Pedicle frozen autograft-prosthesis composite reconstructions for malignant bone tumors of the proximal femur

Allograft-prosthesis composite after proximal femur bone tumor resection in pediatric age: Is it effective in preserving bone stock?

Purpose

The purpose of the study was to answer the following questions. What was functional results of pediatric patients receiving a short stem allograft-prosthesis composite of the proximal femur? What was complication rate and revision-free implant survival? Was it possible to preserve the bone stock of the proximal femur in pediatric patients?

Methods

We reviewed 10 pediatric patients treated with proximal femur resection for a primary bone tumor and reconstruction with short stem allograft-prosthesis composite, with at least 24 months follow-up. The median age was 9 years (4-13) at surgery. The mean resection length was 15 cm (6-29). In six cases, fixation was performed with a short plate positioned under the great trochanter while in four cases a long plate extended over the great trochanter was employed.

Results

Nine complications that required surgical revision were assessed in six patients (one wound dehiscence, two nonunions, two fractures, one acetabular wear, three hypometria), while allograft-prosthesis composite removal was required in three patients. The revision-free survival was 57% (95% confidence interval 33%-100%) at 5 and 10 years. The graft removal-free survival was 75% (95% confidence interval 50%-100%) at 5 and 10 years. The mean Musculo-Skeletal Tumor Society Score was 28 (20-30).

Conclusions

Allograft-prosthesis composites with short stem and compression plate represents an effective reconstructive option after proximal femur resection for primary bone tumors in growing patients, preserving bone stock. The use of a compression plate extended over the greater trochanter seemed to reduce failure rate.

Similar complications, implant survival, and function following modular prosthesis and allograft-prosthesis composite reconstructions of the proximal femur for primary bone tumors: a systematic review and meta-analysis

PURPOSE

There is a lack of consensus regarding the best type of reconstruction of the proximal femur following bone tumor resection. The objective of this study was to analyze the complication risks, implant survival, and functional outcomes following modular prosthesis (MP) and allograft-prosthesis composite (APC) reconstruction of the proximal femur after primary bone tumor resections.

METHODS

We performed a search in the PubMed and Scopus libraries, obtaining 1 843 studies. We included studies reporting functional outcomes, complications, and implant survival of proximal femur reconstruction with MP or APC following primary bone tumor resection with a 2-year minimum follow-up. We excluded studies analyzing metastatic patients or studies with pooled data in which it was impossible to separate the data of patients with primary bone tumors from those with bone metastases.

RESULTS

We analyzed 18 studies (483 patients) reporting on 234 (48%) patients with MP reconstruction and 249 (52%) patients with APC reconstruction. The risk of complications was similar in patients with MP reconstruction (29%; 95% CI [0.11; 0.47]) and APC reconstruction (36%; 95% CI [0.24; 0.47]) (p = 0.48). Implant survival following MP reconstruction ranged from 81 to 86% at 5 years, 75 to 86% at 10 years, and 82% at 15 years. Implant survival following APC reconstruction ranged from 86 to 100% at 5 years and 86% at 10 years, and 86% at 15 years. Functional outcomes following MP reconstruction and APC reconstruction ranged from 24.0 to 28.3 and from 21.9 to 27.8, respectively.

CONCLUSION

Patients with primary bone tumor of the proximal femur who underwent MP or APC reconstruction seem to have similar complication risks, implant survival, and functional outcomes.

Frozen inactivated autograft replantation for bone and soft tissue sarcomas

Background

The frozen inactivation of autologous tumor bones using liquid nitrogen is an important surgical method for limb salvage in patients with sarcoma. At present, there are few research reports related to frozen inactivated autograft replantation.

Methods

In this study, we retrospectively collected the clinical data of patients with bone and soft tissue sarcoma treated with liquid nitrogen-frozen inactivated tumor bone replantation, and analyzed the safety and efficacy of this surgical method. The healing status of the frozen inactivated autografts was evaluated using the International Society of Limb Salvage (ISOLS) scoring system. Functional status of patients was assessed using the Musculoskeletal Tumor Society (MSTS) scale.

Results

This study included 43 patients. The average length of the bone defect after tumor resection is 16.9 cm (range 6.3-35.3 cm). Patients with autograft not including the knee joint surface had significantly better healing outcomes (ISOLS scores) (80.6% ± 15% vs 28.2% ± 4.9%, P<0.001) and limb function (MSTS score) (87% ± 11.6% vs 27.2% ± 4.4%, P<0.001) than patients with autografts including the knee joint surface. The healing time of the end of inactivated autografts near the metaphyseal was significantly shorter than that of the end far away from the metaphyseal (9.8 ± 6.3 months vs 14.9 ± 6.3 months, P=0.0149). One patient had local recurrence, one had an autograft infection, five (all of whom had an autograft including the knee joint surface) had joint deformities, and seven had bone non-union.

Conclusion

Frozen inactivated autologous tumor bone replantation is safe and results in good bone healing. But this method is not suitable for patients with autograft involving the knee joint surface.

Rethinking Antigen Source: Cancer Vaccines Based on Whole Tumor Cell/tissue Lysate or Whole Tumor Cell

Cancer immunotherapies have improved human health, and one among the important technologies for cancer immunotherapy is cancer vaccine. Antigens are the most important components in cancer vaccines. Generally, antigens in cancer vaccines can be divided into two categories: pre-defined antigens and unidentified antigens. Although, cancer vaccines loaded with predefined antigens are commonly used, cancer vaccine loaded with mixed unidentified antigens, especially whole cancer cells or cancer cell lysates, is a very promising approach, and such vaccine can obviate some limitations in cancer vaccines. Their advantages include, but are not limited to, the inclusion of pan-spectra (all or most kinds of) antigens, inducing pan-clones specific T cells, and overcoming the heterogeneity of cancer cells. In this review, the recent advances in cancer vaccines based on whole-tumor antigens, either based on whole cancer cells or whole cancer cell lysates, are summarized. In terms of whole cancer cell lysates, the focus is on applying whole water-soluble cell lysates as antigens. Recently, utilizing the whole cancer cell lysates as antigens in cancer vaccines has become feasible. Considering that pre-determined antigen-based cancer vaccines (mainly peptide-based or mRNA-based) have various limitations, developing cancer vaccines based on whole-tumor antigens is a promising alternative.

Analyzing BMP2, FGFR, and TGF Beta Expressions in High-Grade Osteosarcoma Untreated and Treated Autografts Using Proteomic Analysis

In the last few decades, biological reconstruction techniques have improved greatly for treating high-grade osteosarcoma patients. To conserve the limb, and its function the affected tumor-bearing bones have been treated using liquid nitrogen and irradiation processes that enable the removal of entire tumors from the bone, and these treated autografts can be reconstructed for the patients. Here, we focus on the expressions of the growth factor family proteins from the untreated and treated autografts that play a crucial role in bone union, remodeling, and regeneration. In this proteomic study, we identify several important cytoskeletal, transcriptional, and growth factor family proteins that showed substantially low levels in untreated autografts. Interestingly, these protein expressions were elevated after treating the tumor-bearing bones using liquid nitrogen and irradiation. Therefore, from our preliminary findings, we chose to determine the expressions of BMP2, TGF-Beta, and FGFR proteins by the target proteomics approach. Using a newly recruited validation set, we successfully validate the expressions of the selected proteins. Furthermore, the increased growth factor protein expression after treatment with liquid nitrogen may contribute to bone regeneration healing, assist in faster recovery, and reduce local recurrence and metastatic spread in high-grade sarcoma patients.

Comparative Analysis of Two Surgical Treatment Options for Giant Cell Tumor of the Proximal Femur: Extended Curettage and Segmental Resection

Aim

As a locally destructive intermediate bone tumor with low incidence, high recurrence rate, and difficulty in reconstruction, giant cell tumor of bone (GCTB) in the proximal femur has no unified surgical treatment standard. This study aimed to compare the differences in local recurrence, reconstruction durability, and postoperative function after treatment with either extended curettage (EC) or segmental resection (SR) for GCTB in the proximal femur so as to provide constructive suggestions for the rational selection of EC or SR operation scheme.

Patients and Methods

29 patients (15 men and 14 women) were included in this retrospective study, with a mean age of 32.1 years. According to the division method of proximal femur of International Society Of Limb Salvage (ISOLS), there was 1 case in the H1 area, 17 cases in the H2 area, 10 cases in the H1+H2 area, and 1 case in the H1+H2+H3 area. Among them were 11 cases of Campanacci grade II GCTB, 18 cases of Campanacci grade III GCTB, and 7 cases with pathological fractures. All patients underwent either EC or SR surgery. The Musculoskeletal Tumor Society (MSTS) score was used for patient evaluation. The operation effectiveness was analyzed according to the Mankin evaluation standard. Regular follow-up was performed to evaluate the recurrence rate, limb function, and long-term complications of the two surgical methods.

Results

All patients were followed up for a mean of 60.4 months. Local recurrence occurred in one of 19 patients treated with EC (5.3%) and one of 10 patients treated with SR (10%). The MSTS score of lower limb function in patients in the EC group was better compared to patients in the SR group (P = 0.002). Complications occurred in 2 cases (10.5%) and 5 cases (50%) in the EC group (osteoarthritis, osteonecrosis) and SR group (joint stiffness, infection, prosthesis loosening), respectively, with significant differences between the two groups (P = 0.03). The operation effectiveness was analyzed according to the Mankin evaluation standard. The EC group showed an optimal rate of 94.7% (18/19) as opposed to 80% (8/10) in the SR group.

Conclusions

For GCTB in the proximal femur, when the tumor does not extensively involves the surrounding soft tissues, the articular surface was not damaged, and there is no pathological fracture with apparent displacement, EC surgery should be fully considered.

Risk factors and outcomes for failure of biological reconstruction after resection of primary malignant bone tumors in the extremities

Biological reconstruction is widely used to reconstruct bone defects after resection of bone tumors in the extremities. This study aimed to identify risk factors for failure and to compare outcomes of the allograft, nonvascularized autograft, and recycled frozen autograft reconstruction after resection of primary malignant bone tumors in the extremities. A retrospective study was performed at a single center between January 1994 and December 2017. Ninety patients with primary malignant bone tumors of the extremities were treated with tumor resection and reconstruction using one of three bone graft methods: nonvascularized autograft (n = 27), allograft (n = 34), and recycled frozen autograft (n = 29). The median time for follow-up was 59.2 months (range 24-240.6 months). Overall failure of biological reconstruction occurred in 53 of 90 patients (58.9%). The allograft group had the highest complication rates (n = 21, 61.8%), followed by the recycled frozen autograft (n = 17, 58.6%) and nonvascularized autograft (n = 15, 55. 6%) groups. There was no statistically significant difference among these three groups (p = 0.89). The mean MSTS score was 22.6 ± 3.4 in the nonvascularized autograft group, 23.4 ± 2.6 in the allograft group, and 24.1 ± 3.3 in the recycled frozen autograft group. There was no significant difference among the groups (p = 0.24). After bivariate and multivariable analyses, patient age, sex, tumor location, graft length, methods, and type of reconstruction had no effects on the failure of biological reconstruction. Biological reconstruction using allograft, nonvascularized autograft, and recycled frozen autograft provide favorable functional outcomes despite high complication rates. This comparative study found no significant difference in functional outcomes or complication rates among the different types of reconstruction.

Long-term results of uncemented allograft prosthesis composite reconstruction for the tumor in proximal femur: a minimum follow-up of sixty-five months

BACKGROUND

Uncemented allograft prosthesis composite (APC) has been applied for tumorous bone defect reconstruction in the proximal femur. However, the long-term results are rarely reported. This study aimed to evaluate long-term outcomes of uncemented APC.

METHODS

Eighteen patients who received uncemented APC reconstruction in the proximal femur after tumor resections were retrospectively reviewed.

RESULTS

The average resection length was 110 mm (80-154) and the average follow-up was 106.7 months (65-141). Bone union achieved in all patients with an average duration of 7.6 months (5-10). The average HHS, MSTS score and gluteus medius strength at one-year follow-up were 88.0 (80-94), 25.2 (22-28) and 4 (3-5), respectively. While at the last follow-up, the HHS, MSTS score and gluteus medius strength were 83.0 (48-100), 24.0 (10-30) and 4 (2-5), respectively. Five intraoperative fractures were fixed with cerclage wires. Two postoperative periprosthetic and prosthetic fractures received a revision. Three local recurrent patients received a secondary surgery. One of these three lung metastatic patients underwent lung metastatic tumor resection. Another two patients were diagnosed with both bone and lung metastases, only one of them underwent amputation. Two greater trochanteric fractures received no treatment. There were10 severe, 3 moderate and 5 mild allograft resorptions without treatment.

CONCLUSION

Uncemented APC is a reliable reconstruction for neoplastic bone defect of the proximal femur, especially for the young patient who expected long-life expectancy and good function. Though allograft resorption and trochanteric fracture are the common complications, they seem no effect on the function.