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Scientific Articles:
D. Luis Muscolo, Miguel A. Ayerza, Luis A. Aponte-Tinao, and Maximiliano Ranalletta
Partial Epiphyseal Preservation and Intercalary Allograft Reconstruction in High-Grade Metaphyseal Osteosarcoma of the Knee
J Bone Joint Surg Am 2004; 86: 2686-2693 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read Letter to the Editor] On the Results of Allograft Reconstruction for Osteosarcoma
Kaan Erler   (27 January 2005)
[Read Letter to the Editor] Dr Muscolo and colleagues respond to Dr. Erler
D. Luis Muscolo, M.D., Miguel Ayerza, M.D., Luis Aponte-Tinao, M.D.   (27 January 2005)

On the Results of Allograft Reconstruction for Osteosarcoma 27 January 2005
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Kaan Erler,
Orthopaedic Oncology
Gulhane Military Medical Academy, Ankara, Turkey

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Re: On the Results of Allograft Reconstruction for Osteosarcoma

drkaanerler{at}yahoo.com Kaan Erler

To the Editor:

I am writing to express some concerns about the results reported in the recent article by Muscolo, et al(1). According to publications by Enneking and Mankin (2-11) there were many complications(the bigger the allograft, the higher the ratio of failure).

In this paper, the authors did not report the size of allograft used for reconstruction and did not report complications related to the use of allografts although they were fixed with screws and plate and they were used in patients treated with chemotherapy(9).

I would be grateful for the authors response about these issues.

Sincerely,

Kaan Erler, M.D. Assoc. Prof. Department of Orhopaedics Orthopaedic Oncology Gülhane Military Medical Academy 06018, Ankara, Turkey

References

1.D. Luis Muscolo, Miguel A. Ayerza, Luis A. Aponte-Tinao, and Maximiliano Ranalletta Partial Epiphyseal Preservation and Intercalary Allograft Reconstruction in High-Grade Metaphyseal Osteosarcoma of the Knee J Bone Joint Surg Am 2004; 86: 2686-2693

2: Enneking WF, Campanacci DA. Retrieved human allografts : a clinicopathological study. J Bone Joint Surg Am. 2001 Jul;83-A(7):971-86.

3: Wheeler DL, Haynie JL, Berrey H, Scarborough M, Enneking, WF. Biomechanical evaluation of retrieved massive allografts: preliminary results. Biomed Sci Instrum. 2001;37:251-6.

4: Strong DM, Friedlaender GE, Tomford WW, Springfield DS, Shives TC, Burchardt H, Enneking WF, Mankin HJ. Immunologic responses in human recipients of osseous and osteochondral allografts. Clin Orthop. 1996 May; (326):107-14.

5: Enneking WF, Mindell ER. Observations on massive retrieved human allografts. J Bone Joint Surg Am 1991 Sep;73(8):1123-42.

6: Brigman BE, Hornicek FJ, Gebhardt MC, Mankin HJ. Allografts about the Knee in Young Patients with High- grade Sarcoma. Clin Orthop. 2004 Apr; (421):232-9.

7: Mankin HJ. The changes in major limb reconstruction as a result of the development of allografts. Chir Organi Mov. 2003 Apr-Jun;88(2):101-13. English, Italian.

8: Donati D, Giacomini S, Gozzi E, Salphale Y, Mercuri M, Mankin HJ, Springfield DS, Gebhardt MC. Allograft arthrodesis tratment of bone tumors: a two-center study. Clin Orthop. 2002 Jul;(400):217-24.

9: Fox EJ, Hau MA, Gebhardt MC, Hornicek FJ, Tomford WW, Mankin, HJ. Long-term followup of proximal femoral allografts. Clin Orthop. 2002 Apr;(397):106-13.

10: Hazan EJ, Hornicek FJ, Tomford W, Gebhardt MC, Mankin JH. The effect of adjuvant chemotherapy on on osteoarticular allografts. Clin Orthop. 2001 Apr; (385):176-81.

11: Sorger JI, Hornicek FJ, Zavatta M, Menzner JP, Geghardt MC, Tomford WW, Mankin HJ. Allograft fractures revisited. Clin Orthop. 2001 Jan;(382):66-74.
Dr Muscolo and colleagues respond to Dr. Erler 27 January 2005
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D. Luis Muscolo, M.D.,
Professor of Orthopedics
Institute of Orthopedics, "Carlos E. Ottolenghi," Italian Hospital of Buenos Aires, Argentina,
Miguel Ayerza, M.D., Luis Aponte-Tinao, M.D.

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Re: Dr Muscolo and colleagues respond to Dr. Erler

luis.muscolo{at}hospitalitaliano.org.ar D. Luis Muscolo, M.D., et al.

To the Editor:

We wish to thank Dr. Erler for his interest in our paper. His main concerns seem to be durability of reconstructions and allograft complications. We, as most orthopaedic oncology surgeons, share those concerns in relation to the durability of all reconstructive procedures now available, since we are treating very young patients many of them with several decades of life expectancy.

In relation to complications of intercalary allograft recosntructions, this crucial issue was extensively covered in our manuscript. Table I includes the total number of allograft complications. In the Results section, we reported, “Of the 13 patients in the study, only six healed and had no complications. Surgical procedures were performed for complications in seven patients, which included three fractures, two diaphyseal non-unions, one deep infection, and one soft tissue local recurrence. In four of these patients the allograft was removed. All fractures were localized in the femur and were treated by reconstruction with a new allograft, two with another intercalary graft and one was converted to an osteoarticular allograft, sacrificing the originally preserved epiphysis. In both diaphyseal non- unions a single operation, in which the internal fixation was replaced and autogenous graft was added to the site, resulted in union at the host- donor junction. No non-union was associated with failure of the graft, since all healed after a reoperation. One patient developed and acute deep infection; the allograft was removed and a temporary cement spacer with antibiotics was implanted.”

In the Discussion we stated, “Substantial reconstructive complications should be expected after these technically demanding surgical procedures. Seven patients in this series needed a second operation. Four had a reconstructive failure, defined as the necessity to excise the allograft. However, after reoperations in three patients, the osteoarticular surface was again preserved, and a second intercalary allograft was performed. In the remaining patient the epiphysis was resected and a osteoarticular allograft reconstruction was done.”

“Our findings suggest that, although complications requiring a second operations could be expected after reconstruction, about one of six patients with a metaphyseal osteosarcoma around the knee may be treated with appropiate oncologic margins and preservation of the epiphysis of the affected bone.”

The main purpose of our paper was to analyze, in a small series of patients, the potential preservation of the epiphysis in high grade metaphyseal osteosarcomas of the knee. There are few reconstructive alternatives now available to fill the segmental bone defect originated with this technique, and the use of intercalary allografts is one.

Most likely in the future new procedures with very high predictibility are going to be developed. In the meantime, the use of intercalary allografts, even considering potential complications, is, in our opinion, a very acceptable procedure to reconstruct a bone defect not affecting the articular surface.