n Feature Article
Radial Shaft Reconstruction With an
Intercalary Endoprosthesis Following
Resection of Metastatic Tumor
Peter D. Gibson, MD; Joseph A. Ippolito, BA; Joseph Benevenia, MD
abstract
Improvements in imaging and treatment of musculoskeletal tumors have increased the variety of options for reconstruction following joint-sparing diaphyseal resection. The purpose of this case series was to show that reconstruction
of malignant tumors of the radial shaft with an intercalary prosthesis may be
an option for patients with segmental bone loss. Three consecutive patients
underwent wide resection of the radial diaphysis followed by reconstruction
with a custom intercalary prosthesis. A custom intercalary prosthesis with lap
joint design was used in all 3 cases. Mean follow-up was 18 months (range,
9-25 months). All patients were weight bearing as tolerated 1 week postoperatively. At the most recent follow-up, patients’ mean elbow flexion and extension arc was 137° (range, 130°-140°). At the forearm, mean supination was 60°
(range, 30°-90°) and mean pronation was 70° (range, 60°-90°). At the wrist,
mean palmar flexion was 80° (range, 70°-90°) and mean dorsiflexion was 80°
(range, 70°-90°). All patients reported minimal to no pain and no significant
functional limitations. Mean Musculoskeletal Tumor Society score was 26/30
(87%). Reconstruction with an intercalary prosthesis is a viable option for patients with metastatic disease of the radial shaft. All patients had satisfactory results and early return to function; none required return to the operating room.
Possible advantages of reconstruction with an intercalary prosthesis compared
with reconstruction with a bone graft or polymethylmethacrylate osteosynthesis include early return to function and minimal weight-bearing restrictions
postoperatively. [Orthopedics. 2017; 40(2):e242-e247.]
D
ue to improvements in imaging
and treatment of musculoskeletal
tumors, joint-sparing segmental
resection of diaphyseal tumors has become
more common.1-4 Benefits of reconstruction
following segmental resection include pres-
e242
ervation of joint function and preservation of
the physes in skeletally immature patients.
Options for reconstruction include the use
of autografts,5-7 allografts,8-16 distraction
osteogenesis,17,18 custom implants,19-24 and
modular intercalary endoprostheses.25-28
Although some data exist showing successful outcomes for patients treated with
autograft or allograft following limb-salvage surgery, restriction in weight-bearing
activity to allow for bone union and hypertrophy of graft may be a significant drawback, especially for patients with cancer,
who are at greater risk for complications
and increased time to union because of
radiation and immunosuppressive chemotherapy.8,10-12,21,29-32 Reconstruction with
a metallic prosthesis provides advantages
including immediate postoperative stability, early weight bearing, and low rates of
infection.19-22,27,33,34
The objective of this study was to report
on the functional outcomes of 3 consecuThe authors are from the Department of Orthopaedics, Rutgers New Jersey Medical School,
Newark, New Jersey.
Drs Gibson and Ippolito have no relevant financial relationships to disclose. Dr Benevenia
is an unpaid consultant and invited speaker for
and has received personal fees for attending symposia from Merete Inc and Implant Cast; has received personal fees for attending symposia from
CreOsso LLC; and has a principal equity interest
in CreOsso LLC.
Correspondence should be addressed to:
Peter D. Gibson, MD, Department of Orthopaedics, Rutgers New Jersey Medical School, 140
Bergen St, ACC Bldg, Ste D1610, Newark, NJ
07103 ([email protected]).
Received: April 11, 2016; Accepted: August
1, 2016.
doi: 10.3928/01477447-20160901-03
Copyright © SLACK Incorporated
n Feature Article
tive patients treated at the authors’ institution with a custom intercalary prosthesis
following diaphyseal resection of metastatic lesions of the radial shaft.
Materials and Methods
After institutional review board approval was obtained, 3 consecutive
patients with metastatic disease who
underwent wide resection of the radial diaphysis followed by reconstruction with
a custom intercalary prosthesis between
January 2010 and January 2015 were retrospectively identified. Postoperatively,
range of motion, weightbearing status,
and Musculoskeletal Tumor Society
(MSTS) functional outcome scores were
reviewed.
Custom intercalary prostheses (OrthoTin,
Whippany, New Jersey) with lap joint design
(Figure 1) were used in all 3 cases. Food
and Drug Administration custom device
exemption is required for custom implants.
To make the custom implant, the manufacturer used details regarding the size of the
intramedullary space and the lesion and the
estimated size of resection as per correspondence with the senior surgeon (J.B.).
Both the traditional volar and dorsal
approaches to the forearm were used for
exposure prior to implantation. A volar or
dorsal approach can be used, depending on
surgeon preference for wide resection and
the possible involvement of neurovascular
structures. After the radius was exposed,
circumferential dissection was performed,
extending 2 to 3 cm proximally and distally
of the pathologic segment of bone. Marking the location of planned osseous cuts,
retractors were placed beneath the radius
to protect deep structures during the resection. A sagittal saw was then used to make
parallel cuts for en bloc resection with wide
margins. Resection with wide margins was
obtained in all cases. Subsequently, the resected specimen was removed with the biopsy tract left in continuity. Surgical margins were then obtained and found to have
negative results intraoperatively via frozen
sections prior to reconstruction.
MARCH/APRIL 2017 | Volume 40 • Number 2
Figure 1: Custom intercalary prostheses with lap joint design.
A
B
C
D
Figure 2: Exposure of the radial shaft (A). After en bloc resection (B). Insertion of the prosthesis (C). Fluoroscopic
examination of the custom prosthesis (D).
Reconstruction (Figure 2) began by
inspecting the osseous cuts to the radius,
verifying they were perpendicular to the
radial shaft and parallel to one another, as
uneven cuts can introduce deformity after
implantation. Next, using bone-holding
clamps to stabilize the resected bone,
reaming was performed. Each fragment of
the bone was reamed to a depth 1 cm longer than stem depth. Regarding diameter,
overreaming was performed 1.5 mm to
allow for adequate cement mantle. After
reaming, the implant was trialed to verify
that the prosthesis was seated appropriately within the canal and that adequate
length could be obtained after the lap joint
was secured with screw fixation. If length
was found to be inadequate or lap screw
holes did not correspond when appropriate length was set, an additional bone resection could be made either proximally
or distally until screw holes corresponded
at appropriate length.
After the implant was trialed, the surgical site was then irrigated while polymethylmethacrylate cement was mixed on the
back table. Cement was injected into the
proximal and distal intramedullary space
after reaming. Stems were then cemented
into the proximal and distal medullary canal and held in place until hardening of
the cement. The lap joint was assembled
and reduced, with 2 to 3 set screws placed
to lock in the joint. Following soft tissue
coverage of the implant, all wounds were
closed, with 1 drain left in place.
e243
n Feature Article
A
B
C
D
Figure 3: Preoperative (A) and postoperative (C) anteroposterior and preoperative (B) and postoperative (D) lateral radiographs for patient 1.
A
B
C
D
Figure 4: Preoperative (A) and postoperative (C) anteroposterior and preoperative (B) and postoperative (D) lateral radiographs for patient 2.
Postoperatively, patients were placed
in a volar resting splint for 5 to 7 days
to assist with pain control and soft tissue
healing. Drains were discontinued when
output was minimized to less than 50 mL
during a 24-hour period (1 to 2 days postoperatively). Patients were seen 1 week
postoperatively to assess wound healing,
remove the splint, and encourage range
of motion without restrictions regarding
weight bearing. Subsequently, patients
were seen for clinical and radiographic
examination at 3 weeks, 3 months, 6
months, 1 year, and annually thereafter.
Results
Mean age at diagnosis was 71 years
(range, 59-81 years). Two patients were
male and 1 patient was female. Diagnoses were metastatic multiple myeloma,
melanoma, and renal cell carcinoma, respectively. All patients presented with
painful lesions, with 2 patients presenting with solitary metastases and 1 patient
(patient 3) presenting with metastases to
e244
both the radial and humeral shafts. Wide
margins were obtained in all cases. Mean
resection of the radial shaft was 5.2 cm
(range, 5-5.5 cm) and mean operating
room time, including intraoperative biopsy and pathologic confirmation, was
3.7 hours. However, 1 patient (patient 3)
had a second lesion at the contralateral
humerus, which was treated with resection and osteosynthesis, increasing mean
operating room time considerably. A tourniquet was used for 60 minutes in the case
(patient 3) with renal cell carcinoma, in
addition to preoperative embolization. Patient 1 was initially treated conservatively
with a brace for 2 months after presenting
with a pathologic fracture, but ultimately
decided to undergo resection to relieve
pain. The mean follow-up was 18 months
(range, 9-25 months). Pre- and postoperative imaging for each patient is shown in
Figure 3, Figure 4, and Figure 5.
One patient (patient 2) receiving longterm prednisone for Addison’s disease
presented with a partially healed peripros-
thetic fracture at 17 months postoperatively. It had healed both clinically and radiographically at the most recent follow-up,
19 months postoperatively, following conservative treatment with a brace.
At the most recent follow-up, all patients were pain free and weight bearing
as tolerated. At the elbow, patients had a
mean flexion and extension arc of 137°
(range, 130°-140°). At the forearm, patients had mean supination of 60° (range,
30°-90°) and mean pronation of 70°
(range, 60°-90°). At the wrist, patients had
mean palmar flexion of 80° (range, 70°90°) and mean dorsiflexion of 80° (range,
70°-90°). Mean MSTS score was 26/30
(87%) (Table).
Discussion
Advancements in imaging, chemotherapy, and radiation have contributed
to improved lifespan for patients with
malignant bone tumors. As a result, a
growing emphasis on limb salvage in favor of increasing postoperative function
Copyright © SLACK Incorporated
n Feature Article
A
B
C
D
Figure 5: Preoperative (A) and postoperative (C) anteroposterior and preoperative (B) and postoperative (D) lateral radiographs for patient 3.
Table
Patient Age, Diagnosis, and Functional Outcome
Patient
No.
Diagnosis
Age,
y
Follow-up,
mo
Resected
Segment,
cm
Approach
Complications
Elbow
Flexion
and
Extension
Forearm
Supination/
Pronation
Wrist
Dorsiflexion/
Palmar Flexion
MSTS
Scorea
1
Multiple
myeloma
79
25
5.5
Dorsal
None
140°
90°/90°
90°/90°
26
2
Melanoma
81
19
5
Volar
Periprosthetic
fracture
130°
30°/60°
70°/70°
26
3
Renal cell
carcinoma
59
9
5
Volar
None
140°
60°/60°
80°/80°
26
Abbreviation: MSTS, Musculoskeletal Tumor Society.
a
Out of a possible total of 30.
has led to an advancement of prosthetic
designs and techniques. Although in this
patient population an optimal method of
reconstruction following a diaphyseal
defect is uncertain, reconstruction with
an intercalary prosthesis may provide
numerous advantages over other methods of reconstruction. Goals of limb salvage for patients with metastatic disease
must include reduction of pain and improvement of quality of life with return
to function quickly with minimal restriction.
Reconstruction of segmental defects using large allografts has been successful in
numerous studies8,9,11,12,14,16,35 for patients
with tumors, with a 10-year survival rate between 75% and 89%. Several of these stud-
MARCH/APRIL 2017 | Volume 40 • Number 2
ies16,35 have shown nonunion rates greater
than 30%. Further, the detrimental impact
of chemotherapy on bone healing15,31 contributes to high fracture rates (range, 15%51%)8,11,12,15 and high nonunion rates
(range, 18%-64%),11-14,36,37 as well as risk
of infection (range, 6%-30%).12,15,36 In the
context of survival time of patients with
metastatic bone tumors, morbidity associated with allograft may contribute to poorer
quality of life in the perioperative period.
Because these patients generally have a
lifespan of only a few years, this is an important consideration.
As a way to reduce infections in patients who are immunocompromised,
autoclaved or irradiated autografts have
been investigated but have high rates of
nonunion, fracture, and infection comparable with those of allograft.6 The use
of vascularized fibula transfer is more
traditionally pursued for patients with
primary tumors. Chang and Weber5 used
vascularized fibula transfer both as a primary method of diaphyseal reconstruction
and for patients with allograft nonunion,
finding a mean union time of 6 and 10
months, respectively. Further, results of
several studies suggest that this method of
reconstruction may not be ideal for large
defects.5,7
Cemented intercalary prostheses have
the benefit of not relying on bone healing, thus allowing early weight bearing
and improved range of motion. This
benefit is particularly advantageous to
e245
n Feature Article
patients with metastatic disease, for
whom restoring maximal function earlier
can lead to large improvements in quality of life. To the authors’ knowledge,
no studies have investigated functional
outcomes for patients treated with an
intercalary endoprosthesis at the radius.
However, numerous other studies have
shown satisfactory results with both
custom and modular endoprosthetic reconstruction for diaphyseal defects. In a
study of patients with reconstruction of
the humerus, tibia, and femur, Abudu et
al19 found that although 22% of patients
experienced loosening, no patients developed wear or breakage of implants at a
mean follow-up of 65 months. Additionally, the majority (77%) of patients were
able to achieve 80% or more of their presurgical functional capabilities. A study
by Damron et al26 investigating outcomes
of patients treated with a modular intercalary humerus spacer showed that most
patients were able to use the operative
extremity with activities of daily living
on the first postoperative day. Further, all
but 1 of these patients had an improvement in MSTS scores postoperatively,
and the study showed 100% implant survival at a median 20-month follow-up. In
a multi-institutional study on functional
outcomes for patients treated with an intercalary prosthesis at the humerus, tibia,
and femur, the authors found 100% implant survival at a mean follow-up of 14
months and MSTS scores of 82% at the
upper extremity.25
Individuals with metastatic disease to
the bones are a diverse group with varying functional demands and expected
lifespans. This small case series reveals
a possible surgical option when dealing
with diaphyseal lesions in the radius,
yet is not without its inherit weaknesses.
Only 3 cases were reported and all implants were used in an older patient population. It is difficult to predict whether
similar results would be expected in a
more demanding population with this endoprosthetic reconstruction.
e246
Conclusion
Reconstruction with an intercalary
prosthesis following diaphyseal resection
of the radius is a viable option for patients
with metastatic disease. In comparison
with other limb-salvage options such as
allograft or autograft, reconstruction with
an intercalary prosthesis allows for earlier
weight bearing and more rapid return to
function. In this case series, all patients
were able to return to function with minimal weight-bearing restriction within 2
weeks postoperatively.
References
1. Aksnes LH, Bauer HC, Jebsen NL, et al.
Limb-sparing surgery preserves more function than amputation: a Scandinavian sarcoma group study of 118 patients. J Bone Joint
Surg Br. 2008; 90(6):786-794.
2. Refaat Y, Gunnoe J, Hornicek FJ, Mankin HJ.
Comparison of quality of life after amputation or limb salvage. Clin Orthop Relat Res.
2002; 397:298-305.
3. Rougraff BT, Simon MA, Kneisl JS, Greenberg DB, Mankin HJ. Limb salvage compared with amputation for osteosarcoma
of the distal end of the femur: a long-term
oncological, functional, and quality-oflife study. J Bone Joint Surg Am. 1994;
76(5):649-656.
4. Simon MA, Aschliman MA, Thomas N,
Mankin HJ. Limb-salvage treatment versus
amputation for osteosarcoma of the distal end
of the femur. J Bone Joint Surg Am. 1986;
68(9):1331-1337.
5. Chang DW, Weber KL. Use of a vascularized
fibula bone flap and intercalary allograft for
diaphyseal reconstruction after resection of
primary extremity bone sarcomas. Plast Reconstr Surg. 2005; 116(7):1918-1925.
6. Chen TH, Chen WM, Huang CK. Reconstruction after intercalary resection of malignant bone tumours: comparison between
segmental allograft and extracorporeallyirradiated autograft. J Bone Joint Surg Br.
2005; 87(5):704-709.
7. Rose PS, Shin AY, Bishop AT, Moran SL,
Sim FH. Vascularized free fibula transfer
for oncologic reconstruction of the humerus. Clin Orthop Relat Res. 2005; 438:8084.
8. Alman BA, De Bari A, Krajbich JI. Massive
allografts in the treatment of osteosarcoma
and Ewing sarcoma in children and adolescents. J Bone Joint Surg Am. 1995; 77(1):5464.
9. Brien EW, Terek RM, Healey JH, Lane JM.
Allograft reconstruction after proximal tibial
resection for bone tumors: an analysis of
function and outcome comparing allograft
and prosthetic reconstructions. Clin Orthop
Relat Res. 1994; 303:116-127.
10. Deijkers RL, Bloem RM, Kroon HM, Van
Lent JB, Brand R, Taminiau AH. Epidiaphyseal versus other intercalary allografts for
tumors of the lower limb. Clin Orthop Relat
Res. 2005; 439:151-160.
11. Donati D, Di Liddo M, Zavatta M, et al. Massive bone allograft reconstruction in highgrade osteosarcoma. Clin Orthop Relat Res.
2000; 377:186-194.
12. Gebhardt MC, Flugstad DI, Springfield DS,
Mankin HJ. The use of bone allografts for
limb salvage in high-grade extremity osteosarcoma. Clin Orthop Relat Res. 1991;
270:181-196.
13. Makley JT. The use of allografts to reconstruct intercalary defects of long bones. Clin
Orthop Relat Res. 1985; 197:58-75.
14.Mankin HJ, Gebhardt MC, Jennings LC,
Springfield DS, Tomford WW. Long-term results of allograft replacement in the management of bone tumors. Clin Orthop Relat Res.
1996; 324:86-97.
15. Muscolo DL, Ayerza MA, Aponte-Tinao L,
Ranalletta M, Abalo E. Intercalary femur
and tibia segmental allografts provide an acceptable alternative in reconstructing tumor
resections. Clin Orthop Relat Res. 2004;
426:97-102.
16. Ortiz-Cruz E, Gebhardt MC, Jennings LC,
Springfield DS, Mankin HJ. The results of
transplantation of intercalary allografts after
resection of tumors: a long-term follow-up
study. J Bone Joint Surg Am. 1997; 79(1):97106.
17. Dormans JP, Ofluoglu O, Erol B, Moroz L,
Davidson RS. Case report: reconstruction of
an intercalary defect with bone transport after
resection of Ewing’s sarcoma. Clin Orthop
Relat Res. 2005; 434:258-264.
18. Tsuchiya H, Tomita K, Minematsu K, Mori
Y, Asada N, Kitano S. Limb salvage using
distraction osteogenesis: a classification of
the technique. J Bone Joint Surg Br. 1997;
79(3):403-411.
19. Abudu A, Carter SR, Grimer RJ. The outcome and functional results of diaphyseal
endoprostheses after tumour excision. J Bone
Joint Surg Br. 1996; 78(4):652-657.
20. Ahlmann ER, Menendez LR. Intercalary endoprosthetic reconstruction for diaphyseal
bone tumours. J Bone Joint Surg Br. 2006;
88(11):1487-1491.
21. Aldlyami E, Abudu A, Grimer RJ, Carter SR,
Tillman RM. Endoprosthetic replacement of
diaphyseal bone defects: long-term results.
Int Orthop. 2005; 29(1):25-29.
22.Hanna SA, Sewell MD, Aston WJ, et al.
Femoral diaphyseal endoprosthetic reconstruction after segmental resection of primary
Copyright © SLACK Incorporated
n Feature Article
bone tumours. J Bone Joint Surg Br. 2010;
92(6):867-874.
malignancies. Clin Orthop Relat Res. 1996;
324:233-243.
cidence, nature, and treatment. J Bone Joint
Surg Am. 1988; 70(3):369-376.
23. McGrath A, Sewell MD, Hanna SA, et al.
Custom endoprosthetic reconstruction for
malignant bone disease in the humeral diaphysis. Acta Orthop Belg. 2011; 77(2):171-179.
28.Ruggieri P, Mavrogenis AF, Bianchi G,
Sakellariou VI, Mercuri M, Papagelopoulos PJ. Outcome of the intramedullary
diaphyseal segmental defect fixation system for bone tumors. J Surg Oncol. 2011;
104(1):83-90.
33. Torbert JT, Fox EJ, Hosalkar HS, Ogilvie
CM, Lackman RD. Endoprosthetic reconstructions: results of long-term followup of
139 patients. Clin Orthop Relat Res. 2005;
438:51-59.
24. Sewell MD, Hanna SA, McGrath A, et al. Intercalary diaphyseal endoprosthetic reconstruction for malignant tibial bone tumours.
J Bone Joint Surg Br. 2011; 93(8):11111117.
25. Benevenia J, Kirchner R, Patterson F, et al.
Outcomes of a modular intercalary endoprosthesis as treatment for segmental defects of
the femur, tibia, and humerus. Clin Orthop
Relat Res. 2016; 474(2):539-548.
26. Damron TA, Leerapun T, Hugate RR, Shives
TC, Sim FH. Does the second-generation intercalary humeral spacer improve on the first?
Clin Orthop Relat Res. 2008; 466(6):13091317.
27. Damron TA, Sim FH, Shives TC, An KN,
Rock MG, Pritchard DJ. Intercalary spacers
in the treatment of segmentally destructive
diaphyseal humeral lesions in disseminated
MARCH/APRIL 2017 | Volume 40 • Number 2
29. Burchardt H, Glowczewskie FP Jr, Enneking
WF. The effect of Adriamycin and methotrexate on the repair of segmental cortical autografts in dogs. J Bone Joint Surg Am. 1983;
65(1):103-108.
30. Hernigou P, Delepine G, Goutallier D. Infections after massive bone allografts in surgery
of bone tumors of the limbs: incidence, contributing factors, therapeutic problems [in
French]. Rev Chir Orthop Reparatrice Appar
Mot. 1991; 77(1):6-13.
31. Hornicek FJ, Gebhardt MC, Tomford WW,
et al. Factors affecting nonunion of the allograft-host junction. Clin Orthop Relat Res.
2001; 382:87-98.
32.Lord CF, Gebhardt MC, Tomford WW,
Mankin HJ. Infection in bone allografts: in-
34.Zeegen EN, Aponte-Tinao LA, Hornicek
FJ, Gebhardt MC, Mankin HJ. Survivorship
analysis of 141 modular metallic endoprostheses at early followup. Clin Orthop Relat
Res. 2004; 420:239-250.
35. Brigman BE, Hornicek FJ, Gebhardt MC,
Mankin HJ. Allografts about the knee in
young patients with high-grade sarcoma.
Clin Orthop Relat Res. 2004; 421:232239.
36. Gitelis S, Heligman D, Quill G, Piasecki P.
The use of large allografts for tumor reconstruction and salvage of the failed total hip
arthroplasty. Clin Orthop Relat Res. 1988;
231:62-70.
37. Vander Griend RA. The effect of internal
fixation on the healing of large allografts. J
Bone Joint Surg Am. 1994; 76(5):657-663.
e247