title: Intercalary allograft reconstructions following resection of primary bone tumors: a nationwide multicenter study.
abstract: BACKGROUND
  Favorable reports on the use of massive allografts to reconstruct intercalary defects underline their place in limb-salvage surgery. However, little is known about optimal indications as reports on failure and complication rates in larger populations remain scarce. We evaluated the incidence of and risk factors for failure and complications, time to full weight-bearing, and optimal fixation methods for intercalary allografts after tumor resection.
  
  
  METHODS
  A retrospective study was performed in all four centers of orthopaedic oncology in the Netherlands. All consecutive patients reconstructed with intercalary (whole-circumference) allografts after tumor resection in the long bones during 1989 to 2009 were evaluated. The minimum follow-up was twenty-four months. Eighty-seven patients with a median age of seventeen years (range, 1.5 to 77.5 years) matched inclusion criteria. The most common diagnoses were osteosarcoma, Ewing sarcoma, adamantinoma, and chondrosarcoma. The median follow-up period was eighty-four months (range, twenty-five to 262 months). Ninety percent of tumors were localized in the femur or the tibia.
  
  
  RESULTS
  Fifteen percent of our patients experienced a graft-related failure. The major complications were nonunion (40%), fracture (29%), and infection (14%). Complications occurred in 76% of patients and reoperations were necessary in 70% of patients. The median time to the latest complication was thirty-two months (range, zero to 200 months). The median time to full weight-bearing was nine months (range, one to eighty months). Fifteen grafts failed, twelve of which failed in the first four years. None of the thirty-four tibial reconstructions failed. Reconstruction site, patient age, allograft length, nail-only fixation, and non-bridging osteosynthesis were the most important risk factors for complications. Adjuvant chemotherapy and irradiation had no effects on complication rates.
  
  
  CONCLUSIONS
  We report high complication rates and considerable failure rates for the use of intercalary allografts; complications primarily occurred in the first years after surgery, but some occurred much later after surgery. To reduce the number of failures, we recommend reconsidering the use of allografts for reconstructions of defects that are ≥15 cm, especially in older patients, and applying bridging osteosynthesis with use of plate fixation.
authors.affiliation: Department of Orthopaedic Surgery, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands. E-mail address for J.A.M. Bramer: j.a.bramer@amc.uva.nl.
authors.forename: M P A
authors.initials: MP
authors.lastname: Bus
authors.affiliation: Department of Orthopaedic Surgery, Leiden University Medical Center, Postzone J11-R70, P.O. Box 9600, 2300 RC Leiden, The Netherlands.
authors.forename: P D S
authors.initials: PD
authors.lastname: Dijkstra
authors.affiliation: Department of Orthopaedic Surgery, Leiden University Medical Center, Postzone J11-R70, P.O. Box 9600, 2300 RC Leiden, The Netherlands.
authors.forename: M A J
authors.initials: MA
authors.lastname: van de Sande
authors.affiliation: Department of Orthopaedic Surgery, Leiden University Medical Center, Postzone J11-R70, P.O. Box 9600, 2300 RC Leiden, The Netherlands.
authors.forename: A H M
authors.initials: AH
authors.lastname: Taminiau
authors.affiliation: Department of Orthopaedic Surgery, Radboud University Nijmegen Medical Center, Postzone 357, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
authors.forename: H W B
authors.initials: HW
authors.lastname: Schreuder
authors.affiliation: Department of Orthopaedic Surgery, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands.
authors.forename: P C
authors.initials: PC
authors.lastname: Jutte
authors.affiliation: Department of Orthopaedic Surgery, Radboud University Nijmegen Medical Center, Postzone 357, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
authors.forename: I C M
authors.initials: IC
authors.lastname: van der Geest
authors.affiliation: Department of Orthopaedic Surgery, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands. E-mail address for J.A.M. Bramer: j.a.bramer@amc.uva.nl.
authors.forename: G R
authors.initials: GR
authors.lastname: Schaap
authors.affiliation: Department of Orthopaedic Surgery, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands. E-mail address for J.A.M. Bramer: j.a.bramer@amc.uva.nl.
authors.forename: J A M
authors.initials: JA
authors.lastname: Bramer
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001859:Bone Neoplasms / Q000601:surgery*; D016025:Bone Transplantation / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D023821:Limb Salvage / Q000379:methods; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D012516:Osteosarcoma / Q000601:surgery; D010027:Osteotomy / Q000379:methods; D019651:Plastic Surgery Procedures / Q000379:methods*; D012086:Reoperation; D012189:Retrospective Studies; D016896:Treatment Outcome