Orthopedic Surgical Oncology For Bone Tumors A Case

Study Atlas

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Foreword

This case study atlas represents the development of tumor surgery in sarcomas over the last
40 years. It illustrates techniques ranging from life-saving amputations to rotationplasty, from
resection–reimplantation to tumor prosthesis, allografts and autograft reconstruction with free
flaps and distraction techniques to growing prosthesis. As surgical techniques evolved, so did
imaging techniques, contributing to the success of the surgeon. While multimodality treatment
facilitated life-saving success before the development of limb-saving techniques, the chapters
in this atlas demonstrate the evolution of surgical techniques, including procedures for the
treatment of difficult “gray zone” individual cases, especially in centers experienced in the
management of bone tumors.

Department of Orthopaedics Rainer Kotz

Medical University of Vienna
Vienna, Austria

v
Preface

Knowledge and application of the right tenets and philosophy is the cornerstone of correct
diagnosis and treatment in bone and soft tissue tumors. While resection with safe margins can
determine the fate of the patient, a durable reconstruction determines function and impacts on
the quality of life. Medicine is both a science and an art. We, orthopedic oncologists, are
merely artists, who utilize our science and philosophy to perform our craft. Distinguished
global experts in bone and soft tissue tumors have collaborated to compile this surgical atlas.
These luminaries present either classical surgical methods or their signature operation tech-
niques in a standardized format and language in an attempt to share their knowledge, experi-
ence, and craft—in other words, “their art”—so as to help the readers decide on the best
possible method to treat these complex and challenging cases in their own unique sociocultural
milieu.
We, the editors, are profoundly grateful to our authors for their outstanding work and dedi-
cated efforts undertaken during the tragic and chaotic times of COVID-19 pandemic. The edi-
tors would like to thank Springer for believing in our surgical atlas project and enabling the
publication of this atlas and express our heartfelt gratitude to the dedicated Springer team—
Aruna Sharma, who skillfully orchestrated the busy to-and-fro email traffic, and Barbara
Pittaluga, who meticulously oversaw and supported the project right from its initiation to
conclusion.
An atlas like this would not have been possible was it not for the large number of patients
who entrusted their lives and limbs to us, unfailingly trusting in us and believing that we would
all do our best to try and help them overcome the unique challenges and struggles that they
were facing. We salute all of them for their exemplary courage and fortitude in the face of life-
threatening crises.

Istanbul, Turkey Harzem Ozger

Rochester, MN, USA  Franklin H. Sim
Mumbai, Maharashtra, India  Ajay Puri
Istanbul, Turkey  Levent Eralp

vii
Contents

Part I Philosophy of Limb Salvage Surgery

1 When and Why Biological/Implant Reconstruction? ���������������������������������������������   3

Harzem Özger and Bugra Alpan

Part II Mobile Spine

2 Biological Reconstruction Using Frozen Autograft

in Total En Bloc Spondylectomy for Spinal Tumors����������������������������������������������� 29
Satoru Demura, Satoshi Kato, and Hiroyuki Tsuchiya
3 Implant Reconstruction of the Mobile Spine����������������������������������������������������������� 37
Syed Mohammed Karim, Matthew T. Houdek, Michael J. Yaszemski,
and Peter S. Rose

Part III Sacrum

4 Biological Sacral Reconstruction������������������������������������������������������������������������������� 47

Matthew T. Houdek, Franklin H. Sim, Michael J. Yaszemski,
and Peter S. Rose
5 Total Sacrectomy Without Spinopelvic Reconstruction ����������������������������������������� 53
Piya Kiatisevi, Bhasanan Sukanthanak, Pongsiri Piakong,
and Chaiwat Piyaskulkeaw
6 Implant Reconstruction of the Sacrum: Modular Sacrum Prosthesis������������������� 61
Wei Guo

Part IV Pelvis

7 Biological Reconstruction of the Pelvis: I:

Liquid-Nitrogen Treated Autograft and Onlaid Free Vascular Fibula ����������������� 71
Harzem Özger, Bugra Alpan, and Mehmet Veli Karaaltın
8 Biological Reconstruction of the Pelvis: II:
Femoral Head Plus Total Hip Replacement������������������������������������������������������������� 85
Xiaohui Niu and Hairong Xu
9 Implant Reconstruction of the Pelvis: I: Modular Hemipelvic Prosthesis ����������� 95
Wei Guo
10 Implant Reconstruction of the Pelvis: II: Modular Pedestal Cup Prosthesis������� 105
M. P. A. Bus and M. A. J. van de Sande

ix
x Contents

11 Implant Reconstruction of the Pelvis: III High Acetabular Placement

and Prosthetic Femoral Extension����������������������������������������������������������������������������� 111
Harzem Özger and Bugra Alpan
12 Implant Reconstruction of the Pelvis: IV: 3D-Printed
Custom-Made Prosthesis������������������������������������������������������������������������������������������� 121
Davide Maria Donati and Tommaso Frisoni

Part V Proximal Femur

13 Biological Reconstruction of the Proximal Femur

with Extracorporeally Irradiated Autograft������������������������������������������������������������ 135
Dündar Sabah
14 Implant Reconstruction of the Proximal Femur: Modular Prosthesis ����������������� 143
Apichat Asavamongkolkul
15 Prosthetic Reconstruction for Soft Tissue Sarcomas
with Bone Involvement����������������������������������������������������������������������������������������������� 153
Philip D. Rowell, Jennifer L. Nevin, Rosti Novak, Kim M. Tsoi,
Peter C. Ferguson, and Jay S. Wunder

Part VI Femoral Diaphysis

16 Biological Reconstruction of the Femoral Diaphysis:

Van Nes Rotationplasty ��������������������������������������������������������������������������������������������� 167
Ajay Puri
17 Implant Reconstruction of the Femoral Diaphysis: I:
Intercalary Femur Prosthesis������������������������������������������������������������������������������������� 177
Joseph Benevenia, Zachary Cavanaugh, Joseph Ippolito, Jennifer Thomson,
and Luis Guinand
18 Implant Reconstruction of the Femoral Diaphysis:
II—Short-Segment Dynamic Compression Stem���������������������������������������������������� 181
Lee Jae Morse, Andrew S. Fang, and James O. Johnston

Part VII Distal Femur

19 Biological Reconstruction of the Distal Femur—I:

Massive Allograft and Inlaid Free Vascular Fibula������������������������������������������������� 191
Antonio D’Arienzo, Simone Colangeli, Lorenzo Andreani,
Olimpia Mani, and Rodolfo Capanna
20 Biological Reconstruction of the Distal Femur: II:
Resurfacing Allograft-­Prosthesis Composite����������������������������������������������������������� 203
Domenico Andrea Campanacci, Roberto Scanferla, and Francesco Muratori
21 Biological Reconstruction of the Distal Femur:
III Liquid Nitrogen Treated Autograft and
Inlaid Free Vascular Fibula (the “Frozen Hotdog”) ����������������������������������������������� 211
Harzem Özger, Bugra Alpan, and Şükrü Yazar
22 Implant Reconstruction of the Distal Femur: I—Modular Prosthesis ����������������� 225
Giulia Trovarelli, Jim Georgoulis, Elisa Pala, Andreas F. Mavrogenis,
and Pietro Ruggieri
Contents xi

23 Implant Reconstruction of the Distal Femur: II—Joint-­Preserving Resection

and Reconstruction with ­Image-­Guided Computer Navigation����������������������������� 235
Kwok Chuen Wong and Shekhar Madhukar Kumta
24 Implant Reconstruction of the Distal Femur: III—Expandable Prosthesis��������� 247
Gerhard M. Hobusch, Martina Schinhan, and Reinhard Windhager
25 Implant Reconstruction of the Distal Femur—IV: Prosthesis Revision ��������������� 253
Jendrik Hardes, Arne Streitbürger, Markus Nottrott, Lars Erik Podleska,
and Wiebke K. Guder
26 Percutaneous Osseointegration Prosthesis��������������������������������������������������������������� 265
Taylor J. Reif, Austin T. Fragomen, and S. Robert Rozbruch

Part VIII Proximal Tibia

27 Biological Reconstruction of the Proximal Shaft of Tibia—I:

Pedicle Frozen Autograft ������������������������������������������������������������������������������������������� 275
Norio Yamamoto and Hiroyuki Tsuchiya
28 Biological Reconstruction of the Proximal Tibia—II:
Distraction-­Epiphysiolysis Before Resectioning of the Tumor������������������������������� 291
Blanca Vázquez-García and Mikel San-Julián
29 Implant Reconstruction of the Proximal Tibia:
Modular Prosthesis and Rotational Gastrocnemius Flap��������������������������������������� 299
Philipp T. Funovics

Part IX Tibial Diaphysis and Ankle

30 Biological Reconstruction of the Tibial Diaphysis and Ankle—I:

Ilizarov Technique������������������������������������������������������������������������������������������������������� 313
Hidenori Matsubara and Hiroyuki Tsuchiya
31 Biological Reconstruction of the Tibial Diaphysis and Ankle—II:
Fibular Centralization Technique����������������������������������������������������������������������������� 325
Ajay Puri
32 Biological Reconstruction of the Tibial Diaphysis and Ankle—III:
Arthrodesis with Massive Allograft��������������������������������������������������������������������������� 333
Simone Colangeli, Lorenzo Andreani, Antonio D’Arienzo, Olimpia Mani,
Giuseppe Restuccia, and Rodolfo Capanna
33 Implant Reconstruction of the Tibial Diaphysis and Ankle:
3D-Printed Custom-Made Prosthesis����������������������������������������������������������������������� 345
Panayiotis J. Papagelopoulos and Olga Savvidou

Part X Foot

34 Biological Reconstruction of the Foot: Free Vascular Iliac Flap����������������������������� 357

Harzem Özger, Bugra Alpan, and Murat Topalan
35 Implant Reconstruction of the Foot 3D-Printed Custom-­Made Prosthesis����������� 367
Panayiotis J. Papagelopoulos and Olga Savvidou
xii Contents

Part XI Shoulder Girdle

36 Biological Reconstruction of the Shoulder Girdle:

Scapular Massive Allograft ��������������������������������������������������������������������������������������� 381
Olimpia Mani, Lorenzo Andreani, Giovanni Beltrami, Francesca Totti,
and Rodolfo Capanna
37 Implant Reconstruction of the Shoulder Girdle: Scapular Prosthesis������������������ 391
Joseph Benevenia, Zachary Cavanaugh, Joseph Ippolito,
Jennifer Thomson, and Luis Guinand

Part XII Proximal Humerus

38 Proximal Humerus, Biological Reconstruction ������������������������������������������������������� 399

Bulent Erol
39 Claviculo-Pro-Humero Reconstruction Following
Proximal Humeral Resection������������������������������������������������������������������������������������� 405
Peter F. M. Choong and Emma L. P. Choong
40 Biological Reconstruction of the Proximal Humerus—III:
Massive Allograft and Inlaid Free Vascular Fibula Epiphyseal Transfer������������� 417
Matthew T. Houdek, Elizabeth P. Wellings, and Steven L. Moran
41 Implant Reconstruction of the Proximal Humerus������������������������������������������������� 425
L. van der Heijden and M. A. J. van de Sande
42 Implant Reconstruction of the Proximal Humerus—II:
Reverse Prosthesis������������������������������������������������������������������������������������������������������� 441
Giulia Trovarelli, Alessandro Cappellari, Andrea Angelini,
and Pietro Ruggieri

Part XIII Humeral Diaphysis

43 Biological Reconstruction of the Humeral Diaphysis:

Irradiated Autograft��������������������������������������������������������������������������������������������������� 453
Kuan-Lin Chen, Chao-Ming Chen, Po-Kuei Wu, and Wei-Ming Chen
44 Implant Reconstruction of the Humeral Diaphysis:
Total Humerus Prosthesis������������������������������������������������������������������������������������������ 465
Lee M. Jeys, Guy V. Morris, and Vineet Kurisunkal

Part XIV Distal Humerus and Elbow

45 Implant Reconstruction of the Distal Humerus and Elbow:

Modular Prosthesis����������������������������������������������������������������������������������������������������� 481
Philipp T. Funovics

Part XV Forearm, Wrist and Hand

46 Biological Reconstruction of the Forearm, Wrist,

and Hand—I: Free Vascular Fibula��������������������������������������������������������������������������� 493
Harzem Özger, Bugra Alpan, and Cihangir Tetik
47 Biological Reconstruction of the Forearm, Wrist,
and Hand—II: Transposition of the Distal Ulna����������������������������������������������������� 503
Ajay Puri
Contents xiii

48 Implant Reconstruction of the Forearm, Wrist and Hand:

Distal Radius Endoprosthesis ����������������������������������������������������������������������������������� 513
Lee M. Jeys, Rachel Mahoney, and Vineet Kurisunkal

Part XVI Complications of Orthopedic Oncologic Reconstructions

49 Complications of Orthopedic Oncologic Reconstructions

Using Biological Reconstruction������������������������������������������������������������������������������� 521
Levent Eralp, Ahmet Salduz, and Emre Ozmen
50 Complications of Orthopedic Oncologic Reconstructions
Using Implants ����������������������������������������������������������������������������������������������������������� 545
Levent Eralp, Ahmet Salduz, and Emre Ozmen
 Part I
Philosophy of Limb Salvage Surgery
 When and Why Biological/Implant
Reconstruction? 1
Harzem Özger and Bugra Alpan

1.1 Principles of Limb Salvage Surgery tissue coverage, and function of the limb. Despite the fact
that reconstructive procedures are often the more intriguing
The main principle of treatment for bone and soft tissue and emphasized parts in LSS, reconstruction can never be
tumors is to remove the tumor in its entirety. There are two considered apart from the resection. While an impressive and
main methods for achieving this goal [1–3]: sophisticated reconstruction is likely to fail due to local
recurrence in the setting of an inadequate resection, the
1. Amputation patient’s survival is also at stake with compromised margins.
2. Limb Salvage Surgery (LSS) On the other hand, a carefully planned and skillfully exe-
cuted resection in a well-selected patient will sometimes
Amputation, which is a form of ablative treatment, mandate a certain type of reconstruction or give more than
removes the tumor-afflicted extremity at a safe level. When one reconstructive option to the surgeon. Nevertheless, the
compared to LSS, it can be performed in a much shorter resection is dependent on tumor-related (specific pathology,
duration, is a relatively easier procedure, and can facilitate location, size) and patient-related (demographics) or
faster recovery. Nevertheless, it is a radical procedure and treatment-­related (previous invasive diagnostic/inappropri-
a valuable part of the body is lost forever. For all illnesses, ate procedures, response to neoadjuvant treatment) factors.
especially for cancer, motivation is an important part of the Therefore, LSS is a total concept including all things done
patient’s treatment process. This motivation is tremen- (or not done) starting from the time of presentation to the
dously affected with the loss of a limb that comes with completion of reconstructive efforts and even the completion
amputation. This, by itself, justifies the endeavor to sal- of adjuvant treatment. LSS is the mainstay of treatment today
vage the limb. for most musculoskeletal malignancies and the treatment
Limb salvage surgery is the resection of the tumor with protocols have been standardized for common pathologies
safe margins by including a cuff of healthy tissue while pre- like osteosarcoma and Ewing’s sarcoma in much of the
serving the limb. The absolute requirement for attempting developed world or the developing countries.
LSS is the probability of removing the tumor as safely as Van Nes rotationplasty is a very valuable intermediate
with an amputation. In addition to osseous or osteoarticular surgical treatment method between amputation and LSS [2,
losses, resection may also involve sacrification of critical 3]. When compared to amputation, it preserves significant
structures such as muscles, ligaments, skin, nerves, vessels, function, avoids phantom limb pain, and results in less limb
and/or neighboring organs. In a broad sense, the aim of sub- length discrepancy. However, cultural expectations, peculiar
sequent reconstruction is to ensure integrity, viability, soft cosmesis, need for knowledge and experience of specific sur-
gical technique, and the need for access to a skilled prosthe-
tist limit its use.
H. Özger (*) In the light of this general perspective on amputation and
Department of Orthopaedics and Traumatology, LSS, the goals of treatment in musculoskeletal malignancies
Istanbul University, Istanbul Faculty of Medicine, can be summarized and prioritized as:
Istanbul, Turkey
B. Alpan 1. saving the patient’s life,
Department of Orthopaedics and Traumatology, Acibadem
2. saving the limb,
Mehmet Ali Aydinlar University, School of Medicine,
Istanbul, Turkey 3. preserving function of the limb,
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 3

H. Özger et al. (eds.), Orthopedic Surgical Oncology For Bone Tumors, https://doi.org/10.1007/978-3-030-73327-8_1
4 H. Özger and B. Alpan

4. achieving good cosmesis of the limb, 1.2 When and Why Biological
5. compatibility of the treatment method with psycho-socio-­ Reconstruction?
cultural status of the patient.
The main advantage of biological reconstruction is that when
The treating team must adhere to these priorities and the healing process is complete, the reconstruction material
carefully assess issues such as the required knowledge, becomes totally incorporated into the patient’s body [5–11].
skill, experience, technical resources, and presence of a The biologically reconstructed segment, which either main-
specialist team for each case. Respecting these criteria in tains its vitality and thus unites with the recipient site or
the appropriate order and informing the patient and/or the regains its vitality by creeping substitution after uniting with
family explicitly about the objectives that can be achieved, the recipient site, eventually becomes the patient’s own. The
it is almost always possible to avoid an ablative surgery living nature of the healed segment gives it responsive capa-
today. The local control rate is shown to be similar for bility so that it can remodel, heal if it is fractured or hypertro-
amputation and LSS in the era of advanced imaging and phy under weight-bearing conditions (Fig. 1.1). Therefore,
multimodal adjuvant treatment. The decision to perform a biological reconstruction offers a potentially life-long limb
limb-sparing surgery or what kind of reconstruction to salvage solution, which even facilitates safe participation in
undertake in extreme cases, however, is a very individual- recreational activities in survivors of musculoskeletal
ized process, which should take into account the total malignancies.
impact of the planned procedure on the patient and the Biological reconstruction reduces soft tissue problems
medical team in terms of health-related quality of life, eco- through three different mechanisms. Biological materials
nomical burden, psychosocial effects, allocation of medi- occupy less space (Fig. 1.2), allows adherence of soft tissues
cal resources, and oncological risks [2–4]. onto their surfaces, and also may bring their own soft tissue
Reconstruction in limb salvage surgery can be performed cover as in an osteo-myofasciocutaneous flap. Hence, wound
in two ways: problems and secondary deep infections are less commonly
encountered. Furthermore, early postoperative complica-
1. Biological reconstruction tions such as infected hematoma can be effectively treated. If
• Biological methods utilize materials, which are either the healing of biological reconstruction fails partially, as
living or have the capacity to revitalize and are would be the case in the setting of mechanical insufficiency
obtained from either the patient (autograft) or from while the graft’s vitality is preserved, complications like
another person (allograft), to reconstruct the post-­ graft fracture or nonunion might occur and yet can be treated
resection defect [5–11]. by revision of osteosynthesis as in a normal fracture
• Distraction osteogenesis is also a very important, (Fig. 1.3). Limb length discrepancy can be managed in the
albeit less commonly used biological method in ortho- same way as in a non-oncological setting (Fig. 1.4). If, how-
pedic oncology [12]. ever, biological potential has been lost or cannot be regained
• The definition of biological reconstruction may be in a reasonable time, the reconstructed segment might end up
extended to include hybrid methods (e.g., allograft/ as dead bone and fail totally due to deep infection and/or
recycled autograft and prosthesis composites) and bio- resorption. Biological reconstruction has the advantage of
logical aspects of non-biological methods (e.g., bone possible conversion to implant reconstruction even in this
lengthening in the setting of tumor prosthesis or bioex- worst-case scenario (Fig. 1.5).
pandable prostheses) [5, 13]. While biological methods yield durable reconstructions
2. Implant (non-biological) reconstruction with relatively less morbid and biologically manageable
• Tumor prostheses or megaprostheses are the main complications, the major disadvantage is the substantially
instruments of non-biological defect reconstruction long healing time, which particularly causes problem regard-
[14, 15]. ing lower extremity reconstructions due to prolonged period
• Bone cement is also a very versatile non-biological of restricted weight-bearing (Fig. 1.6). These limb salvage
material, which can be used with tumor pros- considerations are most compatible with a patient who has a
theses or osteosynthesis implants for defect high likelihood of survival and thus can afford to wait for the
reconstruction. lengthy healing period. This, in turn, depends on the pres-
• Non-biological methods may harbor biological com- ence of good prognostic factors such as being non-metastatic
ponents (e.g., graft/prosthesis composites or bioex- at presentation, showing a good neoadjuvant treatment
pandable parts) as also mentioned for biological response, not having a large tumor and not having sustained
methods [5, 13]. a pathological fracture.
1 When and Why Biological/Implant Reconstruction? 5

Fig. 1.1 Early postoperative radiograph demonstrates intercalary closed reduction (c). Follow-up radiograph at postoperative 7 years
biological reconstruction following resection of proximal humerus shows excellent remodeling after fracture healing (d). The case is an
chondrosarcoma in a 35-year-old-male patient (a). The patient pre- excellent example of how biological reconstruction allows simple
sented with fracture of the vascular fibula graft at postoperative and effective management of limb salvage complications
3 months (b). The fracture was conservatively managed following

On the other hand, certain disadvantages associated with sequences in a good-responder. As a general rule, the surgi-
implant reconstruction, such as loss of joint surfaces, loss of cal margins are determined according to radiology at pre-
physeal plates on both sides of the joint, and loss of bone sentation for osteosarcoma and according to follow-up
stock, which could actually be spared, make biological imaging after neoadjuvant treatment for Ewing’s sarcoma
reconstruction with intercalary resection the treatment of since chemosensitivity and radiosensitivity are thought to
choice for some cases or a necessity in others. The feasibility play a bigger role in local tumor control in the latter
of a safe intercalary resection is closely related with pathology.
radiological findings. An interim radiological evaluation Although more rarely performed, biological reconstruc-
may be reasonable in cases, for which biological tion may also play an important role after intraarticular
reconstruction is planned. For example, a magnetic resection in small children (Fig. 1.7) and particularly in the
resonance imaging (MRI) examination performed after the upper extremity. Long-term complications of implant recon-
second cycle of a “3-cycle neoadjuvant chemotherapy” may struction, such as periprosthetic infection, inevitable need for
demonstrate whether if radiological response is good and revision, and continuing loss of bone stock, also bring forth
therefore intercalary resection is safe or if there is tumor biological reconstruction as the method of choice, in younger
progression and an endoprosthetic reconstruction will be patients, particularly in the skeletally immature.
safer. Thus, the reconstruction strategy may be worked out Biological reconstruction might be considered economi-
before final preoperative MRI. Which MRI parameters cally advantageous when compared to implant reconstruction
should be used to determine surgical margins are open to in general. While this advantage may vary according to spe-
debate. While the safest margins can be accepted as those cific method of biological reconstruction used, harvesting a
determined according to pre-­ chemotherapy short tau non-vascular structural bone graft has virtually no cost and
inversion recovery (STIR) or turbo inversion recovery recycling techniques, such as liquid-nitrogen cryotreatment,
magnitude (TIRM) sequences on MRI, the margins most autoclaving, and pasteurization, also have minimal economic
encouraging for intercalary resection, are those determined impact and demand minimal resource and equipment. While
according to post-chemotherapy contrast-­ enhanced microsurgical reconstruction with a vascular bone flap is a
6 H. Özger and B. Alpan

Fig. 1.2 The MRI section, the radiograph, and the clinical photo dem- ated part (d). Free vascular fibular graft with proximal epiphysis was
onstrate an exulcerated telangiectatic osteosarcoma of the proximal used for biological reconstruction of the humerus (e). Despite signifi-
humerus in a 12-year-old non-metastatic male patient (a–c). MRI cant skin and subcutaneous tissue sacrification, the relatively small vol-
shows extensive tumor necrosis following neoadjuvant chemotherapy ume occupied by the fibula graft, in comparison to tumor prosthesis,
(a). Wide intraarticular resection was performed including the exulcer- facilitated excellent primary soft tissue coverage (f–h)
1 When and Why Biological/Implant Reconstruction? 7

Fig. 1.3 Early postoperative radiograph demonstrates “frozen hotdog” shows that full consolidation of the hotdog segment was finally achieved
(liquid nitrogen recycled autograft shell & inlaid vascular fibula combi- after two revision surgeries (c, e). The final radiological outcome con-
nation) reconstruction in a 14-year-old-male patient with distal femur firms that biological activity was preserved, most probably due to inlaid
osteosarcoma (a). Delayed union of the shell resulted in graft fracture vascular fibula. Mechanical failures of biological reconstruction can be
and implant failure in the proximal osteotomy site at postoperative treated in similar fashion to normal fracture complications as long as
9 months (b) and in the distal osteotomy site at postoperative 24 months there is “sufficient” biological potential
(d). Image taken from standing AP orthoroentgenogram at 4 years

time, resource, and effort demanding procedure, it can still be 1.3  hen and Why Implant (Non-­
W
considered as a relatively low-cost treatment if utilized in a biological) Reconstruction?
specialized center setting where the procedure is being per-
formed routinely by a dedicated microsurgery team. The Advanced design features of modern-day implants facili-
availability of a national bone bank might also favor massive tate near-normal biomechanics especially around the knee
allograft use as a more economical option compared to joint, which frequently undergoes non-biological recon-
implant reconstruction. Finally, the long-term solution pro- struction in the oncological setting [14, 15]. Furthermore,
vided by biological reconstruction also eliminates the costs of the modularity of most megaprosthetic systems used today
future implant revisions. allows the surgeon to precisely adjust the extremity length
In the light of these treatment concerns, biological recon- and rotation and to modify the reconstruction plan intraop-
struction may be best indicated in a younger patient with good eratively [14, 15]. These aspects provide great comfort for
prognostic factors and a tumor suitable for safe intercalary both the patient and the surgeon. Taking into account the
resection (Figs. 1.8 and 1.9). Wound problems are better good function and the relative ease of application, implant
prevented or managed with biological reconstruction. While reconstruction should be considered as the treatment of
economic factors should not be cited as a criterion for choice when the joint surface cannot be salvaged due to
determining the best treatment strategy, they often emerge as a tumor invasion or proximity and an intraarticular (or
reality of medical procedures and biological methods offer extraarticular) resection is warranted. While epiphyseal
serious advantages to implant reconstruction. tumor involvement in MRI is not an absolute indication for
8 H. Özger and B. Alpan

Fig. 1.4 Anteroposterior standing orthoroentgenogram of a 20-year-­ left femur due to osteosarcoma (a, b). Following plate removal, length-
old-male patient shows leg length discrepancy of 8 cm in the left lower ening of 4 cm was performed with an intramedullary motorized mag-
extremity 9 years after “frozen hotdog” (liquid nitrogen recycled auto- netic nail (c–f). The procedure was performed in a very similar fashion
graft shell & inlaid vascular fibula combination) reconstruction of the to lengthening in a non-oncological setting

intraarticular resection, plain infiltration of the joint carti- reserved as the primary option for them due to above-­
lage, extension into the joint space or extension over the mentioned reasons. Nevertheless, implant reconstruction
ligaments, and joint capsule mandate an intraarticular (or should be favored particularly in adults with lower extremity
extraarticular) resection (Figs. 1.10, 1.11, 1.12 and 1.13). tumors due to their relatively diminished bone healing capac-
Implant reconstruction offers the main advantage of ity, increased body weight, and time constraints related to
almost immediate or at least faster recovery of functions going back to work and other daily activities. Consequently,
depending on anchorage properties, such as the use of an adult patient with bad prognostic factors and a lower
cemented or cement-less stems, and any associated soft tis- extremity tumor where the joint is non-salvageable is the
sue reconstruction. Similarly, early weight-bearing can often ideal candidate for implant reconstruction.
be allowed in the lower extremity in stark contrast to biologi- An important yet debatable indication for implant
cal reconstruction. Therefore, the healing time is substan- reconstruction might be not having the surgical skill, expe-
tially shorter for implant reconstruction than that of biological rience, infrastructure, and organization to perform a bio-
reconstruction. Patients with bad prognostic factors such as logical reconstruction where an intercalary resection might
being metastatic at presentation, showing a bad neoadjuvant be considered. The orthopedic oncologist might not be
treatment response, having a large tumor, and having sus- familiar with the biological method(s); a microsurgeon
tained a pathological fracture should be very carefully and/or necessary operation room setting for microsurgery,
assessed for biological reconstruction and must strongly be equipment, and facilities required for bone recycling or
considered for implant reconstruction since the prognosis is bone bank for allograft use might not be available.
often incompatible with the prolonged healing expected in Furthermore, tumor destruction may render the bone use-
biological methods (Fig. 1.14). Although pediatric patients less as a recycled autograft, the patient might not accept
tolerate and function very well with implant reconstruction any donor-site morbidity ruling out any graft/flap harvest,
especially around the knee, biological reconstruction is and the patient may not allow the use of cadaveric bone
1 When and Why Biological/Implant Reconstruction? 9

Fig. 1.5 Post-chemotherapy MRI shows good radiological response in dation of the hotdog segment, local recurrence was detected in the
an 11-year-old non-metastatic male patient with distal femur osteosar- epiphysis of the medial condyle at postoperative 38 months (d, e).
coma extending into the epiphysis at presentation (a). Intercalary Despite local recurrence, a second attempt at limb salvage was success-
(intraepiphyseal) resection and biological reconstruction with “frozen ful with resection of the biologically reconstructed segment following
hotdog” (liquid nitrogen recycled autograft shell & inlaid vascular fib- preoperative radiotherapy and implant reconstruction of the distal
ula combination) technique was performed (b, c). Despite full consoli- femur (f, g)

grafts due to sociocultural and/or religious reasons. cerated tumor or one with imminent skin breakdown, neu-
Patients might also reject biological reconstruction due to rovascular involvement, and anticipation of significant soft
concerns about oncological safety of bone recycling meth- tissue defect are common features. These cases, especially
ods or viral disease transmission risk associated with fresh if they are skeletally immature, might actually be good can-
frozen massive allografts. In such cases, the most biologi- didates for Van Nes rotationplasty. However, psycho-socio-
cal approach for an implant reconstruction must be sought. cultural incompatibility may exclude rotationplasty in
If, for example, intercalary resection can be performed, the some cases.
joint might be salvaged and an intercalary diaphyseal Yet for other cases in the gray zone, the indication for
endoprosthesis might be implanted. limb salvage surgery might be a definite one but the deci-
sion to perform a biological or implant reconstruction is
difficult with regard to oncological safety and possible
1.4 The Gray Zone critical gains with the biological method. In certain cases,
neither method is clearly the better choice. In those cases,
Some cases of musculoskeletal tumors fall into a gray zone the patient’s and the treating team’s preferences are deci-
with regard to whether a limb salvage surgery can be per- sive. In rarer cases, when a significant advantage or dra-
formed or not, before any discussion of whether biological matic difference in treatment outcome is anticipated,
or implant reconstruction is better indicated. A huge exul- riskier and unconventional solutions might be sought