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Timothy B. Rapp, M.D., Loyola University Medical Center Melissa Zimmel, Northwestern University

Endoprosthetic vs. “Condyle-Sparing” Intercalary Allografts for Distal Femoral Osteosarcoma: A Comparison of Long-Term Follow-up. Timothy B. Rapp, M.D., Loyola University Medical Center Melissa Zimmel, Northwestern University Ernest U. Conrad III, M.D., University of Washington

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Timothy B. Rapp, M.D., Loyola University Medical Center Melissa Zimmel, Northwestern University

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  1. Endoprosthetic vs. “Condyle-Sparing” Intercalary Allografts for Distal Femoral Osteosarcoma: A Comparison of Long-Term Follow-up Timothy B. Rapp, M.D., Loyola University Medical Center Melissa Zimmel, Northwestern University Ernest U. Conrad III, M.D., University of Washington Presented by Dr. Conrad at the Connective Tissue Oncology Society Annual Meeting, November 2004 Montreal, Canada

  2. Reconstructive Options • Endoprosthetic replacement • 10-year implant survival ~70% • Concern over bone stock long term • Osteoarticular allografts • Knee instability • Allograft complications • “Condyle-Sparing” intercalary allografts • Preserves native knee joint • Allograft complications

  3. ALLOGRAFT: HISTORICAL • Mankin JBJS 1997 • 104 intercalary allografts for malignancy, retrospective • 84 % “successful” • Overall salvage rate 92% • Local recurrence 9% • Survival for high grade tumors 60% • High non-union rate 28% • Deep infection rate 12% • Outcome not affected by • Age, gender, anatomical site, length of graft • Outcome adversely affected by • Infection, fracture, stage of lesion, use of chemotherapy Mankin H, JBJS, 79-A 1997

  4. Distal Femur- Bone Allograft: Osseous Union??

  5. LIMB SALVAGE REVISIONS? REVISIONS=50% !? NOT 25-30% AND 15 YR OLD PT. REVISED @ Age 25/35/?? or Age20/25/30?

  6. Overall “Implant Survival “ Adults vs Children (N=88)

  7. LIMB SALVAGE “HYPOTHESIS”CONDYLE SPARING GRAFTSUPERIOR TO IMPLANT ?

  8. “MATCHED REVIEW” OF OSTEOSARCOMA OFTHE DISTAL FEMUR

  9. CRITERIA:OSTEOSARCOMA- DISTAL FEMUR -GRAFTS vs JOINTS • ISSUES: • ADEQUATE OSSEOUS MARGIN (vs SOFT TISSUE) • ALLOGRAFT vs IMPLANT @ DISTAL FEMUR

  10. Methods • IRB Approved review of Allografts and Implants 1990-2002 • SARCOBASE + Chart Review • Survival • Local recurrence • Surgical complications/revisions • Functional Assessment • Modified MSTS/SF-36 • Careful X-ray Review

  11. ALLOGRAFTS- OVERALL 1990- 2001 N=80/73 Mean age= 28 yrs Mean F/U= 5.3yrs Site=Femur/tibia/pelvis 42/22/16% Grafts= NTC

  12. OVERALL ALLOGRAFT-RESULTS • RADIOGRAPHIC REVIEW= “ NONUNION”=39% DELAYED UNION=10% TIME TO UNION= 14.6mos OTHER: FRACTURE= 5% INFECTION= 5% REVISION=40%

  13. Allografts: New Fixation Techniques vs Immunologic -Biologic Graft Issues

  14. IMPLANTS- OVERALL REVIEW 1986-2002 N=88 AGE= 9-86 yrs mn=33yrs Pediatric age =31/88 Follow-up=70 mos Anatomic=Femur/Tibia =61/27 FunctionalAssess=MSTS /SF 36

  15. Radiographic Outcome • Xrays scored in 3 major categories • Continuous cement mantle (2mm) • No lucencies > 1mm • Cortical bridging from bone to collar • Mean xray score 75/100 • Lower “cement mantle” and “lucency” scores associated with pain and the need for revision • “Bone bridging” did not correlate with revision status!

  16. Statistical Methods • Patient and prosthetic survivorship curves by Kaplan-Meier method • Student t tests to compare radiographic groups

  17. OVERALL IMPLANTRESULTS RADIOGRAPHIC: “ Aseptic Loosenening”=19% Other: Implant Failure= 12.5% Revision=55% Major=40.6% Minor=59.4% Pediatric Prox Tibia p=0.029

  18. Overall Implant Complications Overall Complications=50% --Knee stiffness: 10 pts • Deep infection: 7 pts • Superficial wound: 6 pts • Nerve palsy: 7 pts • Bushing failure: 6 pts • Stem fracture: 5 pts • Patella instability: 4 pts • DVT/PE: 3 pts • MAJOR vs MINOR COMP’S

  19. GOOD NEWS-BAD NEWS ! PEDIATRIC SURVIVAL IS BETTER THAN IMPLANT SURVIVAL !? ( “GOOD RESULT “= GOES SKIING ?? )

  20. Clinical Outcome • SF-36 • 8 standard categories assessed • Physical functioning, Role Physical functioning, Bodily Pain, General Health, Vitality, Social Functioning, Role Emotional, Mental Health • Knee implant population scores lower than general U.S. population in each category, but NOT statistically significant • Differed most in physical function and bodily pain categories

  21. Results -”Matched” Distal Femur Allograft vs Implant • 45 patients between 1989-2000 treated for a distal femoral (meta-diaphyseal) osteogenic sarcoma • All patients received neoadjuvant chemotherapy • 27 patients- “condyle-sparing” allograft • Average age 18.1 years • Average follow-up 6.5 years • 18 patients - primary endoprosthesis • Average age 13.8 years • Average follow-up 6.4 years

  22. SurgicalResults-Matched Series • “Condyle-Sparing” Allografts (n=27) • Ten (37%) patients revised to endoprosthesis • Average 3.5 years after original allograft • Eight cases due to allograft/host non-union • Average of 3.3 revision procedures/pt • Bone grafting/screw or nail exchange • Two deep infections (both eventually converted to implant) • One amputation for local recurrence • Endoprosthesis (n=18) • Four (22%) patients revised • Average 4.8 years after index procedure • Average of 1.1 revision procedures/pt • Three deep infections • One amputation for pain/stiff

  23. Oncologic Results-Matched Series • Overall Survival 84% • Four deaths in allograft group • Three deaths in endoprosthesis group • Local Recurrences • Two in allograft group (avg. 15 months after surgery) • One in endoprosthesis group (five months after surgery) • Surgical Osseous Margins • Allograft=2.7cm(prox)+1.5cm(distal) ave bone margin • Endoprosthesis=3.1cm(prox)=2.6cm(distal-jt) ave margin

  24. Functional Results-Matched Series • Pain • Allografts (n=17): No narcotics • Endoprosthesis (n=18): One patient required occasional narcotics • Walking Aids • Allografts: Two patients using canes, one uses crutches for long distance • Endoprosthesis: One patient using cane, one uses crutches for long distance • ROM • Allografts: One flexion contracture (10º); average motion arc 105º • Endoprosthesis: Three contractures (avg. 15º); avg. motion arc 110º • Strength • Allograft: Four patients with 4/5, otherwise 5/5 • Endoprosthesis: Three patients with 4/5, otherwise 5/5

  25. Clinical Outcome • SF-36 • 8 standard categories assessed • Physical functioning, Role Physical functioning, Bodily Pain, General Health, Vitality, Social Functioning, Role Emotional, Mental Health • Knee implant population scores lower than general U.S. population in each category, but NOT statistically significant • Differed most in physical function and bodily pain categories MSTS=63% GOOD + EXC / Grafts= Implants “TESS” IS BETTER ?

  26. GOOD NEWS-BAD NEWS ! PEDIATRIC PT. SURVIVAL IS BETTER THAN IMPLANT SURVIVAL ORTHOPAEDIC CHALLENGE

  27. Discussion-Matched Series@5yrs Endoprosthesis vs. “Condyle-Sparing” Allografts: • Tumor control -similar • Survival • Local recurrence • Final Functional - Similar?? • Pain meds, walking aids, strength, ROM • Higher Failure Rate in Allografts REVISION RATE=37 vs 22% (GRAFTS vs IMPLANTS)@4-5 yrs

  28. LIMB SALVAGE- FUTURE? • Endoprosthesis • FOCUS ON 10 YR RESULTS +PATTERNS OF FAILURE • ISOLATE +IMPR0VE REVISION SCENARIO • CONSIDER NEW STEM FIXATION IN CHILDREN • FOCUS ON CAUSES OF FAILURE • “Condyle-sparing” allografts • CLEARLY HAVE HIGHER FAILURE RATE-EARLY(5YRS) • EMPHACIZE FIXATION TECH’S • CLOSE BUT CAUTIOUS BONY MARGIN • TIME TO UNION=14 months • ALLOGRAFT BIOLOGY IN THE FUTURE? ALL LIMB SALVAGE PATIENTS ARE DONE ON “PROTOCOL”

  29. THANK YOU

  30. Thank you for your attention! Research supported by educational grants from Stryker Howmedica Osteonics, Inc. and Zimmer, Inc.

  31. Thank You

  32. Implant Overall • Implant group overall (n=88) • “Implant survival” • At five years = 71% • At ten years = 59% • Infection = 7% • Aseptic Loosening = 19%

  33. Overall Implant Survival RateAdults vs. Children (N=88)

  34. “LIMB SALVAGE “They do well ? BEWARE THE SUBTLETIES !!

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