Does Extracorporeal Irradiation and Reimplantation After Acetabular Resections Result in Adequate Hip Function? A Preliminary Report

Does adding sacroiliac (type IV) resection to periacetabular (type II) resection increase complications or provide worse clinical outcomes? An institutional experience and systematic review

BACKGROUND AND OBJECTIVES

Internal hemipelvectomy is a limb sparing procedure most commonly indicated for malignant bone and soft tissue tumors of the pelvis. Partial resection and pelvic reconstruction may be challenging for orthopedic oncologists due to late presentation, high tumor burden, and complex anatomy. Specifically, wide resection of tumors involving the periacetabular and sacroiliac (SI) regions may compromise adjacent vital neurovascular structures, impair wound healing, or limit functional recovery. We aimed to present a series of patients treated at our institution who underwent periacetabular internal hemipelvectomy (Type II) with or without sacral extension (Type IV) in combination with a systematic review to investigate postoperative complications, functional outcomes, and implant and patient survival following pelvic tumor resection via Type II hemipelvectomy with or without Type IV resection.

MATERIALS AND METHODS

A surgical registry of consecutive patients treated with internal hemipelvectomy for primary or secondary pelvic bone tumors at our institution since 1994 was retrospectively reviewed. All type II resection patients were stratified into two separate cohorts, based on whether or not periacetabular resection was extended beyond the SI joint to include the sacrum (Type IV), as per the Enneking and Dunham classification. Patient demographics, operative parameters, complications, and oncological outcomes were collected. Categorical and continuous variables were compared with Pearson's chi square or Fisher's exact test and the Mann-Whitney U test, respectively. Literature review according to PRISMA guidelines queried studies pertaining to patient outcomes following periacetabular internal hemipelvectomy. The search strategy included combinations of the key words "internal hemipelvectomy", "pelvic reconstruction", "pelvic tumor", and "limb salvage". Pooled data was compared using Pearson's chi square. Statistical significance was established as p < 0.05.

RESULTS

A total of 76 patients were treated at our institution with internal hemipelvectomy for pelvic tumor resection, of whom 21 had periacetabular resection. Fifteen patients underwent Type II resection without Type IV involvement, whereas six patients had combined Type II/IV resection. There were no significant differences between groups in operative time, blood loss, complications, local recurrence, postoperative metastasis, or disease mortality. Systematic review yielded 69 studies comprising 929 patients who underwent internal hemipelvectomy with acetabular resection. Of these, 906 (97.5 %) had only Type II resection while 23 (2.5 %) had concomitant Type II/IV resection. While overall complication rates were comparable, Type II resection alone produced significantly fewer neurological complications when compared to Type II resection with sacral extension (3.9 % vs. 17.4 %, p = 0.001). No significant differences were found between rates of wound complications, infections, or construct failures. Local recurrence, postoperative metastasis, and survival outcomes were similar. Type II internal hemipelvectomy without Type IV resection on average produced higher postoperative MSTS functional scores than with Type IV resection.

CONCLUSION

In our series, the two groups exhibited no differences. From the systematic review, operative parameters, local recurrence or systemic metastasis, implant survival, and disease mortality were comparable in patients undergoing Type II internal hemipelvectomy alone compared to patients undergoing some combination of Type II/IV resection. However, compound resections increased the risk of neurological complications and experienced poorer MSTS functional scores.

Comparative efficacy of intraoperative extracorporeal irradiated and alcohol-inactivated autograft reimplantation for the management of osteosarcomas-a multicentre retrospective study

BACKGROUND

Biologic bone reconstruction in limb salvage surgery for the treatment of malignant bone tumours has always been controversial. The various inactivation methods, their convenience and stability, the curative effects elicited and associated costs all need to be considered. This study aimed to compare the clinical efficacy of intraoperative extracorporeal irradiated reimplantation with alcohol-inactivated autograft reimplantation for limb salvage surgery in patients with osteosarcoma.

METHODS

We retrospectively analysed 28 patients with osteosarcoma, 14 patients treated with intraoperative cobalt 60 irradiation and reimplantation (group A), and 14 patients treated by alcohol-inactivated autograft reimplantation (group B). The postoperative complications and clinical efficacy of each treatment method were compared by statistical analysis.

RESULTS

The local recurrence rate was 14.3% in each group. Complete bony union was achieved in 64.3% of patients in group A and 71.4% of patients in group B. The overall 5-year survival rate was 71.4% in group A and 78.6% in group B. The mean Musculoskeletal Tumor Society (MSTS) score was 25.33 ± 4.72 (range 15-30) in group A and 24.00 ± 5.85 (range 15-30) in group B, and the mean International Society of Limb Salvage (ISOLS) score was 25.79 ± 5.13 (range 20-36) in group A and 26.14 ± 5.33 (range 20-30) in group B. P < 0.05 was considered to indicate a significant difference. The results showed that the long-term clinical efficacy did not differ significantly between the two methods.

CONCLUSIONS

In limb salvage surgery for osteosarcoma, intraoperative extracorporeal irradiation and alcohol-inactivated autograft reimplantation yielded equivalent outcomes. The alcohol-inactivated method may be a much more convenient and inexpensive way to reconstruct bone defects. Additional studies as well as more case studies are needed to fully evaluate the clinical efficacy and safety of this treatment method.

Pelvic Chondrosarcoma Treated by En Bloc Resection with Patient-Specific Osteotomy Guides and Reimplantation of the Extracorporeally Irradiated Bone as an Osseocartilaginous Structural Orthotopic Autograft: A Report of Two Cases with Description of the Surgical Technique

Primary tumors of the pelvis are considered difficult to treat due to the complex anatomy and the proximity of important neurovascular structures. The surgical armamentarium for the treatment of these tumors has evolved with the help of cutting-edge technology from debilitating hemipelvectomies to solutions such as precise resections guided by patient-specific instruments or computer navigation and reconstruction by modular prostheses, 3D-printed custom-made implants, or orthotopic autograft reimplantation after extracorporeal irradiation. Different combinations of these techniques have been described in the literature with various rates of success. We present two cases of pelvic chondrosarcomas successfully treated by a combination of periacetabular resection with patient-specific osteotomy guides and orthotopic reimplantation of the extracorporeally irradiated autograft resulting in retention of the native hip.

Reconstructive Challenges of Distal Tibia Bone Tumors: Extracorporeally Irradiated Autograft Combined with a Nonvascularized Autograft Fibula for Superior Reconstruction and Functional Outcomes When Compared to Ipsilateral Pedicled Fibula Transfer Alone

Introduction

Traditionally, centralization of the fibula with fusion across the tibiotalar joint has been used to reconstruct distal tibial defects. Although effective, it requires long periods of protected weight-bearing. The fibula or the fixation often fails before fibular hypertrophy necessitating multiple additional surgeries. A method of using ECRT with the available ipsilateral fibula (nonvascularized) to reconstruct the distal tibia defect with the aim of early return to weight-bearing was evolved. This paper documents our early experience. Patients and Methods. Four patients; with the diagnosis of osteosarcoma in 3 patients and recurrent giant cell tumor of the bone in 1 patient, underwent resection of the distal tibia for tumors between 2017 and 2019. Extracorporeally irradiated (50 Gy) distal tibia along with ipsilateral nonvascularized fibula was used to bridge the defect and fuse the tibiotalar joint. A plate was used to rigidly hold the construct. The final outcome was compared to the historical control group that underwent only pedicled ipsilateral fibula transposition and ankle arthrodesis without recycled autograft or allograft between 2009 and 2017. Oncological reconstruction and functional outcomes were compared for each group. Patient reported outcomes on the acceptability of ankle fusion; cosmesis and function were analyzed and compared between the two groups.

Results

The mean resection length in the study group (4 patients) was 7.75 cm (7 to 8.5 cm). As compared to the historical cohort of 7 patients, the study population showed statistically superior results in all reconstruction, functional, and patient-reported outcomes except time to proximal junction union (p=0.068). There were no reconstruction failures, infection, or nonunions in the study group, whereas the control comparative group had 2 proximal junction nonunions and a mean time to fibular hypertrophy of 143 weeks (82 to 430 weeks) with fibula centralization. Earlier weight-bearing was allowed (mean 26.75 weeks; median 27 weeks) compared to (mean 80.75 weeks; median 80 weeks) in the control group.

Conclusion

We think that ECRT with ipsilateral vascularized fibula is a promising method of reconstructing the distal tibia. The recycled autograft tibia added strength to the distal tibia construct in our study and aided the anatomical reconstruction of the distal tibia. The patient-reported outcomes for cosmesis and acceptability add to the benefits of performing this procedure. Consistent early union across the proximal junction and earlier weight-bearing were clear advantages of this method.

Do irradiated osteo-articular recycled tumor autografts still hold promise for biological joint reconstruction? Our experience with acetabular and proximal ulna ECRT

BACKGROUND

Joint reconstruction following resection of malignant bone tumors is challenging in itself in spite of several options in hand. Ability to restore joint anatomy, function and mobility while achieving optimal oncological outcomes are the requirement of reconstructions today. While biological reconstructions (allograft or recycled tumor autografts) following tumor bone surgery are popular for intercalary resections not involving the joint, their use for osteo-articular reconstructions are associated with concerns over cartilage and joint health. We have used extracorporeal radiation therapy (ECRT) and re-implantation of the osteoarticular segment as a size matched recycled tumor autograft reconstruction after complex acetabular and proximal ulnar resections; owing to the lack of significantly superior reconstruction alternatives in these locations and also review the current literature on other biological/non-biological reconstruction options.

QUESTIONS/PURPOSES

(1) What are the oncological, reconstruction and functional outcomes with osteo-articular reconstruction using ECRT and re-implantation of recycled tumor autograft for the acetabulum and olecranon? (2) Is there an evidence of cartilage loss, joint damage or avascular necrosis resulting from irradiation of the articular autograft?

METHODS

19 patients with primary bone tumors underwent limb salvage surgery with en-bloc resection and reconstruction using the resected articular tumor bone after treating it with extra-corporeal irradiation of 50-60Gy. These included 16 acetabular and 3 proximal ulnar. While all patients were included for oncological assessment; minimum follow-up of 24 months was considered for final outcome assessment of function and joint status.

RESULTS

MSTS scores of the 16 acetabular reconstruction patients with minimum 2 years follow-up was 87% (26/30). Neither delayed union, non-union at osteotomy sites nor was any fractures reported in the irradiated graft. There was no local recurrence within the irradiated graft and only 1 patient required graft excision for uncontrolled infection. All 3 patients of proximal ulna reconstruction achieved healing and full range of movement of the elbow. Scores of MSTS: 100% (30/30), MEPS: 100 and DASH: zero was achieved. Two patients developed osteonecrosis of the femoral head; one requiring a joint replacement and one awaiting replacement. One patient of acetabular reconstruction has joint space narrowing on radiographs with mild clinical symptoms.

CONCLUSIONS

Extracorporeal radiotherapy and re-implantation after osteo-articular resection is an oncologically safe option offering promising outcome in our small series. The availability of size-matched graft, thus avoiding inherent problems of allograft also provides a better economic option over endoprosthesis and its associated complications in select sites. The results can deteriorate over time that may require secondary reconstructive procedures like joint replacement.

LEVEL OF EVIDENCE

Level IV, Therapeutic Study.

What Are the Challenges and Complications of Sterilizing Autografts with Liquid Nitrogen for Malignant Bone Tumors? A Preliminary Report

BACKGROUND

Reconstruction of defects after resection of malignant bone tumors with liquid nitrogen-sterilized recycled autografts is an alternative to bone allografts and endoprostheses in resource-constrained environments. Most studies reporting favorable outcomes with liquid nitrogen-sterilized autografts for bone reconstruction are geographically restricted to a few countries, and the technical challenges of routinely using liquid nitrogen intraoperatively, especially when using the pedicle freezing technique, has not been documented.

QUESTIONS/PURPOSES

(1) What are the technical challenges of liquid nitrogen sterilization of bone tumors for inexperienced surgeons? (2) What are the complications associated with the procedure?

METHODS

Between May 2017 and October 2019, 88 patients underwent limb salvage procedures for malignant bone tumors of the extremities at our institution. An endoprosthesis was used for reconstruction of the defect following resection in 45% (40 of 88) of these patients, mostly in adults (median age 21 years; range 9 to 68). In the remaining 55% (48 of 88) of patients undergoing biological reconstruction, liquid nitrogen-sterilized autograft was used in 90% (43 of 48), extracorporeal irradiation-sterilized autograft was used in 4% (2 of 48) and allograft was used in 6% (3 of 48). Of the 43 patients receiving liquid nitrogen-sterilized autograft, 5% (2 of 43) were excluded due to loss to follow-up and the remaining 95% (41 of 43) were included for the analysis. Liquid nitrogen-sterilized autograft was the preferred method of reconstruction at our institution during the study period, unless the patient had an indication for prosthesis reconstruction; extracorporeal irradiation-sterilized autograft was used due to resource constraints with liquid nitrogen and allograft was used when patients insisted.All surgical procedures were performed by the same team of trained orthopaedic oncology surgeons. The medical records of the included 41 patients were retrieved using an institutional database search in this retrospective study, and all were used to ascertain technical challenges associated with the operations as well as early (within 3 weeks of the index procedure) and late complications (those occurring 3 weeks or more after surgery). The technical challenges were defined as follows: the quantity of liquid nitrogen to be used; arranging, storing and handling of liquid nitrogen in the operating room, type and size of the container to be used for sterilization, the positioning of the container during pedicle freezing, level of fibular osteotomy for pedicle freezing of tibia, soft tissue protection, limb rotation during pedicle freezing, managing tourniquet time, and any other intraoperative factors with the use of liquid nitrogen for sterilizing the autograft. As our experience with the technique gradually grew, the answers to the above-mentioned factors were determined. Considering the removal of autograft as the endpoint of interest, survival of the autograft was determined by Kaplan-Meier analysis.The median (range) patient age was 14 years (2 to 49), and 54% (22 of 41) were males. Osteosarcoma was the most common diagnosis (68%, [28 of 41]) followed by Ewing's sarcoma (20%, [8 of 41]). On presentation, 27% of patients (11 of 41) had radiological evidence of pulmonary metastasis. Tumors were seen frequently around the knee (39% [16 of 41] proximal tibia and 22% [9 of 41] distal femur). Before resection 85% (35 of 41) underwent neoadjuvant chemotherapy. Sixty-six percent (27 of 41) underwent pedicle-freezing and the remaining 34% (14 of 41) underwent free-freezing of the tumor segment of the bone. The median (range) duration of surgery was 280 minutes (210 to 510). The patients were followed up for a median (range) duration of 21 months (5 to 30); two patients were lost to follow-up.

RESULTS

With gradual experience using liquid nitrogen-sterilization over time at our institution, we determined that the following factors helped us in performing liquid nitrogen-sterilization more efficiently. For every operation 15 L to 20 L of unsterilized liquid nitrogen was arranged, 1 or 2 days before the procedure, and stored in industrial-grade cryocylinders in the operating complex. During the procedure, the operating surgeons wore additional plastic aprons under the surgical gowns, surgical goggles, and rubber boots. The staff managing the liquid nitrogen in the operating room wore thermal protective gloves. For most of the pedicle freezing procedures, we used a cylindrical stainless-steel container that was 30 cm in height and 15 cm in diameter, with a narrow opening. The container was kept on a separate moveable cart that was placed next to the operating table at a slightly lower level, and it was wrapped in multiple cotton rolls, plastic sheets, surgical sheets, and a crepe bandage. For pedicle freezing of the tibia, we performed the fibular osteotomy at least 5 cm away from the planned surgical margin, roughly around the axis of rotation of the limb. The soft tissue at the base of the delivered bone segment was dissected for at least 5 cm beyond the planned surgical margin of bone, and was protected with multiple layers of cotton rolls, plastic drapes, a single roll of Esmarch and crepe bandage. The tumor segment was externally rotated during pedicle freezing for all anatomic sites (proximal tibia, distal tibia, proximal humerus, and proximal femur). The tourniquet was inflated just before pedicle freezing to prevent tumor dissemination and not before the initial incision in all pedicle freezing procedures.Thirty-nine percent of patients (16 of 41) experienced complications associated with the procedures, and 15% (6 of 41) underwent revision surgery. Early complications (occurring within 3 weeks of the index procedure) were skin necrosis in four of 16 patients, intraoperative fracture in one of 16, superficial infection in one of 16, and neurapraxia in one of 16 patients. Late complications (occurring 3 weeks or more after surgery) were resorption of the recycled bone in four of 16 patients, nonunion of the osteotomy site in two of 12, delayed union of the osteotomy site in one of 16, collapse of the recycled bone in one of 16, and local recurrence in 1 of 16 patients. Kaplan-Meier survivorship free from removal of autograft at 2 years after surgery was 92% (95% confidence interval 89 to 96).

CONCLUSION

Liquid nitrogen-sterilization is an alternative technique that requires some training and experience for the surgeon to become proficient in treating primary malignant bone tumors. Because it is widely available, it may be an option worth exploring in resource-constrained environments, where allografts and endoprostheses cannot be procured. The methods we developed to address the technical challenges will require more study and experience, but we believe these observations will aid others who may wish to use and evaluate liquid nitrogen sterilization of extremity bone sarcomas.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Extracorporeal radiation and reimplantation: a safe and viable option for reconstruction after sacral tumor resection?

Primary tumors of the sacrum are difficult to manage, as they often require morbid resections and complex reconstructions. In the case of tumors such as chordoma or chondrosarcoma, aggressive resections are often required to achieve appropriate margins (extending disease-free survival), followed by complex reconstructions. These reconstructions are aimed at restoring the pelvic ring and have traditionally resulted in a lumbosacral construct that utilizes structural allograft/autograft bone (fibula most commonly used) and more recently, reconstruction with 3D-printed custom sacral prostheses. While there are no reports of anatomical reconstruction using sacral allografts, extracorporeal radiation therapy (ECRT) and reimplantation provides a size and shape-matched irradiated autograft which avoids the cultural stigma, structural strength and graft-host concerns associated with allografts, as well as the high costs and time to production associated with custom 3D-printed implants. Here we present an illustrative case with technical notes, outlining the steps used at our center for ECRT. While early results with ECRT in the sacrum are promising, future larger studies should be carried out to help detect differences that may exist in long-term complications.

Reconstructive Challenges of Proximal Ulnar Bone Tumors: Our Experience with Biological Osteoarticular Reconstruction Using Extracorporeal Irradiation and Reimplantation

Introduction

Limb salvage surgery following proximal ulna resection poses a challenge in reconstruction of the complex elbow anatomy. Various reconstruction methods described offer inadequate restoration of function and stability. Following resection of proximal ulna tumors, we aimed to restore the joint using the resected osteochondral segment of proximal ulna treated with extracorporeal irradiation and reimplantation.

Questions/Purposes

(1) Does irradiated osteoarticular autograft reconstruction for proximal ulna allow anatomical joint restoration and what are the oncological and functional outcomes? (2) Is there evidence of graft-related complications or osteoarthritis at a minimum of 2 years follow-up with irradiated osteoarticular autografts for the proximal ulna? (3) How does our method of reconstruction fare as compared to reported reconstruction options in the literature? Materials and Methods. 3 patients with primary bone tumors involving the proximal ulna underwent limb salvage surgery with en bloc resection and reconstruction using the resected bone after treating it with extracorporeal irradiation of 50 Gy. Minimum follow-up of 2 years was considered for assessment of final outcomes. Radiographs were assessed for bony recurrence, union across osteotomy junction, and signs of joint arthritis. Functional outcome measures included range of movement, muscle power testing, and functional and disability scores.

Results

2 complete and 1 partial olecranon involving proximal ulnar resections were performed for three cases of Ewing's sarcoma in 2 males and 1 female. Follow-up ranged from 28 to 42 months, and all patients continue to remain disease free. All 3 patients have achieved full range of flexion-extension and pronosupination movement in comparison to the contralateral side. Muscle power for flexion and extension was 5/5. MSTS score: 100% (30/30); MEPS score: 100; and DASH score: zero were achieved for all patients. Union across osteotomy junctions at median follow-up of 8 months without need for intervention/bone grafting was achieved. No complications related to joint laxity/subluxation, infection, graft fracture, or implant failure was noted. None of the patients have clinical or radiological signs of joint arthritis across the irradiated articulation.

Conclusion

Biological restoration of elbow anatomy using osteoarticular irradiated graft for proximal ulna reconstruction offers great joint stability and functional outcomes. Although the potential risks of infection and graft failure need to be considered, reconstruction with the size-matched radiated autograft eliminates donor site morbidity, offers a low-cost alternative to endoprosthesis, and provides outcomes superior to any other methods of reconstruction as analyzed from the literature.