The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 86, Issue 12

Scientific Articles | December 01, 2004

Partial Epiphyseal Preservation and Intercalary Allograft Reconstruction in High-Grade Metaphyseal Osteosarcoma of the Knee

D. Luis Muscolo, MD¹; Miguel A. Ayerza, MD¹; Luis A. Aponte-Tinao, MD¹; Maximiliano Ranalletta, MD¹

¹ Institute of Orthopedics “Carlos E. Ottolenghi,” Italian Hospital of Buenos Aires, Potosí 4215, (1199) Buenos Aires, Argentina. E-mail address for D.L. Muscolo: luis.muscolo@hospitalitaliano.org.ar

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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Read in part at the Annual Meeting of the American Academy of Orthopaedic Surgeons, San Francisco, California, March 11, 2004.

Investigation performed at the Institute of Orthopedics "Carlos E. Ottolenghi," Italian Hospital of Buenos Aires, Buenos Aires, Argentina

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2004 Dec 01;86(12):2686-2693

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Abstract

Background: The purpose of this study was to analyze a series of patients with a high-grade metaphyseal osteosarcoma of the knee who had been treated with a transepiphyseal resection, with preservation of the distal femoral and the proximal tibial (articular) portions of the epiphysis, and an intercalary allograft reconstruction.

Methods: The cases of thirteen patients with a high-grade metaphyseal osteosarcoma around the knee who had transepiphyseal resection and reconstruction with an intercalary allograft were retrospectively reviewed at a mean of sixty-three months. Complications, disease-free survival of the patient, final preservation of the limb and epiphysis, and functional results according to the Musculoskeletal Tumor Society scoring system were documented at the time of the latest follow-up.

Results: At the final follow-up examination, eleven of the thirteen patients continued to be disease-free. One patient died of bone and pulmonary metastases with no evidence of local recurrence, and the remaining patient had no evidence of disease after resection of a local recurrence of the tumor in the soft tissues. No patient had a local recurrence in the remaining epiphysis. Seven patients had complications that included a fracture (three patients), diaphyseal nonunion (two), deep infection (one), and a local recurrence in the soft tissues (one). The allograft was removed in only four of these patients. At the latest follow-up examination, twelve patients were alive with preserved limbs. In one patient, the epiphysis, which originally had been preserved, was resected because of a metaphyseal fracture, and the limb was reconstructed with an osteoarticular allograft. The patients with a preserved epiphysis had an average functional score of 27 points (maximum, 30 points).

Conclusions: Preservation of the epiphysis in high-grade metaphyseal osteosarcoma at the knee is an alternative in carefully selected patients. Crucial factors needed to obtain local tumor control and achieve an acceptable functional result are a positive response to chemotherapy, accurate preoperative assessment of tumor extension to the epiphysis, and appropriate fixation techniques for intercalary allografts.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

The life expectancy of patients with a high-grade osteosarcoma that is diagnosed in a timely manner and treated with modern chemotherapy regimens and proper surgical margins can be more than 70% after five years^1-3. Most surgical techniques presently used to treat high-grade metaphyseal osteosarcomas around the knee include resection of one or both epiphyses. If an osteoarticular allograft is used to reconstruct the joint, the epiphysis of the affected bone is lost, potentially creating anatomical mismatching or joint instability. If a prosthesis is used, then both epiphyses are excised, with gross distortion of the normal anatomy and questionable durability of the reconstruction for a patient with several decades of life expectancy.

Most surgeons would not consider treating a high-grade metaphyseal osteosarcoma in a way that preserves the affected epiphysis because of the difficulties in reconstruction and the risk of contaminating the tissue planes.

Recent evidence has suggested that presently used imaging techniques, particularly magnetic resonance imaging, can safely and accurately define tumor limits in patients who have a metaphyseal osteosarcoma growing toward the epiphysis in the knee joint.

We present the cases of thirteen patients with a high-grade metaphyseal osteosarcoma of the knee who were treated with a transepiphyseal resection and intercalary allograft reconstruction, with preservation of both epiphyses and the potential to maintain a nearly normal joint for several decades.

Materials and Methods

Materials and Methods | Results | Discussion | References

Between February 1991 and December 2000, seventy-six patients with high-grade metaphyseal osteosarcoma around the knee were treated by the Orthopaedic Oncology Service. All patients were managed with chemotherapy, and, after the induction period, definitive surgery of the primary lesion was performed. Magnetic resonance images were acquired with a 1.5-T Magnetom Vision unit (Siemens, Erlangen, Germany) at the time of the diagnosis and after chemotherapy. The whole limb was evaluated with use of a body coil. In order to determine epiphyseal tumor spread and its relation to the articular cartilage, images were acquired with use of an additional knee coil. These studies were reviewed on paired longitudinal T1-weighted and short tau inversion recovery images. The extent of the epiphyseal involvement was calculated with coronal, sagittal, and axial images defining the edge of the tumor as the point in which marrow signal intensity changed from normal to abnormal. All scans were performed by the same radiologist.

Patients were evaluated according to the following criteria: (1) the intrachemotherapy tumor progression, (2) the age and potential for skeletal growth, (3) the tumor growth toward the epiphysis, and (4) the amount of epiphysis to be preserved in order to allow fixation of the osteotomy junction. Magnetic resonance imaging studies acquired before and after chemotherapy were compared in order to evaluate tumor response. Tumors with no evidence of progression clinically or on magnetic resonance imaging studies during chemotherapy were considered to be potential candidates for transepiphyseal resection. Very young patients (those less than eight years old) who were predicted to have a substantial final limb-length discrepancy were excluded. The youngest patient in this series was nine years old. Epiphyseal tumor extension was determined with both T1-weighted and short tau inversion recovery imaging after selection of the longitudinal (usually coronal) section that best showed the tumor. The osteotomy was planned 1 to 2 cm from the lower edge of the tumor growth, defined as the point at which marrow signal intensity changed from abnormal to normal. Areas of intermediate signal intensity adjacent to the tumor edge that may represent microscopic tumor extension, marrow hyperplasia, or edema were considered to be tumor invasion. A residual epiphysis of =1 cm should be obtained in order to allow fixation of the osteotomy junction (Fig. 1). Patients in whom these preoperative imaging planning requirements were not fulfilled were treated with an epiphyseal resection. At the time of surgery, measurements obtained with preoperative magnetic resonance imaging were correlated with the following anatomical landmarks: the epicondyles, the intercondylar notch roof, the articular cartilage limits in the femur and the tibial plateau surface, the proximal end of the fibula, and the patellar tendon insertion on the tibia. In fifteen patients, the lesion was located <5 cm from the articular surface, so a transepiphyseal resection was performed and the bone loss was reconstructed with an intercalary allograft. Two of the fifteen patients were excluded because they had previous surgeries at other centers, leaving thirteen patients for this study (Table I). These patients were followed for a mean of sixty-three months (range, twenty-four to 144 months). Eight tumors were in the femur (Figs. 2-A, 2-B, 2-C, 2-D, 2-E), and five were in the tibia (Figs. 3-A, 3-B, and 3-C). There were eight females and five males, with a mean age of eighteen years (range, nine to forty years).

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Fig. 1: Diagrams and surgical photographs showing the pattern of tumor resection in the distal part of the femur (A) and the proximal part of the tibia (B).

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TABLE I Demographic and Clinical Data on Thirteen Patients with High-Grade Osteosarcoma Treated with a Transepiphyseal Resection

Case	Gender, Age	Site	Enneking Stage²²	Duration of Follow-up (mo)	Induction Chemotherapy	Tumor Necrosis (%)	Metastases	Patient Status	Complications	Functional Score	Final Status of Epiphysis
1	F, 9	Femur	III	66	High-dose methotrexate, doxorubicin, and ifosfamide	90	Pulmonary	Alive with no evidence of disease	Fracture	26	Preserved
2	M, 16	Femur	II B	66	High-dose methotrexate, doxorubicin, and ifosfamide	95	—	Alive with no evidence of disease	Nonunion	30	Preserved
3	F, 18	Femur	II B	24	High-dose methotrexate, doxorubicin, and ifosfamide	90	Pulmonary and bone (18 mo)	Deceased	—	—	Preserved
4	F, 40	Femur	II B	67	Cisplatin, doxorubicin, and ifosfamide	90	—	Alive with no evidence of disease	Fracture	30	Preserved
5	M, 21	Femur	II B	62	High-dose methotrexate, doxorubicin, and ifosfamide	96	—	Alive with no evidence of disease	—	30	Preserved
6	F, 17	Femur	II B	50	High-dose methotrexate, doxorubicin, and ifosfamide	99	—	Alive with no evidence of disease	—	30	Preserved
7	F, 14	Femur	II B	42	Cisplatin, doxorubicin, and ifosfamide	90	—	Alive with no evidence of disease	Fracture	—	Not preserved
8	M, 10	Femur	II B	31	High-dose methotrexate, doxorubicin, and ifosfamide	98	—	Alive with no evidence of disease	Nonunion	20	Preserved
9	F, 18	Tibia	II B	144	High-dose methotrexate, doxorubicin, and ifosfamide	98	—	Alive with no evidence of disease	—	30	Preserved
10	M, 24	Tibia	II B	134	High-dose methotrexate, doxorubicin, and ifosfamide	100	—	Alive with no evidence of disease	Infection	10	Preserved
11	F, 14	Tibia	II B	50	Cisplatin, doxorubicin, and ifosfamide	90	—	Alive with no evidence of disease	—	30	Preserved
12	M, 18	Tibia	II B	44	High-dose methotrexate, doxorubicin, and ifosfamide	95	—	Alive with no evidence of disease	—	29	Preserved
13	F, 14	Tibia	II B	40	High-dose methotrexate, doxorubicin, and ifosfamide	98	—	Alive with no evidence of disease	Recurrence	30	Preserved

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TABLE I Demographic and Clinical Data on Thirteen Patients with High-Grade Osteosarcoma Treated with a Transepiphyseal Resection

Case	Gender, Age	Site	Enneking Stage²²	Duration of Follow-up (mo)	Induction Chemotherapy	Tumor Necrosis (%)	Metastases	Patient Status	Complications	Functional Score	Final Status of Epiphysis
1	F, 9	Femur	III	66	High-dose methotrexate, doxorubicin, and ifosfamide	90	Pulmonary	Alive with no evidence of disease	Fracture	26	Preserved
2	M, 16	Femur	II B	66	High-dose methotrexate, doxorubicin, and ifosfamide	95	—	Alive with no evidence of disease	Nonunion	30	Preserved
3	F, 18	Femur	II B	24	High-dose methotrexate, doxorubicin, and ifosfamide	90	Pulmonary and bone (18 mo)	Deceased	—	—	Preserved
4	F, 40	Femur	II B	67	Cisplatin, doxorubicin, and ifosfamide	90	—	Alive with no evidence of disease	Fracture	30	Preserved
5	M, 21	Femur	II B	62	High-dose methotrexate, doxorubicin, and ifosfamide	96	—	Alive with no evidence of disease	—	30	Preserved
6	F, 17	Femur	II B	50	High-dose methotrexate, doxorubicin, and ifosfamide	99	—	Alive with no evidence of disease	—	30	Preserved
7	F, 14	Femur	II B	42	Cisplatin, doxorubicin, and ifosfamide	90	—	Alive with no evidence of disease	Fracture	—	Not preserved
8	M, 10	Femur	II B	31	High-dose methotrexate, doxorubicin, and ifosfamide	98	—	Alive with no evidence of disease	Nonunion	20	Preserved
9	F, 18	Tibia	II B	144	High-dose methotrexate, doxorubicin, and ifosfamide	98	—	Alive with no evidence of disease	—	30	Preserved
10	M, 24	Tibia	II B	134	High-dose methotrexate, doxorubicin, and ifosfamide	100	—	Alive with no evidence of disease	Infection	10	Preserved
11	F, 14	Tibia	II B	50	Cisplatin, doxorubicin, and ifosfamide	90	—	Alive with no evidence of disease	—	30	Preserved
12	M, 18	Tibia	II B	44	High-dose methotrexate, doxorubicin, and ifosfamide	95	—	Alive with no evidence of disease	—	29	Preserved
13	F, 14	Tibia	II B	40	High-dose methotrexate, doxorubicin, and ifosfamide	98	—	Alive with no evidence of disease	Recurrence	30	Preserved

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Figs. 2-A through 2-E: Case 2, a sixteen-year-old boy who had an osteosarcoma in the distal aspect of the femur. Fig. 2-A Anteroposterior radiograph of the distal aspect of the femur after preoperative chemotherapy. Fig. 2-B Coronal magnetic resonance image showing the tumor extension, without crossing of the physeal plate. Fig. 2-C Gross pathological specimen showing the transepiphyseal osteotomy distal to the growth plate.

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Figs. 2-D and 2-E: Anteroposterior (Fig. 2-D) and lateral (Fig. 2-E) radiographs made sixty-six months after surgery showing healing of the transepiphyseal host to the graft (arrows).

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Figs. 3-A, 3-B, and 3-C: Case 11, a fourteen-year-old girl with an osteosarcoma in the proximal aspect of the tibia. Fig. 3-A Anteroposterior radiograph showing tumor extension without involvement of the proximal tibial epiphysis. Fig. 3-B Coronal magnetic resonance image showing the preoperative extent of tumor extension. Fig. 3-C Anteroposterior radiograph made fifty months after an intraepiphyseal resection and reconstruction with an intercalary allograft. Note that both osteotomies healed with mature callus (arrows).

Operative treatment consisted of resection of the tumor and insertion of an allograft segment tailored to fit the bone defect. Fresh-frozen allografts were obtained and stored according to a technique that has been previously described⁴. The selection of the allograft was performed on the basis of a comparison of the patient's radiographs with those of the donor in order to achieve the closest possible anatomical match. After the donor bone was thawed in a warm solution, it was cut to the proper length. Diaphyseal osteotomies were fixed with plates and screws in eight patients and with intramedullary rods in five. Intraepiphyseal osteotomies were stabilized with plates and screws in three patients. In the remaining ten patients, since only a small part of the epiphysis and articular surface was saved, fixation was obtained with cancellous screws placed across the osteotomies. In tibial allografts, the extensor mechanism was reconstructed by attachment of the allograft patellar tendon to the corresponding host patellar tendon. The donor patellar tendon was cut 2 cm from the insertion on the patella and was sectioned longitudinally. The donor flaps overlapped the host patellar tendon and were sutured to restore the extensor mechanism. Finally, a medial gastrocnemius transposition flap was done to provide soft-tissue coverage to the proximal tibial allograft.

Antibiotics were given intravenously according to the usual prophylactic protocol, and no routine anticoagulation therapy was used. External splinting with a brace with the knee in full extension was used until the wound had healed. Passive range-of-motion exercises were begun at two weeks after the operation for all patients, including those with a proximal tibial resection. Most patients were seen postoperatively at one week, two weeks, one month, two months, and three months, and then every three months thereafter until two years, after which they were seen annually. Plain radiographs were made at every visit, beginning one month after the operation. Complications such as a recurrence, fracture, nonunion, or infection were identified. Union was assessed on the basis of the radiographic findings; nonunion was defined as the absence of union at one year after the reconstruction.

We analyzed allograft survival and the number of patients in whom the preserved epiphysis was eventually maintained. The procedure was considered to be a reconstructive failure when the allograft was removed either as a revision procedure or because of an amputation. The functional evaluation of the patients was performed with use of the revised 30-point functional classification system established by the International Society of Limb Salvage and the Musculoskeletal Tumor Society⁵. This functional score measured six parameters: pain, function, emotional acceptance, use of walking supports, walking ability, and gait. Each parameter is given a value ranging from 0 to 5, according to specific criteria. The individual scores are added together to obtain an overall functional score, with a maximum of 30 points, which then is expressed as a percentage of normal. A score of =23 points is considered an excellent functional result; a score of 15 to 22 points, a good result; a score of 8 to 14 points, a fair result; and a score of <8 points, a poor result.

Results

Materials and Methods | Results | Discussion | References

Following surgery, the resection margins were negative for tumors histologically in all patients. At the final follow-up evaluation, eleven patients continued to be disease-free and one patient had no evidence of disease after resection of a local soft-tissue recurrence. One patient died of bone and pulmonary metastases with no evidence of local recurrence. No patient had a local recurrence in the preserved epiphysis.

Of the thirteen patients in the study, only six healed without complications. A surgical procedure was performed in seven patients because of complications, which included a fracture (three patients), diaphyseal nonunion (two), deep infection (one), and local recurrence in the soft tissues (one). In four of the patients, the allograft was removed.

All fractures were localized in the femur and were treated with reconstruction with a new allograft; two were treated with another intercalary graft, and one was converted to an osteoarticular allograft, sacrificing the originally preserved epiphysis.

In both diaphyseal nonunions, a single operation, in which the internal fixation was replaced and autogenous graft was added to the site, resulted in union at the host-donor junction. Neither nonunion was associated with failure of the graft, since both healed after a reoperation.

One patient had an acute deep infection, which was treated with removal of the allograft and implantation of a temporary antibiotic-impregnated cement spacer. After six weeks of intravenous antibiotics and six weeks of oral antibiotics, another intercalary allograft was reimplanted. Eight years later, the patient had a recurrence of the infection that required aggressive débridement and the implantation of another antibiotic-impregnated cement spacer.

The only local recurrence in this series was in soft tissues with no contact with the reconstruction and at a distance from the osteotomy site; the tumor was resected with wide margins. The patient was alive and disease-free eighteen months after the last operation.

At the latest follow-up examination, twelve patients were alive with no evidence of disease and the limb was preserved in all of them. In only one patient was the originally saved epiphysis not preserved, because of a metaphyseal fracture, and the limb was reconstructed with an osteoarticular allograft. The eleven patients with a preserved epiphysis had an average functional score of 27 points (range, 10 to 30 points). Function was estimated to be excellent for nine patients, good for one, and fair for one. No patient who had the epiphysis preserved had pain in the involved limb. Eight patients had no functional restrictions, two had restrictions in recreational activities, and one had partial disability. Ten of the eleven patients were enthusiastic about the result, and one accepted the result. Nine patients walked without the use of supports, one walked with one cane, and one walked with two canes. Nine patients could walk an unlimited distance, and two had some limitations in walking. Eight patients had no discernible limp, two had a minor limp, and one had a major limp. The mean active flexion of the knee was 107° (range, 80° to 135°) for patients with distal femoral reconstruction and 116° (range, 40° to 135°) for patients with proximal tibial reconstruction. The mean extensor lag was 0° in ten patients and 10° in the patient who had the cement spacer implanted. The two patients (Cases 1 and 8) with a persistently open physis at the latest evaluation had limb shortening of 3.5 and 2 cm, respectively; both used a shoe lift to compensate for the discrepancy.

Discussion

Materials and Methods | Results | Discussion | References

Accurate preoperative assessment of the extent of an intramedullary tumor is crucial when a limb salvage procedure is being considered⁶. Attempts to determine transepiphyseal extension of osteosarcoma in mature or immature patients have been extensively reported^6-12.

Early studies of pathological specimens obtained at the time of surgery have suggested that the prevalence of transepiphyseal spread of the tumor in metaphyseal osteosarcomas is 81%^13,14. In addition, epiphyseal tumor extensions are not accurately detectable by conventional radiography or radioisotope scanning^13,15. More recently, several studies have described the accuracy of magnetic resonance imaging in detecting epiphyseal extension of osteosarcoma^6-12. Those studies have shown a sensitivity of 100%^7,8,11 with no false negatives; however, false positives have been reported, suggesting that abnormal epiphyseal signal intensities do not necessarily indicate spread of the disease⁹. Those studies indicate that magnetic resonance imaging is a sensitive indicator of epiphyseal involvement by osteosarcoma, but it has lower specificity by sometimes overestimating the extent of the tumor.

Only a few small series of patients with metaphyseal osteosarcoma around the knee treated with salvage of the epiphysis and reconstruction have been reported^11,16-20. Reconstructive procedures have included physeal distraction before removing the tumor¹⁷, distraction osteogenesis after tumor resection²⁰, autoclaved autogenous bone supplemented with a vascularized fibular graft¹⁶, and frozen allograft with a vascularized fibular autograft¹⁹. All of those studies described different complications; however, no recurrences at the retained epiphysis were diagnosed.

All patients in the present report had a high-grade metaphyseal osteosarcoma of the distal aspect of the femur or the proximal part of the tibia that was treated with an intraepiphyseal resection and reconstruction with fresh-frozen intercalary bone allograft. Interestingly, they represent 20% of all patients with an osteosarcoma at those locations who were treated at our institution during the same period of time. The percentage of patients without epiphyseal involvement by the tumor was very similar to that reported in the literature^8,10.

Careful preoperative evaluations, particularly with magnetic resonance imaging, were crucial in order to obtain appropriate margins in all patients. Tumor-free margins were determined in all of the specimens, and there were no recurrences at the retained epiphysis, after a minimum follow-up of two years.

Substantial reconstructive complications should be expected after these technically demanding surgical procedures. Seven patients in this series needed a second operation. Four had a reconstructive failure, defined as the need to excise the allograft. However, after reoperations in three patients, the osteoarticular surface was again preserved and a second reconstruction with an intercalary allograft was performed.

All patients, except one, were alive and disease-free with a preserved limb at the last follow-up evaluation. Ten patients had good or excellent functional scores.

Surgeons who are willing to attempt this procedure should be aware of two main and dangerous difficulties. First, it is essential to clearly define the tumor margins with magnetic resonance imaging studies. Preoperative identification of epiphyseal tumor extension should include areas of intermediate signal intensity that may turn out to be hemorrhage or edema upon pathological evaluation of the specimen. Questionable bone-marrow areas seen on the imaging studies should be considered to be tumor and should be included in the resection. Second, it is difficult to correlate the information obtained from the preoperative magnetic resonance imaging studies with the real tumor limits at the time of surgery. Future applications of computer-aided techniques²¹ may prove valuable and help to define with greater precision the tumor margins at the time of resection.

Oncologic orthopaedic surgeons are frequently confronted by a difficult decision when treating a patient with an osteosarcoma after neoadjuvant chemotherapy: they must decide whether to decrease the resection margins to obtain the best possible functional result, but with potential questionable margins and catastrophic oncologic consequences, or to over-treat the tumor by creating excessive margins but having a much less functional result and the potential need for a succession of reconstructive procedures with questionable durability. Our findings suggest that, although complications requiring a second operation could be expected after reconstruction, about one of six patients with a metaphyseal osteosarcoma around the knee may be treated with appropriate oncologic margins and preservation of the epiphysis of the affected bone. However, extensive evaluation with accurate imaging techniques should be performed before this demanding decision is made. ?

References

Materials and Methods | Results | Discussion | References

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Topics

osteosarcoma ; knee region ; knee joint ; pineal body ; reconstructive surgical procedures ; tibia ; neoplasms ; allografting

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D. Luis Muscolo, M.D.

Posted on January 21, 2005

Dr Muscolo and colleagues respond to Dr. Erler

Institute of Orthopedics, "Carlos E. Ottolenghi," Italian Hospital of Buenos Aires, Argentina

To the Editor:

We wish to thank Dr. Erler for his interest in our paper. His main concerns seem to be durability of reconstructions and allograft complications. We, as most orthopaedic oncology surgeons, share those concerns in relation to the durability of all reconstructive procedures now available, since we are treating very young patients many of them with several decades of life expectancy.

In relation to complications of intercalary allograft recosntructions, this crucial issue was extensively covered in our manuscript. Table I includes the total number of allograft complications. In the Results section, we reported, â€œOf the 13 patients in the study, only six healed and had no complications. Surgical procedures were performed for complications in seven patients, which included three fractures, two diaphyseal non-unions, one deep infection, and one soft tissue local recurrence. In four of these patients the allograft was removed. All fractures were localized in the femur and were treated by reconstruction with a new allograft, two with another intercalary graft and one was converted to an osteoarticular allograft, sacrificing the originally preserved epiphysis. In both diaphyseal non- unions a single operation, in which the internal fixation was replaced and autogenous graft was added to the site, resulted in union at the host- donor junction. No non-union was associated with failure of the graft, since all healed after a reoperation. One patient developed and acute deep infection; the allograft was removed and a temporary cement spacer with antibiotics was implanted.â€

In the Discussion we stated, â€œSubstantial reconstructive complications should be expected after these technically demanding surgical procedures. Seven patients in this series needed a second operation. Four had a reconstructive failure, defined as the necessity to excise the allograft. However, after reoperations in three patients, the osteoarticular surface was again preserved, and a second intercalary allograft was performed. In the remaining patient the epiphysis was resected and a osteoarticular allograft reconstruction was done.â€

â€œOur findings suggest that, although complications requiring a second operations could be expected after reconstruction, about one of six patients with a metaphyseal osteosarcoma around the knee may be treated with appropiate oncologic margins and preservation of the epiphysis of the affected bone.â€

The main purpose of our paper was to analyze, in a small series of patients, the potential preservation of the epiphysis in high grade metaphyseal osteosarcomas of the knee. There are few reconstructive alternatives now available to fill the segmental bone defect originated with this technique, and the use of intercalary allografts is one.

Most likely in the future new procedures with very high predictibility are going to be developed. In the meantime, the use of intercalary allografts, even considering potential complications, is, in our opinion, a very acceptable procedure to reconstruct a bone defect not affecting the articular surface.

Kaan Erler

Posted on January 04, 2005

On the Results of Allograft Reconstruction for Osteosarcoma

Gulhane Military Medical Academy, Ankara, Turkey

To the Editor:

I am writing to express some concerns about the results reported in the recent article by Muscolo, et al(1). According to publications by Enneking and Mankin (2-11) there were many complications(the bigger the allograft, the higher the ratio of failure).

In this paper, the authors did not report the size of allograft used for reconstruction and did not report complications related to the use of allografts although they were fixed with screws and plate and they were used in patients treated with chemotherapy(9).

I would be grateful for the authors response about these issues.

Sincerely,

Kaan Erler, M.D. Assoc. Prof. Department of Orhopaedics Orthopaedic Oncology GÃ¼lhane Military Medical Academy 06018, Ankara, Turkey

References

1.D. Luis Muscolo, Miguel A. Ayerza, Luis A. Aponte-Tinao, and Maximiliano Ranalletta Partial Epiphyseal Preservation and Intercalary Allograft Reconstruction in High-Grade Metaphyseal Osteosarcoma of the Knee J Bone Joint Surg Am 2004; 86: 2686-2693

2: Enneking WF, Campanacci DA. Retrieved human allografts : a clinicopathological study. J Bone Joint Surg Am. 2001 Jul;83-A(7):971-86.

3: Wheeler DL, Haynie JL, Berrey H, Scarborough M, Enneking, WF. Biomechanical evaluation of retrieved massive allografts: preliminary results. Biomed Sci Instrum. 2001;37:251-6.

4: Strong DM, Friedlaender GE, Tomford WW, Springfield DS, Shives TC, Burchardt H, Enneking WF, Mankin HJ. Immunologic responses in human recipients of osseous and osteochondral allografts. Clin Orthop. 1996 May; (326):107-14.

5: Enneking WF, Mindell ER. Observations on massive retrieved human allografts. J Bone Joint Surg Am 1991 Sep;73(8):1123-42.

6: Brigman BE, Hornicek FJ, Gebhardt MC, Mankin HJ. Allografts about the Knee in Young Patients with High- grade Sarcoma. Clin Orthop. 2004 Apr; (421):232-9.

7: Mankin HJ. The changes in major limb reconstruction as a result of the development of allografts. Chir Organi Mov. 2003 Apr-Jun;88(2):101-13. English, Italian.

8: Donati D, Giacomini S, Gozzi E, Salphale Y, Mercuri M, Mankin HJ, Springfield DS, Gebhardt MC. Allograft arthrodesis tratment of bone tumors: a two-center study. Clin Orthop. 2002 Jul;(400):217-24.

9: Fox EJ, Hau MA, Gebhardt MC, Hornicek FJ, Tomford WW, Mankin, HJ. Long-term followup of proximal femoral allografts. Clin Orthop. 2002 Apr;(397):106-13.

10: Hazan EJ, Hornicek FJ, Tomford W, Gebhardt MC, Mankin JH. The effect of adjuvant chemotherapy on on osteoarticular allografts. Clin Orthop. 2001 Apr; (385):176-81.

11: Sorger JI, Hornicek FJ, Zavatta M, Menzner JP, Geghardt MC, Tomford WW, Mankin HJ. Allograft fractures revisited. Clin Orthop. 2001 Jan;(382):66-74.

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D. Luis Muscolo, Miguel A. Ayerza, Luis A. Aponte-Tinao, Maximiliano Ranalletta; Partial Epiphyseal Preservation and Intercalary Allograft Reconstruction in High-Grade Metaphyseal Osteosarcoma of the Knee. The Journal of Bone & Joint Surgery. 2004 Dec;86(12):2686-2693.

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