1. MPA Bus 1, JAM Bramer 1, GR Schaap 1, RPH Veth 3, HWB Schreuder 3, PC Jutte 4, MAJ van de Sande 2, ICM van der Geest 3, PDS Dijkstra 2, AHM Taminiau 2 Intercalary Allografts When are they successful? 1 Academic Medical Center, Amsterdam 2 Leiden University Medical Center, Leiden 3 Radboud University Medical Center, Nijmegen 4 University Medical Center, Groningen

2. Resection: save adjacent joints Intercalary reconstruction Diaphyseal tumors

3. Option: intercalary allograft + Stable + Saves bone stock - Dead bone

4. Ortiz-Cruz (JBJS 1997) – 104 patients Non-union 30% Fracture 17% Infection 12% Failure 14% Frisoni (JBJS 2012) – 101 patients (femur) Non-union 46.5% Failure 31.5% Literature

5. Treatment of bone tumors: centralized in 4 appointed centers Dutch situation JAM Bramer GR Schaap PDS Dijkstra MAJ vd Sande (AHM Taminiau) ICM vd Geest HWB Schreuder (RPH Veth) PC Jutte

6. How successful are they? When can we use them? How should we fixate them? Intercalary Allografts – Dutch results

7. Retrospective study in 4 centers – 1989-2009 – Resection primary bone tumor in extremity – Reconstruction with intercalary allograft – Whole circumference – Minimum follow-up six months Methods

8. Characteristics of patient, tumor, treatment, allograft & reconstruction Complications Non-union Infection Fractures Other Time to full weight-bearing Methods

9. 94 total (51 male, 43 female) Patients

10. Diagnoses Osteosarcoma43(46%) Ewings sarcoma18(19%) Adamantinoma15(16%) Chondrosarcoma12(13%) Other 6( 6%)

11. Localization Femur50(55%) Tibia34(36%) Humerus 7( 7%) Radius 2( 2%) Fibula 1( 1%)

12. Mean 15 cm, median 14.5 cm (range 4 – 31 cm) >1/3 of bone length67(71%) > Median-1SD (9.33 cm)83(88%) > 17 cm31(33%) > Median+1SD (19.33 cm)18(19%) Allograft length

13. Osteosynthesis Bridging 67(71%) Non-bridging 27(29%)

14. Osteosynthesis Plate43(46%) Plate + fibular strut22(23%) Plate + im nail12(13%) Im nail12(13%) Screws 5( 5%)

15. Adjuvant therapy Chemotherapy57(61%) Radiotherapy 8( 9%) Both 7( 7%)

16. All:6.3 years(0.5 – 22) 77 survivors: 7.5 years(0.5 – 22) 17 deceased:2.3 years (0.5 – 12) >2 years follow-up: 80% (for survivors: 91%) >5 years follow-up: 60% (for survivors: 68%) Follow-up

17. In 66 patients (70%) 2 in 35 patients (37%) Complications

18. Non-union 33 (35%) Fracture 23 (25%) Infection12 (13%) Re-operation(s) in 59 patients (63%) Complications

19. Median 59 weeks (1 – 288) Time to first complication

20. Median 109 weeks (1 – 884) Time to last complication

21. For femur & tibia (84 patients) Data for 53 patients (63%) – Median 41 weeks – Range 7 weeks – 6.5 years Time to full weight-bearing

22. 16 failures (17%) Failures 6 non-unions(38%) 6 infections(38%) 4 fractures (25%)

23. Reconstruction length – groups compared at different cut-off points Risk of… – Infections? – Fractures? – Non-unions? – Complications? – time to full weight-bearing? When to use – risk factors?

24. Reconstructions >9.33 cm (median-1SD) compared with those <9.33 cm Risk of… – Infections?No – Fractures?No – Non-unions?Significant higher – Complications?No – time to full weight-bearing?No When to use – risk factors?

25. Significant higher risk of non-union in reconstructions > 9.33 cm < 9.33 cm> 9.33 cmp Non-union1 / 11 (9%)32 / 83 (38%)0.05 Allograft length

26. Chemotherapy compared with no chemotherapy Risk of… – Infections?No – Fractures?No – Non-unions?No – Complications?No – time to full weight-bearing?No When to use – risk factors?

27. Radiotherapy compared with no radiotherapy Risk of… – Infections? No – Fractures? Trend to higher risk – Non-unions? No – Complications? No – time to full weight-bearing?Significant longer When to use – risk factors?

28. Trend to higher fracture risk Significant longer time to full weight-bearing RTNo RTp Patients with a fracture 4 / 8 (50%)19 / 86 (22%)0.07 RTNo RTp Mean103500.04 Median7137 Range41 - 2017 - 348 Radiotherapy

29. Non-bridging compared with bridging Risk of... – Infections? No – Fractures? Significant higher – Non-unions? No – Complications?No – time to full weight-bearing? No How to fixate – risk factors?

30. Significant higher fracture risk in case of non-bridging osteosynthesis BridgingNon-bridgingp All12 / 67 (18%)11 / 27 (41%)0.02 Femur & tibia11 / 62 (18%)10 / 22 (45%)0.01 Osteosynthesis

31. Plate compared with other types of osteosynthesis Risk of... – Infections? No – Fractures? No – Non-unions? No – Complications? No – time to full weight-bearing?No How to fixate – risk factors?

32. Im nail compared with other types of osteosynthesis Risk of... – Infections? No – Fractures? No – Non-unions? Higher risk – Complications? No – time to full weight-bearing? Significant longer How to fixate – risk factors?

33. Higher non-union risk Longer time to full weight-bearing Im nail onlyOtherp All7 / 12 (58%)26 / 82 (32%)0.07 Femur & tibia6 / 10 (60%)21 / 74 (28%)0.04 Intramedullary nail Im nail onlyOtherp Mean12046< 0.01 Median7139 Range13 - 3497 - 145

34. High percentage complications (70%) Most in first 3 years but some (very) late (infection, fracture) Considerable risk of – Non-union(35%) – Fracture (25%) – Infection(13%) High percentage re-operation(s) (63%) Long partial- and non weight-bearing time Summary

35. Influence of chemotherapy unsure Radiotherapy – more fractures – longer non weight-bearing time Summary

36. Non-bridging osteosynthesis – more fractures Intramedullary nail only – more non-unions – longer non weight-bearing Reconstruction length > 9.33 cm (median-1SD) – more non-unions Summary

37. Therefore: – Not for short term results – Not in case of poor prognosis – Careful in case of radiotherapy and large defects – Osteosynthesis Bridging Use plates, not (only) im nail Recommendations

38. THANK YOU FOR YOUR ATTENTION

39. Localization within bone piece Epi-diaphyseal10 (11%) Meta-diaphyseal35(37%) Diaphyseal49(52%) Proximal 20(21%) Mid49(52%) Distal25(27%)

40. Vascularized fibula Vascularized fibula 6( 6%) No vascularized fibula88(94%)

41. Complications