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• W3036814097 abstract "Commentary Despite advances in limb reconstruction techniques, one problem that has continued to challenge orthopaedic oncologists is the reconstruction of long-bone diaphyseal defects after tumor resection. No single reconstructive technique is superior, and complication rates remain high. Although replacing a diaphyseal osseous defect is deceptively simple in concept, as compared with a complex joint, the outcomes of intercalary reconstructions are not necessarily superior to those of osteoarticular endoprosthetic reconstructions1,2. Alternatives to allografts for intercalary reconstruction are intercalary endoprostheses (10-year event-free implant survival rate = 68%3, reoperation rate = 26%3, and complication rate = 57%4 for primary bone tumors), vascularized fibula/allograft composites (5-year revision-free survival rate = 72% and rate of major complications = 30%5), bone transport, and amputation. Allografts are advantageous due to preservation of bone stock, which is useful for future reconstructive procedures, and the attachment of major tendons (e.g., the patellar tendon) is facilitated by the allograft’s existing soft-tissue attachments. However, infection and nonunion at the osteosynthesis site are major problems. This report from the Netherlands is an update of the authors’ earlier, 2014 report6. The present report has stricter inclusion criteria, being limited to the lower extremity, requiring a minimum 10-year follow-up, and excluding hybrid constructs (e.g., vascularized fibular composite grafts). In the 2014 report, the complication rate was high (76%), and a reoperation was necessary in 70% of cases. The major complications were nonunion (40%), fracture (29%), and infection (14%). Progress on this reconstructive problem has been slow as clinical research is limited by the rarity of patient candidates as well as heterogeneity in (1) patient age (osteosarcoma and Ewing sarcoma usually occur in adolescents/young adults and chondrosarcoma, in older adults), (2) reconstructive parameters such as resection length and osteosynthesis junction site (diaphyseal versus metaphyseal bone), and (3) other oncologic treatments impairing bone-healing such as chemotherapy and radiation. Given these challenges, the investigators understandably had to “cast a large net” over multiple institutions and include a lengthy time period of 27 years in order to have a sample size (131 cases) sufficient for analysis. Multiple types of fixation were employed, including single or double plates, long plates spanning both osteotomy sites, and intramedullary nails. The strengths of this report, compared with prior reports, are the large number of patients, the long-term follow-up of at least 10 years, and the uniform definition of intercalary reconstruction in contrast to some prior reports that classified allograft-prosthetic constructs as intercalary allografts. Additionally, Sanders et al. made use of a classification schema for limb salvage complications that became available in 2014 and is utilized widely. Study limitations are the retrospective, uncontrolled methodology resulting in a large degree of treatment bias, inclusion of both femoral and tibial sites, and reporting results on a per-patient rather than a per-osteotomy site basis, which would be preferable as each patient with an intercalary graft has 2 osteotomy sites. Furthermore, the reconstructions entailed a wide variety of surgical techniques, a vast age range, unknown variations in allograft processing (e.g., percent of grafts undergoing low-dose gamma irradiation), as well as unknown dosing data regarding the 5% of patients treated with radiation. Nonetheless, the authors have added to our knowledge on this topic, including evidence supporting the contention that plates are better than nails for osteotomy site fixation in this setting. Additionally, unlike oncologic complications such as tumor recurrence that decrease over time, the risk of mechanical complications seems to continue into the long term. Some surprising findings were also noted. Although not statistically significant (p = 0.08), there was a trend for nonunions to develop more often in the femur (20%) as compared with the tibia (7%). The reasons are unknown but may be related to enhanced rigidity provided by the presence of the fibula in some cases or perhaps the inequitable distribution of femoral (68%) and tibial (32%) cases. Another unusual observation is that diaphyseal osteotomies were not associated with a higher risk of nonunion than the metaphyseal osteotomies. While this has been observed by oncologic surgeons, the reasons are unknown. Also unusual is the lack of a significant correlation between external beam radiation and nonunion. This may be explained by the small proportion of patients undergoing radiation treatment. Ultimately, as with most studies, a number of important questions remain unanswered. Comparing different types of intercalary reconstructions in a randomized trial is not feasible. Also, we still do not know the optimal osteotomy configuration—e.g., is it a step-cut, with a greater bone contact area, rather than a transverse cut? Also, is human leukocyte antigen matching important? Does filling the allograft medullary canal with antibiotic-loaded PMMA (polymethylmethacrylate) cement reduce infections and/or improve structural stability or durability? Should plates be placed on the tibia medially, with the higher risk of infection but more structural rigidity, as opposed to laterally? The value of this study is that we now have better prognostic data with which to inform patients. Undoubtedly, ongoing innovations, such as navigated osteotomies, enhanced locking-plate fixation technology, and minimally invasive techniques preserving the soft-tissue envelope, will improve the outcomes of these intercalary reconstructions." @default.
• W3036814097 created "2020-06-25" @default.
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• W3036814097 date "2020-06-17" @default.
• W3036814097 modified "2023-10-18" @default.
• W3036814097 title "Intercalary Reconstructions, Seemingly Simple, But Vexing" @default.
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• W3036814097 doi "https://doi.org/10.2106/jbjs.20.00429" @default.
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