Biological Reconstruction for Extremity Osteosarcoma: Long-Term Results and Current Concept of Intraoperative Extracorporeal Irradiated Bone Graft (IORBG)

Tumor site

No. of cases

Tibia

Femur

Humerus

Pelvis

Scapula

Radius

Ulna

Fig. 13.1

Comparison of tumor site distribution of IORBG to that in the bone tumor registry. The humerus and tibia are preferred sites for the application of this method in order to reconstruct the rotator cuff and patellar tendon

13.2.2 Methods

The procedure of IORBG is shown in Fig. 13.2. Widely resected tumor material (Fig. 13.2a, b) was trimmed up to the bone and ligaments for reconstruction (Fig. 13.2c) and packed into a sterile plastic container filled with saline (Fig. 13.2d). Then, the bone was irradiated using Liniac with 6 or 10-MV photons (Fig. 13.2e). The irradiation dose was 50–80 Gy in one fraction to the whole wrapped container for about 40 min. After irradiation, the autogenous bone graft was reimplanted to the remaining bone (Fig. 13.2f) with intramedullary rods, plates, screws, and so on (Fig. 13.2g).

Fig. 13.2

Method of IORBG. (a) Wide resection of the tumor. The resection line can be planned in any way for this method. In this intraosseous tumor, the IORBG method was necessary for limb salvage. (b) Resected material and host. (c) The resected material was trimmed. The muscles were removed while preserving the ligaments. (d) The trimmed resected bone and ligaments were soaked in a plastic container filled with saline. (e) Irradiation to the whole container for 50 Gy at one time. (f) Reimplantation of the bone. Fixation could be done with screws, plates, rod, and so on. (g) XP after operation

13.2.3 Graft Type

The graft types included osteoarticular in 31 cases (lower extremity 17, upper extremity 13, and pelvis 1), intercalary in 18 cases (lower extremity 18), composite with endoprosthesis in 20 cases (lower extremity 14, upper extremity 5, and pelvis 1), and hemicortical in 3 cases (lower extremity 2 and pelvis 1). For the osteoarticular and intercalary grafts, cement augmentation was used in recent cases to avoid collapse of the epiphysis and fracture (Fig. 13.3). For the composite graft, Link knee prosthesis was used for the lower limb and standard humeral head prosthesis was used for the humerus.

Fig. 13.3

Cement augmentation in intercalary (a, b) and osteoarticular (c) grafts. White and black arrows indicate the injected bone cement before implantation to the host bone. Note that the osteotomy areas were filled not with cement but with hydroxyapatite in order to achieve bone union

13.2.4 Analysis

Disease-specific survival rates, survival rates of the irradiated bone, and the reoperation-free survival rates were evaluated using the Kaplan-Meier method. The survival of the irradiated bone was considered from the date of implantation to the date of the last follow-up or to the removal of more than half of the bone because of complication or tumor recurrence. Reoperation procedures included any minor operation after the main surgery. The trend of IORBG graft types during the last 25 years was also reviewed and visualized. The NCI’s Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 was used for assessment of adverse events.

13.3 Results

13.3.1 Disease-Specific Survival and Local Control

The oncological results were CDF 56 cases, NED 6 cases, and DOD 10 cases at mean follow-up of 102 months (range: 12–299 months). Figure 13.4 shows the overall survival curve. The 5-year survival rate was 90 % and the 10-year survival rate was 81 %. There was one case of local recurrence outside the reimplanted bones. We underwent additional wide resection including the implanted irradiated bone and recurrence lesion and total femoral replacement. This case had no further recurrence and remained alive without disease at 19 years post-surgery.

Fig. 13.4

Overall survival curve of 72 bone tumor cases. The 5-year survival rate was 90 % and the 10-year survival rate was 81 %

13.3.2 Graft Survival According to the Graft Type

Figure 13.5 shows the survival rate of the irradiated bone according to the applied graft type. There was no significant difference between each graft type. There were only three cases of hemicortical graft, and one case got infected and the graft was removed. The 5-year survival rates were 72.3 % for the osteoarticular graft and 82.6 % for the intercalary graft. All composite grafts survived at mean follow-up of 88 months. The irradiated grafts were removed in 11 patients due to complications or local recurrences outside of the irradiated bone grafts. Eight of the 11 cases were osteoarticular grafts; hence, the survival curve of the osteoarticular grafts declined in a short time after the operation. The overall graft survival for all 72 cases was 81 % at 10 years as shown in Fig. 13.6

Fig. 13.5

Graft survival curve of 72 bone tumor cases according to graft types. “Survival” is defined as more than half of the graft remaining. The 5-year survival rate of each graft type was as follows: osteoarticular 72.3 %, intercalary 82.6 %, hemicortical 50 %, and composite graft 100 %

Fig. 13.6

Overall graft survival curve for all 72 bone tumor cases. The 10-year survival rate was 81 %

13.3.3 Complications

Table 13.2 shows the list of complications of IORBG. Infection was the most frequent (11 cases, 15 %) leading to severe complications, which affected seven osteoarticular, two intercalary, and two composite grafts. Surgical debridement was performed in nine cases corresponding to Grade 3 complication of the CTCAE. Antibiotics were administered in the other two cases. In 5 of the 11 cases, the grafts were removed. Collapse of the epiphysis occurred in nine cases of osteoarticular grafts. Five cases underwent observation without any further treatment because there were no pain and no functional disadvantages as shown in Fig. 13.7. The other four cases were treated surgically for partial replacement with prosthesis. Nonunion and fracture occurred mainly in the cases of intercalary graft cases. A femoral case treated with free fibular bone graft showed good function after reoperation (Fig. 13.8). As with this case, nonunion and fracture were salvaged by additional bone grafting with/without additional rigid fixation. Only 1 of 16 intercalary grafts required replacement with prosthesis because of nonunion. Overall, the reoperation rate was as high as 43 %. However, these reoperations due to complications occurred mostly during the short term compared with that of tumor knee prosthesis (Fig. 13.9). There were no Grade 4 or 5 complications.

Table 13.2

Lists of complications of 72 cases

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