Presentation on theme: "The Combined Use of Cryopreserved Recycled Bone and Free Vascularised Fibula Graft in Limb-Salvage Surgery: ″The Bone in the Bun″ Technique (Hot Dog."— Presentation transcript:
1The Combined Use of Cryopreserved Recycled Bone and Free Vascularised Fibula Graft in Limb-Salvage Surgery: ″The Bone in the Bun″ Technique (Hot Dog Technique)Harzem Ozger, Mustafa Sungur,Bugra Alpan, Alauddin Kochai,Levent EralpIstanbul UniversityIstanbul Faculty of MedicineDepartment of Orthopsedics and Traumatology
2? Recycled bone + Amputation ? Rotationplasty ? Megaprosthesis ? Biological reconstruction ?Massive allograftRecycled bone:AutoclavingIrradiationPasteurizationCryopreservationFVFGCompositesMassive allograft +Recycled bone +?There are many ways to repair a bone defect but our preferred method for biological reconstruction is combination of cryopreserved bone and free vascular fibula graft.
3Massive Allograft - alone DisadvantagesAvascularConsolidation too lateExpensiveImmune responseInfectionResorptionAvailabilitySocioreligious problemsAnatomical incongruency6 yo male, ESProximal 2/3 of femur10 yrs follow-upNEDEwing sarcoma of 2/3 proximal femur.Reconstructed with massive allograft.good primary mechanical strength but no blood supply.Consolidation takes too long.May end up as sequestrum.AdvantagesEarly postop. Xray.Mass. allograft fixedw/ IM nailPrimary mechanical strength good+2 yrsExtracortical bonebridging but no union+3 yrsAntiobiotic roddue to infectionAllograftremoveddue to infection
4Free Vascularized Fibular Graft - alone Advantages- Easily availableVascularRapid healingDisadvantagesPrimary mechanicalstrength insufficient14 f, ESFVFG alone!+ 7 yrs follow-upNEDEwing’s sarcoma of the proximal femur.Vascularised fibula alone.Rapid healing but sufficient mechanical strength takes 4 years - too long.4 yrs for full consolidation and full weight bearing – TOO LONG
6Recycled Bone - cryopreservation AvailabilityAnatomical congruenceAutogenous proteins, growth factors, cytokinesAlmost no cost (only recycling cost)No immune reaction? (cryoimmunological function?)Mechanical strength:Cryopreserved ≅ intact boneSuperiorities of cryopreservation:mechanical strength comparable to intact boneeasy availability,less expensive,perfect anatomical congruencebetter osteoinductive and osteoconductive properties.
7LN + FVFG = bone in the bun… Technique1. Tumor resection2. Harvesting of FVFG3. Soft tissue stripping4. Preparation of medullary cavity5. Preparation of cortical window forFVFG pedicle6. Liquid Nitrogen treatmentNitrogen tank……………………20 minRoom temperature (20°)………15 minHeated saline solution (30°) min7. Reimplantation + osteosynthesis8. Insertion of FVFG inside prepared bonesegment and anastomosis of pedicle9. Grafting of osteotomy sites…or ‘hot dog’soft tissue strippingThe stages of preparation of bone in the bun or hot dogtumor resectionbone in the bun!LN treatment
9Patients and Methods Recycled bone: cryopreservation for all patients FVFG:- 11 patients: contralateral single strut- 2 patients: bilateral fibula grafts harvested to bridge a defect longer than single fibula- 1 patient: ipsilateral single strutMean bony defect: 17.2 cm ( )Mean fibular graft length: 18.9 cm (10-28)Plate: 13 pts; IM nail: 1 pt.10 m, OSProximal 2/3 femur43 mo.follow-upNED+ 5 mo.+ 27 mo.+30 mo.For 2 patients we used bilateral fibula grafts to bridge a defect longer than single fibula
10Results Complete consolidation: 8 patients 19 female, OSDistal femurComplete consolidation: 8 patientsMean time for consolidation: 13.4 months (9-19)5 patients awaiting consolidation-mean follow-up: 7.6 months (6-12)No union in 1 pt (29 months follow-up; intramedullary nail)Complications:- implant failure: 3 pts- local recurrence: 1 pt. ( non respondingto tx, synchron. multi-met)- deep infection: 1 pt(complete healing w/ antib.,debr. + VAC)Mean time for consolidation: 13.4 monthsOur complications are- implant failure in 3 patients- local recurrence in 1 patient. Did not respond to treatment, had synchronous multiple-mets.- deep infection in 1 patient which completely healed with treatment10 male, ESDistal femurFull wt bearing and very good knee ROM at 15 mo. postop
11Bone in the bun + 2 mo. + 7 mo. + 11 mo. + 19 mo. + 24 mo. 8 yo. ♀, OSGLN + FVFG24 mo. follow-upNED+ 2 mo.+ 7 mo.+ 11 mo.+ 19 mo.+ 24 mo.osteosarcoma of distal femurReconstructed with HOTDOG technique.Plate was broken at 11 months and revision was performed.Full consolidation at 19 months
12Bone in the bun + 17 months 14 yo. ♀, ES LN + FVFG 23 mo. follow-up NED+ 5 mo+ 20 mo.Ewing’s sarcoma of proximal tibia. Another HOTDOG application. Knee functions at 17 months postop. Full consolidation at 20 months postop.+ 17 months
13Bone in the bun + 0 mo. + 3 mo. + 13 mo. + 13 mo. 12 yo. ♂, OSG LN + double FVFG17 mo. follow-upDODOsteosarcoma of distal ¾ femur. Length of single fibula was not enough so reconstructed with two fibulas.+ 0 mo.+ 3 mo.+ 13 mo.+ 13 mo.
14Bone in the bun 11 ♀, ES Healed pathological fx LN + double FVFG + 6 mo follow-upNEDEwing sarcoma of femur presented with pathological fracture. 28 cm. bone segment was resected.
15Bone in the bun + 5 mo. R R Bone scan at 3 mo. postop Two fibular grafts used for reconstruction. Recycled bone had to be osteotomized due to deformity.Bone scanat 3 mo. postopshows good uptake,FVFGs are alive.
16Conclusion Cryopreserved recycled bone: - readily available - cheap - anatomically congruent- good mechanical strengthBUT- DEAD bone- prolonged consolidation timeCryopreserved recycled bone is strong but dead…
17Conclusion FVFG: - LIVING bone - rapid union BUT - poor mechanical strengthVascularized fibula graft is alive but weak
18Solution Combination (HOTDOG) - faster consolidation - greater mechanical strengthHotdog is strong and alive… thank you for your attention