Departments of Orthopaedic Surgery (P.T.J.S., J.F.S., M.P.A.B., M.A.J.v.d.S., and P.D.S.D.) and Medical Statistics and Biomedical Sciences (M.F.), Leiden University Medical Center, Leiden, the Netherlands.
Carlos E. Ottolenghi Institute of Orthopaedics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
J Bone Joint Surg Am. 2020 Jun 17;102(12):1042-1049. doi: 10.2106/JBJS.18.00893.
Improved survival rates for patients with primary bone tumors of the extremities have increased the demand for reliable and durable reconstruction techniques. Some authors have stated that, after successful ingrowth, allografts are a durable long-term solution. This hypothesis is largely based on small studies with short-to-midterm follow-up. In order to determine the durability of intercalary allograft reconstructions in the lower extremities, we evaluated the long-term clinical outcomes at a minimum of 10 years.
All patients who received an intercalary allograft reconstruction in a lower extremity between 1980 and 2006 were included in this retrospective multicenter cohort study. One hundred and thirty-one patients with a median age of 19 years were included. Eighty-nine (68%) had a femoral reconstruction, and 42 (32%) had a tibial reconstruction. The most prevalent diagnoses were osteosarcoma (55%), Ewing sarcoma (17%), and chondrosarcoma (12%). The median follow-up was 14 years. A competing risk model was employed to estimate the cumulative incidences of mechanical failure and infection. Patient mortality or progression of the disease was used as a competing event.
Nonunion occurred in 21 reconstructions (16%), after a median of 16 months, and was associated with intramedullary nail-only fixation (p < 0.01) and fixation with nonbridging plate(s) (p = 0.03). Allograft fracture occurred in 25 reconstructions (19%) after a median of 42 months (range, 4 days to 21.9 years). Thirteen (52%) of the allograft fractures occurred within 5 years; 8 (32%), between 5 and 10 years; and 4 (16%), at >10 years. With failure for mechanical reasons as the end point, the cumulative incidences of reconstruction failure at 5, 10, and 15 years were 9%, 14%, and 21%, respectively.
Intercalary allograft reconstruction is an acceptable reconstructive option, mainly because of the absence of superior alternatives with a known track record. However, a considerable and continuing risk of mechanical complications should be taken into account.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
原发性四肢骨肿瘤患者的生存率提高，增加了对可靠和耐用重建技术的需求。一些作者指出，在成功植入后，同种异体移植物是一种持久的长期解决方案。这一假设主要基于短期至中期随访的小型研究。为了确定下肢间插异体骨重建的耐久性，我们在至少 10 年的时间里评估了长期的临床结果。
本回顾性多中心队列研究纳入了 1980 年至 2006 年间接受下肢间插异体骨重建的所有患者。共纳入 131 例患者，中位年龄为 19 岁。89 例（68%）行股骨重建，42 例（32%）行胫骨重建。最常见的诊断为骨肉瘤（55%）、尤文肉瘤（17%）和软骨肉瘤（12%）。中位随访时间为 14 年。采用竞争风险模型估计机械故障和感染的累积发生率。患者死亡或疾病进展被用作竞争事件。
21 例（16%）重建发生了骨不连，中位时间为 16 个月，与髓内钉固定（p < 0.01）和非桥接钢板固定（p = 0.03）有关。25 例（19%）重建发生了异体骨骨折，中位时间为 42 个月（范围为 4 天至 21.9 年）。13 例（52%）的异体骨骨折发生在 5 年内；8 例（32%）发生在 5 至 10 年内；4 例（16%）发生在 10 年以上。以机械原因导致的失败为终点，5、10 和 15 年时重建失败的累积发生率分别为 9%、14%和 21%。
间插异体骨重建是一种可接受的重建选择，主要是因为没有已知记录的更好替代方案。然而，应该考虑到相当大且持续存在的机械并发症风险。
治疗 IV 级。有关证据水平的完整描述，请参见作者说明。
