 25.0 cm.Method Reconstruction was performed in two stages. The first stage was the insertion into the defect of a cement spacer, which was responsible for the formation of a pseudosynovial membrane. A soft tissue repair employing a flap was done in the same operating time in 28 cases. The second stage was the reconstruction of the bone defect by a large, fresh, autologous cancellous bone graft.Results The membrane induced by the spacer prevents the resorption of the graft and favours its revascularisation and its corticalisation. Experimental study has also shown that the membrane plays the role of an "in situ growth-factors delivery system".Conclusion In weight-bearing diaphyseal segments normal walking was possible at 8.5 months on average.     

Pedicled vascularized fibular graft with Ilizarov external fixator for reconstructing a large bone defect of the tibia after tumor resection

Background

Large bony defects in the middle or distal third of the tibia resulting from surgical resection of malignant bone tumors present a difficult reconstructive challenge. Various methods of reconstruction are available, such as allografts, vascularized fibular graft (either free or pedicled), or endoprothesis replacement for distal defects.

Materials and methods

Twelve patients—eight males and four females with mean age of 18 years at operation (range 14–25 years)—with malignant bone tumors of the tibial shaft were selected as candidates for wide resection of the tumor and reconstruction of the bony defect by ipsilateral vascularized fibular graft based on the peroneal vessels. Preoperative staging studies, including plain radiography, local MRI, isotopic bone scan, and chest CT, were done for every patient before biopsy. Ilizarov external fixation was then applied in all cases. The average length of the bony gap bridged was 14.5 cm (13–16.5 cm) and the mean length of the harvested graft was 16.3 cm (15–18 cm). The average operation time was 7.5 h (5.5–9.5 h).

Results

The mean follow-up period was 38 months (range 32–52 months). Bony union at the proximal and distal ends of the fibula occurred in nine patients (75 %) and at a mean time of 5.5 months (range 4.5–8 months). Graft hypertrophy occurred in all patients. The mean percentage of hypertrophy was 95 % (range 80–160 %). The mean MSTS functional score was 84 % (range 80–92 %). A leg length discrepancy of 2 cm was reported in two patients and was managed using a shoe lift.

Conclusion

Reconstruction of bony defects of the middle or distal tibia after bone tumor resection using pedicled vascularized fibula is a useful limb salvage procedure. The procedure can be performed relatively quickly and inexpensively and has a low rate of late complications. It leads to a good outcome regarding the union, hypertrophy, and function.     

Rigid bridging of massive femur defect using double vascularized fibula graft with hydroxyapatite

The presence of large and massive segmental defects of the diaphyseal bone following tumor resection is a significant problem for orthopedic surgeons. Double or folded free vascularized fibula graft (FVFG) is used in massive femur defects and is considered to be a reliable reconstructive procedure. However, folded or double fibula grafts cannot prevent stress fractures. Here, a novel surgical procedure for bridging of massive femur defects using double FVFG and hydroxyapatite with autogenous bone grafts to prevent stress fractures is reported.     

Recombinant human bone morphogenetic protein is a valid alternative to autologous bone graft for long bone non-unions: a systematic review and meta-analysis

ObjectiveTo compare the efficacy of recombinant human bone morphogenetic proteins (rhBMPs) and autologous bone graft (ABG) on the healing of long bone non-union.MethodsA systematic literature search was conducted on PubMed, Web of Science, Cochrane Library, and CNKI up to December 2021. Two authors independently screened the studies, extracted data, and assessed the quality of the trials. A Meta-analysis was performed using state software (version 12.0).ResultsA total of 14 studies were included in this meta-analysis. Overall, there was no significant difference between the rhBMPs group and the ABG group in terms of healing rate (RR = 1.04, 95% CI = 0.96–1.12, p = 0.365) and healing time (SMD = −0.31, 95% CI = −0.76–0.14, p = 0.175). Subgroup analysis showed rhBMPs lead to higher healing rates (RR = 1.35, 95% CI = 1.17–1.56, p < 0.001), and shorter healing time (SMD = −0.65, 95% CI = −1.08 to −0.22, p = 0.003) in the subgroup of moderate-quality studies. Sensitivity analysis proved that our conclusions were relatively robust. No significant publication bias was recognized in all studies (Begg’s test, p = 0.193; Egger's test, p = 0.307).ConclusionsRhBMPs or combined with allografts bone, inorganic bone was a valid alternative to ABG for the treatment of long bone non-union.     

自制骨水泥塑形模具在股骨肿瘤大段骨缺损中的应用

目的探讨保肢手术中应用自制骨水泥注入式管状骨塑形模具修复股骨大段骨缺损的疗效。方法自制骨水泥注入式管状骨塑形模具修复股骨大段骨缺损5例。取普通无菌塑料注射器3副,第1副裁取3/4管径作为管状模具主体,套入股骨缺损区;第2副裁取1/2管径并打一注入孔作为模具筒盖;骨水泥装入第3副针筒一次性加压注入管状模具。结果5例均获随访,时间18～54个月。术后切口均一期愈合,无感染、积液、骨水泥毒性反应等情况发生;肢体全部恢复日常活动功能,均无骨水泥及髓内钉松动断裂,骨水泥假体表面有大量骨痂生长。按Enneking肌肉骨骼系统肿瘤外科治疗重建术后功能评定标准：优3例,良1例,可1例。肢体疼痛消失4例,疼痛减轻1例。小细胞性肺癌患者死亡1例,肿瘤病灶局部轻度复发1例。结论骨水泥塑形模具改进了骨水泥充填效果,塑形更好,更坚固,无需保留瘤壳,肿瘤局部复发率和感染率更低,成本低廉,制作简便。     

改良髂骨骨皮瓣游离移植治疗掌背复合组织缺损

目的总结游离改良的以旋髂浅动脉为蒂的髂骨骨皮瓣重建掌背骨与软组织缺损体会。方法2009年3月-2012年3月,应用骨皮瓣修复掌背复合组织缺损7例,平均年龄42．9岁。伤肢均为右手．合并不同程度伸肌腱损伤2例：合并腕骨骨折、脱位2例;掌指关节损伤3例;指骨骨折3例。受伤至再手术时间平均为18．6d。术后7d开始功能练习。定期复查,了解植骨愈合、关节活动度、握力大小、皮瓣感觉恢复及供区副损伤,完成患肢手臂肩残疾问卷表及供区可视疼痛评估表。结果本组皮瓣全部成活．5例甲级愈合,2例乙级愈合。平均骨愈合时间：植骨远端2．3个月,近端2．7个月。随访12～24个月,腕关节平均掌屈38．6°,背伸42．9°,尺偏21．4°,桡偏22．9°。受累掌指关节平均活动度35．7°。患侧平均握力13．9kg。3例皮瓣平均静态两点辨别觉13．7mm,余皮瓣仅恢复深触觉。平均手臂肩残疾问卷评分12．1分。所有患者术后2周可行走,术后3个月轻微疼痛1例,术后1年供区瘢痕平软,无疼痛。结论游离改良的以旋髂浅动脉为蒂的髂骨骨皮瓣可成功治疗掌背部骨与软组织缺损,供区损伤较小。     

在下肢大段骨缺损治疗中Ilizarov技术的选择

[目的]总结应用Ilizarov技术治疗下肢大段骨缺损的临床体会，探讨不同病例的术式选择。[方法]14例下肢大段骨缺损，平均8．5cm，其中股骨2例；胫骨12例；创伤11例，均伴有不同程度的骨感染和（或）软组织缺损，骨肿瘤切除3例？分别采用肢体短缩加骨段截骨延长，或加骨段输送延长，或单纯骨段截骨输送治疗。[结果]全部病例均获得1a以上随访，骨缺损治愈，骨感染消失，皮肤创面消灭，肿瘤无复发，无附加神经血管损伤症状：[结论]Ilizarov技术是治疗骨大段缺损的简单而有效方法，根据不同病例，选择不同术式可简化治疗过程．缩短治愈时间。     

带血管蒂髂骨瓣移植修复下肢骨及其周围软组织缺损

目的探讨带血管蒂髂骨瓣移植在修复下肢骨及其周围软组织缺损中的作用。方法针对小腿、足解剖结构和伤后骨与软组织易缺损的特点,利用游离髂骨移植必须携带周围肌肉,设计带血管蒂的髂骨肌肉瓣,移植修复下肢骨及软组织缺损;髂骨肌肉瓣血管与受区血管吻合后于骨瓣周围肌肉表面皮片覆盖。结果手术后1周,移植皮片全部植在髂骨周围的肌肉表面,皮片成活间接证明移植骨瓣成活;皮片全部成活4例,大部分成活3例;术后1个月均可见髂骨瓣与受区断端间有少量的骨痂形成,修复足跖骨4个月后拔除克氏针,胫骨6～8个月拆除外固定架,扶拐行走2～4个月：术后随访经6～15个月(平均10个月),双下肢等长,无溃疡,行走负重良好,外形及功能满意。结论单纯髂骨游离移植修复骨及软组织缺损一次完成手术操作,解剖塑形及外观比传统术式更满意,是修复小腿及足外伤软组织和骨缺损的较好术式。     

髓内延长修复儿童股骨骨髓炎后骨缺损

目的探讨髓内延长修复儿童股骨干化脓性骨髓炎后大段溶骨性缺损的疗效及其优越性。方法应用带锁髓内钉植入后进行骨痂延长术修复21例因化脓性骨髓炎导致的股骨骨缺损。结果随访6个月~2年,21例患者股骨骨缺损均获愈合并恢复了长度。结论植入带锁髓内钉后进行骨痂延长术是治疗儿童股骨骨髓炎后骨缺损的良好方法。     

Masquelet technique versus Ilizarov bone transport for reconstruction of lower extremity bone defects following posttraumatic osteomyelitis

ObjectiveThis study was to compare the effectiveness of Masquelet technique versus Ilizarov bone transport in the treatment of lower extremity bone defects following posttraumatic osteomyelitis.Patients and methodsWe retrospectively reviewed 39 patients who had been treated at our department for lower extremity bone defects following posttraumatic osteomyelitis. They were 30 males and 9 females with a mean age of 39.18 (range, 12–63 years). The infected bone defects involved 26 tibias and 13 femurs. The mean length of the bone defects after radical debridement was 6.76 cm (range, 2.7–15.7 cm). Masquelet technique (MT, group A) was used in 20 patients and Ilizarov bone transport (IBT, group B) in 19 ones. The measurements were bone outcomes (union, deformity, infection and leg-length discrepancy) and functional outcomes (significant limping, joint contracture, soft tissue dystrophy, pain and inactivity).ResultsThe mean follow-up after removal of the apparatus was 25.26 months (range, 14–51 months). The mean finite fixator time was 10.15 months (range, 8–14 months) in group A versus 17.21 months (range, 11–24 months) in group B. The bone outcomes were similar between groups A and B [excellent (5 vs. 7), good (10 vs.9), fair (4 vs. 2) and poor (1 vs. 1)]; group A showed better functional outcomes than group B [excellent (8 vs. 3), good (9 vs. 6), fair (3 vs. 8) and poor (0 vs. 2)].ConclusionsIn the treatment of segmental lower extremity bone defects following posttraumatic osteomyelitis, both IBT and MT can lead to satisfactory bone results while MT had better functional results, especially in femoral cases. IBT should be preferred in cases of limb deformity and MT may be a better choice in cases of periarticular bone defects.     

Vascularized bone flap for anterior skull base reconstruction

Summary A case is reported where a vascularized outer-table of the frontal bone was successfully used to reconstruct a large defect in the anterior skull base following excision of a massive olfactory groove meningioma extending into the ethmoid sinuses. The flap provided a firm barrier between the cranial cavity and paranasal air sinuses, as the dural and bony integrity of the base was compromised after the radical resection of the tumour. It appears that such a flap can be effectively used for skull base reconstruction.     

复合人工骨修复骨良性病变切除后骨缺损

目的探讨骨良性病变切除后骨缺损的修复方法，并对其疗效进行评估。方法总结1999年1月-2003年10月我科应用混合自体骨松质的异体脱蛋白骨松质复合自体红骨髓治疗骨良性病变切除后骨缺损28例。年龄12—61岁，平均20，5岁。结果除2例因死亡失访外，其余26例均取得满意随访，平均骨愈合时间为4．2个月。骨腔大小或植骨量不同，骨愈合时间不同。骨腔越大，植骨越多，骨愈合时间越长。本组病例未见明显排斥反应及并发感染。随访至今，无一例复发。结论利用这种复合人工骨修复骨良性病变切除后骨缺损的方法可行性好，安全性高，自体损伤小，便于推广，可用于骨缺损的修复。