MASSIVE ALLOGRAFTS IN THE TREATMENT OF OSTEOSARCOMA AND EWING SARCOMAIN CHILDREN AND ADOLESCENTS

A retrospective review was performed of the results of all allograft r econstructions that had been done after the resection of an osteosarco ma or an Ewing sarcoma in a skeletally immature patient between 1982 a nd 1989 at The Hospital for Sick Children in Toronto. There were twent y-six patients. Six reconstructions were intercalary, sixteen were res ection arthrodeses, three followed resection of a bone segment includi ng the epiphysis (osteoarticular reconstruction), and one was a replac ement of the entire humerus. Resection arthrodesis about the knee was performed with a smooth intramedullary rod and with one growth plate l eft intact, Six procedures were performed in the upper extremity. Excl uding the patients who died, the average duration of follow-up was fiv e years and three months, Twenty-one of the twenty-six patients had re ached skeletal maturity at the time of follow-up. Eighteen (69 per cen t) of the patients had a good or excellent result, four (15 per cent) had a fair result, and four had a failure. Twenty patients (77 per cen t) had at least one complication (other than a limb-length discrepancy ), and fourteen (54 per cent) sustained at least one fracture of the a llograft. Fifteen patients who had had a reconstruction in the lower e xtremity had survived with survival of the allograft at the time of th e latest follow-up. A limb-length discrepancy of at least two centimet ers developed in nine of the fifteen patients. Five were managed with a contralateral epiphyseodesis, and one of them had an unsuccessful at tempt at limb-lengthening as well. The patients who had a limb-length discrepancy of more than three centimeters at the time of follow-up ha d been significantly younger (p < 0.05) at the time of the reconstruct ion than those who had a smaller discrepancy. Three allografts (12 per cent), two of which were implanted early in the series, became infect ed. Soft-tissue coverage is of paramount importance for the prevention of infection, and we now routinely perform primary muscle (gastrocnem ius or latissimus dorsi) transfers when dealing with an inadequate mus cle envelope. Twelve patients were followed for more than four years ( average, six Sears and seven months); they had no complications other than increased limb-length discrepancy and one subluxation of the shou lder after the first four years following the reconstruction. Although the rate of complications is higher than in adults, allograft reconst ruction remains a useful option for the management of skeletally immat ure individuals. Its use in the lower extremity should be reserved for patients in whom limb-length inequality can be treated easily.