How to Overcome Complications of Allograft Transplantation?

Yool Cho; Young Choi; Young-Ho Kwon; So Hak Chung; Jae-Do Kim

doi:10.5292/jkbjts.2011.17.2.65

Journal List > J Korean Bone Joint Tumor Soc > v.17(2) > 1051994

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Cho, Choi, Kwon, Chung, and Kim: How to Overcome Complications of Allograft Transplantation?

Original Article

J Korean Bone Joint Tumor Soc 2011;17(2):65-70.

Published online: 10 January 2011

DOI: https://doi.org/10.5292/jkbjts.2011.17.2.65

How to Overcome Complications of Allograft Transplantation?

Yool Cho, M.D., Young Choi, M.D.^*, Young-Ho Kwon, M.D.^*, So Hak Chung, M.D.^*, Jae-Do Kim, M.D.^*

Department of Orthopedic Surgery, Armed Forces Capital Hospital, Seongnam, Korea

^*Department of Orthopaedic Surgery, Kosin University Gospel Hospital, Busan, Korea

Correspondence to: Jae-Do Kim, M.D. Department of Orthopaedic Surgery, Kosin University Gospel Hospital, 34, Amnam-dong, Seo-gu, Busan 602-702, Korea TEL: +82-51-990-6367 FAX: +82-51-243-0181 E-mail: jdkim@ns.kosinmed.or.kr

Received 21 May 2011 Revised 26 November 2011 Accepted 30 November 2011

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

We evaluated the complications of allograft reconstruction after a bone tumor resection, and reviewed literatures to overcome such complications.

Materials and Methods

We retrospectively reviewed clinical records and radiographs of fifteen patients in whom reconstruction with allograft after bone tumor resection.

Results

Eight patients were men and seven were women with a mean age of 27.1 years (1–56 years) and a mean follow-up period of 89.5 months (33–165 months). All postoperative complications related to the allograft were recorded. Twenty patients (80.0%) obtained a radiologic bony union at a mean of 8.35 months (4–12 months). The mean Musculoskeletal Tumor Society score was 73.5% (46.6–93.0%). Nine patients (60.0%) experienced one event and 3 (20.0%) patients experienced multiple events during the follow-up period. Recorded events were infection (3), fracture (2), nonunion (2), limb length discrepancy (2) and varus deformity (2). The mean event free survival period was 60.8 months (6–144 months). The mean allograft survival period was 80.2 months and the 5 year survival rate of the allografts was 83.0%.

Conclusion

In order to overcome complications, the combination of an allograft and vascularized fibular graft is highly recommended. In the near future, the tissue engineering technique, the application of the stem cell and PRP, could reduce the complication of allograft such as resorption and nonunion.

Keywords: bone tumor, allograft transplantation, complication

References

1. Donati D, Colangeli M, Colangeli S, Di Bella C, Mercuri M. Allograft-prosthetic composite in the proximal tibia after bone tumor resection. Clin Orthop Relat Res. 2008; 466:459–65.

2. Mankin HJ, Gebhardt MC, Jennings LC, Springfield DS, Tomford WW. Long-term results of allograft replacement in the management of bone tumors. Clin Orthop Relat Res. 1996. 86–97.

3. Hornicek FJ Jr, Mnaymneh W, Lackman RD, Exner GU, Malinin TI. Limb salvage with osteoarticular allografts after resection of proximal tibia bone tumors. Clin Orthop Relat Res. 1998; 352:179–86.

4. Ogilvie CM, Crawford EA, Hosalkar HS, King JJ, Lackman RD. Long-term results for limb salvage with osteoarticular allograft reconstruction. Clin Orthop Relat Res. 2009; 467:2685–90.

5. Prarrish F. Allograft replacement of all or part of the end of a long bone following excision of a tumor. J Bone Joint Surg Am. 1973; 55:1–22.

6. Ottolenghi CE. Massive osteo and osteoarticular bone grafts. Technique and results of 62 cases. Clin Orthop Relat Res. 1972; 87:156–64.

7. Muscolo DL, Ayerza MA, Aponte-Tinao LA. Long-term results of allograft replacement after total calcanectomy. A report of two cases. J Bone Joint Surg Am. 2000; 82:109–12.

8. Getty PJ, Peabody TD. Complications and functional outcomes of reconstruction with an osteoarticular allograft after intraarticular resection of the proximal aspect of the humerus. J Bone Joint Surg Am. 1999; 81:1138–46.

9. Dick HM, Malinin TI, Mnaymneh WA. Massive allograft implantation following radical resection of high-grade tumors requiring adjuvant chemotherapy treatment. Clin Orthop Relat Res. 1985. 88–95.

10. Ward WG, Heise E, Boles C, et al. Human leukocyte antigen sensitization after structural cortical allograft implantations. Clin Orthop Relat Res. 2005. 31–5.

11. Giannini S, Vannini F, Lisignoli G, Facchini A. Histological and immunohistochemical analysis of an allogenic bone graft engineered with autologous bone marrow mononuclear cells in the treatment of a large segmental defect of the ulna. A case report. Chir Organi Mov. 2008; 91:171–5.

12. Myerson MS, Neufeld SK, Uribe J. Fresh-frozen structural allografts in the foot and ankle. J Bone Joint Surg Am. 2005; 87:113–20.

13. Eward WC, Kontogeorgakos V, Levin LS, Brigman BE. Free vascularized fibular graft reconstruction of large skeletal defects after tumor resection. Clin Orthop Relat Res. 2010; 468:590–8.

14. Heitmann C, Erdmann D, Levin LS. Treatment of segmental defects of the humerus with an osteoseptocutaneous fibular transplant. J Bone Joint Surg Am. 2002; 84A:2216–23.

15. Enneking WF, Spanier SS, Goodman MA. Current concepts review. The surgical staging of musculoskeletal sarcoma. J Bone Joint Surg Am. 1980; 62:1027–30.

16. Enneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res. 1993; 286:241–6.

17. Brigman BE, Hornicek FJ, Gebhardt MC, Mankin HJ. Allografts about the knee in young patients with high-grade sarcoma. Clin Orthop Relat Res. 2004; 421:232–9.

18. Fox EJ, Hau MA, Gebhardt MC, Hornicek FJ, Tomford WW, Mankin HJ. Long-term followup of proximal femoral allografts. Clin Orthop Relat Res. 2002; 397:106–13.

19. Muscolo DL, Ayerza MA, Aponte-Tinao LA. Survivorship and radiographic analysis of knee osteoarticular allografts. Clin Orthop Relat Res. 2000; 373:73–9.

20. Ortiz-Cruz E, Gebhardt MC, Jennings LC, Springfield DS, Mankin HJ. The results of transplantation of intercalary allografts after resection of tumors. A longterm follow-up study. J Bone Joint Surg Am. 1997; 79:97–106.

21. Capanna R, Bufalini C, Campanacci M. A new technique for reconstruction of large metadiaphyseal bone defects. A combined graft(allograft shell plus vascularized fibula). Orthop Traumatol. 1993; 2:159–77.

22. Innocenti M, Abed YY, Beltrami G, Delcroix L, Manfrini M, Capanna R. Biological reconstruction after resection of bone tumors of the proximal tibia using allograft shell and intramedullary free vascularized fibular graft: longterm results. Microsurgery. 2009; 29:361–72.

23. Bae D, Waters P, Gebhardt M. Results of free vascularized fibula grafting for allograft nonunion after limb salvage surgery for malignant bone tumors. J Pediatr Orthop. 2006; 26:809–14.

24. Sorger JI, Hornicek F, Zavatta M, et al. Allograft fractures revisited. Clin Orthop Relat Res. 2001; 382:66–74.

25. Enneking WF, Campanacci DA. Retrieved human allografts: a clinicopathological study. J Bone Joint Surg Am. 2001; 83A:971–86.

26. Lord CF, Gebhardt MC, Tomford WW, Mankin HJ. Infection in bone allografts: incidence, nature, and treatment. J Bone Joint Surg Am. 1988; 70:369–76.

27. Mnaymneh W, Malinin TI, Makley JT, Dick HM. Massive osteoarticular allografts in the reconstruction of extremities following resection of tumors not requiring chemotherapy and radiation. Clin Orthop Relat Res. 1985; 197:76–87.

28. Berrey BH Jr, Lord CF, Gebhardt MC, Mankin HJ. Fractures of allografts. Frequency, treatment, and end-results. J Bone Joint Surg Am. 1990; 72:825–33.

29. Vander Griend RA. The effect of internal fixation on the healing of large allografts. J Bone Joint Surg Am. 1994; 76:657–63.

30. Hornicek FJ, Gebhardt MC, Tomford WW, et al. Factors affecting nonunion of the allograft-host junction. Clin Orthop Relat Res. 2001; 382:87–98.

31. Ceruso M, Taddei F, Bigazzi P, Manfrini M. Vascularised fibula graft inlaid in a massive bone allograft: considerations on the biomechanical behaviour of the combined graft in segmental bone reconstructions after sarcoma resection. Injury. 2008; 39(Suppl 3):S68–74.

32. Friedrich JB, Moran SL, Bishop AT, Wood CM, Shin AY. Free vascularized fibular graft salvage of complications of long-bone allograft after tumor reconstruction. J Bone Joint Surg Am. 2008; 90:93–100.

33. Chang DW, Weber KL. Use of a vascularized fibula bone flap and intercalary allograft for diaphyseal reconstruction after resection of primary extremity bone sarcomas. Plast Reconstr Surg. 2005; 116:1918–25.

34. Chang DW, Weber KL. Segmental femur reconstruction using an intercalary allograft with an intramedullary vascularized fibula bone flap. J Reconstr Microsurg. 2004; 20:195–9.

35. Moran SL, Shin AY, Bishop AT. The use of massive bone allograft with intramedullary free fibular flap for limb salvage in a paediatric and adolescent population. Plast Reconstr Surg. 2006; 118:413–9.

36. Lucarelli E, Fini M, Beccheroni A, et al. Stromal stem cells and platelet-rich plasma improve bone allograft integraftion. Clin Orthop Relat Res. 2005; 435:62–8.

Figure 1.

This graph shows the allograft-related complications that occurred in patients (NU, nonunion; LLD, limb length discrepancy).

Figure 2.

The Kaplan-Meier survival curve represents event free survival for all patients.

Figure 3.

The Kaplan-Meier survival curve represents allograft survival for all patients.

Table 1.

Patients’ Characteristics

No	Age	Sex	Location	Diagnosis	Type of reconstruction	Union (months)	Functional score (%)	Oncologic result	Follow-up (months)	Event number	Event-free survival (months)	Allograft survival (months)
1	12	M	PT	Osa	Arthrodesis	12	60	NED	127	2	69	74
2	24	M	Pelvis	Chondrosa	Arthrodesis	4	50	CDF	113	1	101	113
3	1	M	PT	Osa	Intercalary	8	76	CDF	165	1	21	165
4	6	F	DF	Osa	Intercalary	9	76	CDF	58	1	37	58
5	37	F	ST	Osa	Intercalary		83	CDF	76	1	6	76
6	56	F	PF	MBT	APC	9	60	CDF	166	1	98	98
7	13	M	PH	Osa	Osteoarticular		46.6	CDF	47	2	9	29
8	44	M	PT	Chondrosa	Intercalary	12	77	CDF	40	2	21	40
9	14	F	DF	Osa	APC	5	83	CDF	128	0	128	128
10	11	F	PT	Osa	Intercalary	11	93	CDF	110	0	110	110
11	31	F	PH	Osa	Osteoarticular	12	90	CDF	144	0	144	144
12	53	F	Patella	Osa	Osteoarticular		83	CDF	33	0	33	33
13	22	M	DF	GCT	Intercalary	4	83	CDF	46	0	46	46
14	46	M	DF	GCT	APC	9	83	CDF	38	0	38	38
15	37	M	Pelvis	Chondrosa	APC	5	60	CDF	52	0	52	52
Average	27.1					8.3	73.6		89.5	0.8	60.8	80.2

PT, proximal tibia; Osa, osteosarcoma; NED, no evidence of disease; Chondrosa, chondrosarcoma; CDF, continuous disease free; DF, distal femur; ST, shaft tibia; PF, proximal femur; MBT, metastatic bone tumor; APC, allograft-prosthesis composite; PH, proximal humerus; GCT, giant cell tumor.

Table 2.

Events, Overcome of Events, Fibular Use and Cause of Allograft Removal

No	Events	Overcome of events	Fibular use	Cause of allograft removal
1	Fracture at 69 months	Plating & bone graft	None	Local recurrence
	Limb leg discrepancy at 81 months	Internal bone transport
2	Infection at 101 months	Surgical debridement	None	Intact
3	Varus deformity at 21 months	Ipsilateral fibular transposition	Used	Intact
4	Limb leg discrepancy at 37 months	Lengthening of allograft & VFBG	Used	Intact
5	Nonunion at 6 months	Plating & bone graft	None	Intact
6	Infection at 98 months	Allograft removal	None	Infection
7	Nonunion at 9 months	Iliac bone graft	Used	Infection
	Infection at 29 months	Allograft removal & VFBG
8	Varus deformity at 21 months	Corrective osteotomy & bone graft	None	Intact
	Fracture at 36 months	Long leg cast
9	None	Not applicable	None	Intact
10	None	Not applicable	Used	Intact
11	None	Not applicable	None	Intact
12	None	Not applicable	None	Intact
13	None	Not applicable	None	Intact
14	None	Not applicable	None	Intact
15	None	Not applicable	None	Intact

VFBG, vascularized fibular bone graft.

TOOLS

Similar articles